Popliteal vessel trauma: Surgical approaches and the vessel-first strategy

Anatomical quantitative evaluation of popliteal artery visualization during medial approach in supine position

PURPOSE

The medial approach to the popliteal artery has been less commonly used than the posterior approach in surgical repair of traumatic popliteal injury. This study was performed to quantitatively evaluate the visual field of the popliteal artery obtained by staged myotendotomy in the medial approach to the popliteal artery.

METHODS

Twenty legs of fresh-frozen adult cadavers were dissected using the medial approach to the popliteal artery. In stage 1, the popliteal artery was exposed between the vastus medialis and sartorius muscles without myotendotomy. In stage 2, the medial head of the gastrocnemius muscle was dissected. In stage 3, the tendons of the sartorius and semimembranosus muscles were dissected. In stage 4, the tendons of the gracilis and semitendinosus muscles were dissected to fully expose the popliteal artery. The length of the popliteal artery that could be visualized in each stage was measured.

RESULTS

The anatomical length of the popliteal artery from the hiatus of the adductor magnus to the tendinous arch of soleus muscle ranged from 15 to 20 cm (mean, 16.3 cm). On average, 45%, 59%, 72%, and 100% of the popliteal artery were visualized in stage 1, 2, 3, and 4, respectively.

CONCLUSIONS

The medial approach to the popliteal artery has the advantage of being performed in the supine position, but it requires multiple myotendotomies around the knee. The results of this study may serve as a reference for myotendotomy depending on the site of injury to the popliteal artery.

Lower limb preservation in pediatric trauma: a case study of Gustilo grade IIIC fracture in a 7-year-old

This case report describes the intricate aspects of managing pediatric lower limb trauma. A 7-year-old patient had a severe compound fracture and significant soft tissue damage in the left lower limb, classified as Gustilo Grade IIIC. This necessitated the use of scoring systems such as the Mangled Extremity Severity Score and limb salvage index to assess the likelihood of limb preservation. Despite these high amputation risk indicators, a multidisciplinary approach has led to limb salvage surgery with internal fixation. Detailed postoperative monitoring revealed progressive recovery culminating in restored sensation, bone healing, and functional recovery. The discussion emphasizes the difficulties in deciding between limb salvage and amputation, stressing the importance of tailored care and cautious scoring system interpretation in pediatric cases. This conclusion advocates the prioritization of limb salvage in children owing to their unique healing capabilities while highlighting the need for further research to refine treatment protocols for pediatric lower limb trauma.

Therapeutic management and amputation options in a long time delayed blunt popliteal artery injury

PURPOSE

To report the experience of treatment on blunt traumatic popliteal artery injury (PAI) combined orthopedic injuries and determine the amputation-associated factors.

METHODS

From January 2008 to December 2019, 55 patients in level I trauma center with traumatic blunt PAI were retrospectively reviewed. Variables were retrospectively collected and statistically analyzed. Patients with PAI with limb selvage, primary amputation, and secondary amputation were retrospectively grouped and compared.

RESULTS

A total of 55 patients with a median age of 41.4 years (range 18-70), of which 45 were males (81.8%) and 10 were females (18.2%), were enrolled. The overall amputation rate was 36.4% because 88.6% of patients faced more than 6 h of delay before treatment. The average injury severe score (ISS) and abbreviated injury score (AIS) were 10.4 (range 9-34) and 8.2 (range 5-16), respectively. Multivariate regression analysis showed that the number of hospitalization days was a significantly related factor to amputation. After a median follow-up of 56 months (range 12-132), no death, another limb loss, or claudication was found in all patients.

CONCLUSIONS

Patients with PAI are commonly accompanied by multiple injuries that increase the risk of amputation; therefore, timely treatments are urgently required. Reducing the severity of ischemia by fasciotomy, not losing time by performing preoperative imaging or diagnostic tests, and repairing the associated venous injury can help to optimize the rates of limb salvage. However, impact factors, such as the gender and age of the patient, injured mechanisms, concomitant injuries, AIS, ISS, and surgical times, are not associated with the outcomes of amputation. Nonetheless, endeavors to salvage the limbs as far as possible should be made.

Revisiting Management Strategies for Popliteal Artery Injuries

BACKGROUND

Popliteal artery injuries (PAIs) were reported to own the highest rates of limb loss in vascular injuries of extremities. The complex nature of PAIs makes the treatment more difficult. We aimed to present our cases using our proposed algorithm and revisit the strategies for management.

PATIENTS AND METHODS

A retrospective study of 45 cases with PAIs managed at the Kaohsiung Chang Gung Memorial Hospital over a 10-year period was conducted. The proposed algorithm for decision making was applied, which contains variables including the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, the acquisition of preoperative angiography, and the existence of collateral circulation. Whether the injured limbs were salvaged successfully avoiding amputation was recorded.

RESULTS

Of all the included 45 patients, the rate of a successful salvage of the injured limb from amputation was 71.1%. Six patients did not receive revascularization because of their poor conditions of the injured limbs. In terms of limb salvage in PAIs, the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, or the acquisition of preoperative angiography did not make a significant difference (P > 0.05). Instead, an existence of collateral circulation at the distal injured limb was correlated to a significant higher rate of salvage, regardless of having revascularization or not (P = 0.001 and < 0.001, respectively). Seven patients had the injured vessels repaired directly and all were prevented from amputation. In other patients who underwent vascular repair using a graft, vein graft (n = 20) showed a higher successful rate in salvage significantly than Gore-Tex graft (n = 9, P < 0.001).

CONCLUSIONS

Collateral circulation determines much of the fate of limb salvage in PAIs. As a result, a delayed revascularization could be accepted as long as there is existence of collateral circulation at the distal injured limb. An autologous vein graft is favored when a direct repair is not able to be performed for revascularization. Although fasciotomy was not found to be associated with a successful salvage in this study, its importance could not be neglected and it should be performed when there is an observed or impending compartment syndrome.

Limb Salvage after Lower-Leg Fracture and Popliteal Artery Transection-The Role of Vessel-First Strategy and Bone Fixation Using the Ilizarov External Fixator Device: A Case Report

Open traumatic lesion of the popliteal artery is relatively rare. Ischemia time longer than 6 h and severity of limb ischemia have been shown to be associated with an increased risk of limb loss. Severe local infection is critical in the presence of major soft tissue trauma or open fractures. We report the case of a young female who suffered a traumatic transection of the popliteal artery associated with an open fracture of the distal tibia and fibula managed by direct vessel reconstruction with an end-to-end repair and skeletal stabilization initially with half-pin external fixation, then replaced by an Ilizarov circular frame. The patient had a very satisfactory outcome, but the fracture healed malunited, later corrected by open reduction and internal fixation with lag-screwing and a neutralization plate.

Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy

Purpose

Blunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF).

Methods

Retrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined.

Results

Of 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication.

Conclusion

Blunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01632-0.

A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status

BACKGROUND

Popliteal artery injuries are the second most common arterial injuries below the inguinal ligament. We aimed to compare outcomes in patients with popliteal injuries by hospital teaching status utilizing the National Trauma Data Bank Research Data Set (NTDB-RDS) 2013-2016.

METHODS

Four-year retrospective study using the NTDB-RDS, evaluating popliteal vascular injuries. Patients were divided by popliteal injury type and teaching status into; nonteaching hospital (NTH), community teaching (CTH), or University teaching (UTH). Demographics and outcome measures were compared between groups. Risk-adjusted mortality odds ratios (ORs) were calculated. Significance was defined as P < 0.05.

RESULTS

3,577,168 patients were in the NTDB-RDS, with 1120 having a popliteal injury, (incidence = 0.03%). There was no significant difference in the amputation rate between patients treated in NTHs, CTHs, or UTHs (P > 0.05). There was no significant difference in the raw mortality rate between patients treated in NTHs, CTHs, or UTHs. After adjusting for confounders; compared to NTH, the odds ratio for mortality for popliteal artery injuries in the CTH group was significantly higher (OR: 15.95, 95% CI: 1.19-213.84), and for the UTH group the mortality was also significantly higher (OR: 5.74, 95% CI: 0.45-72.95).

CONCLUSIONS

The incidence of popliteal vascular injuries was 0.03% for 2013-2016. Patients with popliteal artery injuries treated at community teaching hospitals have a 16 times higher risk of mortality and at university teaching hospitals have a 5.7 times higher risk of mortality than patients treated at nonteaching hospitals.

[Challenges to endoprosthetic reconstruction after tumor resection around the knee : Management of intra- and postoperative complications]

BACKGROUND

The good functional outcomes of endoprosthetic knee reconstructions combined with modern oncosurgical concepts have resulted in a decreased rate of primary amputations following tumor resection in the region of the knee, thereby improving the quality of life of affected patients.

OBJECTIVE

This study aimed to reappraise complications which are more common than in conventional arthroplasties performed for arthritis or trauma due to the complexity of the surgical procedures, the size of the endoprosthetic reconstructions, and neo-/adjuvant therapies.

MATERIAL AND METHODS

Possible intra- and postoperative complications and treatment options are presented.

RESULTS

Typical intraoperative complications include malalignment (axis, length, rotation) in implant positioning, unplanned soft tissue defects, impaired implant fixation due to poor bone stock, periprosthetic fractures, vessel/nerve injuries, and lesions/defects of the extensor mechanism. The relevant postoperative complication profile is characterized by local recurrences, periprosthetic infections, thromboembolic events, and mechanical failures (loosening, failure of the constraining mechanism).

CONCLUSION

Depending on anatomic conditions and the systemic oncological status of the patient, these complications represent tremendous challenges to reconstructive management. Knowledge of the potential problems enables them to be avoided. This requires profound experience in oncosurgery and tumor endoprosthesis revisions.