Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy

Dennis Hundersmarck,Gert J De Borst,Marilyn Heng,Falco Hietbrink,Luke P H Leenen

doi:10.1007/s00068-021-01632-0

Abstract

PurposeBlunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF).MethodsRetrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined.ResultsOf 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication.ConclusionBlunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration.

Highlights

Blunt popliteal artery injury (BPAI) is a potentially limbthreatening sequela of tibiofemoral dislocations and fractures
One patient was transferred from a different hospital approximately 17 days after the initial knee injury, latent ischemia caused by a previously undiagnosed popliteal artery dissection resulted in primary amputation
As the choice for initial management strategy in the studied institutions was mostly based on surgeon preference, we aimed to identify specific patient and injury characteristics that influenced that decision

Summary

Introduction

Blunt popliteal artery injury (BPAI) is a potentially limbthreatening sequela of tibiofemoral (knee) dislocations and fractures. The reported incidence of concomitant BPAI in patients with knee dislocations varies widely, ranging from 2% among those that require surgical repair of the popliteal artery in a population-based study to 40% of consecutive knee dislocations at a single tertiary referral institution [1, 2]. Prompt reduction of knee dislocations and careful vascular examination, using computed tomography angiography (CTA) scanning in those suspected for vascular injury, is required [6,7,8]. Those that show signs of vascular impairment prior to reduction and apparent return of vascular patency after reduction are at risk for latent ischemia (due to dissections) and amputation [9]. It is reported that a warm-ischemia period of 8 h or more will most likely result in amputation [10]

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