By Anthony H. Gair, Gair Gair Conason Steigman Mackauf Bloom&Rubinowitz
The popliteal artery is the major source of blood supply to the lower leg. The femoral artery becomes the popliteal artery as it passes through the hiatus of the adductor magnus muscle and enters the popliteal fossa. It generally ends at the inferior border of the popliteus muscle where it divides into the anterior and posterior tibial arteries. It lies directly behind the posterior horn of the lateral meniscus.1 Injuries to the popliteal artery during anterior cruciate ligament reconstruction or arthroscopic meniscectomy are extremely rare.2 The popliteal artery is closely related to the posterior capsule of the knee joint, being separated from it only by a small amount of fat. The artery also kinks forward when the knee is flexed, placing it close to the posterior horn of the medial meniscus. It is thus imperative that surgery in the posterior aspects of the knee is performed under direct visualization. If an arterial injury is suspected following surgery of the knee an opinion from a vascular surgeon should be sought urgently.
As a New York medical malpractice attorney we understand the delayed recognition of a popliteal artery lesion is a major cause of amputation of the affected extremity. Further, true spasm of the popliteal artery is rare. It is thus dangerous to diagnose arterial spasms since in reality thrombosis is usually present. It is further, axiomatic that the absence of pulses in an extremity is due to arterial injury until proven otherwise. Additionally, compartment syndrome may accompany vascular injury secondary to prolonged ischemia, venous injury or partial laceration to the artery with bleeding into the compartments.
The following case involved a young woman who was diagnosed with a tear of the anterior cruciate ligament and of the posterior horn of the medial meniscus of the right knee. Subsequently, the orthopedic surgeon performed arthroscopic assisted surgery for the repair of the ACL and partial medial meniscectomy. On the afternoon following surgery the patient complained of pain behind the knee and decreased sensation in the foot. The foot was noted to be swollen. On post-op day one swelling to the right thigh and foot was noted as persisting. On post-op day two she complained of pain behind the knee and swelling. The leg and foot were edematous, there was no sensation of the toes and an inability to move the toes or foot was noted. The skin was colorless with some mottling at the foot. The surgeon was called and changed her pain medication to percocet. On post-op day three the surgeon was again called and examined the patient. Despite the above symptoms indicative of vascular injury, together with the presence of foot drop, he did not request a vascular consultation. He sent her to the emergency room for an ultrasound to rule out a deep venous thrombosis. The popliteal artery was not studied. The compartment pressures were measured and compartment syndrome ruled out as a cause of the patient’s symptoms, as was deep venous thrombosis. On post-op day four, the patient continued with complaints of severe pain behind her knee. The surgeon was once again called and met the patient at the emergency room. Compartment pressures were measured and were elevated in the anterior compartment only. A fasciotomy was performed at which time the muscles of all compartments were noted to be viable and should have indicated to the surgeon the elevated pressures in the anterior compartment could not have been present for more than eight hours and hence did not explain the patient’s prior symptoms. The post-anesthesia care record noted the right foot to be cold, blanched and mottled at the ball of the foot with decreased movement. A pulse of the right foot was not palpable or obtainable with doppler. Nurses notes for post-op day five noted the toes of the right foot to be cold to touch and non-mobile. No pedal pulses were noted. The knee, calf and foot were edematous. The patient complained of swelling and burning of the leg. A vascular consultation was finally obtained on post-op day six. An angiogram was performed which demonstrated a 2cm pseudoaneurysm of the mid popliteal artery with occlusion just distal to the pseudoaneurysm. Surgery was immediately performed for repair of the artery. However, as a result of prolonged ischemia and resulting necrosis, the patient’s right leg was required to be amputated below the knee.
Plaintiff claimed several departures from proper practice. First was the iatrogenic injury to the popliteal artery at the time of the initial surgery. Secondly, and most glaring, was plaintiff’s claim as to the failure to obtain a vascular consult between the time of the ACL repair and post-op day six despite obvious signs of vascular compromise. It was claimed that had a prompt vascular consult been obtained the arterial injury would have been diagnosed and the leg saved by prompt repair by the vascular surgeon.
It was anticipated, as a result of review of the surgeon’s records, that it would be claimed that this was an unusual presentation, that the symptoms were more likely caused by arterial spasm and/or compartment syndrome and thus the failure to obtain a vascular consult was not negligence. Hence, a good portion of the defendant’s deposition was directed at eliminating these claims as valid defenses.
The surgeon was first questioned as to whether the injury occurred at the time of surgery:
“Q. In your opinion, with a reasonable degree of medical probability, did the patient’s popliteal artery sustain some type of injury during the surgery that you performed?
A. It may have.
Q. Do you believe that the popliteal artery may have been injured prior to your surgery?
A. Not that I am aware of.”
* * *
“Q. Doctor, her blood work before surgery was normal, correct?
Q. Her clotting factors were all normal, and we went over that.
Q. The MRI, the cuts that showed the popliteal artery, other than the anatomical position that you mentioned, show no abnormality; is that correct?
A. None that I detected.
Q. No vascular compromise?
A. It wasn’t a full vascular study, but, no, it didn’t show any.
Q. And it showed no popliteal cysts; is that correct?
* * *
Q. Certainly, you did not diagnose such an injury before the surgery you performed?
The surgeon was thereafter questioned with regard to his examination of the patient on post-op day three at which time she displayed as stated above, obvious signs of vascular compromise.
“Q. With regard to physical examination, it says, physical examination, right leg, and you dictated, there is deformity in terms of soft tissue swelling.
The compartments are full in the leg but they are compressible and not tense. She has no active extension to the toes and ankle, though sensation is intact. When dependent her foot reddens nicely and has nice refill. When she is supine, it starts to blanch and becomes mild and the refill is sluggish.
She is two plus, two plus dorsalis pedis pulses, and then you wrote in, with dependency.
Q. And then you wrote in wound is well healed?
* * *
“Q. When you wrote in this note or when you dictated in this note that there was no active extension to the toes and ankle, you mean she couldn’t move her foot?
Q. What was the significance of the fact that when the patient was supine her right foot starts to blanch?
A. That the blood was not circulating distally when she was not with gravity.
Q. By blanching, you mean it became whiter or pale?
Q. In layman’s terms, she wasn’t getting proper blood supply to the foot, true?
A. In that position, the blood supply was compromised.
Q. Under physical examination, the second to last full sentence, where you dictated when she is supine it starts to blanch and becomes mild and the refill is sluggish, what do you mean by mild?
A. I think it was a typo. It is supposed to be mottled and I didn’t check it.
Q. Mottling, under these circumstances, is also an indication of a diminution in the blood supply to the effected area, true?
A. Yes, it can be from that.
Q. So, can we agree that based upon the findings of your physical examination something was causing a compromise of the blood supply to the foot?
A. That is what I was concerned about.
Q. So, the answer is yes, correct?
* * *
“Q. Would you agree that the findings of swelling of the leg and foot, no active extension of the toes and ankle, blanching of the foot and sluggish capillary refill indicate a vascular injury?
A. It could happen from compartment syndrome also.
Q. So, would you agree that the findings of swelling of the leg and foot, no active extension of the toes and ankle, blanching of the foot and sluggish capillary refill indicate vascular compromise?
Q. Just so I am clear on this, when we refer to vascular compromise, we are referring to an inadequate blood supply to the effected area?
Q. Doctor, is it fair to say that you considered some type of vascular problem as a cause of the positive findings you made?
A. I considered as a secondary effect, I thought, and I mention it in here, I thought it was more likely compartment pressure from fluid extravasation causing the problem.
Q. When you say compartment syndrome, it does cause a vascular problem, correct, as a result of increased pressures and ischemia occurs, correct?
A. Yes, as a secondary effect.
* * *
“Q. Doctor, when you asked them to rule out deep venous thrombosis, you were referring to a clot in a vein; yes or no?
A. To rule out a DVT, yes, that is what you are trying to do.
Q. When you told us before that people can develop blood clots following surgery, what you were referring to is a venous blood clot, a blood clot in a vein; yes or no?
Q. Did you at this point in time consider obtaining a consult with a vascular surgeon?
A. No, I did not.
Q. Why not?
A. My working diagnosis was primarily compartment syndrome or development thereof.
Q. Did you consider ordering an angiogram?
A. At that point, no.
Q. You also note in your plan that you were going to get compartment pressures there and that was because you were concerned about either compartment syndrome or that she was developing compartment syndrome, true?
The surgeon was next forced to admit, that whatever the cause, the patient was obviously suffering from vascular compromise which was an emergent situation:
“Q. When you wrote that you thought that there was a spasm of the artery, what artery were you referring to?
A. Well, primarily, I was thinking of the popliteal artery.”
* * *
“Q. How would spasm of the artery cause a lack of active flexion of the toes and ankle?
A. I feel, if it persisted long enough to interrupt the blood supply to the foot, they would have less ability to function.
Q. So, it must have been present for a while?
A. Yes, I would say it could have been present for a while.”
* * *
“Q. So, according to you, it was your opinion or thought process that this was being caused by a spasm of the artery and therefore a compromise to the lower leg and foot?
A. At this point in time I wasn’t 100 percent sure what was causing it. I was worried about a fluid compression causing it, possible vasospasm, compartment syndrome.
Q. Whatever the cause, you knew she wasn’t getting enough blood to the lower leg and foot, true?
A. I knew she was having problem with the blood supply specifically when she was supine, as I say in my exam.
Q. Doctor, the finding that she had no active flexion of the toes and ankle, is that an indication that she was suffering a significant compromise of the blood supply to her lower leg and foot; yes or no?
A. Yes, it does mean that.
Q. And if that blood supply is compromised long enough, ischemia results, correct?
Q. Eventually, the muscles of the lower leg and the nerves and the muscles of the foot, they are going to die? They are going to necrose, true?
A. They could, yes.
Q. They will if it is unrelieved? It is not that they could —
A. If it is completely unrelieved, if the pressure is completely unrelieved, if it is not successful, yes, they will die.
Q. In point of fact, when one is dealing with compartment syndrome, if elevated compartment pressures are allowed to exist for more than eight hours, the result — and when I say persist for more than eight hours until decompressive surgery is performed — the result will be some loss of function, true?
A. Most of the time, yes. I am not saying it is 100 percent, but yes.
Q. So, this was an emergent situation, true?
A. It was clearly an urgent situation.
Q. Something had to be done to relieve this impairment of the blood supply to this young lady’s lower leg and foot, true or not true?
A. I think something had to be done to change her condition, whatever that might be.
Q. And you knew at the time that there was some type of vascular problem here, whether secondary to compartment syndrome or to a vasospasm of the artery, she was having a vascular problem, true?
A. At this point in time she was having a compromise to he blood supply to the leg.
Q. Which is the vascular system?
The physician then admitted that vasospasm absent other arterial injury is rare. He further admitted that prompt diagnosis of an arterial injury is crucial in order to salvage the affected extremity.
“Q. Doctor, would you agree that a true spasm of the popliteal artery without other injury to the artery seldom occurs?
A. It is not a usual finding.”
* * *
“Q. Would you agree that delayed recognition of a popliteal artery lesion is known to be a major cause of limb loss?
Q. Because we agree, do we, that time is of the essence when dealing with an injury to the popliteal artery?
A. Dealing with any arterial injury, yes.”
The Doctor was next asked to explain what he thought was causing the patient’s problems since he was able to rule out compartment syndrome and deep venous thrombosis and also why he still did not order a vascular consult:
“Q. You measured the compartment pressures?
* * *
“Q. Going over these figures, is it fair to say that the pressure in the anterior compartment was normal?
Q. And the pressure in the lateral compartment was normal?
Q. And the pressure in the deep posterior compartment was normal?
Q. And the pressure in the superficial posterior compartment was either normal or slightly elevated?
Q. Yes, it was elevated.
A. In fact, based upon the recorded pressures, you ruled out compartment syndrome, true?
A. At that point I didn’t feel she had compartment syndrome, though she was fairly swollen.
Q. It says compartment syndrome ruled out. That is your writing?
Q. So, you ruled it out at that time based upon the pressures you took?
Q. And you also ruled out deep venous thrombosis?
Q. There’s a triage note by a nurse that says patient to E.R. by wheelchair with complaint of swollen right leg and discoloration of right foot. It goes on to say, right leg swollen, blanched from ankle to toes?
Q. And she had leg and foot pain, correct; that is, according to the first page of the record.
Q. And according to your findings she had no active extension of the toes or ankle, correct?
Q. And she had diminished capillary refill?
Q. And you had ruled out deep venous thrombosis, correct?
Q. And you had ruled out compartment syndrome, true?
Q. So, what did you think was causing the vascular compromise and these resulting problems?
A. Well, at this point I basically attributed it to spasm from the arteries just within the leg without being overt compartment syndrome because the pressures weren’t high enough. That was my working diagnosis then.
Q. Just so I am clear, you thought that the popliteal artery was in some type of spasm which involuntarily contracted resulting in a diminution of blood supply to the lower leg, true?
A. More or less that is what I was working on.”
* * *
“Q. Did you at this point in time, having ruled out compartment syndrome and having ruled out deep venous thrombosis, consider obtaining a vascular consult?
A. I didn’t.
Q. Why not?
A. Basically, for the same reasons I had mentioned before. I was hopeful with edema control the situation would resolve itself.”
* * *
“Q. Prior to your discharging the patient from the emergency room, did you consider that the findings of swelling of the right leg, blanching of the leg from ankle to toes, the lack of active extension of the toes or ankle and pain of the leg and foot might be caused by ischemia as a result of injury to the popliteal artery?
A. That was not a primary diagnosis of mine.
Q. I didn’t ask you whether it was a primary diagnosis. I asked you whether you considered it.
A. At that point I wasn’t considering it.
Q. Why was that?
A. Because of the length of time from the surgery, I felt, if she had an arterial injury, it would have presented a lot sooner than 72 hours later, or whatever the time frame was at that point in time, and that was the main reason why.
Q. That was a thought process that went through your mind at that time?
A. Well, piecing everything else together that I knew, yes.
Q. In thinking about that and thinking about in your mind that you would have assumed that an arterial injury would have manifested itself somehow differently at an earlier point in time, did you think, as you were thinking about that, about getting a vascular consult?
A. I did not at that point in time.
Q. Do you think you should have?
A. Knowing what the end result was now?
A. Of course.”
Finally, the Doctor was confronted with the findings on fasciotomy which unequivocally eliminated compartment syndrome as a cause of the patient’s symptoms and mandated a vascular consult:
“Q. The surgery that you performed according to this was a four compartment fasciotomy of the right leg?
* * *
“Q. Would you agree that based upon these findings with regard to the muscles in the anterior compartment, the pressures within that compartment had to have been elevated for a period of less than eight hours?
A. It is hard to say, but I was surprised that the muscles looked in good condition at that point in time?
A. Because my thought process was that this was probably going on since the day before and I didn’t know what the muscles would look like, quite honestly, when I went in there.
Q. The fact is this: If the patient had the elevated compartment pressures within the anterior compartment for a period of more than eight hours, wouldn’t you have expected to find a loss of contractility of the muscles together with at least some discoloration?
A. Yes, you would think that would have happened.
Q. And the findings that you made of good contractility, color and consistency of the muscles indicates that she couldn’t have been suffering from compartment syndrome for over eight hours, true?
A. Basically, I agree with that.”
* * *
“Q. Based upon these findings that you made with regard to the muscules within the compartments, is it fair to say that compartment syndrome was not causing the loss of movement of her ankle and foot?
A. The compartment syndrome directly was not the cause of it.”
The inexcusable failure of the surgeon to obtain a vascular consult despite his admission that the patient was suffering from a vascular compromise was irrefutable following his deposition. Once again, this demonstrates the detailed knowledge the plaintiff’s attorney must acquire about the area of medicine involved in order to conduct a meaningful deposition of the defendant physician in a medical malpractice case.
1. Colburn GL, Lumsden MB, Taylor BS, Skandalakis, JE. The Surgical anatomy of the Popliteal Artery. AM Surg 1994 Apr; 60(4) 238-46.
2. Potter D, Morris-Jones W. Popliteal Artery Injury Complicating Arthroscopic Menisectomy. Arthroscopy 1995 Dec; 11(6) 723-6. Roth J.H.; Bray R.C. Popliteal Artery Injury During Anterior Cruciate Ligament Reconstruction: Brief Report. J Bone Joint Surg. Br. 1988 Nov. (70)(5): 840 3. Potter D, Morris-Jones W. Supra. Tawes R.L. SR, Etheredge SN, Webb R.L., Enloe LJ, Stallone RJ Popliteal Artery Injury Complicating Arthroscopic Menisectomy. Am J Surg. 1988 Aug; 156(2):136-8. Jeffries JT, Gainor BJ, Allen WC, Cikrit D. Injury to the Popliteal Artery as a Complication of Arthroscopic Surgery. A Report of Two Cases. J Bone Joint Surg. [AM] 1987 Jun; 60(5):783-5.
4. Seybold EA, Busconi BD. Traumatic popliteal artery thrombosis and compartment syndrome of the leg following blunt trauma to the knee: a discussion of treatment and complications. J Orthop Trauma 1996; 10(2):138-41
For more information on New York Medical Malpractice contact the New York Medical Malpractice Lawyers at Gair,Gair,Conason, Steigman,Mackauf,Bloom and Rubinowitz.