Skip to main content

Advertisement

SpringerLink
Log in

Adequate protection rather than knee flexion prevents popliteal vascular injury during high tibial osteotomy: analysis of three-dimensional knee models in relation to knee flexion and osteotomy techniques

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

(1) To analyse popliteal artery (PA) movement in a three-dimensional (3D) coordinate system in relation to knee flexion and high tibial osteotomy (HTO) techniques (lateral closed wedge HTO [LCHTO], uniplane medial open wedge HTO [UP-MOHTO], biplane medial open wedge HTO [BP-MOHTO]) and (2) to identify safe zones of the PA in each osteotomy plane.

Methods

Sixteen knees of patients who underwent magnetic resonance imaging with extension and 90° flexion were used to develop subject-specific 3D knee flexion models. Displacement of the PA during knee flexion was measured along the X- and Y-axis, as was the distance between the posterior tibial cortex and PA parallel to the Y-axis (d-PCA). Frontal plane safety index (FPSI) and maximal axial safe angles (MASA) of osteotomy, which represented safe zones for the osteotomy from the PA injury, were analysed. All measurements were performed along virtual osteotomy planes. Differences among the three osteotomy methods were analysed for each flexion angle using a linear mixed model.

Results

The average increments in d-PCA during knee flexion were 1.3 ± 2.3 mm in LCHTO (n.s.), 1.4 ± 1.2 mm in UP-MOHTO (P < 0.0001), and 1.7 ± 2.0 mm in BP-MOHTO (P = 0.015). The mean FPSIs in knee extension were 37.6 ± 5.9%, 46.4 ± 5.8%, and 45.1 ± 8.1% for LCHTO, UP-MOHTO, and BP-MOHTO, respectively. The mean MASA values in knee extension were 45.8° ± 4.4°, 37.3° ± 6.1°, and 38.9° ± 6.5° for LCHTO, UP-MOHTO, and BP-MOHTO, respectively.

Conclusion

Although the PA moved posteriorly during knee flexion, the small (1.7 mm) increment thereof and inconsistent movements in subjects would not be of clinical relevance to PA safety during HTO.

Level of evidence

Diagnostic study, Level II.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

Abbreviations

HTO:

High tibial osteotomy

PA:

Popliteal artery

LCHTO:

Lateral closed wedge high tibial osteotomy

MOHTO:

Medial open wedge high tibial osteotomy

UP-MOHTO:

Uniplane medial open wedge high tibial osteotomy

BP-MOHTO:

Biplane medial open wedge high tibial osteotomy

d-PCA:

Distance between posterior tibial cortex and popliteal artery parallel to Y-axis

FPSI:

Frontal plane safety index

MASA:

Maximal axial safe angle

3D:

3-Dimensional

MRI:

Magnetic resonance imaging

MR:

Magnetic resonance

CT:

Computed tomography

dX:

The length between the centre of the popliteal artery at extension and flexion along the X-axis

dY:

The length between the centre of the popliteal artery at extension and flexion along the Y-axis

SD:

Standard deviation

References

  1. Attinger MC, Behrend H, Jost B (2014) Complete rupture of the popliteal artery complicating high tibial osteotomy. J Orthop 11:192–196

    Article  Google Scholar 

  2. Bartoli MA, Lerussi GB, Gulino R, Schroeder M, Branchereau A (2010) False aneurysm at the origin of the anterior tibial artery after opening wedge osteotomy. Vascular 18:45–48

    Article  Google Scholar 

  3. Bhatnagar T, Jenkyn TR (2010) Internal kinetic changes in the knee due to high tibial osteotomy are well-correlated with change in external adduction moment: an osteoarthritic knee model. J Biomech 43:2261–2266

    Article  Google Scholar 

  4. Brouwer RW, Huizinga MR, Duivenvoorden T, van Raaij TM, Verhagen AP, Bierma-Zeinstra SM, et al. (2014) Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev CD004019

  5. Chen HN, Yang K, Dong QR, Wang Y (2014) Assessment of tibial rotation and meniscal movement using kinematic magnetic resonance imaging. J Orthop Surg Res 9:65

    Article  Google Scholar 

  6. Chin PL, Tey TT, Ibrahim MY, Chia SL, Yeo SJ, Lo NN (2011) Intraoperative morphometric study of gender differences in Asian femurs. J Arthroplast 26:984–988

    Article  Google Scholar 

  7. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P (2013) Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc 21:170–180

    Article  Google Scholar 

  8. Franke L, Gosse F (1997) Angiological complications following high tibial head correcting osteotomy—a case report. Z Orthop Ihre Grenzgeb 135:76–78

    Article  CAS  Google Scholar 

  9. Georgoulis AD, Makris CA, Papageorgiou CD, Moebius UG, Xenakis T, Soucacos PN (1999) Nerve and vessel injuries during high tibial osteotomy combined with distal fibular osteotomy: a clinically relevant anatomic study. Knee Surg Sports Traumatol Arthrosc 7:15–19

    Article  CAS  Google Scholar 

  10. Griffith JF, Cheng JC, Lung TK, Chan M (1998) Pseudoaneurysm after high tibial osteotomy and limb lengthening. Clin Orthop Relat Res 354:175–179

    Article  Google Scholar 

  11. Grood ES, Suntay WJ (1983) A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng 105:136–144

    Article  CAS  Google Scholar 

  12. Hantes ME, Natsaridis P, Koutalos AA, Ono Y, Doxariotis N, Malizos KN (2018) Satisfactory functional and radiological outcomes can be expected in young patients under 45 years old after open wedge high tibial osteotomy in a long-term follow-up. Knee Surg Sports Traumatol Arthrosc 26:3199–3205

    Article  Google Scholar 

  13. Kang KT, Kim SH, Son J, Lee YH, Chun HJ (2015) In vivo evaluation of the subject specific finite element model for knee joint cartilage contact area. Int J Precis Eng Manuf 16(6):1171–1177

    Article  Google Scholar 

  14. Kang KT, Kim SH, Son J, Lee YH, Chun HJ (2015) Probabilistic approach for determining the material properties of meniscal attachments in vivo using magnetic resonance imaging and a finite element model. J Comput Biol 22:1097–1107

    Article  CAS  Google Scholar 

  15. Kim J, Allaire R, Harner CD (2010) Vascular safety during high tibial osteotomy: a cadaveric angiographic study. Am J Sports Med 38:810–815

    Article  Google Scholar 

  16. Kim SJ, Chang CB, Choi CH, Yoo YS, Kim SH, Ko JH et al (2013) Intertunnel relationships in combined anterior cruciate ligament and posterolateral corner reconstruction: an in vivo 3-dimensional anatomic study. Am J Sports Med 41:849–857

    Article  Google Scholar 

  17. Koo S, Gold GE, Andriacchi TP (2005) Considerations in measuring cartilage thickness using MRI: factors influencing reproducibility and accuracy. Osteoarthr Cartil 13:782–789

    Article  CAS  Google Scholar 

  18. Lee YS, Lee BK, Kim WS, Choi JS, Baek JR, Moon CW (2014) Sagittal and coronal plane location of the popliteal artery in the open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 22:2629–2634

    Article  Google Scholar 

  19. Lee YS, Park SJ, Shin VI, Lee JH, Kim YH, Song EK (2010) Achievement of targeted posterior slope in the medial opening wedge high tibial osteotomy: a mathematical approach. Ann Biomed Eng 38:583–593

    Article  Google Scholar 

  20. Pape D, Dueck K, Haag M, Lorbach O, Seil R, Madry H (2013) Wedge volume and osteotomy surface depend on surgical technique for high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 21:127–133

    Article  Google Scholar 

  21. Rossi R, Bonasia DE, Amendola A (2011) The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg 19:590–599

    Article  Google Scholar 

  22. Rubens F, Wellington JL, Bouchard AG (1990) Popliteal artery injury after tibial osteotomy: report of two cases. Can J Surg 33:294–297

    CAS  PubMed  Google Scholar 

  23. Ryu SM, Park JW, Na HD, Shon OJ (2018) High tibial osteotomy versus unicompartmental knee arthroplasty for medial compartment arthrosis with kissing lesions in relatively young patients. Knee Surg Relat Res 30:17–22

    Article  Google Scholar 

  24. Sawant MR, Ireland J (2001) Pseudo-aneurysm of the anterior tibial artery complicating high tibial osteotomy—a case report. Knee 8:247–248

    Article  CAS  Google Scholar 

  25. Shaw JA, Dungy DS, Arsht SS (2004) Recurrent varus angulation after high tibial osteotomy: an anatomic analysis. Clin Orthop Relat Res 420:205–212

    Article  Google Scholar 

  26. Shenoy PM, Oh HK, Choi JY, Yoo SH, Han SB, Yoon JR et al (2009) Pseudoaneurysm of the popliteal artery complicating medial opening wedge high tibial osteotomy. Orthopedics 32:442

    Article  Google Scholar 

  27. Shetty AA, Tindall AJ, Nickolaou N, James KD, Ignotus P (2005) A safe zone for the passage of screws through the posterior tibial cortex in tibial tubercle transfer. Knee 12:99–101

    Article  CAS  Google Scholar 

  28. Shetty AA, Tindall AJ, Qureshi F, Divekar M, Fernando KW (2003) The effect of knee flexion on the popliteal artery and its surgical significance. J Bone Jt Surg Br 85:218–222

    Article  CAS  Google Scholar 

  29. Shiomi J, Takahashi T, Imazato S, Yamamoto H (2001) Flexion of the knee increases the distance between the popliteal artery and the proximal tibia: MRI measurements in 15 volunteers. Acta Orthop Scand 72:626–628

    Article  CAS  Google Scholar 

  30. Smith PN, Gelinas J, Kennedy K, Thain L, Rorabeck CH, Bourne RB (1999) Popliteal vessels in knee surgery. A magnetic resonance imaging study. Clin Orthop Relat Res 367:158–164

    Article  Google Scholar 

  31. Song SJ, Bae DK (2016) Computer-assisted navigation in high tibial osteotomy. Clin Orthop Surg 8:349–357

    Article  Google Scholar 

  32. Song SY, Pang CH, Kim CH, Kim J, Choi ML, Seo YJ (2015) Length change behavior of virtual medial patellofemoral ligament fibers during in vivo knee flexion. Am J Sports Med 43:1165–1171

    Article  Google Scholar 

  33. Stoffel K, Stachowiak G, Kuster M (2004) Open wedge high tibial osteotomy: biomechanical investigation of the modified Arthrex Osteotomy Plate (Puddu Plate) and the TomoFix Plate. Clin Biomech (Bristol, Avon) 19:944–950

    Article  Google Scholar 

  34. Szyber P Jr, Skora J, Rybak W, Pupka A (2011) Iatrogenic pseudoaneurysm of the popliteal artery following corrective tibial osteotomy. Vasa 40:414–417

    Article  Google Scholar 

  35. Tandon SC, Kharbanda Y, Fraser AM (1996) Aneurysm complicating high tibial osteotomy: a case report. Acta Orthop Scand 67:73–74

    Article  CAS  Google Scholar 

  36. Vernon P, Delattre JF, Johnson EJ, Palot JP, Clement C (1987) Dynamic modifications of the popliteal arterial axis in the sagittal plane during flexion of the knee. Surg Radiol Anat 9:37–41

    Article  CAS  Google Scholar 

  37. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE (2005) High tibial osteotomy. J Am Acad Orthop Surg 13:279–289

    Article  Google Scholar 

  38. Yoo JH, Chang CB (2009) The location of the popliteal artery in extension and 90 degree knee flexion measured on MRI. Knee 16:143–148

    Article  Google Scholar 

  39. Zaidi SH, Cobb AG, Bentley G (1995) Danger to the popliteal artery in high tibial osteotomy. J Bone Jt Surg Br 77:384–386

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors wish to thank Prof. Myung Ku Kim, Prof. Sung-Jun Kim, and Prof. Yong Oock Kim for their helpful comments and discussions.

Funding

Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. There were no external sources of funding, and none of the authors had any conflicts of interest.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Severance Hospital, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea

    Chong-Hyuk Choi, Min Jung, Hyun-Soo Moon, Jongtaek Oh, Sung-Jae Kim & Sung-Hwan Kim

  2. Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06237, Republic of Korea

    Woo-Suk Lee & Sung-Hwan Kim

  3. Department of Radiology, Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea

    Young-Han Lee

  4. Department of Orthopedic Surgery, YonseSarang Hospital, Seoul, Republic of Korea

    Sung-Jae Kim

Authors
  1. Chong-Hyuk Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Woo-Suk Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Min Jung
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hyun-Soo Moon
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Young-Han Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jongtaek Oh
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sung-Jae Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sung-Hwan Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The project was coordinated by CHC, SJK, and SHK; CHC drafted the manuscript, together with MJ, HSM, JT, and YHL; SHK generated the concept of the study. The design of the study, acquisition of data, and analysis and interpretation of data were all performed jointly by all authors; SJK, WSL, and SHK revised the final draft critically for important intellectual content and approved the version to be submitted. All of the authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Sung-Hwan Kim.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This study was ethically approved by the Institutional Review Board (IRB) of Severance Hospital (IRB number: 4-2013-0449).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (XLSX 9 kb)

167_2019_5515_MOESM2_ESM.tif

Local coordinate system of the femur and tibia. F-HC, femoral head centre; F-LAEC, lateral apex of the femoral epicondyle; F-MAEC, medial apex of the femoral epicondyle; F-ICNC, femoral intercondylar notch centre; F-MA, femoral mechanical axis; F-ECA, femoral transepicondylar axis. T-LPC, tibial lateral plateau centre; T-MPC, tibial medial plateau centre; T-PL, tibial plateau line; T-AC, tibial plafond centre; T-HPC, midpoint between T-LPC and T-MPC; T-CP, tibial plateau centre; T-MA, tibial mechanical axis. (TIFF 3843 kb)

167_2019_5515_MOESM3_ESM.tiff

Surface models from each experimental subject were co-registered with the most matching base model, which was pre-aligned to the defined coordinate system. (TIFF 5511 kb)

Supplementary material 4 (DOCX 14 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Choi, CH., Lee, WS., Jung, M. et al. Adequate protection rather than knee flexion prevents popliteal vascular injury during high tibial osteotomy: analysis of three-dimensional knee models in relation to knee flexion and osteotomy techniques. Knee Surg Sports Traumatol Arthrosc 28, 1425–1435 (2020). https://doi.org/10.1007/s00167-019-05515-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-019-05515-1

Keywords

Search

Navigation