Early detection and nonsurgical management of popliteal artery thrombosis after high tibial osteotomy: two case reports

Introduction and Importance: Popliteal artery thrombosis is a rare but potentially limb-threatening complication following high tibial osteotomy, with an incidence ranging between 0.05% and 1.7%. Early detection and appropriate management are crucial in preventing irreversible ischemic damage. Pulse oximetry, traditionally used for systemic oxygen monitoring, has emerged as a valuable tool for detecting peripheral vascular compromise. This report highlights two cases of peripheral artery thrombosis following medial opening wedge HTO, both managed nonsurgically. We emphasize the role of pulse oximetry waveform analysis as a valuable diagnostic adjunct in clinical decision-making. Case Presentation: Case 1: A 55-year-old woman with no significant medical history developed weak distal pulses and limb pallor postoperatively. Although pulse oximetry readings remained within the normal SpO₂ range (96%–98%), with a normal dicrotic waveform, Doppler ultrasound confirmed popliteal artery thrombosis. Anticoagulation therapy with heparin followed by rivaroxaban led to complete recovery, with no recurrence at 18-month follow-up. Case 2: A 42-year-old woman also developed absent distal pulses, a cold and pale foot, and normal oxygen saturation with a normal dicrotic waveform. Doppler confirmed thrombosis 2.5 cm proximal to the popliteal bifurcation. She was treated conservatively with the same anticoagulation protocol and fully recovered after 2 years, with no complications or recurrence. Clinical Discussion: Pulse oximetry waveform analysis proved instrumental in both cases, detecting compromised perfusion even when SpO₂ values were normal. The dicrotic notch alteration served as an early indicator of vascular injury. These findings suggest that waveform analysis may offer higher sensitivity in early detection compared to SpO₂ readings alone. Conclusion: Pulse oximetry, particularly waveform analysis, is a practical and noninvasive tool for the early detection of vascular injury following HTO. Its routine use in the postoperative period could enable timely diagnosis and facilitate conservative management, potentially reducing the need for vascular surgical intervention.