Pseudo-aneurysm of the anterior tibial artery complicating high tibial osteotomy--a case report

Surgical strategy and complication management of osteotomy around the painful degenerative varus knee: ESSKA Formal Consensus Part II

PURPOSE

The purpose of the European consensus was to provide recommendations for the treatment of patients with a painful degenerative varus knee using a joint preservation approach. Part II focused on surgery, rehabilitation and complications after tibial or femoral correction osteotomy.

METHODS

Ninety-four orthopaedic surgeons from 24 countries across Europe were involved in the consensus, which focused on osteotomies around the knee. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence of the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released.

RESULTS

The ideal hinge position for medial opening wedge high tibial osteotomy (MOW HTO) should be at the upper level of the proximal tibiofibular joint, and for lateral closing wedge distal femoral osteotomy (LCW DFO) just above the medial femoral condyle. Hinge protection is not mandatory. Biplanar osteotomy cuts provide more stability and quicker bony union for both MOW HTO and LCW DFO and are especially recommended for the latter. Osteotomy gap filling is not mandatory, unless structural augmentation for stability is required. Patient-specific instrumentation should be reserved for complex cases by experienced hands. Early full weight-bearing can be adopted after osteotomy, regardless of the technique. However, extra caution should be exercised in DFO patients. Osteotomy patients should return to sports within 6 months.

CONCLUSION

Clear recommendations for surgical strategy, rehabilitation and complications of knee osteotomies for the painful degenerative varus knee were demonstrated. In Part 2 of the consensus, high levels of agreement were reached by experts throughout Europe, under variable working conditions. Where science is limited, the collated expertise of the collaborators aimed at providing guidance for orthopaedic surgeons developing an interest in the field and highlighting areas for potential future research.

LEVEL OF EVIDENCE

Level II, consensus.

Navigation of femoral and popliteal artery around the knee with CT angiography: implications for surgical interventions

PURPOSE

Uncertainty about the exact position of the femoral and popliteal arteries in the medial thigh and posterior knee might increase vascular complications in surgical procedures. This study aimed to document femoral and popliteal arteries in the medial thigh and around the knee to assist surgeons in developing safer surgical approaches.

METHODS

The study included 120 patients-180 lower limbs-who underwent CT angiography (CTA) of the lower extremity. The distance from the femoral artery to the anterior border, midsagittal axis, and posterior border of the femur and the popliteal artery to the medial, lateral, and midpoint posterior cortex of the proximal tibia was measured in two- and three-dimensional CTA images.

RESULTS

The femoral artery was found to be on average 236.93 ± 29.61 mm, 195.34 ± 26.12 mm, and 146.28 ± 33.18 mm away from the adductor tubercle at the anterior, midsagittal axis, and posterior borders of the femur, correspondingly. The popliteal artery was to be located on average 5.40 ± 2.50 mm posterior to the midpoint of the plateau tibia at the joint line.

CONCLUSION

Considering the mentioned femoral/popliteal artery distances to the femur and proximal tibia would direct surgeons to the safe zones for more accurate surgical approaches in the medial thigh and around the knee when performing osteotomies, knee arthroplasty, arthroscopy, and trauma surgeries, to reduce possible vascular damages.

LEVEL OF EVIDENCE

IV.

Adequate protection rather than knee flexion prevents popliteal vascular injury during high tibial osteotomy: analysis of three-dimensional knee models in relation to knee flexion and osteotomy techniques

PURPOSE

(1) To analyse popliteal artery (PA) movement in a three-dimensional (3D) coordinate system in relation to knee flexion and high tibial osteotomy (HTO) techniques (lateral closed wedge HTO [LCHTO], uniplane medial open wedge HTO [UP-MOHTO], biplane medial open wedge HTO [BP-MOHTO]) and (2) to identify safe zones of the PA in each osteotomy plane.

METHODS

Sixteen knees of patients who underwent magnetic resonance imaging with extension and 90° flexion were used to develop subject-specific 3D knee flexion models. Displacement of the PA during knee flexion was measured along the X- and Y-axis, as was the distance between the posterior tibial cortex and PA parallel to the Y-axis (d-PCA). Frontal plane safety index (FPSI) and maximal axial safe angles (MASA) of osteotomy, which represented safe zones for the osteotomy from the PA injury, were analysed. All measurements were performed along virtual osteotomy planes. Differences among the three osteotomy methods were analysed for each flexion angle using a linear mixed model.

RESULTS

The average increments in d-PCA during knee flexion were 1.3 ± 2.3 mm in LCHTO (n.s.), 1.4 ± 1.2 mm in UP-MOHTO (P < 0.0001), and 1.7 ± 2.0 mm in BP-MOHTO (P = 0.015). The mean FPSIs in knee extension were 37.6 ± 5.9%, 46.4 ± 5.8%, and 45.1 ± 8.1% for LCHTO, UP-MOHTO, and BP-MOHTO, respectively. The mean MASA values in knee extension were 45.8° ± 4.4°, 37.3° ± 6.1°, and 38.9° ± 6.5° for LCHTO, UP-MOHTO, and BP-MOHTO, respectively.

CONCLUSION

Although the PA moved posteriorly during knee flexion, the small (1.7 mm) increment thereof and inconsistent movements in subjects would not be of clinical relevance to PA safety during HTO.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

Pseudoaneurysm Formation due to Popliteal Artery Injury Caused by Drilling during Medial Opening Wedge High Tibial Osteotomy

We report a case of 53-year-old woman with an injured popliteal artery due to excessive drilling with a drill bit during medial opening wedge high tibial osteotomy (MOWHTO). Pseudoaneurysm was diagnosed three days after surgery and confirmed by urgent computed tomography (CT) angiography. Open vascular surgery with resection of the perivascular hematoma and end-to-end anastomosis using ipsilateral saphenous vein interposition graft was performed. CT angiography at 8 months postoperatively showed that blood flow was maintained without obstruction of the graft site and active dorsiflexion of the foot was possible. To reduce neurovascular injury during MOWHTO, it is important not to drill the far cortex at the proximal part of the osteotomy site when using a drill bit, and the metal should be positioned posteromedially as much as possible.

Posterior Tibial Neuropathy Secondary to Pseudoaneurysm of the Proximal Segment of the Anterior Tibial Artery with Delayed Onset

Anterior tibial artery is a nonvital artery which is one of the three arteries of the leg. This artery has a short proximal l segment in the popliteal region and a long segment in the anterior compartment of the leg designated as distal segment. With consideration of the deep location of the proximal segment in the popliteal fossa, it is less susceptible to trauma and subsequent formation of an aneurysm. On the contrary, the superficial long distal segment is more susceptible to trauma with high chance of pseudoaneurysm formation at the site of unrecognized injury. In this article, a 38-year-old military man being manifested about a decade after a trivial missile fragment injury with progressive posterior tibial neuropathy is presented. A giant pseudoaneurysm arising from the proximal segment of the anterior tibial artery was confirmed with angiography and the exact size of this pathology was documented with contrasted computed tomographic scan. The aneurysmal sac removal was accomplished after ligation of the corresponding artery proximal and distal to the sac followed by tibial nerve neurolysis which result in full recovery. In careful review we found that neither pseudoaneurysm arising from the proximal tibial artery nor posterior tibial neuropathy due to the compressive effect of the aneurysmal sac of this segment has been reported previously. Our primary purpose for reporting this case is not to describe the rarity of pseudoaneurysm formation at proximal segment of this artery but rather to describe delayed-onset posterior tibial vascular compressive neuropathy due to such an aneurysm. Eventually due to the potential sequel of a pseudoaneurysm, it is important for the surgeons to have high index of suspicion to prevent a missed or delayed diagnosis.

Pseudoaneurysm of anterior tibial artery following a diaphyseal fracture of the tibia mimicking a malignant bone tumor

Pseudoaneurysms of the lower limb are rare and frequently iatrogenics complications. Closed traumas are likely to generate lesions of the arterial wall, which generally become symptomatic at a later stage. The diagnosis of such vascular lesion is difficult because the symptomatology and the onset can be delayed. We herein report the case of a 15-year-old patient in whom the diagnosis of pseudoaneurysm of the anterior tibial artery was made 5 months after a non-displaced closed fracture of the tibial shaft. The radiographs were evocative of a malignant bone tumor. The study of vessels by a contrast-enhanced CT-scan enabled us to diagnose the pseudoaneurysm. Before the occurrence of late onset swelling, a history of trauma must be sought, even old.

Vascular injuries during closing-wedge high tibial osteotomy: A cadaveric angiographic study

INTRODUCTION

Closing-wedge high tibial osteotomy is a surgical option for patients with isolated medial compartment osteoarthritis and varus knee alignment. Vascular complications are rare, but incriminate the use of oscillating saw or osteotome. It is important to know the steps of this surgery that involve risk of vascular injury and what to do to decrease that risk.

HYPOTHESIS

Performing the distal osteotomy cut using an oscillating saw is a step with high risk of vascular injury. A protective device behind the tibia may decrease this risk.

MATERIALS AND METHODS

In this descriptive angiographic cadaver study, closing-wedge high tibial osteotomy was performed on 6 cadaveric knees in 90° knee flexion, and the distance between the surgical instrument and the popliteal artery was measured on fluoroscopy with artery opacification at the various steps of surgery.

RESULTS

Tibial osteotomy with oscillating saw involves high vascular risk: the mean distance between the saw-blade and the popliteal artery is 10.6mm in 90° knee flexion. Using a specific device placed behind the tibia protects the vascular structures.

DISCUSSION

High tibial osteotomy is indicated in medial compartment osteoarthritis of the knee and can be performed by closing or opening-wedge. Vascular injuries in closing-wedge osteotomy exist and it is recommended to perform this surgery at 90° knee flexion, although some studies report that this does not move the artery out of the way. A risk of vascular lesion should be kept in mind. The oscillation of the saw and the direction of the osteotomy should also be taken into consideration when performing a closing-wedge high tibial osteotomy in order to protect the popliteal artery.

STUDY DESIGN

Descriptive cadaver study. Level IV.

Complete rupture of the popliteal artery complicating high tibial osteotomy

We present two cases of high tibial osteotomies performed at our institution. Both cases were complicated with the immediate postoperative occurrence of an ischaemic syndrome of the lower leg. Urgent diagnostics revealed a complete rupture of the popliteal artery that required re-operation and a vascular repair. Although neurovascular complications during high tibial osteotomies are rare the awareness of this potentially catastrophic complication should be present when performing this common procedure. All precautions to minimize the harm to the neurovascular bundle should be put into practice. A summary of the surgical precautions is presented and discussed in this paper.

Early complications of medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation

Despite several advantages of medial opening wedge high tibial osteotomy, this procedure has been noted to have a high rate of complications especially with the use of a spacer plate for fixation. We retrospectively evaluated the early complications of 138 medial opening wedge high tibial osteotomies done using autologous tricortical iliac bone graft and T-plate fixation(AO locking compression T-plate, Ti/3H 4.5-5.0 mm, Synthes, Switzerland, Model No. 440.131 in 30 and low-profile locking T-plate and low-profile locking T-plate in 128 patients. At a mean follow-up of 36.8 months (13 to 78), 26 knees (18.8%) developed complications. Complications varied from osteotomy site infection, loss of correction, broken screws and lateral tibial plateau fracture to joint fluid leakage, pseudoaneurysm and iliac bone fractures. Using the "safe zone" technique and penetrating the lateral cortex with Steinmann pins may help to avoid complications such as loss of correction and lateral tibial plateau fractures. The results of this study indicate that medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation may be a technically demanding procedure associated with a moderate rate of complications. However, these complications could be minimized with proper planning, adequate intra-operative precautions and few modifications to avoid technical error.

Pseudoaneurysm of the medial inferior genicular artery after anterior cruciate ligament reconstruction

We present a case of pseudoaneurysm formation of the medial inferior genicular artery after anterior cruciate ligament reconstruction. The patient presented with repeated knee hemarthrosis. He was diagnosed by means of magnetic resonance angiography and was treated by means of transluminal embolization. The patient's normal was normal after resolution of the vascular pathologic condition.

Vascular safety during high tibial osteotomy: a cadaveric angiographic study

BACKGROUND

High tibial osteotomy is technically demanding. Risks include injury to the popliteal neurovascular bundle. The present goal was to further define this risk.

HYPOTHESIS

The distance from the posterior tibia to the popliteal artery increases with increasing knee flexion. A saw angle perpendicular to the coronal plane can injure the popliteal artery.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Seven fresh-frozen cadaveric lower extremities were used. Lateral radiographs at knee flexion angles of 90 degrees , 60 degrees , 45 degrees , 30 degrees , and 0 degrees were taken to measure the distance from the anterior border of the popliteal artery to the posterior cortex of the tibia 5.0 mm and 2.0 cm below the joint line. After an opening wedge high tibial osteotomy was made, qualitative assessments were made of the depth of a saw blade inserted into the kerf and the relative encroachment of the saw blade on the popliteal artery. The interval through which the space anterior to the popliteus can be accessed was identified by gross dissection in all specimens.

RESULTS

The distance from the posterior tibia to the popliteal artery increased with knee flexion. At 5.0 mm and 2.0 cm below the joint line, the mean distance at 90 degrees was significantly greater than at all other angles. The popliteal artery could be injured by the oscillating saw at angles greater than 30 degrees to the coronal plane. A protective device inserted anterior to the popliteus protects the neurovascular structures.

CONCLUSION

The popliteal artery is farthest from the posterior tibia at 90 degrees of knee flexion. Saw angles greater than 30 degrees from the coronal plane put the popliteal neurovasculature at risk of injury.

CLINICAL RELEVANCE

To perform a safe osteotomy, the knee should be positioned in 90 degrees of flexion with the saw angled less than 30 degrees from the coronal plane. A protective device deep to the popliteus may protect against popliteal injury.

False aneurysm at the origin of the anterior tibial artery after opening wedge osteotomy

We report the case of a false aneurysm at the origin of the anterior tibial artery complicating upper tibial osteotomy. The proximally located lesion compressed the posterior tibial nerve, and despite successful decompression, the patient suffers from probably irreversible neurologic after-effects. Even though it is rare, this complication must be considered when faced with leg pain consecutive to upper tibial osteotomy without deep venous thrombosis.

Complications of closing wedge high tibial osteotomy

Closing wedge high tibial osteotomy is a common, effective and well-established procedure to treat unicompartment osteoarthrosis of the knee. It is, however, not without its complications. This article will discuss some of these complications and present an overview of the current literature. It will examine current thoughts on aetiology, techniques to try to avoid, and methods of treatment of these complications.

Pseudoaneurysm of the popliteal artery complicating medial opening wedge high tibial osteotomy

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.

Osteotomy for the Early Varus Arthritic Knee

High tibial osteotomy is a well-established procedure for the management of medial compartment arthritis that is currently experiencing a resurgence in popularity. A number of techniques have been described, with the ultimate goal of obtaining appropriate alignment to provide pain relief and functional improvement over a long-term period. Appropriate patient selection and careful surgical technique is necessary to achieve these goals with a minimal risk of complication. Newer technology such as computer navigation promises to improve the overall accuracy of the procedure. The need for alignment correction in combination with ligament reconstruction and chondral resurfacing surgery will increase the indications for this procedure. This article discusses the techniques available for high tibial osteotomy, the results and relative advantages of each, and the appropriate surgical technique to achieve optimal results while minimizing complications.