Periprosthetic tibial fracture after total knee arthroplasty
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• Author experienced a case of periprosthetic tibial fracture after total knee arthroplasty with popliteal artery injury.

• There have been no reports of periprosthetic fracture associated with popliteal artery injury.

• Because this injury process is not specific and caused by a minor injury, the chances of encountering this injury are expected to increase in the future.

A 79-year-old woman had undergone surgery on the medial collateral ligament of her right knee several decades previously and had then undergone TKA for right-knee osteoarthritis two years previously.

She fell from a height of about 50 cm, overstretched the right knee at landing, and was aware of right knee pain. She was immediately transported to a nearby hospital. The patient was diagnosed with a periprosthetic tibial fracture after TKA and was admitted to the hospital. However, the right dorsalis pedis artery was not palpable, raising the suspicion of a popliteal artery injury, and she was therefore transferred to an emergency and critical care medical center for the purpose of revascularization. Popliteal artery injury at the fracture level was diagnosed by computed tomography angiography (CTA) and, on the same day, emergency surgery for revascularization was performed. The popliteal artery showed a semicircular partial rupture at the bifurcation of the anterior and posterior tibial arteries, suggesting direct injury by a bone fragment from the posterior tibia. The bifurcation was excised and an anastomosis made between the popliteal and posterior tibial arteries. Because damage to the popliteal vein was also observed, the injured area was excised and an end-to-end anastomosis was performed to complete revascularization.

In addition, external fixation across the knee was performed to stabilize the fracture, and the operation was completed. On the 11th day after the injury, internal fixation was performed. A diagnosis of Felix classification IIB was made, and anatomical locking plates were placed and fixed from the inside and outside of the proximal tibia. Screws were inserted forwards and backward of the keel of the tibial implant to support the implant and prevent postoperative dislocation. On the 5th day after internal fixation, antibiotic treatment was started because of surgical-site sepsis (SSI). Debridement was performed seven days after surgery. After 21 days, the exposed plate was covered using the gastrocnemius muscle flap. After 50 days, the infection had resolved. Partial weight-bearing started 3 months after surgery, and the bone union was confirmed 5 months after surgery.