Original Research

Geniculate Artery Injury During Primary Total Knee Arthroplasty

Publish date: October 29, 2018

References

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Major arterial injury associated with total knee arthroplasty (TKA) is a rare and potentially devastating complication. The majority of literature in this context consists of case reports, small case series, and large retrospective studies that have examined the type, location, and mechanism of injury present in these cases.^1-13 Reported arterial injuries include occlusion, laceration, aneurysm, pseudoaneurysm, and arteriovenous fistula formation in the femoral (believed to be due to the tourniquet around the proximal thigh) and popliteal arteries causing combinations of ischemia and hemorrhage necessitating treatment ranging from endovascular arterial intervention to amputation.^{4,5,9-11,13-17} In addition, several studies have asserted that the risk of major arterial injury may be increased with tourniquet use, suggesting that tourniquet use should be minimized for routine primary TKAs.^3,6

There are very few cases in the literature specifically addressing injury to the more commonly encountered geniculate arteries (GAs). The medial GAs are typically visualized and coagulated during the standard medial parapatellar approach. In addition, if performed, a lateral release can damage the lateral superior and inferior GAs and the middle GA can be cut with posterior cruciate ligament resection. However, the middle and lateral inferior GAs are anecdotally the most difficult to detect and treat intraoperatively, especially after implantation of TKA and deflation of the tourniquet. The potential lack of recognition of such GA injury can result in harmful sequelae, including ischemia of the patella, hemorrhage, and painful pseudoaneurysms.^2,18-29 Currently, there are only 2 case reports of lateral inferior GA injury, 2 cases of medial inferior GA injury, and no reports of middle GA injury.^2,23,24,29

The rate, the timing within surgery, the risk factors, including tourniquet use, and the clinical effects of GA injury are largely unknown. If these factors were better understood, prophylactic measures and/or awareness could be better applied to prevent adverse outcomes, especially in cases of the middle and lateral inferior GAs. The aims of this study are to elucidate the rate and timing of middle and lateral inferior GA injury during primary TKA; determine the factors related to injury, including intraoperative blood loss, postoperative drain output, and tranexamic (TXA) acid use; and investigate any differences in the rate of injury with and without the use of a tourniquet.

MATERIALS AND METHODS

PATIENT DEMOGRAPHICS AND SURGICAL TECHNIQUE

From November 2015 to February 2016, 3 surgeons (MJT, TMM, and RTT) at a single institution performed 100 consecutive unilateral primary TKAs and documented the presence or absence and the timing of GA injury. After obtaining approval from our Institutional Review Board, a retrospective study was performed to investigate the prospectively recorded rate of middle and lateral inferior GA injuries occurring during primary TKAs. Patients with a diagnosis of isolated osteoarthritis were included, and those with any previous surgery on the operative knee were excluded. The average age of patients at the time of surgery was 67 years (range, 25-91 years), the average body mass index was 33 kg/m² (range, 18-54 kg/m²), and there were 63 (63%) female patients.

All TKAs were performed through a medial parapatellar approach with a posterior-stabilized, cemented design, and each patient received a postoperative surgical drain. One of the 3 lead surgeons (TMM) in this study used a tourniquet from the time of incision until the completion of cementation, and the other 2 (MJT and RTT) predominantly used the tourniquet only during cementation. To elucidate any differences in GA injury between these 2 methods of tourniquet use, the patients were categorized into 2 groups base d on tourniquet use. Group 1 included patients in whom a tourniquet was used to maintain a bloodless surgical field from the time of incision until the completion of cementation, and Group 2 included patients in whom tourniquet use was more selective (ie, applied only during cementation). Group 1 comprised 31% (31/100) of patients, while Group 2 comprised 67% (67/100) of patients; no tourniquet was used in 2% (2/100) of cases. In addition, TXA was used in 98% (98/100) of patients: 84 patients received intravenous (IV) and 14 received topical TXA administration.

Continue to: ANALYSIS OF GENICULATE ARTERY INJURY