Combined arteriovenous fistula and venous aneurysm following knee arthrodesis

We study a case of a 65-year-old woman who developed popliteal arteriovenous fistula (AVF) and venous aneurysm following left knee arthrodesis. Presenting features included left popliteal and calf pain, a tender pulsatile mass posterior to her left knee, popliteal bruit and a thrill at the popliteal fossa and ankle. Left femoral angiography showed an AVF arising from the right tibioperoneal trunk and an aneurysm at the level of the AVF. Findings at open investigation included AVF between the tibioperoneal trunk and the popliteal vein, and a venous aneurysm arising from the popliteal vein opposite the neck of the arteriovenous communication. The aneurysm and fistula were repaired using prolene suture.     

Popliteal Arteriovenous Fistula Following Total Knee Arthroplasty

Postoperative popliteal arteriovenous fistula is a very rare complication. We report a unique asymptomatic fistula in a 77-year-old male patient, seven months after total knee replacement. The diagnosis was suspected by a clinical palpable thrill and confirmed with a typical doppler ultrasound signaling. This vascular malformation was successfully treated by surgical resection of the fistula. Referring to the literature, considering the management of popliteal aneurysms, we suggest to prefer an open procedure in patients who are in good general condition.     

Pseudoaneurysm after revision total knee arthroplasty

Arterial vascular complications following knee replacement are uncommon with reported incidence ranging from 0.03 to 0.12%. The complication rate is rising with increased number of primary and revision total knee replacements. Vascular complications following TKR can result in arterial thrombosis, AV fistula, haemorrhage, pseudoaneurysm and arterial transection. They are associated with significant morbidity and can be limb-threatening. Early recognition and management of vascular injury is essential although some times its presentation may be delayed. We report a case of pseudoaneurysm arising from inferior lateral genicular branch of the anterior tibial artery after revision right total knee replacement.     

Popliteal pseudoaneurysm and arteriovenous fistula after arthroscopic anterior and posterior cruciate ligament reconstruction: A case report

IntroductionVascular injuries are a well recognised but very rare complication of surgery or trauma around the knee, especially associated with arthroscopic anterior and posterior cruciate ligament reconstruction.Presentation of caseThis report describes a case of a Popliteal pseudoaneurysm and arteriovenous fistula after Arthroscopic anterior and Posterior Cruciate Ligament Reconstruction. An 57-year-old male who complained of pain and swelling around the left lower extremity after the ACL and PCL reconstruction using a semitendinosus graft from the two limbs caused by bicycle accident. He was diagnosed with the popliteal pseudoaneurysm and arteriovenous fistula by the Doppler ultrasonographic examination and CTA, and transferred to the interventional radiology suite where a successful vascular stent implantation was made. There was no postoperative complication.DiscussionThe most important finding of the present case were a popliteal pseudoaneurysm and arteriovenous fistula after the ACL and PCL reconstruction. To our knowledge, very few cases reporting an arteriovenous fistula with popliteal pseudoaneurysm following arthroscopy have been described. Vascular injury is a very rare complication of knee surgery, but surgeons should always consider this possibility in patients who have undergone knee arthroscopy. If the patient has symptoms of pain in the popliteal area and unexplainable swelling following arthroscopic ACL and PCL reconstruction, a popliteal vascular injury should be suspected.ConclusionsIn order to minimize the risk of vascular complications in ACL and PCL reconstructive surgery, we advise to look for less traumatizing instruments and to limit the amount of riskful actions, precise attention should be paid in the establishment of the tibial tunnels.     

Acute arterial thrombosis after bilateral total knee arthroplasty

Arterial thrombosis is a rare complication of total knee arthroplasty (TKA). The overall incidence of arterial complications after TKA, including arterial occlusion, arteriovenous fistula, arterial aneurysm, and arterial severance, varies between 0.03% and 0.17% in reports published in the orthopedic literature (J Vasc Surg 1994;20:927-932). We report a case of acute popliteal artery thrombosis and its sequelae immediately following bilateral TKA performed sequentially under the same anesthesia. This is the first reported case of a post-TKA popliteal artery thrombosis in a patient younger than 60 years without the commonly accepted risk factors.     

An evidence-based review of enhanced recovery interventions in knee replacement surgery

IntroductionTotal knee replacement (TKR) is a very common surgical procedure. Improved pain management techniques, surgical practices and the introduction of novel interventions have enhanced the patient’s postoperative experience after TKR. Safe, efficient pathways are needed to address the increasing need for knee arthroplasty in the UK. Enhanced recovery programmes can help to reduce hospital stays following knee replacements while maintaining patient safety and satisfaction. This review outlines common evidence-based pre, intra and postoperative interventions in use in enhanced recovery protocols following TKR.MethodsA thorough literature search of the electronic healthcare databases (MEDLINE^®, Embase™ and the Cochrane Library) was conducted to identify articles and studies concerned with enhanced recovery and fast track pathways for TKR.ResultsA literature review revealed several non-operative and operative interventions that are effective in enhanced recovery following TKR including preoperative patient education, pre-emptive and local infiltration analgesia, preoperative nutrition, neuromuscular electrical stimulation, pulsed electromagnetic fields, perioperative rehabilitation, modern wound dressings, different standard surgical techniques, minimally invasive surgery and computer assisted surgery.ConclusionsEnhanced recovery programmes require a multidisciplinary team of dedicated professionals, principally involving preoperative education, multimodal pain control and accelerated rehabilitation; this will be boosted if combined with minimally invasive surgery. The current economic climate and restricted healthcare budget further necessitate brief hospitalisation while minimising costs. These non-operative interventions are the way forward to achieve such requirements.     

Intra-arterial injection therapy with ethanol for a patient with renal arteriovenous fistula

A case of renal arteriovenous fistula (A-V fistula) treated by transcatheter embolization using absolute ethanol is reported. The catheter was superselectively placed in the proximal renal artery supplying cirsoid vessels and 15 ml of absolute ethanol was injected into the renal artery at a rate of 1 ml per second. Ten minutes after injection, complete occlusion of the fistula was confirmed. The postembolization syndrome was mild, particularly back pain and fever were mitigated. Repeat arteriogram after 3 months demonstrated persistent occlusion of the fistula. From this experience and a review of the literature, we postulate that the advantages of therapeutic embolization with ethanol for A-V fistula compared with other embolization techniques are the following: (1) persistence of arterial occlusion extending to the peripheral vessels, (2) less frequent possibility of recanalization and collateral formation, (3) less systemic toxicity even if ethanol has escaped into the systemic circulation through A-V fistula, and (4) no danger of accidental embolization of other arteries. Herein, we also review briefly the literature concerning both mechanism and feature of action of ethanol injected into the artery.     

“The Disappearing Patella”: an unusual sequel following total knee replacement

Patello femoral complications have been described following total knee replacement (TKR) surgery. Majority of the reports are on the position and the biomechanics across the patello femoral joint. An unusual finding which shows the patella to be gradually disappearing following a TKR has not been reported. We report this finding in a 74-year-old lady who underwent a right total knee replacement (TKR) 5 years ago. Check radio graphs taken at 2 years showed osteolysis and on follow up at 5 years the right patella has become very thin and appears to be disappearing. The right patella measured 17 mm (anterior posterior thickness) at time of surgery and now measures 4 mm. There is osteolysis adjacent to the tibial and femoral components. However, there are no features of infection and there is no history of trauma. The patient continues to be asymptomatic and mobilises with a normal pain free gait. This interesting and unusual sequel is being reported for its rarity. A similar finding following a TKR has not been cited in literature.     

Popliteal aneurysm after total knee arthroplasty: Case reports and review of the literature

Vascular complications after total knee arthroplasty include arterial occlusion, arterial severance, arteriovenous fistula, and arterial aneurysm. Both a false aneurysm and a true aneurysm of the popliteal artery are described. The false popliteal aneurysm resulted from direct surgical trauma and required excision and repair. The true popliteal aneurysm was unsuccessfully treated with excision, transfemoral thrombectomy, and bypass surgery. Many of the vascular complications after total knee arthroplasty may be preventable and the following prudent guidelines are suggested. Careful preoperative evaluation is critical, including past medical history, palpation of pedal pulses, and review of radiographs to identify abnormal calcification in the vessels. Vascular consultation may be necessary. Should a vascular complication occur, immediate intervention with the advice and assistance of a vascular surgeon is imperative.     

Endovascular stent graft repair of iatrogenic popliteal artery injuries--a report of 2 cases

Popliteal artery injury during total knee replacement (TKR) is rare. We report 2 cases of post-TKR popliteal artery occlusions treated endovascularly with Viabahn stent grafts. Long-term duplex follow-up and secondary re-intervention may be necessary.     

Arterio-venous popliteal fistula: a rare late complication of a civilian trauma. A clinical case and review of the literature

In spite of the relatively high frequency of popliteal injuries following war and civilian traumas, a late development of an arteriovenous fistula can be considered an uncommon complication. We report a case of a chronic arterio-venous popliteal fistula in a young boy, caused five years previously by a blunt trauma, while playing. The tardive onset of symptomatology and the conspicuous enlargement of the vein underline the unusuality of the case. A review of the literature and the technique for fistula repair, using adsorbable suture, are examined.     

Popliteal arteriovenous fistula after corrective upper tibial osteotomy

Summary Injuries to the popliteal artery or vein are rare complications of knee arthroscopy or osteosynthesis at the distal femur or the proximal tibia. We report a case of iatrogenic arteriovenous fistula after proximal tibial osteotomy for varus deformity. A 71-year-old woman complained of pain and swelling of the foot 9 weeks after a corrective barrel-vault osteotomy of the left tibia. Angiography demonstrated an arteriovenous fistula between the popliteal vessels due to osteotomy of the tibial head. The fistula was separated and popliteal vessels closed by continuous suture and a small saphenous vein patch.     

Concept of arteriovenous loupes in high-risk free-tissue transfer: history and clinical experiences

The present study describes the concepts of arteriovenous (A-V) loupes prior to microsurgical free flap transfer in a selected high-risk group of patients. A one-stage concept was employed in 26 patients; 5 patients underwent two-stage flap transfer. Seven thrombotic occlusions of the A-V fistula or flap vessels were recorded; 6 patients underwent successful revision. Overall flap survival was 96.8% and compared favorably to reports in the literature. Defect coverage could be achieved in all but one case. It can be concluded from the data that in selected high-risk patient groups, i.e., following radiation, compound trauma, chronic infection, or multiple comorbidities, the creation of an A-V fistula prior to flap transfer may facilitate innovative reconstructive solutions.     

Minimally invasive total knee replacement: techniques and results

In this review, we outlined the definition of minimally invasive surgery (MIS) in total knee replacement (TKR) and described the different surgical approaches reported in the literature. Afterwards, we went through the most recent studies assessing MIS TKR. Next, we searched for potential limitations of MIS knee replacement and tried to answer the following questions: Are there selective criteria and specific patient selection for MIS knee surgery? If there are, then what are they? After all, a discussion and conclusion completed this article. There is certainly room for MIS or at least less invasive surgery for appropriate selected patients. Nonetheless, there are differences between approaches. Mini-medial parapatellar is easy to master, quick to perform and potentially extendable, whereas mini-subvastus and mini-midvastus are trickier and require more caution related to risk of haematoma and vastus medialis oblique (VMO) nerve damage. Current evidence on the safety and efficacy of mini-incision surgery for TKR does not appear fully adequate for the procedure to be used without special arrangements for consent and for audit or continuing research. There is an argument that a sudden jump from standard TKR to MIS TKR, especially without computer assistance such as navigation, patient-specific instrumentation or robotic, may breach a surgeon’s duty of care towards patients because it exposes patients to unnecessary risks. As a final point, more evidence is required on the long-term safety and efficacy of this procedure which will give objective shed light on real benefits of MIS TKR.     

An unusual presentation of a popliteal arteriovenous fistula after primary total knee arthroplasty

Iatrogenic popliteal arteriovenous fistula after total knee arthroplasty is extremely rare (Int Surg. 1998 Jul-Sep;83(3):198-201). We report this complication in a 78-year-old female patient 3 years after total knee arthroplasty. She presented with symptoms of persistent swelling and recurrent cellulitis of the operated leg. A fistula was detected between the popliteal artery and vein by vascular duplex scan and confirmed by peripheral arteriography. This was successfully treated by resection of the fistula and direct repair of the artery and vein.     

Motor-sparing nerve blocks for total knee replacement: A scoping review

Study objectiveThis scoping review investigates the optimal combination of motor-sparing analgesic interventions for patients undergoing total knee replacement (TKR).DesignScoping review.InterventionMEDLINE, EMBASE and CINAHL databases were searched (inception-last week of May 2020). Only trials including motor-sparing interventions were included. Randomized controlled trials lacking prospective registration and blinded assessment were excluded.Main resultsThe cumulative evidence suggests that femoral triangle blocks outperform placebo and periarticular infiltration. When combined with the latter, femoral triangle blocks are associated with improved pain control, higher patient satisfaction and decreased opioid consumption. Continuous femoral triangle blocks provide superior postoperative analgesia compared with their single-injection counterparts. However, these benefits seem less pronounced when perineural adjuvants are used. Combined femoral triangle-obturator blocks result in improved analgesia and swifter discharge compared with femoral triangle blocks alone.ConclusionsThe optimal analgesic strategy for TKR may include a combination of different analgesic modalities (periarticular infiltration, femoral triangle blocks, obturator nerve block). Future trials are required to investigate the incremental benefits provided by local anesthetic infiltration between the popliteal artery and the capsule of the knee (IPACK), popliteal plexus block and genicular nerve block.     

Are current thrombo-embolic prophylaxis guidelines applicable to unicompartmental knee replacement?

Symptomatic and asymptomatic deep-vein thrombosis (DVT) is a common complication of knee replacement, with an incidence of up to 85% in the absence of prophylaxis. National guidelines for thromboprophylaxis in knee replacement are derived from total knee replacement (TKR) data. No guidelines exist specific to unicompartmental knee replacement (UKR). We investigated whether the type of knee arthroplasty (TKR or UKR) was related to the incidence of DVT and discuss the applicability of existing national guidelines for prophylaxis following UKR. Data were collected prospectively on 3449 knee replacements, including procedure type, tourniquet time, surgeon, patient age, use of drains and gender. These variables were related to the incidence of symptomatic DVT. The overall DVT rate was 1.6%. The only variable that had an association with DVT was operation type, with TKR having a higher incidence than UKR (2.2% versus 0.3%, p < 0.001). These data show that the incidence of DVT after UKR is both clinically and statistically significantly lower than that after TKR. TKR and UKR patients have different risk profiles for symptomatic DVT. The risk-benefit ratio for TKR that has been used to produce national guidelines may not be applicable to UKR. Further research is required to establish the most appropriate form of prophylaxis for?UKR.     

A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement

Patients who undergo total knee replacement (TKR) are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative. We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group. We conclude that the neither method provides superior prophylaxis.     

Peroneal arteriovenous fistula. A complication of Fogarty catheter thromboembolectomy

The Fogarty catheter is an important device used by vascular surgeons to simplify the surgical treatment of thromboembolic disorders. Complications from use of the catheter are rare. This case report is about a patient who developed a peroneal arteriovenous fistula following popliteal thromboembolectomy. The literature regarding this unusual injury is reviewed.     

A brief report on managing infected nonunion of a high tibial osteotomy in two stages: a case series involving seven knees

The management of nonunion following high tibial osteotomy by total knee replacement (TKR) has been reported previously. We have extended the treatment to embrace cases with an infected high tibial osteotomy by performing an initial debridement with a period of antibiotic treatment followed by TKR. We have reviewed the results of seven knees in six patients with a mean follow-up of 40.5 months (20 to 57) after the staged TKR. At the latest follow-up, all the pseudarthroses had healed and there had been no recurrence of infection. The mean Hospital for Special Surgery knee score improved from 51.2 (35 to 73) to a mean of 91.7 (84 to 98) at final review. Management of nonunion following high tibial osteotomy with a TKR can be extended to infected cases when treated in two stages with a debridement and antibiotic therapy prior to TKR.