Rev. bras. ortop. vol.50 número3

rev bras ortop.2015;50(3):348–351

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Case

Report

Popliteal

artery

injury

during

posterior

cruciate

ligament

reconstruction

夽

Marcos

Henrique

Frauendorf

Cenni

_,

_Bruno

_Fajardo

_do

_Nascimento,

Guilherme

Galvão

Barreto

Carneiro,

Rodrigo

Cristiano

de

Andrade,

Lúcio

Flávio

Biondi

Pinheiro

Júnior,

Oscar

Pinheiro

Nicolai

HospitalMaterDei,BeloHorizonte,MG,Brazil

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Articlehistory: Received7June2014 Accepted13June2014 Availableonline23April2015

Keywords: Poplitealartery

Posteriorcruciateligament Intraoperativecomplications

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Thisstudyreportsacaseofpoplitealarteryinjuryduringarthroscopicreconstructionof theposteriorcruciateligament.Theevolutionoftheinjuryisdescribedandcommentsare maderegardingtheanatomyofthisarteryandpotentialrisksofthissurgicaltechnique.This studyhadtheaimsofalertingthemedicalcommunity,especiallykneesurgeons,regarding aseveresurgicalcomplicationanddiscussingthewaysofpreventingit.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Lesão

da

artéria

poplítea

durante

a

reconstruc¸ão

do

ligamento

cruzado

posterior

Palavras-chave: Artériapoplítea

Ligamentocruzadoposterior Complicac¸õesintraoperatórias

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e

s

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m

o

Este trabalho relata uma lesão da artéria poplítea (AP) durante uma reconstruc¸ão artroscópicadoligamentocruzadoposterior,descrevesua evoluc¸ãoefazconsiderac¸ões sobreaanatomiadessaartériaeosriscospotenciaisdessatécnicacirúrgica.Temcomo objetivoalertara comunidademédica, emespecial os cirurgiões dejoelho, sobreuma complicac¸ãocirúrgicagraveediscutirasformasdepreveni-la.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽

WorkdevelopedintheKneeGroupofHospitalMaterDei,BeloHorizonte,MG,Brazil. ∗ _{Correspondingauthor.}

E-mail:cenni14@gmail.com(M.H.F.Cenni).

http://dx.doi.org/10.1016/j.rboe.2015.04.005

rev bras ortop.2015;50(3):348–351

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Introduction

Reconstruction surgery on the posterior cruciate ligament (PCL) is a procedure that is well known among knee sur-geons for its complexity, technical difficulty and potential risksofinjuringthevascular-nervousbundleofthepopliteal fossa. The reconstruction techniques can be arthroscopic, openormixed(ofinlaytype).Arthroscopicreconstructionis lessaggressivetowardthepatient,butpresentsgreater tech-nicaldifficultiesandrisks.1

Case

report

OnNovember19,2010,thepatientR.J.M.sufferedacar acci-dent,withseveremultipletrauma,whichledhimtobekept intheintensivecarecenterforfourdays.Hismostsignificant injurieswereamulti-fragmentfractureoftheleftfemoral dia-physis,dislocationoftherightkneeoftypeKDIIIL(tearingof theanteriorandposteriorcruciateligamentsinassociation withinjurytotheposterolateralcorner),tearingofthespleen andavarietyofabrasions(Figs.1and2).

On November 24, 2010, he underwent intramedullary osteosynthesiswitharetrogradenailintroducedintotheleft femur.OnDecember1,2010,heunderwentacuteperipheral repairoftheposterolateralinjurytotherightknee(Fig.3).

HewasreleasedfromhospitalonDecember5,2010,ina goodconditionbutwithanindicationforPCLreconstruction, tobeperformed asasecond operationafterthe peripheral injurieshadhealed.

OnMarch2,2011,heunderwentPCLreconstruction arthro-scopically,inwhichaquadruplegraft fromthegracilisand semitendinosusflexortendonswasused.Attheendofthe operation,it was notedthat the popliteal artery had been injured,giventheeffusivebleedingthroughthe posterome-dialportalandtheabsenceofpulseand distalperfusionin theoperatedlimb.

Thevascularsurgeonwascalledin,onanemergencybasis. Hegot the callpromptly and arrivedinthe operating the-aterafteraround50min.Noadditionaldiagnostictestswere requested, given the high degree of suspicion of vascular injuryandtheneedforemergencyintervention.

Fig.1–Appearanceofthelimbwithposteriorfallofthe tibia.

Fig.2–Magneticresonanceimagingoftheinitiallesion, showingthesevereligamentinjury.

Thepatientwaspositionedinventraldecubitusand under-went revascularizationsurgerywithinterpositionofagraft fromthegreatsaphenousvein,bymeansofTrickey’sposterior access.Therevascularizationwasterminatedfivehoursand 45minafterinflationofthetourniquetfortheligament recon-structionsurgery(i.e.thiswasthetotaldurationofischemiain thelimb)andthepatientwassenttotheintensivecarecenter forpostoperativerecovery.Afterafewhours,thepatientwas returnedtothesurgicalcenterduetopoorperfusionofthe rightleg.AFoghartcatheterwasintroducedandthepatient underwent decompressive fasciotomyofthe four compart-mentsofthesameleg.Thepatientwaskeptintheintensive carecenterforanotherthreedaysandwasreleasedfrom hos-pitalinagoodconditionafter24days.

Aftersixmonthsofrehabilitation,thepatient’scondition presented excellent evolution, with satisfactory functional

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recoveryandwithoutanyclinicalsignsofposteriorinstability orpoordistalperfusionofthelimbaffected.

Discussion

Complicationsrelatingtoarthroscopicsurgeryarerare. Mul-ticenterstudiesconductedinthe1980sobservedincidences ranging from 0.56% to 1.68%.In 1985, DeLee,2 _{leading the} complicationscommitteeoftheArthroscopyAssociationof North America (AANA), coordinated a national survey on 118,590arthroscopicproceduresperformedonseveraljoints andobservedthat930casesofcomplicationsoccurred(0.8%). Amongthesecases,onlyninewerevascularcomplications,all intheknee,andsixofthemresultedinamputation. Subse-quently,Small3_{conductedfurtherstudiesthroughthesame} committeeoftheAANAandobservedcomplicationratesfrom 0.56%to1.68%.

Thus,vascularcomplicationsareveryrare,butpotentially serious.Outofallkneesurgicalprocedures,PCL reconstruc-tionandtotalarthroplastyaretheonesthatpresentgreatest risk,becauseoftheproximityofthesurgicalinstrumentsto thepoplitealvessels.1,4_{Severalstudieshavedrawnattention} tothestagesofsurgicalproceduresthatpresentrisksof vas-cularinjury,suchasconstructionoftheposteromedialportal, debridement ofthe posteriorcapsule, passageofthe tibial tunnelguideandtunneldrilling.

Usingmagneticresonanceimaging,Kieser4_demonstrated thatin93.4%ofthepatientsevaluated,thepoplitealarterywas locatedlaterallytothemidlineoftheknee.Intheremaining patients,itwaslocatedinthecentralareaandnever medi-allytothisline.Thedistancefromthearterytotheposterior edgeofthetibiarangedfrom2.6mmto9.9mm.These find-ingsconfirmthatthereisapotentialriskofinjurythrough passageofthetibialguidewire,whichisorientedslightly lat-erally.

In2004,Barlettetal.,5_{attheUniversityofMelbourne,} Aus-tralia,conductedastudyoninjuriesofthepoplitealvessels and evaluated their incidence, anatomical factors and the influenceofsurgeryandprevioustraumaontheriskofsuch injuriesduringproceduresontheknee.Theydemonstrated thatinaroundonethirdofnormalknees(23/60),thepopliteal arterycameclosetothetibiaasthekneewasflexed.Inknees withPCLinjuries,thisoccurred inalmost79%(11/14).They alsoemphasizedthatpreviousinjuriesorsurgicalprocedures affectingtheposteriorcapsuleofthekneecouldincreasethe riskofinadvertentinjurytothepoplitealvessels,whichmight be adhering to the posterolateral scar tissue. After careful analysisofthecasereportedhere,itwasconcludedthatthe lacerationofthepoplitealarteryoccurredexactlyatthetime ofdebridementoftheposteriorrecessusingashaver,which hadbeendoneinanattempttoobtainagoodviewofthepoint atwhichthetibialtunnelemerged.

Matavaetal.6_{usedfreshcadaverstostudytheanatomical} relationshipbetweenthepoplitealarterialandconstructionof thetibialtunnel.Theydemonstratedthatthetibialguidewire gaverisetoariskofperforationinallthetenmodelsobserved, atflexionsof0◦_,45◦_and90◦_{.Onlyatflexionofgreaterthan100}◦

didthisriskdiminishpartiallyforsixoftheten.

In2003,Wuetal.7_{reportedacaseofacutepoplitealartery} occlusionduringPCLreconstruction,withspontaneous reso-lutionin12h.

In2005,Makinoetal.8_{describedanoccurrenceof} lacera-tionofthepoplitealarterythatrequiredvascularrepair.The casepresentedgoodevolution.

Nemanietal.9_{reportedacaseoflacerationofthepopliteal} vein and highlighted some suggestionsfor avoiding occur-rencesofthisnature,suchas:keepingtheArthropumpata lowerpressure,toavoidproximitywiththepoplitealvessels; useofdevicestoblockthetibialguidewire,soastoavoid sit-uations inwhichitmight gobeyondthe limitsofthe tibia posteriorly;anduseofradioscopyduringthepassageofthe guideanddrillingofthetibialtunnel.

Theprognosisforpoplitealarteryinjuriesdependsdirectly onthedurationofischemiaandthemagnitudeofthe soft-tissueinjury.Whenpatientsarerevascularizedoveraperiodof lessthansixhoursandnosignificantmusculoskeletaltrauma occurs,theriskofamputationbecomesminimal,asobserved by Khan et al.10 _{in 2011. Since our patient was promptly} attended to bythe vascular surgeon, the total duration of ischemiaoffivehoursand45minwasafundamentalfactor inthegoodevolutionofthecondition.

Although rare, popliteal artery injuries may place the patient’s lower limb, and even hislife, at risk. Intraopera-tivecare needstoberigorouslyobserved, withsafe useof instruments,withradioscopicassistanceandalwayswiththe presenceofavascularsurgeonpreparedtoperform immedi-atevascularrepairorgrafting.Ifvascularinjuryoccurs,the intervention needs to beimmediate, so as toimprove the patient’sprognosis.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.FurieE,YerysP,CutcliffeD,FebreE.Riskfactorsfor arthroscopicpoplitealarterylaceration.Arthroscopy. 1995;11(3):324–7.

2.DeLeeJC,CommitteeonComplicationsoftheArthroscopy AssociationofNorthAmerica.Complicationsofarthroscopy andarthroscopicsurgery:resultsofanationalsurvey. Arthroscopy.1985;1(4):214–20.

3.SmallNC,CommitteeonComplicationsoftheArthroscopy AssociationofNorthAmerica.Complicationsinarthroscopy: thekneeandotherjoints.Arthroscopy.1986;2(4):253–8.

4.KieserC.Areviewofthecomplicationsofarthroscopicknee surgery.Arthroscopy.1992;8(1):79–83.

5.BarlettRJ,RobertsA,WongJ.Risktopoplitealvesselsinmajor kneesurgery,ananatomicalstudyandsurveyofvascular surgeons.JBoneJointSurgBr.2004;86(Suppl4):468.

6.MatavaMJ,SethiNS,TottyWG.Proximityoftheposterior cruciateligamentinsertiontothepoplitealarteryasa functionofthekneeflexionangle:implicationsforposterior cruciateligamentreconstruction.Arthroscopy.

2000;16(8):796–804.

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8. MakinoA,Costa-PazM,Aponte-TinaoL,AyerzaMA,Muscolo DL.Poplitealarterylacerationduringarthroscopicposterior cruciateligamentreconstruction.Arthroscopy.

2005;21(11):1396.

9. NemaniVM,FrankRM,ReinhardtKR,Pascual-GarridoC, YankeAB,DrakosM,etal.Poplitealvenotomyduring

posteriorcruciateligamentreconstructioninthesettingofa poplitealarterybypassgraft.Arthroscopy.2012;28(2): 294–9.