Skip to main content

Advertisement

SpringerLink
Log in

Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study

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

Abstract

Purpose

This study evaluated major vascular injury risk in distal femoral osteotomy (DFO) via the subvastus approach and examined the relationship between the posterior border of the vastus medialis (VM) and the superficial femoral artery (SFA) and vein (SFV).

Methods

Eighty limbs from 80 patients were evaluated using lower extremity computed tomographic venography. The positional relationship between the VM, SFA, and SFV was evaluated by measuring the angle between each structure and the horizontal reference point (VMA: VM angle, FAA (femoral arterial angle), FVA (femoral venous angle) and the distance between VM and the SFA and SFV (VMAD: VM-arterial distance, VMVD: VM-venous distance) in each axial slice (0/10/20/30/40 mm) proximal to the level of the superior patellar margin. The proximity of the posterior border of the VM and the SFA/SFV as a vertical distance, measured between the slice of the superior border of the patella and the slice where the posterior border of the VM contacted the SFA was evaluated. Single and multiple regression analyses were performed using the vertical distance as the objective variable.

Results

As the slice shifted proximally, the VMA significantly increased (24.9 ± 8.5, 36.3 ± 8.8, 47.4 ± 11.8, 59.9 ± 14, 70.3 ± 13.7 degrees, respectively, p < 0.001 between all slices) and moved posteromedially from a medial direction. FAA (94.2 ± 7, 86.9 ± 9.2, 78.4 ± 9.7, 71.4 ± 9.8, 66.6 ± 10.5 degree, respectively, p < 0.001 between all slices) and FVA (100.6 ± 4.9, 98.3 ± 5.9, 93.7 ± 7.5, 88 ± 9.2, 81.1 ± 10.5 degrees, respectively, p < 0.001 between all slices) decreased and moved from a posterolateral to a posteromedial direction, while VMAD (35.4 ± 7.8, 24.1 ± 7.3, 14.3 ± 6, 8.4 ± 7, 6.2 ± 6.3 mm, respectively, p < 0.001 between all slices) and VMVD significantly decreased (42.7 ± 7.3, 32 ± 7.4, 22.4 ± 6.8, 14.5 ± 10.6, 8.7 ± 7.1 mm, respectively, p < 0.001 between all slices). The average vertical distance was 36 ± 9.3 mm (range 18.6–61.5 mm). The body height and the patellar length significantly affected the vertical distance.

Conclusion

The posterior border of the VM shifted posteromedially from distal to proximal and contacted the SFA at an average of 36 mm from the suprapatellar border. Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy.

Level of evidence

Case series, Level IV.

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

Similar content being viewed by others

Abbreviations

DFO:

Distal femoral osteotomy

CTV:

Computed tomographic venography

VM:

Vastus medialis

SFA:

Superficial femoral artery

SFV:

Superficial femoral vein

VMA:

VM angle

FAA:

Femoral arterial angle

FVA:

Femoral venous angle

VMAD:

VM arterial distance

VMVD:

VM venous distance

References

  1. Apivatthakakul T, Siripipattanamongkol P, Oh CW, Sananpanich K, Phornphutkul C (2018) Safe zones and a technical guide for cerclage wiring of the femur: a computed topographic angiogram (CTA) study. Arch Orthop Trauma Surg 138:43–50

    Article  PubMed  Google Scholar 

  2. Bisicchia S, Rosso F, Pizzimenti MA, Rungprai C, Goetz JE, Amendola A (2015) Injury risk to extraosseous knee vasculature during osteotomies: a cadaveric study with CT and dissection analysis. Clin Orthop Relat Res 473:1030–1039

    Article  PubMed  Google Scholar 

  3. Choi CH, Lee WS, Jung M, Moon HS, Lee YH, Oh J, Kim SJ, Kim SH (2020) 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

    Article  PubMed  Google Scholar 

  4. Darnis A, Villa V, Debette C, Lustig S, Servien E, Neyret P (2014) Vascular injuries during closing-wedge high tibial osteotomy: a cadaveric angiographic study. Orthop Traumatol Surg Res 100:891–894

    Article  CAS  PubMed  Google Scholar 

  5. Devendra A, Avinash M, Chidambaram D, Dheenadhayalan J, Rajasekaran S (2018) Vascular injuries due to cerclage passer: relevant anatomy and note of caution. J Orthop Surg (Hong Kong) 26:2309499018762616

    Article  PubMed  Google Scholar 

  6. Dubois G, Lopez R, Puwanarajah P, Noyelles L, Lauwers F (2010) The corticoperiosteal medial femoral supracondylar flap: anatomical study for clinical evaluation in mandibular osteoradionecrosis. Surg Radiol Anat 32:971–977

    Article  PubMed  Google Scholar 

  7. Duethman NC, Bernard CD, Camp CL, Krych AJ, Stuart MJ (2019) Medial Closing Wedge Distal Femoral Osteotomy. Clin Sports Med 38:361–373

    Article  PubMed  Google Scholar 

  8. Ferner F, Lutter C, Schubert I, Schenke M, Strecker W, Dickschas J (2021) Perioperative complications in osteotomies around the knee: a study in 858 cases. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03696-w

    Article  PubMed  Google Scholar 

  9. Jiamton C, Apivatthakakul T (2015) The safety and feasibility of minimally invasive plate osteosynthesis (MIPO) on the medial side of the femur: a cadaveric injection study. Injury 46:2170–2176

    Article  CAS  PubMed  Google Scholar 

  10. Kang T, Lee DW, Park JY, Han HS, Lee MC, Ro DH (2020) Sawing toward the fibular head during open-wedge high tibial osteotomy carries the risk of popliteal artery injury. Knee Surg Sports Traumatol Arthrosc 28:1365–1371

    Article  PubMed  Google Scholar 

  11. 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  PubMed  Google Scholar 

  12. 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  PubMed  Google Scholar 

  13. Lu Y, Ren X, Liu B, Xu P, Hao Y (2021) Tibiofemoral rotation alignment in the normal knee joints among Chinese adults: a CT analysis. BMC Musculoskelet Disord 21:323

    Article  Google Scholar 

  14. Migliorini F, Aretini P, Driessen A, El Mansy Y, Quack V, Tingart M, Eschweiler J (2020) Better outcomes after mini-subvastus approach for primary total knee arthroplasty: a bayesian network meta-analysis. Eur J Orthop Surg Traumatol 30:979–992

    Article  PubMed  PubMed Central  Google Scholar 

  15. Nakamura R, Akiyama T, Takeuchi R, Nakayama H, Kondo E (2021) Medial closed wedge distal femoral osteotomy using a novel plate with an optimal compression system. Arthrosc Tech 10:1497–1504

    Article  Google Scholar 

  16. Narulla RS, Kanawati AJ (2016) Safe zone for the superficial femoral artery demonstrated on computed tomography angiography. Injury 47:748–751

    Article  PubMed  Google Scholar 

  17. Scheibel MT, Schmidt W, Thomas M, von Salis-Soglio G (2002) A detailed anatomical description of the subvastus region and its clinical relevance for the subvastus approach in total knee arthroplasty. Surg Radiol Anat 24:6–12

    Article  CAS  PubMed  Google Scholar 

  18. Shivji FS, Foster A, Risebury MJ, Wilson AJ, Yasen SK (2021) Ten-year survival rate of 89% after distal femoral osteotomy surgery for lateral compartment osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 29:594–599

    Article  PubMed  Google Scholar 

  19. Ruzbarsky JJ, Arner JW, Ridley TJ, Cooper JD, Hackett TR (2020) Medial biplanar closing wedge distal femoral osteotomy using an articulated tensioning device for controlled osteotomy closure. Arthrosc Tech 10:79–84

    Article  Google Scholar 

  20. Valentine RJ, Wind GG (2021) Popliteal artery. Anatomic exposures in vascular surgery, 4th edn. Lippincott Williams and Wilkins, USA, pp 435–468

    Google Scholar 

  21. van der Woude JA, van Heerwaarden RJ, Bleys RL (2016) Periosteal vascularization of the distal femur in relation to distal femoral osteotomies: a cadaveric study. J Exp Orthop 3:6

    Article  PubMed  PubMed Central  Google Scholar 

  22. Visser J, Brinkman JM, Bleys RL, Castelein RM, van Heerwaarden RJ (2013) The safety and feasibility of a less invasive distal femur closing wedge osteotomy technique: a cadaveric dissection study of the medial aspect of the distal femur. Knee Surg Sports Traumatol Arthrosc 21:220–227

    Article  CAS  PubMed  Google Scholar 

  23. Yamamoto H, Jones DB Jr, Moran SL, Bishop AT, Shin AY (2010) The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg Eur 35:569–574

    Article  CAS  Google Scholar 

Download references

Acknowledgements

None.

Funding

No funding was received to assist with the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan

    Keiji Tensho, Daiki Kumaki, Tomoya Iwaasa, Suguru Koyama, Hiroki Shimodaira & Jun Takahashi

  2. Department of Rehabilitation, Shinshu University Hospital, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan

    Shota Ikegami & Hiroshi Horiuchi

  3. Department of Radiology, Shinshu University School of Medicine, 3-26-1, Asahi, Matsumoto, Nagano, 390-8621, Japan

    Yoshinori Tsukahara

Authors
  1. Keiji Tensho
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daiki Kumaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tomoya Iwaasa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Suguru Koyama
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hiroki Shimodaira
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Shota Ikegami
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hiroshi Horiuchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yoshinori Tsukahara
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Jun Takahashi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KT and YT were responsible for the design of the study. SK, HS, TI and DK were responsible for all recruitment and data collection procedures. SK, TI and DK participated in the data analysis and interpretation. SK and KT drafted the manuscript. KT, HH and JT revised and approved the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Keiji Tensho.

Ethics declarations

Conflict of interest

The author(s) declare that they have no competing interests.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Shinshu University (July 27th, 2020/ No. 4804).

Informed consent

The documentation of informed consent was waived by the Institutional Review Board because of the retrospective nature of the study and the analysis used anonymous clinical data. We disclosed the information on conducting the study to the research subjects, guaranteed an opportunity to refuse to conduct or continue the study.

Additional information

Publisher's Note

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

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tensho, K., Kumaki, D., Iwaasa, T. et al. Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study. Knee Surg Sports Traumatol Arthrosc 31, 1556–1562 (2023). https://doi.org/10.1007/s00167-022-06996-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-022-06996-3

Keywords

Search

Navigation