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.     

Cyclops syndrome occurring after partial rupture of the anterior cruciate ligament not treated by surgical reconstruction.

Cyclops syndrome is one of the specific causes of loss of extension of the knee following anterior cruciate ligament (ACL) reconstruction. The syndrome is manifested by progressive loss of extension associated with pain and audible clunk at terminal extension caused by a pedunculated nodule of fibrovascular proliferative tissue usually arising from the graft. The entity has been described recently and has been reported exclusively as a complication of ACL reconstructions. We report the case of a patient with symptoms and arthroscopic and histological findings compatible with cyclops syndrome that developed after a partial ACL rupture that was not treated by surgical reconstruction. A different etiology and classical histological and immunohistological microscopic analysis of the nodule presented in this report may further clarify the pathogenesis of the cyclops syndrome.     

Injury to the Anterior Tibial Artery during Bicortical Tibial Drilling in Anterior Cruciate Ligament Reconstruction

Many complications have been reported during or after anterior cruciate ligament (ACL) reconstruction, including infection, bleeding, tibial tunnel widening, arthrofibrosis, and graft failure. However, arterial injury has been rarely reported. This paper reports a case of an anterior tibial arterial injury during bicortical tibial drilling in arthroscopic ACL reconstruction, associated with an asymptomatic occlusion of the popliteal artery. The patient had a vague pain which led to delayed diagnosis of compartment syndrome and delayed treatment with fasciotomy. All surgeons should be aware of these rare but critical complications because the results may be disastrous like muscle necrosis as in this case.     

Pulmonary embolism masqueraded as severe bronchospasm following coronary artery bypass surgery

Late cardiac tamponade following coronary artery bypass surgery is an uncommon complication. It is associated with subtle signs and symptoms within days or weeks after cardiac surgery. Late cardiac tamponade usually presents with atypical clinical, haemodynamic, or echocardiographic manifestations. Combined Pulmonary Embolism (PE) and late cardiac tamponade occurring in a patient, is an extremely rare complication following coronary artery bypass surgery. In patients following cardiac surgery who experience repeated severe bronchospasm which does not respond to conventional modes of treatment, it would be prudent to rule out PE as a cause and manage accordingly. One should be vigilant and high index of suspicion is needed to diagnose and intervene early for better outcome.     

Editorial Commentary: Anatomic or Not,the Tunnel Will Get Wider!

In our experience, arthroscopic tunnel widening is one of the major complications after anterior cruciate ligament (ACL) reconstruction. Even though this complication doesn’t require an acute correction or intervention, patients with failed ACL reconstruction along with tunnel widening may need a 2-stage revision in which we have to fill the gap in the tunnels first. Otherwise, this tunnel widening after ACL reconstruction doesn’t affect the clinical outcomes of the primary surgery and it won’t affect the success of the surgery in the aspects of clinical and functional outcomes.     

Anterior Tibial Artery Pseudoaneurysm in a Patient with Hemophilia: A Complication of Ankle Arthroscopy

Arterial pseudoaneurysm formation as a complication of ankle arthroscopy is extremely rare. We present a case of anterior tibial artery pseudoaneurysm identified 10 days after ankle arthroscopy in a patient with hemophilia. The diagnosis was confirmed with a duplex ultrasound scan. The patient was referred to the vascular surgeon and underwent evacuation of the hematoma, resection of the damaged segment of the artery, and reconstruction with a reversed long saphenous vein interposition graft. The patient had an uneventful recovery after the second surgery. The prevention of this complication in patients with hemophilia is discussed, as well as diagnosis and management. Preventative measures include careful dissection while making the portals, preoperative mapping of the artery with a duplex or a handheld Doppler in patients with coagulopathy, and performance of open rather than arthroscopic surgery to excise large osteophytes.     

Heterotopic bone formation following anterior cruciate ligament reconstruction with BPTB autograft

In this study, we present a 36-year-old male patient who developed heterotopic ossification after anterior cruciate ligament (ACL) reconstruction performed using bone-patellar tendon-bone autograft harvested from the 1/3 middle part of the patellar tendon. This ossified part, which restricted range of motion of the affected knee, was excised surgically 1 year after diagnosis. Physical examination, conducted 36 months later, revealed the achievement of full range of motion without any complaints or recurrences. Heterotopic ossification following ACL reconstruction is a very rare complication, which should be removed with open surgery.     

Arterial complications,venous thromboembolism and deep venous thrombosis prophylaxis after anterior cruciate ligament reconstruction: A systematic review

AIM To summarize the current knowledge on vascular complications and deep venous thrombosis(DVT) prophylaxis after anterior cruciate ligament(ACL) reconstruction.METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. MEDLINE, EMBASE, Cochrane,Web of Science, CINAHL, PubMed publisher, and Google scholar medical literature databases were searched up to November 10, 2015. Any arthroscopic surgical method of primary or revision intra-articular ACL reconstruction of all graft types in humans was included. A risk of bias assessment was determined.RESULTS Fourty-seven studies were included in the review.Pseudaneurysms were the most frequently reported arterial complication after ACL reconstruction, irrespective of graft type or method of graft fixation with an incidence of 0.3%. The time to diagnosis of arterial complications after ACL reconstruction varied from days to mostly weeks but even years. After ACL reconstruction without thromboprophylaxis, the incidence of DVT was 9.7%, of which 2.1% was symptomatic. The incidence of pulmonary embolism was 0.1%. Tourniquet time 2 h was related to venous thromboembolism.Thromboprophylaxis is indicated in patients with risk factors for venous thromboembolism.CONCLUSION After ACL reconstruction, the incidence of arterial complications,symptomatic DVT and pulmonary embolism was 0.3%, 2.1% and 0.1% respectively. Arterial complications may occur with all types of arthroscopic ACL reconstruction, methods of graft fixation as well as any type of graft. Patients considered to be at moderate or high risk of venous thromboembolism should routinely receive thromboprophylaxis after ACL reconstruction.     

Accumulation of irrigation fluid in the calf as a complication during high tibial osteotomy combined with simultaneous arthroscopic anterior cruciate ligament reconstruction.

Extravasation of irrigation fluid during arthroscopy is a well-known complication. We report a case of accumulation of fluid into the calf during open wedge high tibial osteotomy combined with simultaneous arthroscopic anterior cruciate ligament (ACL) reconstruction. The main cause for fluid extravasation was the drilling of the tibial tunnel, which allowed the fluid to cross the osteotomy gap and invade the flexor compartments. Although an elevation of the intracompartmental pressure was measured, there was no clinical evidence of compartment syndrome. A subcutaneous release of the flexor compartment of the leg was performed. The patient suffered no further sequelae. High tibial osteotomy combined with simultaneous arthroscopic ACL reconstruction has to be performed carefully, and potential complications must be detected immediately to prevent compartment syndrome.     

Mucoid Degeneration of Both ACL and PCL

Unlike meniscal tears and chondral defects, the mucoid degeneration of the anterior cruciate ligament (ACL) is a rare cause of knee pain and there have been no case reports of mucoid degeneration of both the ACL and the posterior cruciate ligament (PCL). A 48-year-old-male patient presented with knee pain and limitation of motion. The patient''s magnetic resonance imaging, arthroscopic findings, and pathologic diagnosis confirmed a clinical diagnosis of mucoid degeneration of both the ACL and the PCL. The symptoms disappeared after arthroscopic partial excision of the ACL and PCL.     

Nonunited avulsion fractures of the intercondylar eminence of the tibia

Summary: We report 3 cases of nonunited avulsion fracture of the intercondylar eminence of the tibia. Characteristics of the clinical symptoms were limitation of knee extension, pain at knee extension, and a small amount of anterior instability. For the patient with a normal anterior cruciate ligament (ACL), the fragment was fixed by sutures with a button after curettage of the fibrous tissue. Two patients underwent endoscopic ACL reconstruction using quadrupled semitendinosus tendon because their ACLs had degenerated. Since the technique of ACL reconstruction under arthroscopic control has been well refined, endoscopic ACL reconstruction is considered to be 1 of the surgical options for nonunited avulsion fracture with symptomatic anterior instability if the ACL is degenerated.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 757–762     

The Removal of a Dislocated Femoral Interference Screw Through a Posteromedial Portal

The intra-articular migration of a femoral interference screw is a rare complication after anterior cruciate ligament (ACL) reconstruction in the knee. Only a few reports of cases have been published within the last few years and different approaches toward this complication have been described. We report the case of a 23-year-old female patient who was admitted with knee pain after undergoing an ACL reconstruction 4 years previously. After the clinical examination, a knee radiograph in 2 planes revealed a dislocated femoral interference screw lying in the popliteal fossa. During arthroscopy, the interference screw was retrieved through an additional posteromedial portal to avoid an arthrotomy. The causes for intra-articular screw migration are multiple and most cases were reported in the early postoperative period. The arthroscopic removal of a screw is recommended because of the lower morbidity.     

Anterior spinal artery syndrome after minimally invasive direct coronary artery bypass grafting under general combined epidural anesthesia

A 65-year-old patient with ischemic heart disease and severe diabetes mellitus underwent minimally invasive direct coronary artery bypass grafting under general combined with epidural anesthesia. Paraplegia developed after surgery and the diagnosis of anterior spinal artery syndrome was made based on the patient s neurological condition and magnetic resonance imaging findings. Paraplegia following epidural anesthesia is a rare but recognized complication and this complication should be taken into account, especially in patients at risk, when considering epidural analgesia techniques in the minimally invasive cardiac surgery.     

Case Report Accumulation of Irrigation Fluid in the Calf as a Complication During High Tibial Osteotomy Combined With Simultaneous Arthroscopic Anterior Cruciate Ligament Reconstruction

Summary: Extravasation of irrigation fluid during arthroscopy is a well-known complication. We report a case of accumulation of fluid into the calf during open wedge high tibial osteotomy combined with simultaneous arthroscopic anterior cruciate ligament (ACL) reconstruction. The main cause for fluid extravasation was the drilling of the tibial tunnel, which allowed the fluid to cross the osteotomy gap and invade the flexor compartments. Although an elevation of the intracompartmental pressure was measured, there was no clinical evidence of compartment syndrome. A subcutaneous release of the flexor compartment of the leg was performed. The patient suffered no further sequelae. High tibial osteotomy combined with simultaneous arthroscopic ACL reconstruction has to be performed carefully, and potential complications must be detected immediately to prevent compartment syndrome.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 8 (November), 1999: pp 864–866     

Misdiagnosis of an atypical cyclops lesion 4 years after single-bundle anterior cruciate ligament reconstruction

Development of a cyclops lesion is a well described complication after anterior cruciate ligament (ACL) reconstruction. It commonly results in gradual extension loss during the early postoperative course, and magnetic resonance imaging (MRI) of the soft tissue nodule attached to the ACL graft is needed. Cyclops lesions are easy to diagnose based on the symptoms and MRI findings. Previous study showed that 78.6% of cyclops lesions had extension loss within 6 weeks postoperatively, and the diagnosis of 92.8% cases of cyclops lesions was established within 6 months.This article describes a case of misdiagnosis of a cyclops lesion 4 years after ACL reconstruction as a meniscal lesion combined with a meniscal cyst. The patient was asymptomatic for 4 years and then presented with a locked left knee and pain at the inferior pole of the patella during an attempt to gently extend the knee. Magnetic resonance imaging revealed a lateral meniscal cyst. The knee locking was released suddenly 2 days preoperatively. The authors had attributed the missed diagnosis to an atypical history and symptoms and an associated meniscal cyst.The purpose of this article is to help prevent misdiagnosis of atypical cyclops lesions. Cyclops lesions should be considered in the differential diagnosis of patients who present with gradual or sudden loss of extension after ACL reconstruction, regardless of how much time has passed postoperatively.     

Second-look arthroscopy with removal of bioabsorbable tacks

Eleven years after tearing her anterior cruciate ligament (ACL) (not reconstructed), a 36-year-old dancer reinjured her knee and required arthroscopic ACL reconstruction. At arthroscopy, the medial meniscus had a bucket-handle tear that was repaired by using three bioabsorbable tacks. The ACL was then repaired in the usual manner. Because of persistent posterior knee pain throughout her rehabilitation, we performed "second-look" arthroscopy 14 weeks after reconstruction. The meniscus had healed and was stable; however, tack motion was evident and the tacks were easily removed. Inspection of the tacks showed that the barbs had been resorbed. The patient recovered uneventfully, and pain-free flexion 28 days after surgery was 0 degrees-136 degrees. We believe this to be the first reported case demonstrating the early stages of tack degradation in meniscal repair.     

Septic Thrombophlebitis of the Internal Jugular Vein in an Immunocompromised Patient with Lemierre Syndrome: A Case Report

Lemierre syndrome is a rare complication of oropharyngeal infection, especially acute pharyngotonsillitis, associated with septicemia and thrombophlebitis of the internal jugular vein (IJV). We present the case of a 52-year-old patient who underwent liver transplantation and returned with symptoms of pain, redness and left cervical bulging 1 month after surgery. After investigation, the diagnosis of septic thrombophlebitis of the IJV was made. The patient responded well to treatment with antibiotic therapy and full anticoagulation. To the best of our knowledge, the present report is the first report of Lemierre syndrome in a post–liver transplant patient.     

An unusual case of vascular dysplasia related to knee arthroscopy

Acquired or traumatic arteriovenous fistula (AVF) following arthroscopic surgery is a rare complication. This case presents a patient who developed symptoms suggestive of an AVF following arthroscopic partial menisectomy and anterior cruciate ligament reconstruction. Evaluation and diagnostic procedures of choice as well as treatment alternatives are discussed herein.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp 196–199     

膝关节多韧带损伤的临床研究

目的探讨膝关节多韧带损伤的诊断与治疗方法并评价其治疗效果。方法治疗51例单侧膝关节多韧带损伤,其损伤类型：21例前交叉韧带（ACL）＋内侧副韧带（MCL）,1例ACL＋后外侧复合体（PLC）,4例后交叉韧带（PCL）＋MCL,6例PCL＋PLC,6例ACL＋PCL＋MCL,3例ACL＋PCL＋PLC,8例ACL＋PCL,2例PCL＋髌腱。14例急性Ⅲ度MCL和3例急性Ⅲ度PLC损伤行切开手术,原位缝合,外固定制动3周,再行关节镜下其他韧带手术。2例Ⅲ度慢性MCL和3例Ⅲ度慢性PLC损伤行切开韧带重建术,并同期行关节镜下ACL或PCL重建术。在总共39条ACL损伤中,20条行关节镜下自体Hamstring腱ACL重建术,17条行关节镜下自体骨-髌腱-骨（BPB）重建ACL术,2条行同种异体肌腱重建ACL;在总共29条PCL损伤中,19条行关节镜下自体Hamstring腱PCL重建术,2条行同种异体肌腱重建PCL,另8条急性损伤经固定后由Ⅲ度变为〈Ⅱ度损伤,故未特别治疗。其中,17例ACL＋PCL损伤处理方法为：4例先行PCL重建,二期再行ACL的重建,7例同期自体Hamstring腱重建PCL、自体BPB重建ACL,2例为同种异体肌腱同期重建ACL和PCL,4例仅做ACL重建术。1例髌腱完全性断裂原位修复,另1例部分性髌腱损伤者未治疗。4例合并腓总神经损伤均未做特别治疗。结果平均随访2.4年（9个月～5年）。术后Lysholm评分平均为86.3（51～100）,Tegner活 动评分为5.2（2～8）,均较术前显著增加（P〈0.001）。1例外翻试验为2＋,2例Lachman试验或轴移试验≥2＋,6例应力后沉征或后抽屉试验2＋,4例内翻试验或反轴移试验2＋。其余的对应各种体格检查均为≤1＋。4例合并腓总神经损伤者,术后3例自行恢复,1例未恢复。结论在多韧带损伤中,≤Ⅱ度的MCL或者PLC损伤应采用保守治疗,Ⅲ度损伤者应尽早手术原位修复内侧副韧带及其关节囊或PLC,以利于后期进行其他重要韧带的治疗。交叉韧带或关节内重要组织可二期在?     

关节镜下前交叉韧带重建术后膝关节感染的临床诊断与治疗

目的 探讨前交叉韧带重建术后膝关节感染的临床诊断与治疗方法.方法 回顾性研究1997年1月至2007年7月关节镜下前交叉韧带重建术后膝关节感染的患者,通过对术后关节感染的发病率、危险因素、临床表现、实验室检查结果、治疗方法及临床预后情况的观察,分析总结临床诊断与治疗方法.结果 关节镜下前交叉韧带重建手术共3638例,术后关节感染者16例,感染率0.44%.临床表现有体温增高,膝关节肿胀、疼痛,关节活动度受限.细菌培养阳性11例,以表皮葡萄球菌最多见.治疗包括静脉抗炎、关节冲洗注药、关节镜下清理术等方法,所有患者均治愈.清创术后1年以上的12例患者中失访3例,9例术后获得随访,随访时间平均19.7个月,膝关节活动度及韧带功能良好.结论 前交叉韧带重建术后膝关节感染的发牛率较低,但可能会导致关节功能障碍、软骨破坏及韧带移植物失效等严重后果.因此早期诊断、早期治疗尤为重要.尽早行关节镜下清理手术,术后结合抗生素治疗,辅以积极有效的功能康复,可以取得很好的临床效果.