Updated: 3/26/2017

TKA Vascular Injury and Bleeding

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https://upload.orthobullets.com/topic/12751/images/knee_vasculature.jpg
Vascular Injury
  • Incidence
    • 0.017%-0.2%
  • Risk factors 
    • revision surgery
    • peripheral vascular disease
  • Causes
    • direct laceration
      • sharp dissection in posterior compartment of knee
    • blunt trauma 
      • posterior retractor placement
        • stay medial with single-prong retractor (do not go lateral to PCL)  
        • popliteal artery is a lateral structure at the level of the joint line
        • do not insert retractor more >1cm into posterior soft tissues
        • hyperflexion displaces artery and can avoid injury   
      • excessive hyperextension/dissection in hyperextension 
    • thrombosis
Anatomy
  • Popliteal artery 
    • origin before knee
      • a continuation of the superficial femoral artery
      • transition is at hiatus of adductor magnus muscle
      • anchored by insertion of adductor magnus as enters region of posterior knee
    • course in posterior knee
      • relation to anatomy structures of knee
        • lies posterior to the posterior horn of the lateral horn of the lateral meniscus
          • lies directly behind posterior capsule
    • branches within knee
      • at supracondylar ridge gives branches the provide blood supply to the knee
        • above knee joint branches include
          • medial and lateral sural arteries
          • cutaneous branch
          • middle genicular artery
        • at level of knee joint branches include
          • medial genicular artery
          • lateral genicular artery
    • exit of knee
      • anchor
        • as artery exits knee it is anchored by soleus tendon (originates form medial aspect of tibial plateau)
      • distal branches
        • branches into anterior and posterior tibial arteries at distal popliteus muscles

Presentation
  • Intraoperative
    • brisk bleeding
    • loss of pulses
  • Postoperative
    • ischemia
    • sensory changes
    • loss of distal pulses
    • skin mottling
Imaging
  • Intraoperative
    • angiogram 
      • indications
        • if brisk intraoperative bleeding and/or loss of pulses than obtain immediate vascular surgery consultation.
        • vascular consultation will dictate intraoperative imaging, including angiogram.
  • Postoperative
    • CT angiogram 
      • indications
        • signs of ischemia
          • loss of pulses
          • skin mottling
          • sensory changes
Treatment
  • Immediate vascular surgery consultation
    • indications
      • whenever a concern for injury to the popliteal artery
    • modalities may include
      • nonoperative and observation
        • closed suction drainage is associated with increased incidence of transfusion 
      • stent placement 
      • bypass
      • endarterectomy 
      • prophylactic fasciotomy
        • may be indicated to avoid reperfusion compartment syndrome
Complications
  • Compartment syndrome
  • Amputation
  • Mortality
  • Socioeconomic consequences
    • increased length of stay
    • increased cost
 

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(OBQ05.142) A 65-year old healthy male has just undergone primary total knee arthroplasty. Which of the following is associated with use of a closed suction drain in this procedure? Review Topic

QID: 1028
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1

Increased incidence of wound dehiscence

1%

(21/2542)

2

Increased incidence of transfusion

73%

(1863/2542)

3

Decreased incidence of infection

1%

(23/2542)

4

Decreased incidence of hematoma formation requiring return to OR

21%

(535/2542)

5

Decreased pain scores on post-op days 1 and 2

4%

(95/2542)

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