Popliteal Artery Injury Risk in Total Knee Arthroplasty Related to Anatomic Variations: A Scoping Review

Popliteal artery (PA) injury during total knee arthroplasty (TKA) is rare but can lead to devastating complications, including PA repair or bypass, limb ischemia, compartment syndrome, fasciotomy, amputation, and death. Anatomical variations, such as high PA bifurcation or aberrant anterior tibial artery (ATA), may elevate this risk. Awareness of these variants during preoperative planning may reduce the likelihood of vascular injury and postoperative complications. This study aimed to assess the prevalence of PA anatomical variants, their relevance to TKA, and associated vascular complications. We hypothesized that aberrant arterial anatomy increases complication risk.

A systematic literature search was conducted in EMBASE, MEDLINE, and Scopus in February 2025 using terms related to "aberrant popliteal artery," "anterior tibial artery anomaly," and "vascular complications in knee surgery." Studies were screened via Covidence. Inclusion criteria included the following: studies evaluating PA variation, prevalence, or TKA-associated vascular complications. Exclusion criteria included the following: non-English, abstracts, reviews, or unrelated studies. Extracted data included anatomical findings, imaging, and surgical outcomes. This study is compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews and Level of Evidence IV.

Of 5093 articles, 11 met inclusion criteria. Four case reports described vascular injuries during TKA in patients with aberrant PA anatomy (mean age 63 ± 18.2; 75% women). Imaging studies reported aberrant ATA prevalence ranging from 0.4% to 6%; one magnetic resonance imaging (MRI) study found a 3.2% prevalence in 280 knees. Proximity of the ATA to key landmarks increased injury risk, especially in women. Two cadaveric studies and 1 cohort study identified high PA bifurcations and variant ATA origins as risk factors.

PA anatomical variation may be an underrecognized anomaly and be a risk factor for vascular injury during TKA. Awareness of the anatomical variation, careful review of pre-existing MRIs, and selective vascular imaging may improve surgical planning and help mitigate complications.