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Green JS, Marcel A, Li ZI, Moran J, Schenck RC, Alaia MJ, Medvecky MJ. Variability in the Spectrum of Reporting on the Schenck KD I Classification in the Orthopaedic Literature: A Systematic Review and Meta-analysis. Orthop J Sports Med 2024; 12:23259671241264214. [PMID: 39291123 PMCID: PMC11406613 DOI: 10.1177/23259671241264214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/13/2024] [Indexed: 09/19/2024] Open
Abstract
Background There has been a marked increase in the number of Schenck knee dislocation (KD) I injuries reported in the multiligament knee (MLK) injury (MLKI) and KD literature. Purpose To examine the heterogeneity of the Schenck KD I classification in the MLKI and KD literature. Study Design Systematic review; Level of evidence, 4. Methods A systematic literature search of PubMed, CINAHL, Scopus, Web of Science, EMBASE, and Cochrane Library was conducted for all studies that investigated KDs and/or MLKIs, utilized the Schenck or an MLKI classification system, and included patients with KD I or MLK 1 injuries. Pooled analysis determined the total number of KD I or MLK 1 injuries and the specific ligamentous tear patterns. Binary meta-analyses of the studies that reported neurovascular injury within each Schenck KD class compared the pooled odds ratio (OR) of vascular and neurological injury in unicruciate (KD I) and bicruciate (KD II-IV) injuries. Results Included were 50 studies in which 3460 KD I injuries were reported out of 7872 KDs and MLKIs (43.9%). Of the 2912 patients reported to have had a Schenck KD I injury, 26 patients (0.9%) had a clinically and/or radiographically confirmed tibiofemoral KD. The overall prevalence of Schenck KD I injury with documented tibiofemoral KD was 26 of 7872 (0.3%). A total of 22 studies (n = 1702 patients) reported the specific ligamentous tear patterns; the most common patterns were posterior cruciate ligament (PCL)/lateral collateral ligament (LCL) (n = 526; 30.9%), anterior cruciate ligament (ACL)/LCL (n = 488; 28.7%), ACL/medial collateral ligament (MCL) (n = 408; 24.0%), and PCL/MCL (n = 198; 11.6%). Meta-analyses demonstrated that when compared with bicruciate KD or MLKI, unicruciate KD or MLKI was significantly less likely to have concomitant vascular injury (OR, 0.28; 95% CI, 0.15-0.51; P < .0001) and concomitant neurologic injury (OR, 0.49; 95% CI, 0.37-0.65; P < .00001). Conclusion The number of true, clinically and/or radiographically confirmed unicruciate KDs was extremely rare, representing <1% of all reported Schenck KD I injuries. A misappropriation of these injury patterns as true KDs may be taking place, affecting outcome studies and potentially biasing published clinical results. An MLKI classification system must document whether a confirmed KD has occurred.
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Affiliation(s)
- Joshua S Green
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
| | - Aaron Marcel
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
| | - Zachary I Li
- Department of Orthopedic Surgery, Division of Sports Medicine, New York University Langone Orthopedic Center, New York, New York, USA
| | - Jay Moran
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert C Schenck
- Department of Orthopaedics & Rehabilitation, University of New Mexico, Albuquerque, New Mexico, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, Division of Sports Medicine, New York University Langone Orthopedic Center, New York, New York, USA
| | - Michael J Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
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Rai A, Chopra J, Irfan A, Roy S, Gourav G, Parihar A, Kumar S. Variations in the Termination of the Popliteal Artery: A Multidetector Computed Tomography Angiography (CTA)-Based Retrospective Study. Cureus 2024; 16:e63092. [PMID: 39055442 PMCID: PMC11270629 DOI: 10.7759/cureus.63092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Comprehension of the intrucate anatomy and variations in the termination of the popliteal artery (PA) is increasingly essential for endovascular interventionists, plastic surgeons, vascular surgeons, and orthopedic surgeons, due to the rise in procedures like embolectomy, vascular grafting, free fibular flap surgery, and high-tibial osteotomy. Few studies from India have reported on the variant anatomy of PA termination, and none have used 128-slice tomography. This study aimed to observe the terminal branching pattern of the PA and the morphology of its terminal branches using 128-slice computed tomography angiography (CTA) and to analyze its relation to gender and laterality. METHODOLOGY A retrospective review of CTA images of 181 lower extremities from 100 patients (137 males and 44 females), aged five to 75 years, was conducted. RESULTS The usual type I-A pattern was found in 75.69% of cases, while 24.31% exhibited variant patterns. Type III was the most common variation observed (19.34%), with type III-A being the most prevalent (11.05%). Types II-B and II-C were not observed. Among 84 bilaterally examined cases, 19.05% had unilateral variations and 15.48% had bilateral variations, with 8.33% showing bilaterally similar variations and 7.14% dissimilar variations. No significant difference in branching patterns was found between genders or sides. The mean length of the tibial-peroneal trunk (TPT) in the type I-A pattern was 3.00 ± 0.99 cm (right side: 3.21 ± 1.02 cm; left side: 2.82 ± 0.93 cm; males: 2.9 ± 1.00 cm; females: 3.37 ± 0.85 cm), with statistically significant differences between sides and genders. In the type II-A pattern, the mean TPT length was 7.16 ± 3.75 cm. An exceptionally long TPT (12.97 cm) was noted in one case of the III-B pattern. CONCLUSION There is a high prevalence of variation in the termination pattern of the PA. Knowledge of these variations is crucial for any interventions in this region to avoid postoperative vascular complications and reduce patient suffering.
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Affiliation(s)
- Anurag Rai
- Thoracic Surgery, King George's Medical University, Lucknow, IND
| | - Jyoti Chopra
- Anatomy, King George's Medical University, Lucknow, IND
| | - Amber Irfan
- Anatomy, King George's Medical University, Lucknow, IND
| | - Shubhajeet Roy
- Gandhi Memorial and Associated Hospitals, King George's Medical University, Lucknow, IND
| | - Gourav Gourav
- Anatomy, King George's Medical University, Lucknow, IND
| | - Anit Parihar
- Interventional Radiology, King George's Medical University, Lucknow, IND
| | - Shailendra Kumar
- Thoracic Surgery, King George's Medical University, Lucknow, IND
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Karmakar S, Singla P. An Unreported Variation of Origin of Posterior Tibial Artery Encountered During Free Fibula Flap Harvest. Ann Plast Surg 2023; 91:101-103. [PMID: 37450867 DOI: 10.1097/sap.0000000000003577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
ABSTRACT Variations in the division of popliteal artery and origin of the 3 vascular systems are well documented. Here, we report a case in which the posterior tibial artery originated from the peroneal artery, in lower leg and then followed the normal course. The anomaly was detected intraoperatively precluding the harvest of free fibula flap. The procedure was abandoned and fibula was fixed using plates and screws and a free radial forearm flap was done over 2 mini-plates, which spanned the bone gap. A second bone flap procedure was to be planned in another sitting.The anomalous origin of posterior tibial artery from the peroneal artery in lower leg did not fall into any of the categories described previously by Kim et al (Ann Surg 1989;210:776-81.). In the event such atypical anatomy is encountered, it must be delineated, and the surgical plan adjusted accordingly. Flexibility in surgical approach can prevent vascular catastrophe.
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Affiliation(s)
- Shilpi Karmakar
- From the Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, India
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4
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Gherasie FA, Popescu MR, Bartos D. Acute Coronary Syndrome: Disparities of Pathophysiology and Mortality with and without Peripheral Artery Disease. J Pers Med 2023; 13:944. [PMID: 37373933 DOI: 10.3390/jpm13060944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/29/2023] Open
Abstract
There are a number of devastating complications associated with peripheral artery disease, including limb amputations and acute limb ischemia. Despite the overlap, atherosclerotic diseases have distinct causes that need to be differentiated and managed appropriately. In coronary atherosclerosis, thrombosis is often precipitated by rupture or erosion of fibrous caps around atheromatous plaques, which leads to acute coronary syndrome. Regardless of the extent of atherosclerosis, peripheral artery disease manifests itself as thrombosis. Two-thirds of patients with acute limb ischemia have thrombi associated with insignificant atherosclerosis. A local thrombogenic or remotely embolic basis of critical limb ischemia may be explained by obliterative thrombi in peripheral arteries of patients without coronary artery-like lesions. Studies showed that thrombosis of the above-knee arteries was more commonly due to calcified nodules, which are the least common cause of luminal thrombosis associated with acute coronary events in patients with acute coronary syndrome. Cardiovascular mortality was higher in peripheral artery disease without myocardial infarction/stroke than in myocardial infarction/stroke without peripheral artery disease. The aim of this paper is to gather published data regarding the disparities of acute coronary syndrome with and without peripheral artery disease in terms of pathophysiology and mortality.
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Affiliation(s)
| | - Mihaela-Roxana Popescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila," 050474 Bucharest, Romania
- Department of Cardiology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, 011461 Bucharest, Romania
| | - Daniela Bartos
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila," 050474 Bucharest, Romania
- Department of Internal Medicine, Clinical University Emergency Hospital, 014461 Bucharest, Romania
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Arayapithak K, Suwannanon R, Hongsakul K. Popliteal artery branching variations on computed tomography angiography of 1542 lower limbs and its associated factors. Acta Radiol 2023; 64:874-880. [PMID: 35350850 DOI: 10.1177/02841851221088801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The identification of popliteal artery branching variation is of anatomical importance for surgical and endovascular procedures in the posterior region of the knee and below. PURPOSE To evaluate the variations and associated factors of popliteal artery branching by computed tomography angiography (CTA). MATERIAL AND METHODS CTA of the lower extremities of 1542 lower limbs in 771 patients (513 men and 258 women) were retrospectively reviewed to assess the popliteal artery branching patterns. The patient's sex, side of lower limbs, and population were recorded and evaluated for their association with popliteal artery branching patterns. P < 0.05 was considered to indicate statistical significance. RESULTS Variations in the branching of the popliteal artery were recorded in 9.3% of patients. The three most common variations were found to be hypoplastic-aplastic posterior tibial artery (PT) (3.6%), trifurcation (2.0%), and hypoplastic-aplastic anterior tibial artery (0.8%). A new pattern was detected in 2 (0.1%) cases, which were described as double PTs. Statistically significant differences were noted in the proportion of variation branching between the male and female groups (odds ratio = 1.52; 95% confidence interval = 1.07-2.16; P = 0.02). CONCLUSION The findings on popliteal variational branching patterns in the present study were in conformance to previous reports. Our study identified a novel variation of popliteal artery branching, which has not been mentioned in the literature so far. Sex was found to be an associated factor of branching variation.
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Affiliation(s)
- Karakkada Arayapithak
- Department of Radiology, Faculty of Medicine, 37689Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Ruedeekorn Suwannanon
- Department of Radiology, Faculty of Medicine, 37689Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Keerati Hongsakul
- Department of Radiology, Faculty of Medicine, 37689Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Troisi N, Melani A, Raspanti C, Panci S, Chisci E, Pratesi C, Michelagnoli S. A comparative analysis of anatomical variations of popliteal artery and its branches in concomitant aneurysmal disease. Vascular 2023; 31:33-38. [PMID: 34809515 DOI: 10.1177/17085381211052369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Open or endovascular treatment of popliteal artery aneurysms (PAAs) is still debated. Data about the popliteal artery anatomy and its branches are essential to plan a surgical approach. The aim of this study was to report the anatomical variations of the popliteal artery and its branches in a population with aneurysmal disease and compare them with a standard population with non-aneurysmal disease. METHODS A retrospective review of consecutive patients who underwent surgical PAA repair in our center between January 2011 and December 2020 was performed. One-hundred-forty-six limbs in 128 patients underwent PAA treatment (Group 1). Computed tomography angiography images using a 128-section configuration were reviewed for anatomical variations of the popliteal artery and its branches. A control population of 178 limbs in 89 patients with non-aneurysmal disease was used to compare the outcomes (Group 2). All limbs were classified according to Kim's classification. The two groups were analyzed and compared by means of nonparametric Pearson chi-square test. RESULTS Both groups were homogeneous in terms of demographics, risk factors, and clinical presentation. In Group 1, the limbs with PAA were classified as type IA, 133 (91.1%); type IB, 2 (1.4%); type IC, 0; type IIA1, 1 (0.7%); type IIA2, 1 (0.7%); type IIB, 4 (2.7%); type IIC, 0; type IIIA, 3 (2.1%); type IIIB, 0; and type IIIC, 2 (1.4%). In Group 2 the limbs with non-aneurysmal disease were classified as type IA, 163 (91.6%); type IB, 5 (2.8%); type IC, 1 (0.6%); type IIA1, 1 (0.6%); type IIA2, 3 (1.7%); type IIB, 2 (1.1%); type IIC, 0; type IIIA, 3 (1.7%); type IIIB, 0; and type IIIC, 0. No difference in terms of anatomy of the popliteal artery and its branches was found between the two groups (P = NS). CONCLUSIONS Knowledge of anatomical variations of the popliteal artery and its branches is mandatory in case of the surgical approach. Anatomy in PAA patients is not different. Studies with larger population size are needed to validate these outcomes.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery26187, University of Pisa, Pisa, Italy
| | - Alberto Melani
- Department of Vascular Surgery, 9300University of Florence, Florence, Italy
| | - Claudio Raspanti
- Department of Diagnostic Imaging, 26187San Giovanni di Dio Hospital, Florence, Italy
| | - Simone Panci
- Department of Diagnostic Imaging, 26187San Giovanni di Dio Hospital, Florence, Italy
| | - Emiliano Chisci
- 26187Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Carlo Pratesi
- Department of Vascular Surgery, 9300University of Florence, Florence, Italy
| | - Stefano Michelagnoli
- 26187Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
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Perugini AJ, Passias BJ, Pelz NC, Temperato JR, Mehta S. Anomalous Posterior Tibial Artery Course-Anatomic Considerations for the Posterolateral Ankle Approach: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00029. [PMID: 36735803 DOI: 10.2106/jbjs.cc.22.00637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CASE We report a unique anatomical case of an anomalous course of the posterior tibial artery found on dissection during the posterolateral approach to the ankle. To the best of our knowledge, no such case has been documented. CONCLUSION The vascular bundle consistent with that of the posterior tibial artery and vein was encountered in the far lateral aspect of the deep posterior compartment, which suggests physicians should proceed with caution when performing the posterolateral approach to the ankle so as to avoid iatrogenic injury of this named anatomic structure.
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Gosslau Y, Warm TD, Foerch S, Zerwes S, Scheurig-Muenkler C, Hyhlik-Duerr A. Iatrogenic injury of the popliteal artery in orthopedic knee surgery: clinical results and development of a therapeutic algorithm. Eur J Trauma Emerg Surg 2022; 48:4169-4179. [PMID: 35359157 PMCID: PMC9532315 DOI: 10.1007/s00068-022-01961-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/13/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Intraoperative injury to the popliteal artery is a rare complication of orthopedic surgery, however, it can have serious consequences, including major amputation. Recommendations for a standard approach are lacking. The aim of this study was to develop an interdisciplinary therapeutic algorithm to assist in complication management. METHODS From 01/11 to 12/20, 16 arterial injuries after knee surgery were analyzed in a retrospective single-center study. Four cases involved recurrent orthopedic surgery. Procedures performed included eleven total knee arthoplasties (TKA), two TKA replacements, one arthroscopy, and two high tibial osteotomies. Clinical presentation of patients was hemorrhage (n = 2), ischemia (n = 7), the combination of both (n = 4), or pseudoaneurysm formation (n = 3). RESULTS Ten patients underwent endovascular treatment, some as combined procedures: (stent)-PTA (n = 6), aspiration thrombectomy (n = 5), thrombin injection (n = 1), and embolization (n = 1). Six patients were treated surgically: four with bypass/interposition and one with a patch plasty and one as a hybrid procedure, respectively. Only autologous great saphenous vein was used. All extremities could be preserved. Functional impairment remained in six cases. CONCLUSION Both endovascular and surgical procedures can be used to treat arterial injuries after knee surgery. Efficient standardized diagnosis and the involvement of vascular expertise are essential to prevent functional impairment or limb loss, as suggested in the algorithms.
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Affiliation(s)
- Yvonne Gosslau
- Vascular Surgery, Faculty of Medicine, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Tobias Dominik Warm
- Vascular Surgery, Faculty of Medicine, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Foerch
- Trauma Surgery, Faculty of Medicine, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Sebastian Zerwes
- Vascular Surgery, Faculty of Medicine, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Christian Scheurig-Muenkler
- Diagnostic and interventional Neuroradiology, Faculty of Medicine, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Alexander Hyhlik-Duerr
- Vascular Surgery, Faculty of Medicine, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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Hsieh YH, Lee MC, Hsu CC, Chen SH, Lin YT, Lin CH, Lin CH. Popliteal Artery Injury After Fracture and/or Dislocation of the Knee: Risk Stratification for Revascularization Outcome. Ann Plast Surg 2022; 88:S50-S55. [PMID: 35225847 DOI: 10.1097/sap.0000000000003076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Managing complex knee trauma involving both vascular and osseous injuries is challenging, yet the available guidelines for efficient popliteal artery injury management after high-velocity blunt knee trauma remain conflicting and inconsistent. In this study, the authors aim to identify the risk factors associated with delayed limb amputation and ischemic muscular sequela postrevascularization. Furthermore, we propose a treatment algorithm to improve the limb salvage rate. METHODS Patients who presented with traumatic popliteal artery injury resulting in vessel occlusion or rupture, followed by fracture and/or dislocation of the knee from January 2008 to December 2013, were included for retrospective review. RESULTS Overall delayed amputation rate was 24% (7/29) and 16% (4/25) after successful revascularization. Mangled Extremity Severity Score is higher in the delayed amputation group than the limb-salvaged group (P = 0.02). Higher-impact force (P = 0.03), ischemic limb on presentation (P = 0.03), prolonged ischemia time (P = 0.04), unstable hemodynamics (P = 0.01), longer operation time (P = 0.04), and prolonged intensive care unit stay (P = 0.03) are risk factors of delayed amputation. Longer ischemia time (P = 0.04) and length of popliteal artery injury (P = 0.02) are associated with ischemic muscular sequela. CONCLUSIONS Mangled Extremity Severity Score is a reliable predictor of limb salvage. An algorithmic approach may improve the outcome of popliteal artery injury after high-velocity blunt knee trauma.
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Affiliation(s)
- Yun-Huan Hsieh
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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Ramírez-Bermejo E, Gelber PE, Pujol N. Management of acute knee dislocation with vascular injury: the use of the external fixator. A systematic review. Arch Orthop Trauma Surg 2022; 142:255-261. [PMID: 33222023 DOI: 10.1007/s00402-020-03684-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Vascular injuries after traumatic knee dislocation pose a potential limb threat for the patient. The benefits of external fixation have been described by many authors. However, the usefulness of the external fixator during acute management of knee dislocations with vascular injuries is a controversial aspect that has no consensus in the literature. The purpose of the present study was to provide data from the current literature on the utility of the external fixator and to investigate the percentage of knee dislocations with vascular injuries treated with an external fixator, the timing between external fixator and vascular repair, and the total time of external fixator. MATERIAL AND METHODS The present systematic review was conducted according to the PRISMA checklist. MEDLINE (Pubmed), Web of Science, and SCOPUS databases were searched for articles from 1 January 2000 to 6 February 2019. Studies reporting outcomes of treatment of knee dislocations with vascular injuries were included. Exclusion criteria included studies investigating chronic knee dislocations, knee arthroplasties, editorials, case reports, and expert opinions. Two authors independently extracted data and appraised the quality of evidence and risk of bias using the Methodological quality and synthesis of case series and case reports. RESULTS Descriptive statistics were used to report the outcome of our findings. Seven studies related to the usefulness of the external fixator during acute management of knee dislocations with vascular injuries were included. The external fixator had been used in the majority of knee dislocations with vascular lesions (72%). Timing between external fixator and vascular repair was reported on four studies (57%), two studies performed external fixation before vascular repair, and two studies performed external fixation after vascular repair. Total time of external fixator was only reported on three studies, ranging from 3 weeks to 3 months. These studies reported acute management, without referring to long-term results and without comparative groups. CONCLUSIONS External fixator was used in the majority of knee dislocations with vascular injuries but the justification for its use remained unclear. Larger studies are needed to fully understand the merit of the external fixator in knee dislocations with vascular injuries. Joint protocols between vascular surgeons and trauma surgeons are necessary to agree on the aspects related to the management of knee dislocations with vascular injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Eduard Ramírez-Bermejo
- Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain.
| | - Pablo Eduardo Gelber
- Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain
- ICATME, Hospital Universitari Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Nicolas Pujol
- Department of Orthopaedic Surgery and Traumatology, Versailles Hospital, University of West Paris-St Quentin, Versailles-Paris, France
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Ma C, Wang L, Tian Z, Qin X, Zhu D, Qin J, Shen Y. Standardize routine angiography assessment of leg vasculatures before fibular flap harvest: lessons of congenital and acquired vascular anomalies undetected by color Doppler and physical examinations. Acta Radiol 2021; 62:1716-1725. [PMID: 33455413 DOI: 10.1177/0284185120980001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fibular flaps have been widely used for mandibular and maxillary reconstructions. On occasion, anatomical variants of fibular arteries (FA) will be encountered. PURPOSE Although anatomical variants of FA during fibular harvest have been reported, controversy exists regarding whether simple color Doppler ultrasonography (CDU) and physical examinations (PE) are sufficient for early preoperative detection. MATERIAL AND METHODS A 10-year retrospective analysis in our department was performed to find the patients with various FA anomalies confirmed by computed tomography angiography (CTA) or intraoperative findings. RESULTS A total number of 19 FA anomalies were found either pre- or intraoperatively in 16 patients, in whom three cases were with bilateral FA variants. Type IIIC variants, also called arteria peronea magna (great peroneal artery), were confirmed in two legs, while the majority (13 legs) had type IIIA hypoplastic/aplastic posterior tibialis arteries (PTA). Four legs had new type IIID (low FA and PTA bifurcations). Preoperative CDU and PE only suspected anomalies in two legs. Six cases proceeded with using the affected fibulas, within whom vascular grafts were used in half of them for lengthening the FA pedicle. Local ischemia, partial soleus muscle necrosis, and claudication were reported in one. CONCLUSIONS Routine CTA before every fibular harvest, rather than simple PE and CDU, should be added for screening contraindications and ensuring safety for fibular flap harvest.
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Affiliation(s)
- Chunyue Ma
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Lei Wang
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Zhuowei Tian
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Xingjun Qin
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Dan Zhu
- Department of Radiology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Jinbao Qin
- Department of Vascular Surgery, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Yi Shen
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
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Prevalence and characteristics of the aberrant anterior tibial artery: a single-center magnetic resonance imaging study and scoping review. BMC Musculoskelet Disord 2021; 22:922. [PMID: 34727902 PMCID: PMC8564972 DOI: 10.1186/s12891-021-04801-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 10/19/2021] [Indexed: 12/01/2022] Open
Abstract
Background Planning surgical procedures of the lower leg benefits from considering the possibility of an aberrant anterior tibial artery (AATA), but previously published data on the frequency of this anatomic variant shows heterogeneity. We assessed the prevalence of AATA in a Latin American cohort using magnetic resonance imaging (MRI) and compared these with other studies reported in the literature. Methods We retrospectively included consecutive patients who had undergone multiplanar knee MRI at a radiology department in Lima, Peru. The MRI protocol included coronal T1 weighted, axial, sagittal and coronal proton density fat-saturated (PDFS) and sagittal T2 weighted images. Two experienced radiologists assessed all images and were blinded to each other’s findings. The frequency of the AATA was compared to previous cohorts. A scoping review was undertaken to provide an overview of previously published data on the prevalence of ATAA. Results We analyzed 280 knee MRI examinations of 253 patients (median age 41 years (IQR 31–52), 53.8% male). The aberrant anterior tibial artery variant was present in 8 of 280 (2.9%) evaluated knees, resulting in a prevalence of 3.2% in our study population. The PDFS sequence in the axial or sagittal orientation was most effective to identify AATA. The frequency of AATA in the reviewed literature using different radiological modalities ranged from 0.4 to 6% (median 1%, IQR (0.5–2.3%). Conclusions The AATA is a frequent vascular variant that can be detected by MRI in the preparation of invasive interventions of the lower leg. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04801-9.
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Reproducibility of Skin Temperature Response after Cold Stress Test Using the Game Ready System: Preliminary Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168295. [PMID: 34444044 PMCID: PMC8392449 DOI: 10.3390/ijerph18168295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/28/2021] [Accepted: 08/03/2021] [Indexed: 01/02/2023]
Abstract
The objective of this preliminary study was to determine the reproducibility of lower limbs skin temperature after cold stress test using the Game Ready system. Skin temperature of fourteen participants was measured before and after cold stress test using the Game Ready system and it was repeated the protocol in four times: at 9:00, at 11:00, at 19:00, and at 9:00 h of the posterior day. To assess skin temperature recovery after cold stress test, a logarithmic equation for each region was calculated, and constant (β0) and slope (β1) coefficients were obtained. Intraclass correlation coefficient (ICC), standard error (SE), and within-subject coefficient of variation (CV) were determined. No differences were observed between measurement times in any of the regions for the logarithmic coefficients (p > 0.38). Anterior thigh (β0 ICC 0.33–0.47; β1 ICC 0.31–0.43) and posterior knee (β0 ICC 0.42–0.58; β1 ICC 0.28–0.57) were the regions with the lower ICCs, and the other regions presented values with a fair and good reproducibility (ICC > 0.41). Posterior leg was the region with the better reproducibility (β0 ICC 0.68–0.78; β1 ICC 0.59–0.74; SE 3–4%; within-subject CV 7–12%). In conclusion, cold stress test using Game Ready system showed a fair and good reproducibility, especially when the posterior leg was the region assessed.
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High-Entry Vertebral Artery Variant during Anterior Cervical Discectomy and Fusion. Case Rep Orthop 2021; 2021:8105298. [PMID: 34341694 PMCID: PMC8325584 DOI: 10.1155/2021/8105298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/15/2021] [Indexed: 11/17/2022] Open
Abstract
Anterior surgical approaches to the cervical spine have allowed for treatment of common and complex pathologies with excellent outcomes. During the approach, complications can result from injury to the surrounding structures. The transverse processes usually protect the vertebral artery (VA) as it enters at C6 and courses cranially through the transverse foramina to C2 (referred to as the V2 segment). This is a case report of a patient who presented with myeloradiculopathy attributed to a C4-C5 disc herniation, severe canal stenosis, and marked bilateral neural foraminal stenosis. Preoperative imaging showed the right VA entering the C4 transverse foramen. This anatomic variant on a routine MRI led to further imaging and precautions when performing an uneventful anterior cervical discectomy and fusion (ACDF) at C4-C5. A high VA entry point into the transverse foramen above C6 could increase the risk of iatrogenic vascular injury in anterior approaches to the cervical spine. Rarely reported, the currently presented case describes a patient with a C4 right VA entry variant and highlights the importance of proper surgical planning.
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Moran J, Porrino J, Cheng R, Schneble CA, Kahan JB, Molho DA, Katz L, Miller MD, Medvecky MJ. An Imaging Overview of the Posterior Septum of the Knee and Trans-Septal Portal Procedure: Normal Anatomy, Indications, and Unique Imaging Considerations. Curr Probl Diagn Radiol 2021; 51:562-567. [PMID: 34217559 DOI: 10.1067/j.cpradiol.2021.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/24/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
The posterior trans-septal portal technique is an arthroscopic surgery of the knee providing surgeons with the ability to fully visualize the posterior compartment. With this procedure, portals are placed at the posteromedial and posterolateral aspect of the knee. Visualization of the medial and lateral posterior compartments then allows working space for the creation of the intra-articular portal that is made by dividing the posterior septum. We provide an imaging overview of the posterior septum, the trans-septal portal technique, possible indications, and introduce how surrounding anatomy may warrant unique imaging considerations.
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Affiliation(s)
- Jay Moran
- Yale School of Medicine, Medical school, New Haven, CT
| | - Jack Porrino
- Yale School of Medicine, Department of Radiology and Biomedical Imaging, New Haven, CT
| | - Ryan Cheng
- Yale School of Medicine, Medical school, New Haven, CT
| | | | - Joseph B Kahan
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, CT
| | - David A Molho
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, CT
| | - Lee Katz
- Yale School of Medicine, Department of Radiology and Biomedical Imaging, New Haven, CT
| | - Mark D Miller
- University of Virginia, Department of Orthopaedics, Charlottesville, VA
| | - Michael J Medvecky
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, CT.
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Kahan JB, Schneble CA, Li D, Petit L, Huang P, Bullock J, Porrino J, Richter DL, Schenck RC, Medvecky MJ. Increased Neurovascular Morbidity Is Seen in Documented Knee Dislocation Versus Multiligamentous Knee Injury. J Bone Joint Surg Am 2021; 103:921-930. [PMID: 33587513 DOI: 10.2106/jbjs.20.01151] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This article was updated on May 19, 2021 because of previous errors, which were discovered after the preliminary version of the article was posted online. In the legend for Figure 3-A, the phrase that had read "T1-weighted coronal MRI showing a right knee" now reads "T1-weighted coronal MRI showing a left knee." On page 924, in the section entitled "Materials and Methods," the sentence that had read "If there was no radiographic evidence or if there was a clinical note that documented visible deformity around the knee with no reduction maneuver being performed, then the patient was classified into the non-dislocated MLKI group." now reads "If there was no radiographic evidence or if there was no clinical note that documented visible deformity around the knee with no reduction maneuver being performed, then the patient was classified into the non-dislocated MLKI group." On page 925, in the section entitled "Analysis," the sentence that had read "Our study included 78 dislocated MLKIs and non-dislocated MLKIs, so both cohorts were adequately powered for the overall analysis." now reads "Our study included 45 dislocated MLKIs and 78 non-dislocated MLKIs, so both cohorts were adequately powered for the overall analysis." Finally, on page 927, in the section entitled "Discussion," the sentence that had read "Interestingly, we found that MLKIs with a documented knee dislocation had a substantially higher rate of vascular injury (23%) compared with those without (3%)." now reads "Interestingly, we found that MLKIs with a documented knee dislocation had a substantially higher rate of vascular injury (18%) compared with those without (4%)."
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Affiliation(s)
- Joseph B Kahan
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Christopher A Schneble
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Don Li
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Logan Petit
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Patrick Huang
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - James Bullock
- Orthopaedic Center of South Florida, Plantation, Florida
| | - Jack Porrino
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Dustin L Richter
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Robert C Schenck
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Michael J Medvecky
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
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Taskin B, Bender R, Schäller S, Wilke J, Pennig D, Mannil L. [Soft tissue reconstruction of the lower extremity with cross-leg flap as a salvage procedure]. HANDCHIR MIKROCHIR P 2021; 53:383-385. [PMID: 33851376 DOI: 10.1055/a-1276-1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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18
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Schneble CA, Kahan JB, Burroughs PJ, Nasreddine AY, Sumpio BE, Medvecky MJ. Popliteal Artery Occlusion with Collateral Blood Flow in a Reducible Knee Dislocation During Pregnancy: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00016. [PMID: 33835994 DOI: 10.2106/jbjs.cc.20.00516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 29-year-old healthy woman, 19 weeks pregnant, sustained a right posterolateral knee dislocation with multiligamentous injury and a complete occlusive injury to the right popliteal artery yet had adequate distal perfusion. She declined operative management for both the knee dislocation and the arterial injury, and successful collaboration between obstetrical, vascular, and orthopaedic surgical services resulted in limb preservation and restoration of function. CONCLUSION This is a unique case of traumatic complete popliteal artery occlusion with adequate collateral arterial perfusion after a reducible posterolateral knee dislocation in a pregnant patient that resulted in limb preservation with nonoperative management.
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Affiliation(s)
- Christopher A Schneble
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Joseph B Kahan
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | | | - Adam Y Nasreddine
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Bauer E Sumpio
- Division of Vascular Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael J Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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Naylor WM, Johnson DJ, Welter JM, Dunn ASM. Injury to the Popliteal Artery and Vein During Open Fibular Collateral Ligament Reconstruction: A Case Report. JBJS Case Connect 2020; 10:e1900666. [PMID: 32910619 DOI: 10.2106/jbjs.cc.19.00666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present a case involving a 26-year-old male who sustained an iatrogenic injury to the right popliteal artery and vein during open fibular collateral ligament reconstruction. The lesions were repaired immediately and required subsequent procedures on postoperative day 1. CONCLUSIONS Iatrogenic vascular injuries during knee surgery can be devastating for patients and may lead to increased medical costs, unexpected hospital admissions, and additional surgical procedures. Surgeons should scrutinize preoperative imaging to identify the anatomic location of the popliteal artery and vein, which may be at risk during posterolateral knee reconstruction.
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Affiliation(s)
- William M Naylor
- 1Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio 2Department of Orthopaedic Surgery, University Hospitals Regional Hospitals, Richmond Heights, Ohio 3Department of Orthopaedic Surgery, TriPoint Medical Center, Painesville, Ohio 4Precision Orthopaedic Specialties, Inc., Chardon, Ohio
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Oner S, Oner Z. Popliteal Artery Branching Variations: A Study on Multidetector CT Angiography. Sci Rep 2020; 10:8147. [PMID: 32424241 PMCID: PMC7235002 DOI: 10.1038/s41598-020-65045-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 04/25/2020] [Indexed: 11/16/2022] Open
Abstract
Determining the branching pattern of the popliteal artery (PA) is an important step in planning some radiological and surgical procedures. The aim of this study was to investigate the course and morphology of the terminal branches of the popliteal artery using multidetector computed tomography (MDCT) angiography, and also to determine possible role gender in branching pattern. Three-hundred forty lower extremity MDCT angiography images for 170 patients (118 M, 52 F), who were between 20–80 years old, were examined. Popliteal artery branching types were grouped as percentage incidences. TPT diameters and lengths in Type IA extremities were compared based on gender and right or left side. Anterior tibial artery (ATA), posterior tibial artery (PTA) and peroneal artery dominance rates were calculated. 5000 times measurement data was mixed so that the cascade mean filter values were calculated for the right and left TPT length each time. It was observed that Type IA was the most common branching pattern (89.4%). The variational pattern incidence was 10.6% and the most common category was Type III (4.1%). The most common pattern was Type IB (3.2%). Variational pattern was 2 times more prevalent in females when compared to the males. The mean TPT diameter was 4.5 mm (2.7–7.3 mm) and there was no difference based on gender and the right-left side. The most common dominant artery for the right and left legs was PTA in both genders. The cut-off values calculated for the right and left TPT independent of gender were 31.30 ± 2.40 and 28.36 ± 2.58, respectively. Three new subtypes were identified as short (S ≤ 2 cm), standard (N = 2–4 cm) and long (L ≥ 4 cm) in Type IA, since it is in a wide variational range although it is a typical PA branching pattern.
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Affiliation(s)
- Serkan Oner
- Faculty of Medicine Department of Radiology, Karabuk University, Karabuk, Turkey
| | - Zulal Oner
- Faculty of Medicine Department of Anatomy, Karabuk University, Karabuk, Turkey.
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21
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Wanken ZJ, Barnes JA, Eppolito AJ, Zwolak RM, Suckow BD. Coil embolization of an aberrant posterior tibial artery pseudoaneurysm after total knee arthroplasty. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:497-500. [PMID: 31763507 PMCID: PMC6859296 DOI: 10.1016/j.jvscit.2019.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/21/2019] [Indexed: 11/26/2022]
Abstract
Arterial injury is a recognized but rare complication of total knee arthroplasty. These injuries, however, can be exceptionally devastating and potentially result in limb loss. Presentation may be delayed with symptoms associated with mass effect rather than with ischemia. We describe treatment of a patient with presentation delayed 2 weeks. In addition, the patient's arterial branch pattern demonstrated aberrant anatomy with high takeoff of the posterior tibial artery. This patient was successfully treated with transcatheter coil embolization. The current treatment options and published literature are reviewed.
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Affiliation(s)
- Zachary J Wanken
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - J Aaron Barnes
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Anna J Eppolito
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Robert M Zwolak
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Teissier V, Tresson P, Gaudric J, Davaine JM, Scemama C, Raux M, Chiche L, Koskas F. Importance of Early Diagnosis and Care in Knee Dislocations Associated with Vascular Injuries. Ann Vasc Surg 2019; 61:238-245. [PMID: 31344468 DOI: 10.1016/j.avsg.2019.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/04/2019] [Accepted: 04/06/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Arterial injury secondary to acute knee dislocation (KD) is a rare but devastative complication. The aim of this study is to evaluate functional sequelae and factors of poor prognosis. METHODS A retrospective monocentric series of consecutive KD with acute ischemia by popliteal artery injury was analyzed between 2005 and 2017. The main outcome was the amputation rate. RESULTS Sixteen dislocations were included. Nine (56%) were due to public road accidents, 5 (31%) were due to falls from height, and 2 (13%) were due to sports injuries. Dislocation had occurred in the posterior location in 8 (50%) cases. Regarding arterial injury, there were 7 (44%) ruptures, 7 (44%) dissections, and 2 (13%) isolated thromboses. Eleven (69%) KDs with vascular trauma were associated with signs of acute ischemia. Revascularization was achieved by anatomical venous bypass in 14 (88%), resection and direct anastomosis in one (6%), and isolated thrombectomy in one (6%). Median time to surgery (time between trauma and vascular repair) was 7 hours (3.25-60.92 hours). Primary revascularization was performed in 12 (75%) cases. In three cases (19%), orthopedic reduction and stabilization were performed first. In one case, (6%) three-step management with vascular shunt at first, then with knee stabilization, and finally vascular bypass was carried out. Stabilization was achieved by using an external fixator in 13 (82%) cases, by open reduction and internal fixation in one case (6%), by ligamentoplasty in one (6%), and by using a long leg cast in one (6%). Fasciotomy was required in 12 (75%) cases. Two patients had early vascular complications, and 2 had early systemic complications. Three secondary transfemoral amputations were performed. Median follow-up duration was 23 months. No secondary amputation was recorded. At the end of follow-up, functional outcomes were evaluated using the Oxford Knee Score (OKS). The median OKS was 30 versus the pretrauma median OKS of 47 (P < 0.00028). No risk factor associated with limb amputation has been highlighted. CONCLUSIONS Analysis of these results provided indications for therapeutic management of this condition. This study shows poor functional outcomes because of severity of vascular lesion in patients with orthopedic trauma but with healthy arteries.
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Affiliation(s)
- Victoria Teissier
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Philippe Tresson
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France.
| | - Julien Gaudric
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Jean-Michel Davaine
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Caroline Scemama
- Department of Orthopaedic Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Mathieu Raux
- Sorbonne Université, INSERM, UMRS1158, Neurophysiologie respiratoire expérimentale et clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département d'Anesthésie Réanimation, Paris, France
| | - Laurent Chiche
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
| | - Fabien Koskas
- Department of Vascular Surgery, Groupe Hospitalier Pitié-Salpétrière Charles Foix, APHP, Université Paris6, Paris, France
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Lee CJ, Loo R, Wohlauer MV, Patel PJ. Diagnostic workup and endovascular treatment of popliteal artery trauma. VASA 2018; 48:65-71. [PMID: 30326793 DOI: 10.1024/0301-1526/a000756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an endovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with significant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard. Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data regarding endovascular techniques for the management popliteal arterial trauma.
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Affiliation(s)
- Cheong J Lee
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Rory Loo
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Max V Wohlauer
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Parag J Patel
- 2 Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, USA
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Evaluation of popliteal artery branching patterns and a new subclassification of the 'usual' branching pattern. Surg Radiol Anat 2017; 39:1005-1015. [PMID: 28251279 DOI: 10.1007/s00276-017-1834-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/13/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the frequency of popliteal artery branching variations in a wide study cohort and to investigate the relationship between these variations and infrapopliteal peripheral arterial disease (PAD). A subclassification was proposed for the most encountered type I-A, utilizing tibio-fibular trunk (TFT) length. METHODS A total number of 1184 lower extremity digital subtraction angiography (DSA) studies of 669 patients were evaluated. Following exclusion, 863 lower extremity DSA studies (431 right, 432 left) of 545 patients were enrolled. Popliteal artery branching type, patency of anterior tibial artery (ATA), fibular artery (FA) and posterior tibial artery (PTA) in each extremity and TFT length for type I-A extremities were recorded. Percentages of branching patterns, mean length and cut-off value of TFT and incidence of PAD in different types of branching were calculated. RESULTS Type I-A was the most common type of branching (81.3%). Frequency of branching pattern variation was 18.7%, the most common variation category was category III (12.2%) and the most common variation type was type III-A (5.6%). ATA and PTA had higher percentages of PAD in extremities with variant branching types. Cut-off value of 3 cm for TFT length was proposed in order to subclassify type I-A. CONCLUSIONS Our study cohort presents a higher incidence of popliteal artery branching variations. Some branching variations might have effect on the involvement pattern of the infrapopliteal arteries by PAD. We propose a subclassification for type I-A; type I-A-S (TFT < 3 cm) and type I-A-L (TFT ≥ 3 cm) which might have impact on interventional procedures.
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Zhong S, Zhang X, Chen Z, Dong P, Sun Y, Zhu W, Pan X, Qi D. Endovascular Repair of Blunt Popliteal Arterial Injuries. Korean J Radiol 2016; 17:789-96. [PMID: 27587969 PMCID: PMC5007407 DOI: 10.3348/kjr.2016.17.5.789] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/05/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility and effectiveness of endovascular repair for blunt popliteal arterial injuries. MATERIALS AND METHODS A retrospective analysis of seven patients with clinical suspicion of popliteal arterial injuries that were confirmed by arteriography was performed from September 2009 to July 2014. Clinical data included demographics, mechanism of injury, type of injury, location of injury, concomitant injuries, time of endovascular procedures, time interval from trauma to blood flow restoration, instrument utilized, and follow-up. All patients were male (mean age of 35.9 ± 10.3 years). The type of lesion involved intimal injury (n = 1), partial transection (n = 2), complete transection (n = 2), arteriovenous fistula (n = 1), and pseudoaneurysm (n = 1). All patients underwent endovascular repair of blunt popliteal arterial injuries. RESULTS Technical success rate was 100%. Intimal injury was treated with a bare-metal stent. Pseudoaneurysm and popliteal artery transections were treated with bare-metal stents. Arteriovenous fistula was treated with bare-metal stent and coils. No perioperative death and procedure-related complication occurred. The average follow-up was 20.9 ± 2.3 months (range 18-24 months). One patient underwent intra-arterial thrombolysis due to stent thrombosis at 18 months after the procedure. All limbs were salvaged. Stent migration, deformation, or fracture was not found during the follow-up. CONCLUSION Endovascular repair seems to be a viable approach for patients with blunt popliteal arterial injuries, especially on an emergency basis. Endovascular repair may be effective in the short-term. Further studies are required to evaluate the long-term efficacy of endovascular repair.
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Affiliation(s)
- Shan Zhong
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
- Department of Medical Imaging, Weifang Medical University, Weifang 261053, P.R.China
| | - Xiquan Zhang
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Zhong Chen
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Peng Dong
- Department of Medical Imaging, Weifang Medical University, Weifang 261053, P.R.China
| | - Yequan Sun
- Department of Medical Imaging, Weifang Medical University, Weifang 261053, P.R.China
| | - Wei Zhu
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Xiaolin Pan
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Deming Qi
- Department of Medical Imaging, Qilu Medical University, Zibo 255200, P.R.China
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Lavery KP, Parcells BW, Hosea T. Posterior Tibial Arterial System Deficiency Mimicking Chronic Exertional Compartment Syndrome: A Case Report. JBJS Case Connect 2016; 6:e72. [PMID: 29252649 DOI: 10.2106/jbjs.cc.15.00071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 15-year-old female competitive high school basketball player presented as an outpatient with a 3-month history of bilateral exertional calf pain. Patient history and compartment pressure measurements were consistent with the diagnosis of chronic exertional compartment syndrome, and the patient underwent bilateral fasciotomies. Postoperatively, her symptoms recurred and she was found to have a deficient posterior tibial arterial system bilaterally, as confirmed on advanced imaging. CONCLUSION We advocate the careful consideration of vascular etiologies in athletes who present with exertional leg pain.
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Affiliation(s)
- Kyle P Lavery
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
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Demirtaş H, Değirmenci B, Çelik A, Umul A, Kara M, Aktaş A, Parpar T. Anatomic variations of popliteal artery: Evaluation with 128-section CT-angiography in 1261 lower limbs. Diagn Interv Imaging 2016; 97:635-42. [DOI: 10.1016/j.diii.2016.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 11/26/2022]
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Tomaszewski KA, Popieluszko P, Graves MJ, Pękala PA, Henry BM, Roy J, Hsieh WC, Walocha JA. The evidence-based surgical anatomy of the popliteal artery and the variations in its branching patterns. J Vasc Surg 2016; 65:521-529.e6. [PMID: 26994952 DOI: 10.1016/j.jvs.2016.01.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/26/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The goal of our study was to analyze the prevalence of branching pattern variations in the popliteal artery (PA) along with morphometrics of the PA to better address its importance in disease and vascular surgical procedures. METHODS An extensive search for the PA and its anatomic variations was done in the major online medical databases. The anatomic data found were extracted and pooled for a meta-analysis. RESULTS A total of 33 studies (N = 12,757 lower limbs) were included in the analysis. The most common variant was a division of the PA below the knee into the anterior tibial artery and a common trunk for the posterior tibial and peroneal arteries, with a prevalence of 92.6% (95% confidence interval [CI], 90.2-93.8). The second most common variation was a trifurcation pattern of all three branches dividing within 0.5 cm of each other, with a prevalence of 2.4% (95% CI, 1.4-3.5). Of the three studies that reported the diameter of the PA at the level of the subcondylar plane, a mean diameter of 8 mm (95% CI, 7.29-8.70) was found. CONCLUSIONS The PA most commonly divides below the knee into the anterior tibial artery and the common trunk of the posterior tibial artery and the peroneal artery. Knowledge of the prevalence of possible variations in this anatomy as well as morphometric data is crucial in the planning and execution of any surgical intervention in the area of the knee.
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Affiliation(s)
- Krzysztof A Tomaszewski
- International Evidence-Based Anatomy Working Group, Krakow, Poland; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland.
| | - Patrick Popieluszko
- International Evidence-Based Anatomy Working Group, Krakow, Poland; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Matthew J Graves
- International Evidence-Based Anatomy Working Group, Krakow, Poland; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Przemysław A Pękala
- International Evidence-Based Anatomy Working Group, Krakow, Poland; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Brandon Michael Henry
- International Evidence-Based Anatomy Working Group, Krakow, Poland; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Joyeeta Roy
- International Evidence-Based Anatomy Working Group, Krakow, Poland; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Wan Chin Hsieh
- International Evidence-Based Anatomy Working Group, Krakow, Poland; First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jerzy A Walocha
- International Evidence-Based Anatomy Working Group, Krakow, Poland; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
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Oztekin PS, Ergun E, Cıvgın E, Yigit H, Kosar PN. Variants of the popliteal artery terminal branches as detected by multidetector ct angiography. Open Med (Wars) 2015; 10:483-491. [PMID: 28352741 PMCID: PMC5368887 DOI: 10.1515/med-2015-0056] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/15/2015] [Indexed: 12/05/2022] Open
Abstract
Objective To evaluate variants of the popliteal artery (PA) terminal branches with 64-multidetector computed tomographic angiography (64-MD CTA). Materials and Methods A total of 495 extremities (251 right, 244 left) of 253 patients undergoing a 64-MD CTA examination were included in the study. Of these, 242 extremities were evaluated bilaterally, whereas 11 were evaluated unilaterally. The terminal branching pattern of the PA was classified according to the classification scheme proposed by Kim; the distance between the medial tibial plateau and the origin of the anterior tibial artery (A) and the length of the tibioperoneal trunk (B) have been measured and recorded. Results In 459 cases (92.7%) branching of PA occurred distal to the knee joint (Type I); in 18 cases (2.8%) PA branching was superior to the knee joint (Type II); and hypoplasia of the PA branches was found in 27 cases (5.5%) (Type III). Among these types the most frequent branching patterns were Type IA (87.5%), Type IIIA (3.9%), and Type IB (3.8%). The ranges of A and B mean distances were 47.6 mm and 29.6 mm, respectively Conclusion Variations in popliteal artery terminal branching pattern occurred in 7.4% to 17.6% of patients. Pre-surgical detection of these variations with MD CTA may help to reduce the risk of iatrogenic arterial injury by enabling a better surgical treatment plan.
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Affiliation(s)
- Pelin Seher Oztekin
- Ankara Training and Research Hospital Radiology Department, Ankara, Turkey , Department of Radiology, Ankara Training and Research Hospital (SB Ankara Eğitim ve Araştırma Hastanesi), Şükriye Mh. Ulucanlar Cd. No:89, 06340 Cebeci/ Ankara, Turkey
| | - Elif Ergun
- Ankara Training and Research Hospital Radiology Department, Turkey
| | - Esra Cıvgın
- Ankara Training and Research Hospital Radiology Department, Turkey
| | - Hasan Yigit
- Ankara Training and Research Hospital Radiology Department, Turkey
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Medina O, Arom GA, Yeranosian MG, Petrigliano FA, McAllister DR. Vascular and nerve injury after knee dislocation: a systematic review. Clin Orthop Relat Res 2014; 472:2621-9. [PMID: 24554457 PMCID: PMC4117866 DOI: 10.1007/s11999-014-3511-3] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vascular injury is a devastating complication of acute knee dislocation. However, there are wide discrepancies in the reported frequency of vascular injury after knee dislocations, as well as important differences among approaches for diagnosis of this potentially limb-threatening problem. QUESTIONS/PURPOSES We determined (1) the frequency of vascular and neurologic injury after knee dislocation and whether it varied by the type of knee dislocation, (2) the frequency with which surgical intervention was performed for vascular injury in this setting, and (3) the frequency with which each imaging modality was used to detect vascular injury. METHODS We searched the MEDLINE(®) literature database for studies in English that examined the clinical sequelae and diagnostic evaluation after knee dislocation. Vascular and nerve injury incidence after knee dislocation, surgical repair rate within vascular injury, and amputation rate after vascular injury were used to perform a meta-analysis. Other measures such as diagnostic modality used and the vessel injured after knee dislocation were also evaluated. RESULTS We identified 862 patients with knee dislocations, of whom 171 sustained vascular injury, yielding a weighted frequency of 18%. The frequency of nerve injuries after knee dislocation was 25% (75 of 272). We found that 80% (134 of 160) of vascular injuries underwent repair, and 12% (22 of 134) of vascular injuries resulted in amputation. The Schenck and Kennedy knee dislocation classifications with the highest vascular injury prevalence were observed in knees that involved the ACL, PCL, and medial collateral liagment (KDIIIL) (32%) and posterior dislocation (25%), respectively. Selective angiography was the most frequently used diagnostic modality (61%, 14 of 23), followed by nonselective angiography and duplex ultrasonography (22%, five of 23), ankle-brachial index (17%, four of 23), and MR angiography (9%, two of 23). CONCLUSIONS This review enhances our understanding of the frequency of vascular injury and repair, amputation, and nerve injuries after knee dislocation. It also illustrates the lack of consensus among practitioners regarding the diagnostic and treatment algorithm for vascular injury. After pooling existing data on this topic, no outcomes-driven conclusions could be drawn regarding the ideal diagnostic modality or indications for surgical repair. In light of these findings and the morbidity associated with a missed diagnosis, clinicians should err on the side of caution in ruling out arterial injury.
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Affiliation(s)
- Omar Medina
- Department of Orthopaedic Surgery, University of California-Los Angeles, 10833 Le Conte Avenue, Box 956902, Los Angeles, CA 90095-6902 USA
| | - Gabriel A. Arom
- Department of Orthopaedic Surgery, University of California-Los Angeles, 10833 Le Conte Avenue, Box 956902, Los Angeles, CA 90095-6902 USA
| | - Michael G. Yeranosian
- Department of Orthopaedic Surgery, Rutgers University-New Jersey Medical School, Newark, NJ USA
| | - Frank A. Petrigliano
- Department of Orthopaedic Surgery, University of California-Los Angeles, 10833 Le Conte Avenue, Box 956902, Los Angeles, CA 90095-6902 USA
| | - David R. McAllister
- Department of Orthopaedic Surgery, University of California-Los Angeles, 10833 Le Conte Avenue, Box 956902, Los Angeles, CA 90095-6902 USA
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Posterolateral approach for plating of tibial plateau fractures and the risk of injury to the anterior tibial vessels. J Orthop Trauma 2013; 27:e228-9. [PMID: 23799353 DOI: 10.1097/bot.0b013e31829ff3e9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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