Treatment of vascular injuries in the multiple-ligament-injured knee

Popliteal vascular injury associated with the multiple-ligament-injured knee, including knee dislocation, continues to be an uncommon but morbid injury. The tethering of the popliteal vessels to the femur at Hunter's canal and to the tibia by the soleus muscle allows for significant vascular injury when the supporting ligamentous structure is disrupted. The majority of injuries are related to motor vehicle accidents, including driver and passenger injuries, motor vehicle versus pedestrian injuries (bumper injuries), and motorcycle accidents. The mechanisms of vascular injury, both artery and vein, include stretching that results in intimal injury, contusion, laceration, transection, or avulsion. A high index of suspicion must be maintained in the evaluation of these injuries. Modes of evaluation include physical examination, ankle brachial indices, duplex examination, magnetic resonance imaging, and angiography. Given the potentially devastating consequence of a missed popliteal artery injury, routine arteriography or serial physical examination with duplex examination is recommended for patients with a multiple-ligament-injured knee. Vascular repair to include primary repair, patch angioplasty, or interposition grafting is performed from either a medial or posterior approach. Adjunctive measures include 4-compartment fasciotomy, mannitol administration, and vasodilator therapy. Several controllable factors have been found to improve limb salvage, such as decreased ischemia time, systemic anticoagulation, and 4-compartment fasciotomy. Prompt recognition of vascular injury, prompt restoration of flow, and use of proven adjuncts provides the optimal possibility of limb salvage with popliteal artery injuries associated with the multiple-ligament-injured knee.