Pseudoaneurysm of the superior lateral genicular artery: case report of a rare complication after total knee arthroplasty
© Saini et al.; licensee BioMed Central Ltd. 2013
Received: 20 February 2013
Accepted: 15 May 2013
Published: 20 May 2013
Pseudoaneurysm of superior lateral genicular artery following total knee arthroplasty is a rare complication and has been reported following lateral release performed for eversion of patella in a knee with tight lateral structures.
This report describes a case of pseudo aneurysm of superior lateral geniculate artery that developed after primary Total knee arthroplasty for a stiff knee in a 68 year old patient. Patient presented with pain and rapidly increasing swelling in early post operative period. Diagnosis was made on duplex ultrasound and confirmed by angiography. Angiographic coil embolisation of the pseudoaneurysm was performed. Since no lateral release was performed in this case, the probable mechanism was shear injury to the vessel.
Pseudoaneurysm of superior lateral genicular artery can occur in absence of lateral release by shear injury to an atherosclerotic vessel. Angiographic coil embolisation appears to be the best method for treating such post arthroplasty pseudoaneurysm because of less chance of infection, non interference with rehabilitation and diagnosis and treatment during same procedure.
Vascular complications after Total knee arthroplasty (TKA) are quite rare, thier incidence being 0.03% to 0.2% . Pseudoaneurysms following TKA involving poplitieal artery, anterior tibial artery and geniculate arteries have been reported previously [2–9]. To the best of our knowledge no case of pseudoaneurysm following Total knee arthroplasty in a stxciff knee has been reported. Though rare, they can adversely affect the final outcome and may even be limb threatening. High index of suspicion may help in early identification and treatment of this potentially devastating complication. We report a case of 68 year old male who presented with rapidly increasing swelling in early post operative period following TKA for a stiff knee with 30° of flexion contracture. We present this case to discuss probable aetiology, diagnosis and management of this rare complication.
A knee with preoperative arc of motion less than 50 deg° is considered to be stiff [10, 11]. Eversion of patella is the most difficult step during TKA in such knees due to contracture and fibrosis of surrounding tissue needing additional steps like lateral release, quadriceps snip, quadricepsplasty, tibial tubercle osteotomy and also skeletaonization of the proximal medial tibia [10, 11]. During these steps the surrounding neurovascular structures are at risk and can be damaged directly by instruments or indirectly by stretch and shear force.
Pseudoaneurysms following arthroplasty are rare with one study reporting incidence of 0.03% . In contrast to true aneurysm, a pseudoaneurysm has a fibrous wall which under the effect of systemic pressure increases in size. It may compress surrounding structures causing distal neurovascular deficit or may rupture into surrounding tissues producing swelling , bleeding from suture line , calf pain and ecchymosis mimicking DVT  or acute and recurrent haemarthrosis [8, 9]. Many mechanisms have been described such as-perforation by a retractor, injury by tourniquet, direct trauma to the vessel or secondary to the heat of the cement, repeated local trauma and injury to an atherosclerotic artery [3–7].
Pseudo aneurysms of superior lateral geniculate artery following TKA have been previously reported [5, 7, 8]. In these reports, lateral release performed during exposure was reported to be the cause [7, 8]. The superior genicular arteries branch from the popliteal artery, curving round proximal to both femoral condyles to reach the anterior aspect of the knee. This artery is found within a triangle limited anteriorly by the vastus lateralis muscle, posteriorly by the short head of the biceps femoris muscle, and inferiorly by the lateral condyle of the femur. The lateral superior genicular artery passes under the tendon of biceps femoris and divides into superficial and deep branches. The superficial branch supplies vastus lateralis and anastomoses with the descending branch of the lateral circumflex femoral and lateral inferior genicular arteries, while the deep branch anastomoses with the medial superior genicular artery, forming an anterior arch across the femur with the descending genicular artery. The superficial branch is vulnerable if the lateral patellar retinaculum is divided surgically .
The probable mechanism in this case might be shear injury to the vessel resulting in intimal injury during manipulation or surgical exposure since lateral release was not performed. This assumption is strengthened by a recent report of ruptured pseudo aneurysm following manipulation under anaesthesia of a stiff total knee arthroplasty . Since the patient had a long history of hypertension, the vessels may have been atherosclerotic making them prone to injury [3, 4, 6, 7].
Aneurysm smaller than 2 cm in size can be managed with direct compression to induce thrombosis . For those upto 5 cm in size, options are excision of aneurysm and ligation of feeding vessel [4, 8], percutaneous thrombin injection  and intravascular coils and beads [3–9]. Surgical wound exploration requires additional anaesthesia and in the presence of an implant, it increases the risk of infection. Also, repeat surgery interferes with rehabilitation protocol. Ultrasound guided percutaneous thrombin injection and angiographic coil embolisation are minimal invasive alternatives. However, thrombin injections are associated with failures, propagation of thrombus and chances of infection through injection site. Angiographic embolisation appears to be the best method for these small vessels as it can be performed by percutaneous arterial catheterization of femoral artery under local anesthesia without any associated risk of infection. There is no need for altering rehabilitation programme and patient can be mobilised as soon as pain subsides. Most importantly, angiography provides the ability to diagnose and treat simultaneously.
Though rare, soft tissue handling during primary total knee arthroplasty in a stiff knee can cause pseudo aneurysm. High index of suspicion should be maintained for this complication in post operative patients with acute swelling. Doppler ultra sound is the initial diagnostic method of choice with angiography being the definitive one. Intravascular coils provide a useful modality of treatment without any associated risk of infection or need of modifying rehabilitation protocol.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.
We thank Dr Vivek Tiwari for acquiring relevant images from department of Radiodiagnosis.
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