Acute popliteal thrombus following total knee arthroplasty
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A 38-year-old male presented for right total knee arthroplasty (TKA) at Johns Hopkins Bayview Medical Center. He elected to undergo primary TKA, secondary to end-stage posttraumatic osteoarthritis that was refractory to non-operative treatment. The patient was a non-smoker with no known significant past medical history, other than a body mass index (BMI) of 37.53. His past surgical history was significant for open reduction internal fixation (ORIF) of a right tibial plateau fracture, and subsequent right knee arthroscopies. Due to persistent pain and symptoms after exhausting conservative treatment, he wished to proceed with surgical intervention.

A staged hardware removal followed by TKA was recommended. The hardware removal was performed without complications, and the TKA was planned for 3 months later. Popliteal artery thrombus confirmed by angiogram and venous duplex. Interventions: Immediate vascular surgery consult and subsequent embolectomy. A joint replacement specialist performed a cruciate-retaining R-TKA under spinal anesthesia. Two grams of Ancef was given 30 minutes prior to the operation. Zimmer-Biomet Nex Gen CR Flex primary knee (Warsaw, IN) implants were used. Blood loss was minimal (100 mL). Tourniquet time was less than 60 minutes. There were no apparent intraoperative complications but the patient had significant preoperative stiffness, which made soft tissue mobilization slightly more difficult throughout the case.

Postoperative radiographs demonstrated excellent alignment and fixation of the femoral and tibial components. Two hours postoperatively, the patient developed increased right anterior shin pain and lower leg swelling. The patient's right lower extremity gross sensation was intact but overall diminished, compared to the left. Left lower limb pulses were 2+; however, the right posterior tibial and dorsalis pedis pulses were non-palpable and undetectable via Doppler ultrasound. CT Angiography with contrast and an arterial duplex ultrasound revealed a thrombus in the right distal popliteal artery, inferior to the joint line. Vascular surgery was immediately consulted, and the patient was taken emergently to the operating room for an open popliteal artery thrombectomy. Two medium-sized clots and 1 small sized clot were evacuated successfully. At one year postoperatively, the patient is doing well with no further complications.