Oct 20, 1994 - DANGER. TO THE POPLITEAL. ARTERY. IN. HIGH. TIBIAL. OSTEOTOMY. S. H. A. ZAIDI,. A. G. COBB. G. BENTLEY. From the Royal. National.
DANGER HIGH
TO THE TIBIAL
S. H. A. ZAIDI,
From
We
report
case
Orthopaedic
in
which
upper tibial of fiexion.
9O
We
used
duplex
the
the
to the posterior surface degrees of fiexion of the knee. in 12 of 20 knees the popliteal
popliteal
artery Joint
Received
artery
was
performed
tibia,
Surg
from (Br!
21 October
ten the
healthy popliteal
of the tibia at various Our results showed that artery was closer to the
after
revision
of the
tibial
plateau.
likely to be injured when the knee allows the artery to fall back from Crenshaw 1987; Adams 1992),
we could
injury. Accepted
level
but
20 October
supported
by
any
published
studied the movement plane during flexion embalmed cadavers. artery
kinked
varied
very
applied Our
to the tibia. study used
1994
Repair
recovery. popliteal
by
artery
direct is less
is flexed to 90#{176} since this the tibia (Coventry 1973; but this concept is not
work.
Vernon
et
al
(1987)
of the popliteal artery in the sagittal of the knee using angiography in nonThey noted that the femoral part of the
during little,
flexion,
but
maintaining duplex
that
the
a constant
tibial
section
curve
closely
ultrasonography
relationship of the popliteal and to assess the protection
l995:77-B:384-6. 1 993:
at the
artery
suture resulted in an uncomplicated It is generally believed that the
in from
England
with is believed to
of knee fiexion than in full extension. performing upper tibial osteotomy should that flexing the knee does not protect the
9iO
J Bone
the
distance
artery
Middlesex,
popliteal
ultrasonography
to measure
tibia in Surgeons be aware
Hospital,
osteotomy This position
allow it to fall safely back from find no published confirmation. volunteers
IN
G. BENTLEY
National
a
divided during the knee in
ARTERY
OSTEOTOMY
A. G. COBB.
the Royal
POPLITEAL
to
artery to the back afforded by flexing
define
the
of the tibia the knee.
ANATOMY
Injury to the popliteal artery is rare: only one case was operations reported
of
popliteal ton and
artery after such Bouchard 1990).
during reported
upper tibial osteotomy in a review of 804
in ten series (Insall 1984). Two cases have been the formation of a false aneurysm in the an osteotomy We report
(Rubens, one case
Wellingof severe
Anatomical only to the position in ly down to into
description of the popliteal artery usually refers extended knee. The artery is in a slightly lateral the intercondylar fossa and then passes obliquethe lower border of popliteus where it divides
the anterior
and posterior
occasionally above the anterior artery descends
arteries.
applied
Case report. A 63-year-old woman had osteoarthritis of the medial compartment of the knee and a varus deformity. With the knee flexed to 90#{176}, a laterally-based wedge of tibia was removed using an osteotome. When the tourniquet was
ed from the bone as the soleal line
released exploration
the level of a high tibial osteotomy, below the joint line, and winds round muscles. The medial inferior geniculate
was showed
profuse complete
arterial bleeding. division of
Immediate the popliteal
1990). The
lateral
In most
specimens
by the popliteus (Warwick and
inferior
geniculate
The
popliteus, of this
injury.
there
to the tibia.
tibial
level of in front
division
and muscle,
the artery
muscle Williams artery
is
then the closely is separat-
as far inferiorly 1973; McMinn
takes
origin
at about
between 1 and 2 cm the tibia deep to the artery arises higher.
Soleus and the lateral head of the gastrocnemius are posterior to the artery at this level; they are close to their origins and, free S. H. A. Zaidi, MA, MB, BChir, Senior House Officer A. G. Cobb, BSc, FRCS, Senior Lecturer in Orthopaedic Surgery G. Bentley, ChM, FRCS, Professor of Orthopaedic Surgery The Institute of Orthopaedics, Royal National Orthopaedic Hospital Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK. Correspondence Thane Villas,
should Finsbury
©1995 British 030l-620X/95/3994
Editorial
384
be sent to Dr S. H. A. Zaidi Park, London N7 7PE, UK. Society
$2.00
of Bone
and
Joint
at 3 Thane
NHS
being
embedded
to move. The lower
forward vessels,
half
in the deep of the
popliteal
fascia artery
against the popliteus muscle the soleus and the lateral head
of the
leg,
is therefore
are
not held
by the geniculate of gastrocnemius.
Mansions.
METHODS Surgery
We
attempted
to
image THE
the JOURNAL
popliteal OF BONE
artery AND
at JOINT
various SURGERY
DANGER
TO THE
POPLITEAL
ARTERY
IN HIGH
TIBIAL
385
OSTEOTOMY
;j:.: Fig. I Diagram to show artery and the the
the distance tibia.
X measured
degrees of flexion of the knee from the artery to the posterior the joint line We used (Advanced colour-flow image the volunteers were
(Fig. an
I). ATL
uppermost.
on
popliteal
and to determine the distance tibial cortex at 1 .5 cm below
Ultramark
The
their
probe
fossa. The colour-flow popliteal artery and between surface
9
sides, was
with
Duplex
the
placed
imaging the posterior
Fig. 2
machine
In one
against
to be the
popliteal
fully
performed images.
extended
and
on one
knee
at
of any
structures
which
might
affect
its mobility.
RESULTS Duplex teal
ultrasonography. artery
and
the
The posterior
distance tibial
between cortex
the poplivaried
from
VOL.
77-B.
minimally
No. 3, MAY
larger 1995
in the
other
8. The
reduction
popliteal
artery
(P)
and
the
the popliteal artery and angles of knee flexion
the tibial
(degrees)
20
60
90
110
4.2 3.9
4.3 3.2
5.5 4.0
4.7 4.2
6.3 4.7
0.5 0.3
2 L
7.5
5.2
4.9
4.6
5.9
-2.9
R
6.4
5.1
5.7
5.9
6.5
-0.7
3 L R
9.8 10.8
8.0 8.4
8.1 7.6
8.3 7.6
9.2 8.7
-1.5 -3.2
Subject I L R
0
Difference (9OtoO)
L
7.2
5.1
5.2
5.0
6.1
R
6.8
4.8
4.7
5.1
5.9
-2.2 -1.7
5 L R
8.5 8.9
6.3 6.5
6.7 6.2
6.6 7.3
7.2 7.5
-1.9 -1.6
6 L R
5.7 5.4
5.8 5.6
5.5 5.9
6.1 5.7
6.6 6.5
0.4 0.3
7 L R
6.1 6.9
6.4
6.2
6.4
6.7
0.3
7.4
7.4
7.9
8.1
1.0
5.1
4.8
4.6
4.9
5.2
-0.2
R
5.4
5.3
5.1
5.1
6.3
-0.3
L R
7.8 6.9
6.2 5.9
6.4 6.2
5.9 6.1
6.3 6.6
-1.9 -0.8
L R
5.6 5.8
6.2 5.4
6.1 5.7
6.1 6.4
7.2 7.1
0.5 0.6
4
3.9 mm to 10.8 mm in normal knees in full extension (Table I). Change in this distance between full extension and 90#{176} 9 of flexion varied from -3.2 mm to +1.0 mm (mean 10 -0.75 mm). The distance became smaller with flexion in I 2 and
the
flexion
8 L
knees,
showing
(T).
Knee
for
anatomical specimen from a 66-year-old woman 70 kg was dissected to discover the tissues supthe popliteal artery behind the upper tibia, and the
position
tibia
scan
Table 1. Distance in mm between in ten normal subjects at various
tested
the anterior border of the artery and the of the tibia at 1.5 cm distal to the articular
volunteer, MRI was with the ultrasound
comparison
leg
Ultrasound
made it easy to identify the tibial cortex (Fig. 2). The
surface was measured with the knee 20#{176}, 60#{176}, 90#{176} and I 10#{176} of flexion.
One weighing porting
the
Technology Laboratory, Letchworth, UK) with doppler and a 7.5 MHz linear-array probe to popliteal arteries of both knees in ten healthy (six female, age 27 to 69 years). The subjects
examined
distance posterior
between
cortex
S. H. A. ZAIDI.
386
produced
by
(p < 0.01 ; paired The distance increased from at full extension The image
flexion
reached
t-test
for 0#{176} and
statistical
significance
increased in all knees when flexion 90#{176} to 1 10#{176}, but remained smaller than in 9 of the 20 knees (Table I).
minimised
this
resonance
bone
on the ultrasound of points on the
error.
imaging.
was
measured
as 1 1 mm
at 20#{176} flexion. Difficulty from the scan pictures
to only ±1 mm, but those from ultrasound.
Anatomical
dissection.
and
dissection the lateral
as well passing
At the level
confirmed the close head of gastrocnemius
as the origin anteriorly.
of the lateral
at full
in choosing reduced the
measurement sistent with omy
error may direction. however,
In the right knee of subject was possible only in full extension and at 20#{176} of because of the dimensions of the coil. The artery to
space
8 mm points
was that
image representing the bone and the artery was and open to two types of error: interobserver systematic error by one observer. The use of one
Magnetic
the
results
of a high
extension
and
reproducible accuracy were tibial
conosteot-
geniculate
artery
that
popliteal to injury
artery during
away high
flexion
of the knee
does
not move
of the popliteus
minority,
high
muscle,
but
means
that
branching
the anterior tibial artery is closely applied to the tibia deep to this muscle (Warwick and Williams 1973; McMinn 1990). Ultrasonography showed a significant mean decrease in the distance and it may be that the changing bulk of the popliteus muscle accounted for this variation. The artery would probably be at greater risk under the tension of full extension, but the typical patient undergoing tibial osteotomy may not have much arterial elasticity. Although it would seem wise to continue the practice of performing high tibial position of some flexion. fails to confer that the artery No benefits commercial article.
Adams JC. Churchill
osteotomies with the knee in a we have shown that flexion to 90#{176}
any advantage. Surgeons should remains in a vulnerable position.
in any form party related
have been directly
Standard Livingstone,
Ort/iopaedic 1992:398-9.
received or will or indirectly to
be
aware
be received the subject
from a of this
the
from the tibia; it remains vulnerable tibial osteotomy. In most cases the
Operations.
4th
ed.
Edinburgh:
Coventry MB. Osteotomy about the toid arthritis: indications, operative Siity [A,n] 1973:55-A:23-48.
knee for degenerative technique, and results.
and rheumaJ Bone Joint
Crenshaw, AH. Campbell CV Mosby Co. 1987.
orthopaedics.
ed. St Louis:
s operative
Insall J. Osteotomy. Suien Livingstone. 1984:551.
Rubens tibial
shown
by the bulk small
McMinn RMH, ed. Edinburgh: Churchill
DISCUSSION We have
is protected
REFERENCES
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3, this flexion,
artery
90#{176}).
accuracy of the measuring cursor was ±0.2 mm, but the selection
ultrasound subjective error and
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Last
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