Chapter 77 Vascular Complications After Anterior Cruciate Ligament Reconstruction

Vascular complications after anterior cruciate ligament (ACL) reconstructions cause serious morbidity and potential mortality. Fortunately, their incidence is low. Only a few peer-reviewed case reports provide information,¹^–⁵ and even a specific review article on complications after ACL surgery does not mention these rare complications.⁶

This chapter will be subdivided into discussions of arterial and venous complications after arthroscopic ACL reconstruction.

Arterial Complications

Knee arthroscopy is generally a safe procedure with a low incidence of complications. The two largest studies to date report complication rates of 0.54% and 0.8%.^7,⁸ Penetrating popliteal artery injuries were described by DeLee in 6 of 118,540 arthroscopies.⁷ Small noted 9 cases (of 375,000 arthroscopic procedures) of penetrating trauma to the popliteal artery.⁸ A subsequent study of 8741 cases done by experienced arthroscopists showed no vascular complications.⁹ Pseudoaneurysm is the most frequently published popliteal artery lesion after arthroscopy of the knee. It is associated with direct violation of the posterior capsule or previous (open) knee surgery. However, it is still rare and published in case reports only.¹⁰^–²³

The incidence of arterial lesions after arthroscopic ACL reconstruction is unknown. Five case reports have been published on various techniques of ACL reconstruction.

Roth and Bray ¹ described an occlusion of the popliteal artery 7 cm proximal to the knee joint line. A composite graft, consisting of a polypropylene ligament augmentation and the middle third of the quadriceps patellar tendon, was used as ACL reconstruction and fixed to the lateral femur with a single staple in an over-the-top position. The patient had a burning pain in the foot 6 hours after surgery. Doppler signals of the pedal arteries were intact. The symptoms subsided. Dull aching at the posterior calf occurred at 3 weeks. Pain and dysesthesia in the foot recurred at 6 weeks. Angiography revealed the occlusion. The artery was trapped between the composite graft and the femur at surgical exploration. A saphenous bypass was performed.

Spalding et al ² reported a case of unilateral claudication 8 years after ACL reconstruction with use of a GoreTex polytetrafluoroethylene braided ligament. Computed tomography (CT) analysis demonstrated a cyst had formed around the femoral insertion of the ruptured GoreTex ligament. The cyst was excised without the need for vascular repair.

Evans et al ³ reported a pseudoaneurysm of the medial inferior genicular artery following ACL reconstruction with a central third patellar tendon graft fixed with interference screws into the tibia and femur. It was detected at 5 weeks postsurgery with a 10-day history of pulsating swelling on the medial side of the knee with normal femoral, popliteal, and distal pulses. Diagnosis was made by contrast angiography. Ligation of the artery and removal of the thrombus from the pseudoaneurysm led to an excellent recovery. The cause of the lesion was elevation of the periosteum on the medial side of the tibia for tibial tunnel preparation.

Aldridge et al ⁴ described an avulsion of the middle genicular artery after arthroscopic ACL reconstruction with a bone–patellar tendon–bone (BPTB) autograft fixed with interference screws in both the tibia and femur. After tourniquet release, serious hemorrhage was detected with absent dorsal pedal pulse and a cold foot. The patient had a history of intravenous contrast dye allergy; therefore a CO₂ arteriogram was performed with no evidence of vascular injury. The symptoms resolved overnight. At 2 weeks, the patient experienced difficulty with knee extension and felt a mass in the popliteal fossa. No mass was felt at examination, and pedal pulses were normal. Ultrasound examination showed no sign of venous thrombosis. At 4 weeks, a palpable mass in the fossa with 30-degree flexion contracture of the knee led to hospital readmission. Contrast angiography showed the vascular lesion. Surgical exploration revealed a tear in the popliteal artery, which was repaired with a short running stitch after removal of the hematoma. There was no rupture of the posterior capsule, and the avulsion of the middle genicular artery was hypothesized to have occurred during débridement of the femoral ACL stump.

In our own consecutive series of 625 hamstring graft arthroscopic ACL reconstructions (1998–2005), three arterial complications occurred. In this series, the quadruple hamstring graft is fixed with a Bone Mulch Screw on the femoral side and a WasherLoc device in the tibia (rationale and surgical technique according to S.M. Howell; fixation devices by Arthrotek). The latter is a spiked washer with bicortical screw fixation.

Our first case was a 44-year-old male with a previous history of open medial and lateral ligament repair of the same knee 15 years previously (motor vehicle accident). The hospital recovery was uneventful after ACL reconstruction. On day 17 postsurgery, he experienced pain and swelling in the popliteal fossa of the knee. The complaints partially resolved with physiotherapy. Two days later, the fossa pain returned with alterations of skin color, sensory loss, and an increasingly cold foot. Adequate dorsal pedal and posterior tibial pulses were noted. Duplex ultrasound examination showed no sign of venous thrombosis. Angiography revealed a subtotal occlusion of the popliteal artery at the level of the superior genicular artery (Fig. 77-1). An embolectomy was performed using a Fogarty catheter inserted in the femoral artery. The pedal pulses were diminished after embolectomy, and a second angiography was performed. The occlusion at the level of the popliteal artery was no longer detected. No further emboli were noted; however, the peripheral flow qualified as too slow and suggestive of small distal occlusions. Anticoagulant therapy with intravenous heparin as well an epidural analgesia were administered until complete recovery of peripheral circulation was attained. The patient developed a superficial infection of the groin wound, which was treated by antibiotics. He was mobilized and discharged after 8 days. Sensory loss of the foot slowly recovered after 4 months. Vascular analysis in rest and strenuous activity was performed at 4 months. He had no more complaints, a symmetrical ankle-brachial index in both legs, and intact pulses at the foot and ankle. Our hypothesis of the cause was the traumatic knee dislocation 15 years previously. Precursors could have been preexistent intimal vascular damage or adhesions of the artery at the level of the superior genicular artery in combination with the use of the tourniquet.

Fig. 77-1 Angiography of the right knee showing subtotal occlusion of the popliteal artery at the level of the superior genicular artery.

We have previously published our second case of pseudoaneurysm of the popliteal artery due to damage by the bicortical tibial drill.⁵ A 24-year-old man had an ACL reconstruction using a quadruple hamstring graft. The patient was allowed full weight bearing, and an aggressive rehabilitation was started the day after surgery. The hospital stay was uneventful. Twelve days after surgery, the patient complained of progressive pain in the popliteal fossa that had started on day 5 postsurgery. On physical examination, a pulsating mass was felt in the popliteal fossa and there was a sensory loss of the medial foot as well as the plantar heel. The dorsal pedal and posterior tibial pulses were intact. Duplex analysis and CT angiography demonstrated a pseudoaneurysm of the infragenicular popliteal artery near the site of the bicortical tibial screw (Fig. 77-2). The pseudoaneurysm measured 3.5 × 1.5 cm on the sagittal view and 3.5 × 4 cm in the frontal aspect (Figs. 77-3 and 77-4). Surgical exploration was immediately performed. A vascular defect (3 mm) of the infragenicular popliteal artery was found just proximal to the origin of the anterior tibial artery (Fig. 77-5

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