ARTERIOVENOUS FISTULA AS A COMPLICATION AFTER TOTAL KNEE JOINT REPLACEMENT

ARTERIOVENOUS FISTULA AS A COMPLICATION AFTER TOTAL KNEE JOINT REPLACEMENT

Dmitrov I.A., Zakharyan N.G., Bezverkhiy S.V., Takiev A.T., Alekseeva O.S., Asmaldi Ya.M.I., Aliev R.N.

Moscow City Clinical Hospital No.31, Moscow, Russia

Total knee replacement (TKR) is one of the most efficient surgical interventions providing the functional recovery and alleviation of pain syndrome. Also it improves the life quality in patients with degenerative dystrophic diseases of the knee joint. Knee joint replacement has become the conventional surgery. However the rate of complications increases with increasing number of surgical interventions. According to various studies, the risk of complications after TKR is about 5 % [1-6]. The most common complications are bleeding, wound infection, thromboembolic complications, medial collateral ligament damage, aseptic instability, knee joint stiffness, deep periprosthetic infection, periprosthetic fractures, injury to the extensor mechanism of the knee joint [7]. The less common complications are associated with disordered integrity of vessels surrounding the knee joint.
One of such complications is formation of arteriovenous fistula of the knee joint, but it is the extremely rare. According to some studies, the fistula of branches of the popliteal artery and vein is about 0.03-0.17 % of all complications of TKR [8]. The number of publications relating to this problem is low. Currently, according to the literature data, the precise causes of development of the arteriovenous fistula are unknown. Anahita Dua et al. (2014) in their study described a clinical case of the asymptomatic course of the arteriovenous fistula after TKR without clarification of the cause of its development [9]. Thomas R. et al. (2008) demonstrate a case of formation of the arteriovenous fistula, which was diagnosed after 18 months from the surgery [10]. P. O´ Ceallaigh et al. (2004) presented a follow-up with the arteriovenous fistula, which was diagnosed within one year after TKR, and usually without any clinical signs. The authors describe a clinical case of the arteriovenous fistula. After TKR, the patient received the fixation of a transtrochanteric fracture with use of the dynamic femoral screw. After two months from the moment of osteosynthesis, the arteriovenous fistula was identified. The single clinical sign was only evident noise in the popliteal region [11]. Kane I. et al. (2016) relate the formation of the arteriovenous fistula to an injury to popliteal vessels after injection of a local anesthetic into the posterior part of the knee joint capsule of the knee joint for decreasing pain syndrome in the early postsurgical period [12]. According to Burger T. et al. (1998), the cause of formation of the arteriovenous fistula in their clinical observation was an iatrogenic injury to popliteal artery and vein during knee joint replacement [13].
Among diagnostic instrumental examinations, the authors selected the ultrasonic examination of lower extremity vessels, and multi-spiral computer imaging (MSCT-angiography). According to the authors, the treatment of this pathology is variable and includes the conservative treatment for cases with absent clinical signs of the fistula, without influence on laboratory data and functional results, as well as surgical treatment, which usually includes the endovascular embolization of injured vessels, opened plasty of a vascular defect with use of the stent or the autograft, or the opened vascular suture [14, 15].
Objective – to review the causes of formation of arteriovenous fistula by the example of a clinical case. 

MATERIALS AND METHODS

We present our experience with treatment of a patient with formation of the arteriovenous fistula between the branches of popliteal artery and vein after 9 months from the moment of total knee replacement. The study corresponded to World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and to the Rules for Clinical Practice in the Russian Federation (the Order by Russian Health Ministry, 19 June 2003, No.266), with the written consent for participation and use of the data, with approval from the ethical committee of Moscow City Clinical Hospital No.31 (the protocol No.04-18, 13 December 2018).
The patient Kh., female, age of 66, (the history of hypertonic disease of stage 3) permanently received the hypotensive agents (ACE inhibitors, beta-blockers, diuretics). The previous surgery was appendectomy at the adolescent age. The presurgical range of motions in the knee joint was 5-120°. The pain was intense. The conservative treatment included the intraarticular injections of hyaluronic acid, oral administration of non-steroidal anti-inflammatory agents, resulting in moderate improvement. In 2015, on the occasion of right-sided gonarthrosis, the patient received the total knee replacement with use of the posterior stabilized implant for cement fixation (Fig. 1). In the postsurgical period, the intraarticular injections were not used. The patient was discharged on the ninth day after the surgery. 9 months after the surgery, the patient noted the hyperemia, sharp pain, the feeling of spreading and edema in the right leg. Several weeks before appearance of complaints, the patient fell from the height of her own stature. According to the data of ultrasonic dopplerography of arteries and veins of the lower extremities, and ultrasonic examination of soft tissues along the salens muscle, a liquid formation with a capsule about 30 ml was visualized. This formation was connected to the cavity of the knee joint. MSCT-angiography of pelvic and lower extremity arteries showed an arteriovenous fistula in the region of surgical intervention (Fig. 2, 3).

Figure 1. The X-ray image of the knee joint of the patient Kh., age of 66, after primary knee joint replacement. The frontal and lateral views



Figure 2. Ultrasonic examination of soft tissues. A liquid formation about 30 ml



Figure 3. MSCT-angiography of pelvic and lower extremity arteries. Absent contrast in the field of the arteriovenous fistula

Embolization of the injured arterial branches was performed in cooperation with the vascular surgeons. This type of treatment caused the formation of leg skin necrosis, and subsequent infection of the knee joint. Due to infection and development of instability of the prosthesis components, the revision of the knee joint was carried out, the components of the endoprosthesis were removed, and the cement spacer was installed (Fig. 4). In the postsurgical period, a defect in the upper one-third along the medial surface of the leg healed with secondary tension and with formation of rough scarry changes on the skin (7 × 10 mm) (Fig. 5a). Due to necessity for recurrent knee joint replacement and owing to the presence of rough scarry changes in the skin in the region of the planned approach, a decision was made to install a tissue elastic balloon expander in the region of the lower one-third of the hip with aim of extension of skin surface and for creation of full-thickness skin flap for closure of the skin defect during revision knee joint replacement (Fig. 5b).
Three months after formation of the skin flap, the revision endoprosthetics of the right knee joint was conducted (Fig. 5c, 6).

Figure 4. The X-ray image after delivery of the cement spacer. The frontal and lateral views



Figure 5. The condition of the postsurgical scar at different stages of surgical treatment of the patient Kh.: a) cicatrical changes of the skin (7 × 10 cm) in the region of the upper one-third along the medial surface of the leg before delivery of the balloon expander; b) a picture after delivery of the tissue balloon expander; c) the result after dissection of cicatrical changes of the skin and suturing of the postsurgical wound after revision prosthetics



Figure 6. The X-ray image after recurrent revision prosthetics. The frontal and lateral views

The patient tolerated the surgery well. The postsurgical period was without any features. Before hospital discharge, the patient was activated, and the physiotherapeutic treatment was continued. After 3, 6, 9 and 24 months of the postsurgical period, the patient did not show any complications. The range of movements in the right knee joint was 0-90°. Therefore, the patient was satisfied with the treatment outcome. 

DISCUSSION

As any other surgical intervention, the knee joint replacement causes some risks of postsurgical complications. The least understood and rare complication is formation of the arteriovenous fistula. According to the analysis, the main causes of this pathology can be separated.
The most common risk factors of the arteriovenous fistula are intrasurgical manipulations such as vibrations of the saw, the use of retractors, high temperature during polymerization of bone cement [16, 17]. Moreover, the injection of a local anesthetic into the posterior part of the knee joint capsule can cause the development of this pathology according to the opinion by Kane I. et al. (2016) [12]. Moreover, a clinical case of treatment of a patient with the arteriovenous fistula after a traumatic injury as result of external factors (for example, falling from height of own stature, contusions, penetrating injuries) was described [11]. The less common cases include a vascular abnormality (pseudoaneurysm of the popliteal artery and its branches) as the cause of this condition [16, 17]. In the postsurgical period, the diagnostics of such diseases should include the ultrasonic examination of the lower extremities, and, in case of suspected arteriovenous fistula, MSCT-angiography. The management of such patients is variable and is usually determined by means of hemodynamic and laboratory values. So, if this pathology does not demonstrate any clinical signs and does not worsen the life quality, a decision is made to conduct the conservative treatment and dynamic follow-up. In case of evident clinical symptoms in view of a painful pulsating focus with local hyperemia, increasing temperature, formation of a hematoma, auscultative noise in this region, changes in the laboratory values, the urgent surgical intervention is carried out including subcutaneous embolization, placement of the stent made of the endovascular allo- or autograft or opened application of the vascular suture [14, 15]. 

RESULTS

In our described case, considering the history of the disease (falling from height of the patient’s stature) and absence of data on intrasurgical and postsurgical complications for period of 9 months, we can suppose that the possible cause of formation of the arteriovenous fistula between the branch of the popliteal artery and vein is a traumatic impaction in the postsurgical period.
In our clinical case, the MSCT-angiography data of the lower extremity arteries enabled the visualization of the arteriovenous fistula in the region of the popliteal fossa.
In cooperation with the vascular surgeons, the method of embolization of injured vessels with use of EmboSphere® agent was selected. The use of this method caused the obstruction of other branches of the popliteal artery which delivered the blood to the skin. As result, the necrosis of skin surface of the leg and the knee appeared. Since the incapsulated liquid accumulation after bleeding from the injured artery to soft tissues connected to the joint cavity, it caused the infection of the knee joint, and some additional surgical interventions were required for achievement of the final goal – ultimate installment of the knee  endoprosthesis and recovery of the extremity functioning. 

CONCLUSION

The formation of the arteriovenous fistula is the underinvestigated complication after total knee replacement. One should give attention to such symptoms as pain syndrome and pulsation in the popliteal region, local edema and hyperemia, vascular murmur. Each symptom allows suspecting the presence of the arteriovenous fistula.
In the postsurgical period, it is recommended to perform the long term follow-up of patients’ condition with use of laboratory and instrumental methods. Also the individual approach for selection of the most appropriate treatment method for each individual case is required. Early identification of this pathology promotes the improvement of treatment results and favorable prognosis for the patient. 

Information on financing and conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.                                 

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