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Popliteal artery injury in knee arthroplasty: a population based, nationwide study
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
2013 (English)In: Journal of Bone and Joint Surgery, ISSN 0301-620X, E-ISSN 2044-5377, Vol. 95, no 12, 1645-1649 p.Article in journal (Other academic) Published
Abstract [en]

Popliteal artery injury (PAI) is a feared but rare complication during knee arthroplasty (KA). The aim was to study PAI during KA: Type of injury, treatment and outcome.

Thirty-two cases were identified in the national Swedish vascular registry (Swedvasc) and the Swedish Patient Insurance databases. Prospective data from the registries was supplemented with case-records, including long-term follow-up.

Twenty-five injuries (78%) were due to penetrating, seven to blunt trauma. Three different presentations of injury were identified: Bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Five (16%) cases were during revision KA. Twelve injuries (38%) were detected intraoperatively, eight (25%) within 24 hours (range 3-24) and twelve (38%) >24 hours postoperatively (range 2-90), 28 (88%) were treated with open surgery. Patency at 30 days was 97% (one amputation). Twenty-five (78%) patients had residual symptoms at the end of follow-up (median 546 days, range: 24-1251). Six of the seven patients with complete recovery had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital.

Outcome after popliteal artery injury during KA is often negatively affected by diagnostic and therapeutic delay. Bleeding and pseudoaneurysm were the most common clinical presentations.

Place, publisher, year, edition, pages
2013. Vol. 95, no 12, 1645-1649 p.
Keyword [en]
Vascular injury, popliteal artery, knee arthroplasty, complication, adverse event, pseudoaneurysm
National Category
Orthopedics Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-194380DOI: 10.1302/0301-620X.95B12.31611ISI: 000327788000010PubMedID: 24293594OAI: oai:DiVA.org:uu-194380DiVA: diva2:605143
Funder
Swedish Research Council, K2010-65X-20406-04-3
Available from: 2013-02-13 Created: 2013-02-13 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Iatrogenic Vascular Injuries
Open this publication in new window or tab >>Iatrogenic Vascular Injuries
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Iatrogenic vascular injuries (IVIs) and injuries associated with vascular surgery can cause severe morbidity and death. The aims of this thesis were to study those injuries in the Swedish vascular registry (Swedvasc), the Swedish medical injury insurance where insurance claims are registered, the Population and Cause of death registries, and in patient records, in order to explore preventive strategies.

Among 87 IVIs during varicose vein surgery 43 were venous, mostly causing bleeding in the groin. Among 44 arterial injuries, only 1/3 were detected intraoperatively. Accidental arterial stripping predominated, with poor outcome. Four patients died, all after venous injuries.

IVIs increased over time, and constitute more than half of the vascular injuries registered in the Swedvasc. Lethal outcome was more common (4.9%) among patients suffering IVIs than among non-iatrogenic vascular injuries (2.5%). Risk factors for death were age, diabetes, renal insufficiency and obstructive lung-disease.

Fifty-two patients died within 30 days after IVI. The most common lethal IVIs were puncture during endovascular procedures (n=24, 46%), penetrating trauma during open surgery (11) and occlusion after compression (6). Symptoms were peripheral ischemia (n=19), external bleeding (14), and hypovolemic chock without external bleeding (10). Most died within two weeks (n=36, 69%). After >2 weeks the IVI as a cause of death was uncertain.

Among 193 insurance claims after vascular surgery during 2002-2007, nerve injuries (91) and wound infections (22) dominated. Most patients suffered permanent injuries, three died. Patients with insurance claims were correctly registered in the Swedvasc in 82%.

In 32 cases of popliteal artery injury during knee arthroplasty symptoms were bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Only twelve injuries (38%) were detected intraoperatively. Patency at 30 days was 97%, but only seven (22%) patients had complete recovery. Six of those had intraoperative diagnosis of popliteal injury and immediate vascular repair.

In conclusion, registration of IVIs is increasing and outcome is often negatively affected by diagnostic and therapeutic delay. Not all fatalities after IVIs are attributable to the injury itself. The most common causes of insurance claims after vascular surgery were nerve injuries, and 82% were correctly registered in Swedvasc.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 867
Keyword
vascular injuries, vascular surgery, vascular trauma, injury, medical error, patient safety, postoperative death, postoperative mortality, patient insurance, varicose veins
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-194346 (URN)978-91-554-8597-9 (ISBN)
Public defence
2013-04-12, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-03-22 Created: 2013-02-12 Last updated: 2013-04-02Bibliographically approved
2. Orthopaedic Patients with Lower Limb Vascular Injuries
Open this publication in new window or tab >>Orthopaedic Patients with Lower Limb Vascular Injuries
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Vascular injuries in lower limbs are rare but serious events. If not detected and managed correctly and timely they can lead to permanent functional impairment and even limb loss. The increasing number of orthopaedic interventions, worldwide, makes awareness of this problem among orthopaedic surgeons important.

The overall aim of this thesis was to describe lower limb orthopaedic injuries with associated concomitant arterial injuries, especially to the popliteal artery. Epidemiology, mechanisms of injury, management, outcomes and the patient perspective were all addressed. The research questions were generated from clinical praxis. 

Vascular injuries are rare events, but by using as the National Patient (NPR) and National Vascular registries (Swedvasc) a relatively speaking large cohort was studied. Deep interviews with qualitative study method were used to investigate the patients’ perspective.

In papers I and II iatrogenic popliteal artery injuries (PAI) in knee-replacements, and in non-knee-replacements, were investigated. The number of knee arthroplasties in Sweden increased 1987-2008, but not the frequency of iatrogenic PAI. The most common mechanism of injury was sharp, directly to the artery. One third of the injuries resulted in pseudo-aneurysms. This was an unexpected and important finding, since these patients were often diagnosed late, resulting in poor outcome.

Paper III. The interviewed patients narrated substantial functional, cosmetic and psychological impairments,4-17 years after their accidents, yet they described their lives as “normal”. Patients with saved limbs reported a need for better interpersonal support in their rehabilitation and adaptation back to “normal” life.

Paper IV. Popliteal artery injury is feared in knee dislocations and fractures. The proportion incidence of vascular injury was previously reported to be 2-60%. In this large population-based study, the incidence proportion in knee dislocations was 3.4-8.2%, depending on the definition of dislocation/ligamentous injury. In knee fractures the incidence proportion was lower, only 0.2%. The dominating cause of arterial injury in knee dislocations was fall, in knee fractures it was motor vehicle accidents. Amputation- free survival after arterial injury was inferior in knee fractures compared with knee dislocations.

In conclusion, PAI is a serious injury but on sequences can be limited by awareness and timely action.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1234
National Category
Surgery Orthopedics
Research subject
Orthopaedics; Surgery
Identifiers
urn:nbn:se:uu:diva-296141 (URN)978-91-554-9611-1 (ISBN)
External cooperation:
Public defence
2016-09-23, Gustavianum, Akademigatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-08-18 Created: 2016-06-13 Last updated: 2016-08-25

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Bernhoff, KarinRudström, HåkanGedeborg, RolfBjörck, Martin

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