Total knee replacements and high tibial osteotomies are commonly performed orthopaedic operations with low complication rates. Both of these procedures involve surgery in close proximity to the popliteal artery with the use of power tools and sharp instruments. The behaviour of the popliteal artery during knee flexion, in particular the change in distance between itself and the posterior tibial cortex, is poorly understood. Many previous studies have been on stiff embalmed knees or with the patient lying supine, so as to subject the popliteal artery to an anterior pull from gravity. We used duplex ultrasonography on 100 healthy knees to determine the distance of the popliteal artery from the posterior tibial surface at 0 and 90 degrees of flexion. One observer was used throughout. At 1–1.5cm below the joint line, we found the artery was closer to the posterior tibial surface in 24% of knees when the knee was flexion. This was also the case for 15% of knees at 1.5–2cm below the joint line. These two levels were chosen as they represent the usual positions for the tibial cuts performed in total knee replacement and tibial osteotomy. We provide an anatomical account to help explain our findings using cadaveric dissections, arteriography and static MRI studies. The first of our explanations for this posterior movement of the artery is the increase in the antero-posterior thickness of the popliteus muscle during knee flexion. We also observed a posterior pull on the popliteal artery from the sural vessels. 6% of the knees had a high branching anterior tibial branch. We highlight this anatomical variant as an example of an extremely vulnerable vessel. We review the existing literature regarding the popliteal artery dynamics, and conclude that 90 degrees of knee flexion is the safer position for tibial procedures, but repeat the warning that the surgeon must still take great care

Purpose: Knee dislocation is associated with blunt popliteal artery trauma in almost 30% of cases. In such injuries, prompt diagnosis and appropriate management is essential for limb salvage. Both our methods and outcomes of popliteal artery thrombosis treatment after knee dislocation are presented in this retrospective study. Methods: During the last six years, eight patients (all male, average age 25 years) were admitted to our hospital with knee dislocation and associated blunt popliteal artery thrombosis following automobile accidents (7/8) and fall from height (1/8). The average delay before accessing the emergency room was 14 hours (ranging from 2 to 24 hours). Seven patients were experiencing signs of distal ischemia (absence of distal pulses, motor and sensory loss) and one patient, admitted two hours after vehicle accident, was presented with absent distal pulses but maintained motor and sensory ability. Seven patients underwent external fixation and one plaster cast immobilization. In all cases, digital subtraction arteriography was performed. Results: All patients were treated by performing below knee femoropopliteal bypass, using reversed saphenous vein in seven cases and a vscs graft in one. All patients underwent fasciotomies. One above knee amputation was performed postoperatively while three patients experience permanent neurologic discrepancy. Conclusions: In any case of knee dislocation, there must be a high clinical suspicion of popliteal artery thrombosis. Meticulous and repeated physical examination and rapid admission to a department of vascular surgery are of vital importance for limb salvage and minimization of amputation rate and permanent neurologic deficiency

Purpose. We aim to determine the amputation rate and identify predictors of outcome in patients with tibial fractures and associated popliteal artery injuries at a level 1 trauma unit draining a large geographical region. Material and methods. All patients with popliteal artery injuries and tibial fractures treated at a level 1 trauma unit between 1999 and 2010 were assessed retrospectively regarding amputation rates and prognostic factors and tested for significance with a Z-test of proportions. Results. Thirty consecutive patients were reviewed with a mean age of 30.5 years and a male preponderance of 73.3%. Motor vehicle accidents (MVAs) and gunshot wounds (GSWs) constituted the mechanism of injury in 17 patients (56.7%) and 11 patients (36.7%) respectively. Twenty-one cases were polytrauma patients. Intra and extra-articular metaphyseal fractures (AO 41 A-C) were seen in 19 patients and diaphyseal fractures (42 A-C) in 7 patients. Primary amputation was performed in 7 patients and delayed amputation in 10 patients giving an overall amputation rate of 56.7%. Amputation rates in MVAs and GSWs were similar (57.9% and 54.5% respectively). Delays from injury to revascularization of more than 6 hours, delays from hospital admission to revascularization of more than 2 hours and initial clinical assessment of non-viability were associated with higher rates of limb loss of 60.9%, 62.5% and 60% respectively. Signs of threatened viability together with delay from admission to theatre more than 2 hours showed the highest amputation rate of 68,4%. These results are trends and not statistically significant with 95% confidence interval. Conclusion. More than half of the patients with these injuries required amputation. Predictors of amputation remain elusive; however, these results suggest that initial presentation of a threatened limb in the context of a tibial fracture may necessitate intervention within the first 2 hours of presentation in order to improve the outcome. NO DISCLOSURES

Introduction. Regional anesthesia is commonly utilized to minimize postoperative pain, improve function, and allow earlier rehabilitation following Total Knee Arthroplasty (TKA). The adductor canal block (ACB) provides effective analgesia of the anterior knee. However, patients will often experience posterior pain not covered by the ACB requiring supplemental opioid medications. A technique involving infiltration of local anesthetic between the popliteal artery and capsule of knee (IPACK) targets the terminal branches of the sciatic nerve, providing an alternative for controlling posterior knee pain following TKA. Materials and Methods. IRB approval was obtained, a power analysis was performed, and all patients gave informed consent. Eligible patients were those scheduled for an elective unilateral, primary TKA, who were ≥ 18 years old, English speaking, American Society of Anesthesiologists physical status (ASA PS) classification I-III. Exclusion criteria included contraindication to regional anesthesia or peripheral nerve blocks, allergy to local anesthetics, allergy to nonsteroidal anti-inflammatory drugs (NSAIDs), chronic renal insufficiency with GFR < 60, chronic pain not related to the operative joint, chronic (> 3 month) opioid use, pre-existing peripheral neuropathy involving the operative limb, and body mass index (BMI) ≥ 40 kg/m. 2. . Patients were randomized into one of two treatment arms: Continuous ACB with IPACK (IPACK Group) block or Continuous ACB with sham subcutaneous saline injection (No IPACK Group). IPACK Group received single injection of 20 mL 0.25% Ropivacaine. Postoperatively, all patients received a standardized multimodal analgesic regimen. The study followed a double-blinded format. Only the anesthesiologist performing the block was aware of randomization status. Following surgery, a blinded medical assessor recorded cumulative opioid consumption, average and worst pain scores, and gait distance. Results. 72 people were enrolled in the study and three withdrew. There were 35 people in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the Post Anesthesia Care Unit (PACU), the average (P=0.0122) and worst (P=0.0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy. (P=0.2080) There was no difference in opioid consumption in the PACU (P=0.7928), at 8 hours (P=0.2867), 16 hours (P=0.2387), 24 hours (P=0.7456), or 30 hours (P=0.8029). There was no difference in pain scores on POD 1 in the AM (P=0.4597) or PM (P=0.6273), nor was there any difference in walking distance (P=0.5197). There was also no difference in length of stay in the PACU (P=0.9426) or hospital (P=0.2141) between the two groups. Discussion/Conclusion. Overall, pain was well controlled between the two groups. The IPACK group had lower pain scores at rest in the PACU, but this may not be clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be use of the IPACK block as a rescue block or in patients whom have contraindications to our standard multimodal treatment regimen, or in patients with chronic pain or opioid dependence

Introduction The aim of the study was to investigate the incidence, in Australia, of popliteal artery injury during knee surgery; to assess the distance from the popliteal artery to the posterior tibia in flexion and extension; and to investigate the influence of major trauma or surgery on the anatomy. Methods A questionnaire was sent to Australian members of the ANZ Society of Vascular Surgeons. Duplex ultrasound studies were obtained through the Vascular Laboratory University of Melbourne. Studies in extension and 90° of flexion assessed the distance from the popliteal artery to the posterior tibia. Twelve persons with normal knees were assessed bilaterally. Eight patients with a posterior cruciate ligament deficient knee were assessed bilaterally. Seventy vascular surgeons responded documenting 115 popliteal artery injuries occurring during knee surgery. There were 69 lacerations, 27 thromboses, 13 AV fistula and 19 false aneurysms. In 12 normal people (24 knees) the popliteal artery was 5.5 mm (2.9 to 9.9) from the tibia in extension and 5.7 mm (2.9 to 10.0) in 90° of flexion. In ten of 24 knees the artery moved closer in flexion. In the eight posterior cruciate ligament deficient knees the artery was 4.7 mm (2.7 to 6.9) from the tibia in extension and 3.8 mm (2.6 to 4.5) at 90° of flexion. In all eight PCL knees the artery moved closer in flexion. In normal knees the popliteal artery may move closer to the tibia in flexion, the average distance being about 5.5 mm. Conclusions The popliteal artery is closer to the knee joint following trauma or surgery and specifically closer in flex-ion than in extension. Risks of injury are significant

The February 2014 Knee Roundup. 360 . looks at: whether sham surgery is as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether trans-tibial tunnel placement increases the risk of graft failure in ACL surgery; whether joint replacements prevent cardiac events; the size of the pulmonary embolism problem; tranexamic acid and knee replacement haemostasis; matching the demand for knee replacement and follow-up; predicting the length of stay after knee replacement; and popliteal artery injury in TKR

Orthopaedic problems are common in patients with Ehlers-Danlos Syndrome (EDS). Articular hypermobility can be particularly disabling leading to instability in the appendicular skeleton. We present a case of an EDS patient presenting with knee pain and instability. It highlights important lessons to be learned when considering joint replacement in this patient group. A 51 year old lady with EDS underwent a posterior cruciate retaining total knee replacement for pain and instability. She dislocated her knee replacement three months post-operatively after a fall. Her knee was reduced at her local emergency department causing injury to the popliteal artery. She required urgent popliteal artery repair and fasciotomies. The common peroneal nerve was also irreversibly damaged by the dislocation. She has since had one further dislocation and is now awaiting revision surgery. When considering total knee replacement (TKR) in EDS, the patient must be warned of the inferior results compared to TKR for other causes. The increased risk of complications must be explained and a more constrained TKR design considered to address the inherent joint laxity. The potential consequences of a dislocated TKR can be disastrous and therefore relocation must be performed in a controlled environment in the operating theatre

A 55-year-old man developed a pseudoaneurysm of the popliteal artery after tibial valgization osteotomy performed for degenerative genu varum. A tourniquet was used for the procedure. A wedge osteotomy was performed two centimeters under the joint line; the correction angle was ten degrees. Immediately after the end of the procedure, the distal pulses disappeared for ten minutes. Doppler exploration of the arterial network did not demonstrate any anomaly. Ten days postoperatively, the patient complained of sudden onset pain in the knee and tension in the popliteal fossa. Arteriography demonstrated a pseudo-aneurysm of the popliteal artery. The lesion caused an interruption of arterial flow and was successfully treated by emergency resection and suture

The superficial anterior vasculature of the knee is variably described; most of our information comes from anatomical literature. Descriptions commonly emphasise medial-dominant genicular branches of the popliteal artery. Describing the relative contribution of medial and lateral vessels to the anastomotic network of the anterior knee may help provide grounds for selecting one of a number of popular incisions for arthrotomy. The aim of this study is to describe the relative contribution of vessels to anastomoses supplying the anterior knee. Cadaveric knees (n = 16) were used in two cohorts. The first cohort (n = 8) were injected at the popliteal artery with a single colour of latex, and then processed through a modified diaphanisation technique (chemical tissue clearance) before final dissection and analysis. This was repeated for the second cohort, but with initial dissection to identify potential source vessels at their origin. Each source vessel was injected with a different colour of latex. The dominant sources were determined in each specimen. The majority of the specimens (n = 13; 81%) demonstrated that an intramuscular branch though the vastus medialis muscle was the dominant vessel. Anastomoses were most common over the medial side of the knee, both superiorly and inferiorly (3-5 anastomoses in all cases). Anastomosis over the lateral knee was infrequent (1 anastomosis in 1 specimen). The results suggest that anterior vasculature of the knee is predominately medial in origin, but not from the genicular branches as previously described. This network of vessels found in the anterior knee is thought to be the main supply to the patella, extensor apparatus, anterior joint capsule and skin. Optimum placement of incision for arthrotomy is a subject of debate. Considering the main blood supply to the anterior knee may help in choosing a particular approach

Introduction. The superficial anterior vasculature of the knee is variably described; most of our information comes from anatomical literature. Descriptions commonly emphasise medial-dominant genicular branches of the popliteal artery. Quantifying the relative contribution of medial and lateral vessels to the anastomotic network of the anterior knee may help provide grounds for selecting one of a number of popular incisions for arthrotomy. Aim. To describe the relative contribution of vessels to anastomoses supplying the anterior knee. Method. Cadaveric knees (n = 16) were injected at the popliteal artery with a single colour of latex; then processed through a modified diaphanisation technique (chemical tissue clearance) before final dissection and analysis. The dominant sources were determined in each specimen. Specimens were reconstructed using 3D microscribe technology for further quantification. Results. The majority of the specimens (n = 13/16; 81%) demonstrated that an intramuscular branch though the vastus medialis muscle was the dominant vessel, giving rise to 65% of all vessels seen on the medial side of specimens. Mean gauge of source vessel seen over the superior medial aspect of the knee (2.4mm) was greater than that of the lateral side (1.0mm; p< 0.05). Medial-medial anastomoses (n=13/16; 81%) were seen more frequently than lateral to lateral (n=4/16; 25%; p< 0.05). Discussion. The results suggest that anterior vasculature of the knee is predominately medial in origin, but not from the genicular branches as previously described. The networks of vessels found in the anterior knee are thought to be the main supply to the patella, extensor apparatus, anterior joint capsule and skin. Optimum placement of incision for arthrotomy is a subject of debate. Considering the main blood supply to the anterior knee may help in choosing a particular approach

Aim: The orthopedic surgeons, especially those who are specialized in arthroplasty, should be conversant with all the anatomic variations of the popliteal bothrium. After a wide research we present our conclusions about the variations of the popliteal bothrium. Material-method: The study was carried out in the Anatomic Laboratory of Athens Medical University during the last 16 years and for our purpose we dissected 110 cadavers (220 legs). Results: The length of the popliteal artery, from the major adductor foramen to the division into anterior and posterior tibial artery, is 4–9 cm. We have classified the observed variations into two groups, according to whether the division is below or above the level of the popliteal muscle:. 1. below the level of the popliteal muscle (194/220). A. The division occurs after the origin of the peroneal artery (172/220). B. The peroneal artery arises at the level of the division (16/220). C. The popliteal artery divides into posterior tibial and peroneal artery, while the anterior tibial artery arises from the peroneal (6/220). 2. above the level of the popliteal muscle (26/220). A. The peroneal artery arises from the posterior tibial artery (10/220). B. The peroneal artery arises from the posterior tibial artery, while the anterior tibial artery runs in front of the popliteal muscle (8/220). C. The peroneal artery arises from the anterior tibial artery (8/220)

Introduction. Postoperative pain is a concern for patients undergoing Total Knee Arthroplasty (TKA) and plays an important role in opioid consumption, length of stay, and postoperative function. The purpose of this study was to compare outcomes in patients who underwent primary TKA comparing femoral and sciatic (F+S) combination motor nerve block versus an adductor canal and the interspace between the popliteal artery and the capsule of the posterior knee (ACB+IPACK) combination sensory nerve block. Methods. 100 consecutive primary TKA cases performed by a single surgeon using the same surgical approach and implant design were reviewed. The first 50 patients received F+S nerve blocks and the second 50 received ACB+IPACK blocks preoperatively. Both groups also received total intravenous anesthesia (TIVA). Differences in opioid requirements, length of stay (LOS), distance walked, Western Ontario & McMasters University Osteoarthritis Index (WOMAC), Knee Society (KSS) function scores, Visual Analog Scores (VAS) for pain at rest and with activity, and postoperative complications were analyzed. There were no differences in the groups with respect to age, sex or BMI. Results. 62% of patients were discharged on postoperative day #1 in the ACB+IPACK group compared to 14% in the F+S group (p<.0001). The ACB+IPACK patients had a shorter LOS (average 1.48 days versus 2.02 days, p<0.0001), ambulated further on postop day #0 (average 21.4 feet versus 5.3 feet, p<0.0001), required less narcotics the day after surgery (average 15.7 versus 24.0 morphine equivalents p<0.0001) and at 2 weeks postoperative (average 6.2 versus 9.3 morphine equivalents, p=0.025), and required less manipulations under anesthesia (1 versus 5, p=0.204). WOMAC, KSS, and VAS scores were not significantly different. Discussion. The use of combination adductor canal and IPACK sensory blocks demonstrated improved early ambulation with decreased opioid use, length of stay, and postoperative manipulations. This study suggests that the use of combination sensory adductor canal and IPACK nerve blocks are superior to motor nerve blocks in patients undergoing primary TKA

This was a retrospective study of all patients with soccer injuries admitted to our orthopaedic unit over 42 months. Patients treated as outpatients were assessed for purposes of comparison. Thirty-two patients were admitted with severe injuries, including 18 fractures of the tibial and femoral shaft. Two tibial shaft fractures were compound. There were four tibial plateau fractures and five epiphyseal injuries. One patient had a fracture dislocation of the hip. One patient with a popliteal artery injury, who presented 48 hours after a soccer injury, underwent an above-knee amputation. In the same period, 122 patients were treated as outpatients. The types of injuries in this group were similar to soccer injuries reported in other countries. Very serious injuries are sustained in community soccer players in South Africa and urgent measures need to be taken to prevent such injuries

The so called “floating knee” is the result of ipsilateral fractures of femur and tibia. The definition of floating knee dates back to 1974, when Blake and Mc Bryde proposed it in order to move the attention from the skeletal plane of the lower limb to the articular and vasculonervous plane of the knee, where complications are more frequent and dreadful: lesions of popliteal artery or sciatic nerve, stiffness or instability of the knee. The timing of surgical treatment is still debated: in fact it may be immediate but provisional, with necessity of a second operation, or delayed but definitive. Also the strategy of osteosynthesis may be controversial, because of the association of fractures. We present a series of 3 cases (among them there were also 2 ipsilateral fractures of patella) with both femur and tibia treated by osteosynthesis with plate (1 case, with complications) or nail (2 cases, without complications): the patients were followed-up clinically and with X-rays for 1 year. Our experience confirms the gold standard for this kind of fractures is locked intramedullary nailing, retrograde for femur and antegrade for tibia

Introduction. Fast track arthroplasty regimens require preservation of motor power to perform early rehabilitation and ensure early discharge (1). Commonly performed nerve blocks like femoral and Sciatic nerve blocks results in motor weakness thereby interfering with early rehabilitation and may also predispose to patient falls (2, 3). Hence, targeting the terminal branches of the femoral and sciatic nerves around the knee joint under ultrasound is an attractive strategy. The nerve supply of interest for knee analgesia are the terminal branches of the femoral nerve, the genicular branches of the lateral cutaneous nerve of thigh, obturator and sciatic nerves (4). Methods. We modified the performance of the adductor canal block and combined it with US guided posterior pericapsular injection and lateral femoral cutaneous nerve block to provide analgesia around the knee joint. The femoral artery is first traced under the sartorius muscle until the origin of descending geniculate artery and the block is performed proximal to its origin. A needle is inserted in-plane between the Sartorius and rectus femoris above the fascia lata and 5 ml of 0.5% ropivacaine (LA) is injected to block the intermediate cutaneous nerve of thigh. The needle is then redirected to enter the fascia of Sartorius to deliver an additional 5ml of LA to cover the medial cutaneous nerve of thigh following which it is further advanced till the needle tip is seen to lie adjacent to the femoral artery under the Sartorius to perform the adductor canal block with an additional 15–20 ml of LA to cover nerve to vastus medialis, saphenous nerve and posterior division of the obturator nerve (Fig 1). The lateral cutaneous nerve of thigh is optionally blocked with 10 ml of LA near the anterior superior iliac spine between the origin of Sartorius and tensor fascia lata (Fig 2). The terminal branches of sciatic nerve to the knee joint is blocked by depositing 25 ml of local anesthetic solution between the popliteal artery and femur bone at the level of femoral epicondyles (Fig 3). Results. The initial experience of the block performed on 10 patients reveal the median (IQR) block duration is noted to be around 20 (±6.5) hours. The median (IQR) pain scores in the first 24 postoperative hours ranged from 0 (±0.5) to 3 (±2.5) at rest and 1.5 (±3.5) to 5.5 (±1) on movement. All patients were successfully mobilized on the morning of the first postoperative day. Conclusion. Motor sparing from the blocks while providing adequate analgesia can be achieved by selectively targeting the sensory innervation of the knee joint. Future comparative studies are needed to evaluate the performance of the block against other modes of analgesia for knee arthroplasty

Proximal tibial epiphyseal injuries are rare. Reported incidence varies from 0.5 – 3% of epiphyseal injuries. Proximal tibial epiphysis is well protected unlike distal femoral epiphysis. Thus, the distal femoral injuries are 7 times more frequent than proximal tibial epiphyseal injuries. Case Report: 12-year old boy, hit a pole at the bottom of a dry ski slope and presented to A& E within 20 minutes. He had a swollen, deformed knee and leg that was immobilised in a temporary splint. He had absent posterior tibial and dorsalis pedis pulses. Emergency manipulation under GA and further stabilised with K-wires, A/K Back Slab in 450 flexion. Distal pulses returned on table. K-wires were removed after 4 weeks and physiotherapy started. At 3 months, he was back to normal activities except sports. At 2 years, he was longer by 1 cm in left tibia, valgus of 120 at the knee, full ROM, no ligament laxity and reports occasional anterior knee pain. Discussion: Posteriorly displaced proximal tibial Salter Harris II injuries are very rare. Emergency reduction and stabilisation, absence of popliteal artery tear had prevented the immediate complications. The late complications did not warrant a surgical intervention

Background: Vascular injuries associated with total joint arthroplasty are the most feared complication. The arterial and venous injury can occur due to direct or indirect trauma. A high index of suspicion, recognition of the injury and prompt treatment, with the immediate availability of a vascular surgeon is vital for good outcome. Methods: Using prospectively collected data on 13624 patients undergoing total joint arthroplasty at our institution, all incidences of vascular injury were identified. Detailed data regarding the mode of presentation, the type and the outcome of intervention delivered, and the eventual functional outcome of the total joint arthroplasty were determined. Results: There were a total of 17 vascular injuries (0.1%). Majority (16/17) of these vascular injuries were detected in the postoperative recovery area. 9 injuries occurred after TKA and 8 occurred after THA. Indirect injury was the mechanism in TKA patients with popliteal artery thrombosis being the mechanism. In contrast direct injury was the mechanism in THA patients. Fasciotomy was performed in all TKA patients and none were needed in the THA patients. One patient died of complications related to vascular injury. 12 of 17 patients (70%) had launched a legal suit against the operating surgeon. Conclusions: After more than 80 years of accumulated experience and more than 35000 joint replacements performed by 5 surgeons in our center, the vascular complication still continues to occur. Patient awareness regarding this real problem may play a role in defraying the extremely high likelihood of legal suits associated with this complication

Aims: The purpose of this study is to review the results of our experience in the treatment of all of the cases of traumatic knee dislocations (TKD) from 1988 to 1998 by means of a retrospective study. Methods: 26 patients, 20 males and six females, mean age 37 y. o. average follow up 36 months. Right involved in þfteen cases. The mechanism of injury was a motor vehicle accident in 19 cases. Posterior type was the most frequent with 8 cases. In twelve cases it was reduced on initial presentation, so it was not possible to classify the type of dislocation. PCL was the most frequent damaged ligament (22 cases). In most cases (81%) TKD was reduced under general anesthesia and an early surgical repair was performed as each case required. The follow up assessment included the Lysholm scoring system. Results: Excellent or good results were obtained in 14 of 26 patients (55%). Fair or poor results were obtained in 12 of 26 cases (45%). In 5 of 12 cases the treatment was conservative. Peroneal nerve palsy (23%) and popliteal artery disruption (8%) were the most frequent complications. The most common residual symptom was instability compared with contralateral knee (85%). Conclusions: Early operative repair of all damaged structures was associated with the best functional result (55%). Non-operative treatment was associated with 100% unsatisfactory results

Purpose: Despite a number of recently published reports on the success of meniscal repair devices, there are no anatomic studies documenting their safety. The purpose of this cadaveric and radiographic study was to anatomically determine the proximity of a common commercially available meniscal repair device to the popliteal neurovascular structures. Methods: Five human cadaveric knees were obtained and procured from the medical school anatomy lab. Two Biostingers (Linvatec) measuring 16mm in length were placed in the posterior one third of the medial meniscus. Each specimen was then placed prone with the knee extended to expose the posterior aspect of the knee. The distance to the neurovascular bundle for each device was then measured with a ruler calibrated to the nearest 0.1cm. To validate our anatomic dissection results, fifty calibrated human knee MRI scans were reviewed by two independent radiologists. The distances measured were from the popliteal artery to the closest point at the lateral meniscus periphery/capsule and the medial meniscus periphery/capsule. The average distance as measured by the two radiologists was calculated as was the average for the entire population of fifty subjects. Results: The mean distance in the cadaveric study was 15.6mm (14.0–18.0mm) between the tip of the repair device needle and the neurovascular bundle. The mean distance on MRI from the popliteal neurovascular bundle to the closest point in the posterior medial meniscus was 20.0 mm (13.0 mm–28.7 mm). The mean distance from the popliteal structures to the posterior lateral meniscus was 9.4 mm (3.2 mm–16.5 mm). Conclusions: Considering the potential for significant morbidity, we recommend medial meniscal repair should be performed carefully with repair devices. Specifically, one should limit posterior capsule penetrations to less than 15 mm based on these findings

The literature states pre-operative angiography of open tibial fractures (OTFs) should only be considered if abnormal pedal pulses are present. Aim. Does pre-operative angiography of OTFs benefit patient management?. Method. 43 patients were admitted with OTFs to Charing Cross Hospital, London between 3/2004 and 6/2005. Pedal pulses were documented and routine pre-operative angiography performed following primary surgical debridement. At definitive operation, data was collected prospectively assessing vasculature and the microsurgical findings. All patients underwent free flap reconstruction or amputation. Comparison was made with angiographic findings and whether surgical management had been affected. Retrospective audit of all angiograms was performed by a consultant radiologist establishing the sensitivity/specificity. Results. Patients' mean age was 36 (18-86) with ratio 31M:12F. 40 patients had normal pedal pulses; 3 abnormal. 26 had normal angiography and 17 abnormal. 13/17 were due to injury, 2 anatomical variants and 2 atherosclerotic disease. Commonest vessel damaged was the anterior tibial (AT) n=8. Posterior tibial artery (PT) was not damaged alone but with AT n=3. AT damaged alone n=4 and AT with peroneal n=1. Popliteal artery was damaged alone n=1. 4/13 vessels with injury-induced damage required adjustment of pedicle anastomosis along with 1 from the variant group and 1 from the atherosclerotic group. Therefore 6/43 (14%) patients had surgery adjusted and the findings detected angiographically were confirmed clinically. 40 free flaps were performed and 3 amputations. All free flaps survived. 2 cases had abnormal vasculature not detected by angiogram (thrombosed venae commitans n=1 and distal PT ligated n=1). Audit of the angiograms when compared to clinical findings revealed sensitivity 90% and specificity 100%. Conclusion. A six times increase in vessel damage was discovered after angiography compared with clinical assessment alone. The findings significantly affected surgical practice. A high degree of sensitivity/specificity was seen with angiography. The authors advocate routine angiography for all OTFs