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

Surgical Techniques for the Treatment of Vascular Injury in Total Knee Arthroplasty

Total knee arthroplasty is done in the supine position with or without the use a nonsterile or sterile tourniquet. Once the vascular injury occurs and direct pressure is applied, an additional medial distal femoral incision can be done (Figure 13), followed by a medial subvastus approach. A Cobra retractor can be positioned to expose the distal medial femur (Figure 14). Careful but rapid dissection of the medial septum needs to be done to access and expose the proximal popliteal artery (Figures 15 and 16). Once the posterior compartment is accessed, direct pressure can be applied to the popliteal vessels. Once the patient is hemodynamically stable and in the presence of the vascular team, further dissection can be done to attain proximal control of the vasculature. Additional vascular reconstruction with a femoropopliteal bypass can be done in the supine position to restore perfusion distally in the affected extremity.

Figure 13.

Figure demonstrating the location of the second incision that should be created to find the proximal popliteal artery.

Figure 14.

Figure demonstrating the careful placement of a Cobra retractor that allows for easy visualization of the proximal popliteal artery.

Figure 15.

Once the proximal popliteal artery has been identified, a vessel loop can be passed to gain proximal control.

Figure 16.

Illustration demonstrating passing a vessel loop to gain proximal control of the popliteal artery. The Hohmann retractor is placed under the vastus medialis to retract the quadriceps muscle.

As previously stated, most vascular injuries in total knee arthroplasty are indirect and are frequently not noticed until postoperatively. A pulse check should be done once the surgical drapes are removed and again in the recovery room. If a difference is noted from the preoperative vascular examination, dressings should be removed and a doppler should be used to identify a pulse. If a distal pulse cannot be identified, a vascular surgery consult should be immediately obtained. If this occurs at a surgery center and vascular surgery is not readily available, we recommend emergent transfer to a higher care center where vascular surgery is present.