Popliteal Artery Injuries in Orthopedic Knee Surgery: A Narrative Review with an Italian Medico-Legal Perspective

To provide a narrative overview of popliteal artery injury (PAI) associated with orthopedic knee surgery, focusing on its mechanisms, risk factors, diagnostic challenges, treatment strategies, and medico-legal appraisal within the Italian civil healthcare liability framework.

A non-systematic literature review was conducted using PubMed, Scopus, and Web of Science, including articles published up to December 2025. Original studies, reviews, case series, and case reports addressing vascular anatomy, mechanisms of injury, diagnosis, treatment, and outcomes were selected. During revision, a separate targeted medico-legal search was conducted in PubMed, Scopus, and Web of Science on 7 September 2026, and Italian statutory, judicial, and deontological sources were examined for the civil healthcare liability analysis.

The clinical synthesis included 47 studies. Popliteal artery injury was identified as a rare but serious complication of procedures such as total knee arthroplasty, ligament reconstruction, arthroscopy, osteotomies, and hardware removal. Injury mechanisms included thrombosis, arterial incision, pseudoaneurysm formation, and arteriovenous fistulae. Computed tomography angiography emerged as the preferred imaging modality in uncertain cases, while both open surgical and endovascular treatments showed satisfactory results when performed promptly. Delayed diagnosis was consistently associated with worse functional outcomes and increased risk of limb loss. The targeted medico-legal search found only sparse literature directly addressing PAI; the Italian analysis therefore focused on professional conduct, causal attribution, informed consent, and evidentiary reconstruction rather than treating the adverse event itself as evidence of liability.

Although uncommon, PAI remains a potentially limb-threatening complication of knee surgery. Thorough anatomical knowledge, early recognition, and timely vascular intervention remain central to clinical management. Within the Italian civil liability framework, the occurrence of a recognized complication neither establishes nor excludes negligence. Medico-legal appraisal should distinguish the primary vascular event from any additional harm attributable to delayed recognition or treatment and should address informed consent and documentation as separate issues.