The popliteal artery is vulnerable to injury during surgeries performed around the knee joint. Pseudoaneurysm of the popliteal artery following a high tibial osteotomy is rare. Few case reports describe the development of this complication after a lateral closing wedge high tibial osteotomy.
Our patient underwent an uneventful medial opening wedge high tibial osteotomy and autogenous bone grafting fixed with dual plating for medial osteoarthritis of the knee. The procedure was performed under tourniquet control, which was released only once after the wound closure. Postoperatively, the dressing was soaked, and a large volume of hemorrhagic collection was present in the suction drain. The patient experienced decreased sensation over the sole, which was successfully treated conservatively with medication. Other clinical parameters like motor function and distal pulses were normal. The patient was discharged after 2 weeks. Two days later, the patient presented with pain and numbness over the entire lower limb and a pulsatile swelling in the popliteal fossa. A femoral angiogram revealed a pseudoaneurysm arising from the popliteal artery just below the osteotomy site. Open vascular surgery with resection of the pseudoaneurysm and end-to-end anastomosis using contralateral saphenous vein interposition graft was performed. During the vascular surgery, a pinhead-sized tear was clearly identified on the anterior wall of the popliteal artery, which may have occurred while using the oscillating saw during opening wedge high tibial osteotomy. Careful placement of retractors around the osteotomy site during sawing and flexing the knee to displace the popliteal artery away are recommended to prevent this complication. To our knowledge, this is the first report of a popliteal artery pseudoaneurysm occurring after a medial opening wedge high tibial osteotomy.
Pseudoaneurysms of the popliteal artery following a high tibial osteotomy are rare. Major complications of popliteal artery injury, such as limb loss, can be prevented by prompt diagnosis and urgent treatment. Pseudoaneurysms of the popliteal and anterior tibial arteries following lateral closing wedge high tibial osteotomy have been reported.1-4 To our knowledge, this is first report of a popliteal artery pseudoaneurysm occurring after a medial opening wedge high tibial osteotomy. Direct injury to the vessel while using the oscillating saw probably led to the condition.
A 60-year-old woman underwent medial opening wedge high tibial osteotomy for medial compartmental osteoarthritis with associated genu varum. Arthroscopic examination of the knee joint revealed a horizontal tear of the posterior horn of the medial meniscus for which a partial meniscectomy was performed. A 6-cm longitudinal incision was then made over the anteromedial aspect of the tibia. The inferomedial part of the patellar ligament and superficial medial collateral ligament (MCL) was exposed. A Hohmann retractor was placed posteromedial to the proximal tibia to protect the popliteal vessels. A Steinmann pin was then inserted through the proximal tibial metaphysis, approximately 3.5 cm below and parallel to the joint line, under fluoroscopic guidance. Osteotomy was performed using an oscillating saw approximately two-thirds of the distance and completed with a narrow osteotome. Cancellous bone graft harvested from the contralateral iliac crest was used to fill the gap after correction, which was maintained by dual plate fixation (Figure 1). The wound was closed over a suction drain. No problems occurred during the procedure. A tourniquet was used throughout the procedure, which was released only after wound closure.
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Figure 1: Postoperative AP radiograph of the left knee showing the opening wedge high tibial osteotomy fixed using dual plating and bone grafting. Figure 2: Femoral angiography study showing pseudoaneurysm (arrow) from the anterior wall of the popliteal artery with the neck just below the lateral end of the osteotomy site.
On the first postoperative day, a large volume of hemorrhagic collection was present in the suction drain. The neurovascular status was normal. On the second postoperative day, the patient reported decreased sensation over the plantar surface of the left foot. Clinical examination revealed normal motor function with palpable distal pulses with good volume. Marked swelling of the proximal leg was treated with limb elevation. With this, the swelling and pain reduced over a few hours. Dressings were changed daily due to minimal soakage; therefore, drain removal was delayed and performed on the fifth postoperative day. The remainder of the postoperative period was uneventful except for some pain at the operative site and mild numbness over the sole of the left foot. The patient was discharged 2 weeks postoperatively.
Two days later, she returned to the hospital with increased pain and numbness in the leg and swelling in the popliteal fossa. Distal pulses were well felt, although the sensation in her sole had reduced further. A femoral angiogram showed a pseudoaneurysm arising from the popliteal artery just below the osteotomy site (Figure 2). The popliteal fossa was explored by the vascular surgeons using the posterior approach, which revealed a pinhead-sized tear in the anterior wall of the popliteal artery. A 5-cm resection of the arterial segment that included the pseudoaneurysmal region and an end-to-end anastomosis was performed using an interposed saphenous vein graft harvested from the contralateral leg. Distal pulses were present at the end of the surgery. The postoperative color Doppler examination revealed normal flow through the affected popliteal vessels (Figure 3). The high tibial osteotomy proceeded to union and the clinical outcome was satisfactory at 18 months postoperatively.
Figure 3: Color Doppler showing normal blood flow and pulsation of popliteal artery (PA) and popliteal vein (PV) after squeezing of calf muscle following vascular repair.
The popliteal artery enters the superomedial part of the popliteal space through the tendinous arch in the adductor magnus muscle. It then passes parallel to the semitendinosus until it reaches the middle of the limb. At that point, it descends down passing through the tendinous arch of the soleus muscle and terminates by dividing into the anterior and posterior tibial arteries. The genicular arteries form extensive collaterals around the knee, and theoretically these should be sufficient to maintain blood flow to the lower extremity when the popliteal artery is injured. But ischemic lesions of the foot and toes may result in up to 45% of cases.5 Anomalous origin of the anterior tibial artery has also been described, which can predispose the artery to injury during surgical procedures around the knee.6
Most surgeons prefer to use a high frequency oscillating saw to make the osteotomy while performing an opening wedge high tibial osteotomy. Once the limb alignment is corrected, the gap is filled with bone graft and stabilized with an implant. While performing the osteotomy, the knee is flexed to 90°, which has been shown to displace the artery away from the operative site.7,8
Following high tibial osteotomy, popliteal artery pseudoaneurysms typically present in the early postoperative period with pain, localized swelling, and vascular or neurological impairment or sometimes both. They have also been reported following other procedures around the knee, sometimes even several months after surgery.9,10 Our patient had an unexpectedly large drain collection in the immediate postoperative period. This was followed by a protracted period of hemorrhagic oozing and repeated episodes of pain and swelling at the operated site. This was considered to be a normal postoperative phenomenon at the time, especially because elevation of the limb and analgesics helped to relieve symptoms. This made it difficult to consider an immediate femoral angiography.
To our knowledge, there are no reports in the literature regarding popliteal artery pseudoaneurysm occurring after a medial opening wedge high tibial osteotomy. It has been reported to occur following a lateral closing wedge high tibial osteotomy.1,2 During surgery, precautions were taken to prevent injury to the posterior vessels, such as keeping the knee flexed during osteotomy and using the saw only two-thirds of the tibia width. Injury caused by the Hohmann retractor is a possibility that cannot dogmatically be ruled out. However, extra precaution was taken in the placement of the retractor and the soft tissues were retracted gently. This leads us to believe that the oscillating saw was the probable cause of the arterial injury. In hindsight, release of the tourniquet prior to closure might have alerted us to the possible injury to the vessel.
Clinically, a popliteal artery aneurysm presents as a severely painful, pulsatile mass in the popliteal fossa, usually with edema and ecchymosis. Femoral arteriogram confirms the diagnosis, and vascular surgical intervention is mandatory. The high incidence of early occlusion when treated by endovascular direct techniques suggests it is a less desirable treatment for these injuries.11,12
Surgeons should take proper precautions while using the oscillating saw for procedures around the knee joint. The knee must always be kept flexed to displace the artery away from the proximal tibia while performing the osteotomy. Care must also be taken while placing retractors for the procedure to prevent injuries during sawing. Release of the tourniquet before wound closure and cauterizing the bleeding vessels is advocated. Early recognition of a popliteal arterial injury is essential in reducing the patient morbidity following these routine procedures in current practice.
- Rubens F, Wellington JL, Bouchard AG. Popliteal artery injury after tibial osteotomy: report of two cases. Can J Surg. 1990; 33(4): 294-297.
- Tandon SC, Kharbanda Y, Fraser AM. Aneurysm complicating high tibial osteotomy. Acta Orthop Scand. 1996; 67(1):73-74.
- Goubier JN, Laporte C, Saillant G. False popliteal aneurysm after tibial osteotomy: a case report. Rev Chir Orthop Reparatrice Appar Mot. 2000; 86(6):621-624.
- Sawant MR, Ireland J. Pseudoaneurysm of the anterior tibial artery complicating high tibial osteotomy: a case report. Knee. 2001; 8(3):247-248.
- Ottolenghi CE. Vascular complications in injuries about the knee joint. Clin Orthop Relat Res. 1982; (165):148-156.
- Tindall AJ, Shetty AA, James KD, Middleton A, Fernando KW. Prevalence and surgical significance of a high-origin anterior tibial artery. J Orthop Surg (Hong Kong). 2006; 14(1):13-16.
- Shetty AA, Tindall AJ, Qureshi F, Divekar M, Fernando KW. The effect of knee flexion on the popliteal artery and its surgical significance. J Bone Joint Surg Br. 2003; 85(2):218-222.
- Zaidi SH, Cobb AG, Bentley G. Danger to the popliteal artery in high tibial osteotomy. J Bone Joint Surg Br. 1995; 77(3):384-386.
- Aldrich D, Anschuetz R, LoPresti C, Fumich M, Pitluk H, OBrien W. Pseudoaneurysm complicating knee arthroscopy. Arthroscopy. 1995; 11(2):229-230.
- Riti MJ, Te Slaa RL, Koning J, Bruijn JD. Popliteal pseudoaneurysm after arthroscopic menisectomy. A report of two cases. Clin Orthop Relat Res. 1993; (295):198-200.
- Tielliu IF, Verhoeven EL, Prins TR, Post WJ, Hulsebos RG, van den Dungen JJ. Treatment of popliteal artery aneurysms with the Hemobahn stent graft. J Endovasc Ther. 2003; 10(1):111-116.
- Tielliu IF, Verhoeven EL, Zeebregts CJ, Prins TR, Span MM, van den Dungen JJ. Endovascular treatment of popliteal artery aneurysms: results of a prospective cohort study. J Vasc Surg. 2005; 41(4):561-567.
Drs Shenoy, Oh, Choi, Yoo, and Nha are from the Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Ilsan, Dr Han is from the Department of Orthopedic Surgery, Korea University, Anam Hospital, Dr Yoon is from the Department of Orthopedic Surgery, Seoul Veterans Hospital, and Dr Koo is from Koo JS Orthopedic Hospital, Seoul, South Korea
Drs Shenoy, Oh, Choi, Yoo, Han, Yoon, Koo, and Nha have no relevant financial relationships to disclose.
Correspondence should be addressed to: Kyung Wook Nha, MD, Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, 2240 Daehwa-dong, Ilsanseo-gu, Koyang-si, Ilsan, South Korea.