Acute Surgical Management of Vascular Injuries in Hip and Knee Arthroplasties

Christopher M. Melnic, MD; Marilyn Heng, MD, MPH, FRCSC; Santiago A. Lozano-Calderon, MD, PhD


J Am Acad Orthop Surg. 2020;28(21):874-883. 

In This Article

Vascular Anatomy About the Knee

The superficial femoral artery and vein exit the adductor hiatus (Hunter canal) between the oblique and medial heads of adductor magnus and pass posterior to the knee capsule to become the popliteal artery and vein (Figure 4). A vascular injury can occur at this level because of either an errant saw blade or placement of a retractor (Figures 5–7). At the level of the adductor hiatus, the branch of the descending geniculate artery has taken off medially. From the popliteal artery branches, the superior and inferior medial geniculate arteries and the superior and inferior lateral geniculate arteries form an anastomosis around the knee. The middle geniculate artery branches off from the popliteal posteriorly to supply the knee cruciate ligaments and synovium (Figures 8 and 9).

Figure 4.

Figure demonstrating the illustration of the anatomic location of the proximal popliteal artery.

Figure 5.

Figure demonstrating the errant tibial cut and potential laceration of the proximal popliteal artery.

Figure 6.

Figure demonstrating the errant posterior retractor placement and potential injury to the proximal popliteal artery.

Figure 7.

Illustration highlighting the proximity of the popliteal artery to the posterior tibia with an "X" demonstrating the potential site of injury by a retractor that is not placed directly on the posterior tibia.

Figure 8.

Figure demonstrating the coronal depiction of the vascular anatomy around the knee.

Figure 9.

Figure demonstrating the axial illustration of the vascular anatomy around the knee.

The popliteal artery trifurcates into the anterior tibial artery (AT), posterior tibial artery (PT), and peroneal artery (PR). In the majority of people, the level of the trifurcation of the popliteal artery is located below the level of the knee joint, on average 6 cm inferior to the medial tibial plateau surface.[17] The most common anatomical variation of the trifurcation is type II-A, where the popliteal artery branches into the AT and PT below the level of the knee, and then the PT further branches into PT and PR.[17,18] This configuration exists in approximately 90% of patients. Instances in which the trifurcation occurs at the level of the knee joint (type II variants) occur with a prevalence of 4%.[19]