What is the management of a popliteal artery injury during a Total Knee Replacement (TKR)?

Management of Popliteal Artery Injury During Total Knee Replacement

Immediate recognition and vascular surgical intervention are essential for managing popliteal artery injury during TKR to prevent limb loss and mortality.

Mechanisms of Injury

• Direct trauma is the predominant cause of popliteal artery injury during TKR 1
• Common mechanisms include:
  • Sharp trauma from surgical instruments
  • Improper placement of posterior retractors (especially lateral to midline) 2
  • Hyperextension of the knee causing arterial tenting over posterior joint line 2
  • Hyperflexion causing vessel kinking 2

Immediate Intraoperative Management

1. Recognition of injury:

   • Excessive bleeding
   • Expanding hematoma
   • Absent distal pulses
   • Pallor or mottling of distal extremity

2. Initial actions:

   • Immediate vascular surgery consultation
   • Direct pressure for hemorrhage control
   • Avoid blind clamping which may worsen injury
   • Release tourniquet (if used) to assess distal circulation

3. Vascular assessment:

   • Perform urgent arteriography if patient is stable and diagnosis uncertain 3
   • CTA is preferred for suspected vascular injuries with high accuracy 3
   • MRA may be considered as an alternative with similarly high accuracy 3

Definitive Management

Surgical Approach

1. Exposure:

   • Medial knee surgical incision provides optimal exposure for vascular repair 1
   • Extensile approach may be necessary for adequate visualization

2. Repair techniques (in order of preference):

   • Primary repair - for clean lacerations with minimal vessel damage 4
   • Interposition graft - using autogenous vein (preferably saphenous) 3, 5
   • Bypass graft - for extensive injury or when tension-free repair isn't possible 4
   • Endovascular stenting - for select cases (pseudoaneurysms, focal injuries) 4, 6

3. Critical adjunctive procedures:

   • Thrombectomy and distal heparinization before repair to ensure adequate outflow 5
   • Consider popliteal vein repair when practical 5
   • Perform fasciotomy to prevent compartment syndrome 5

Specific Injury Types

• Thrombosis: Requires thrombectomy followed by appropriate repair 4
• Pseudoaneurysm: May be treated with interposition grafting or endovascular stenting 4, 6
• Arteriovenous fistula: Requires separation and repair of both vessels 4
• Hemorrhage: Direct repair or interposition grafting based on injury extent 4

Postoperative Management

1. Immediate monitoring:

   • Regular assessment of distal pulses, capillary refill, and limb temperature
   • Monitor for signs of compartment syndrome
   • Consider antiplatelet therapy unless contraindicated 7

2. Long-term follow-up:

   • Regular vascular assessment
   • Duplex ultrasound surveillance for patients with endovascular repairs 6
   • Monitor for late complications (stenosis, pseudoaneurysm formation)

Outcomes and Prognosis

• Incidence of popliteal artery injury during TKR is approximately 0.23% 4
• Prompt recognition and appropriate management can result in good outcomes (84% full recovery reported) 1
• Limb loss occurs in approximately 10.5% of cases despite intervention 1
• Delayed diagnosis significantly increases amputation risk

Prevention Strategies

• Place posterior retractors medial to midline of tibial plateau 2
• Avoid extreme hyperextension and hyperflexion during the procedure 2
• Use caution with lateral retractor placement
• Consider preoperative vascular assessment in patients with known peripheral arterial disease

Special Considerations

• Patients with pre-existing peripheral arterial disease are at higher risk
• Atherosclerotic vessels are more susceptible to injury with manipulation 2
• Consider using autogenous vein grafts whenever possible for better long-term patency 3

Popliteal artery injury during TKR represents a surgical emergency that requires immediate recognition and intervention to prevent devastating consequences for the patient.