Pt in for TKA revision. Post op patient develops foot pain and returns to ED. Ed does ultrasound and finds possible blood flow issue. IR takes patient to interventional suite and finds as follows:
At this point the 014 Nitrex wire was advanced through the
popliteal artery and into the peroneal artery. The CAT 8 suction aspiration
catheter was used to perform suction thrombectomy of the left popliteal artery.
At this point balloon angioplasty of the left popliteal artery and peroneal
artery was performed with a 2.5-3.0 x 210 mm rapid cross tapered balloon.
Repeat angiogram was obtained which did show some flow through the area. At
this point there was concerns for possible injury adjacent to the prosthetic
hardware of the knee of the popliteal artery. Therefore I elected to place a 7
x 50 Gore viabahn covered stent in the left popliteal artery adjacent to the
knee hardware. The post stent dilatation balloon angioplasty was performed
with a 6 x 40 Nano cross balloon. Repeat angiogram was obtained which now
showed inline flow through the left popliteal artery with what appeared to be
the area of injury and two-vessel runoff into the ankle of the posterior tibial
artery and peroneal arteries with reconstitution of the dorsalis pedis in the
foot.
Files:
No questions yet!
Do you believe there might have been medical error?
The wire misplaced and the prosthetic misplaced as well should have been noted during the surgery and investigates at the time. The injured vessel should have been addressed at that point as well as proper placement of the Arthroplasty
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above please. The wire hitting the artery would have caused a hematoma that should have been noticed prior to discharge. In addition. X-rays would show the prostheses in the incorrect position
What makes you a good expert for this case?
I think a Joint surgeon is a better fit to be honest. I have experience in this area but not as of recent
How often do you encounter cases similar to this one in your practice?
Not often. This is not a common finding (misplacement of the prosthesis)
Do you believe there might have been medical error?
The lateral fluoroscopic image included in the case vignette reveals significantly greater than 1 cm of overhang of the revision total knee tibial tray that appears to directly impinge upon the popliteal artery. This is an unforced error that is preventable by standard sizing techniques and appropriate placement of the tibial prosthesis during surgery and is controllable by the surgeon. Postoperative imaging in PACU or first post-op visit would also document the problem and allow for an acute return to the OR to correct the surgical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is more likely than not that the oversized/overhanging tibial prosthesis caused the popliteal artery damage that resulted in the IR procedure. The solid cornered metallic prosthesis kinks the normal structure and vector of the vessel leading to intimal damage and the formation of a thrombus
What makes you a good expert for this case?
I perform knee arthroplasty (mostly medial, lateral, and patellofemoral) and complex knee stabilization cases (proximal tibial osteotomies, plateau fracture fixation and knee dislocation surgery) on a regular basis and work in and around the posterior aspect of the knee joint on a regular basis. I understand the 3-d anatomy of all the important soft tissues (ligaments, tendons, vessels, and nerves) in and around the knee) and can base my judgement of injury and causation on my twenty-eight plus years of clinical expertise in managing complex knee injuries.
How often do you encounter cases similar to this one in your practice?
In the trauma setting, I have managed such cases on referral and helped manage the extremity in conjunction with vascular surgery throughout my career.
Do you believe there might have been medical error?
Based on the fact that the popliteal artery thrombosis/injury occurred directly posterior to the revision total knee components, it is very likely that medical error caused this event. This was confirmed based on the angiographic findings. It would be helpful to learn how soon after the revision total knee arthroplasty the patient developed the popliteal artery injury/thrombosis. I would expect this to occur very shortly after the procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, the surgeon performing the revision total knee arthroplasty very likely made this medical error which caused the popliteal artery thrombosis/injury.
What makes you a good expert for this case?
I am an orthopedic surgeon who is dual fellowship-trained in orthopedic trauma and orthopedic foot and ankle surgery. I have a thorough knowledge of lower extremity anatomy and regularly perform joint arthroplasty.
How often do you encounter cases similar to this one in your practice?
Cases of arterial injury associated with total joint arthroplasty and revision total joint arthroplasty are uncommon but do occur. They are more likely to occur in the setting of joint contracture and revision total joint arthroplasty.
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