Society For Clinical Vascular Surgery

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Delayed Diagnosis of Popliteal Artery Injury After Total Knee Arthroplasty
Paul E. Collier, MD1, Andrew J. Collier, Jr., MD2, Timothy Hanlon3.
1Greater Pittsburgh Surgical Alliance, Sewickley, PA, USA, 2Philadelphia Orthopedic Associates, Philadelphia, PA, USA, 3Drexel University, Philadelphia, PA, USA.

Delayed Diagnosis of Popliteal Artery Injury After Total Knee Arthroplasty
Objective: Popliteal artery injuries after total knee arthroplasty (TKA) are reported to be rare events. Limb loss from these injuries is felt to be even more uncommon. The occurrence and diagnosis of ischemia that develops slowly after intraoperative arterial injury has only been reported anecdotally. This event is more common than has been reported and often leads to a devastating outcome and litigation.
Methods: The records of 24 patients who underwent TKA and developed ischemia postoperatively and resulted in malpractice claims over the course of ten years were analyzed to determine the mechanism of injury, the clinical course of the ischemia, why the malpractice claims arose and how practices could be changed to improve outcomes in the future.
Results: 14 men and 10 women, ages 50 to 78, were diagnosed with post-TKA ischemia up to 5 days after leaving the PACU. Pain was often reported to be non-specific or was masked by the use of some regional anesthesia in 16. All 24 developed numbness, which was usually attributed to a prolonged anesthetic block or tourniquet injury to a nerve. 18 were noted to have motor disfunction prior to the diagnosis of the ischemia. Pulses were documented in 8 patients and CRT was normal in all 24. There were 1 AVF, 6 partial or total transections, and 17 thromboses (10 with documented intimal lesions). 18 patients underwent major amputations and 6 remain with dysfunctional legs. All of the operating surgeons who were asked during deposition believed that popliteal artery occlusion would immediately cause profound ischemia postoperatively.
Conclusions: Contrary to the commonly held belief that intraoperative popliteal thrombosis rapidly causes symptoms, ischemia after TKA can present insidiously because of the presence of geniculate collaterals. CRT is a meaningless test that should not be relied upon. Pulse examinations are subjective and can be inaccurate. If a patient develops any signs or symptoms in the postoperative period after TKA that suggest ischemia objective testing should be immediately obtained so that revascularization can be performed before ischemia becomes irreversible.


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