The Effect of Knee Flexion on Active and Passive Popliteal Venous Flow When Using Crutches or Knee Scooter While Immobilized

Abstract

Category:Trauma; OtherIntroduction/Purpose:Knee flexion has been demonstrated to impede popliteal venous return with large effect size among patients lying supine for surgery. Passive popliteal flow impedance has also been suggested to occur with knee scooter usage due to knee flexion. This study compared the effect of knee flexion angles on popliteal venous return between upright, crutch and knee scooter positioning when immobilized. Further, the countervailing effect of standardized hallux musculovenous pump activation was observed.Methods:This was an IRB approved study of young, healthy volunteers. Popliteal venous diameter and flow metrics were assessed with venous ultrasonography and compared between straight leg, crutch, and knee scooter positioning while wearing a walking boot and nonweightbearing. Flow was assessed with muscles at rest and with hallux musculovenous pump activation via active oscillation between hallux metatarsophalangeal joint extension and flexion at one motion per second (0.5 Hz) as paced by a metronome. Observer consistency was assessed. Paired-sample Student’s t-test and the Wilcoxon signed rank tests were used to assess within-subject differences for diameter and venous flow parameters, respectively. Knee flexion and musculovenous pump activation effects sizes were calculated. A priori sample size indicated 24 subjects were needed to achieve 80% power to detect a significant ( p < 0.006 ) difference in medial flow for any of 8 comparisons, assuming large effect sizes.Results:16 of 24 (67%) subjects were female. Twelve limbs (50%) were right sided. The mean age was 21.9 years (SD 3.0 years) and the mean body mass index was 21.9 (SD 1.9). Observer consistencies were excellent (0.93 to 0.99). No significant differences in mean vessel diameter, time-averaged mean velocity, and total volume flow occurred. Corresponding knee flexion effect sizes were small (range -0.04 to -0.26). A significant decrease (-24%) in active median time-averaged peak velocity (TAPV) occurred between upright and crutch position (20.89 cm/s vs. 15.92 cm/s, p < 0.001) with a medium effect size (-0.51). Hallux musculovenous pump increased all flow parameters (all p< 0.001) and effect sizes were comparatively larger (>0.6) across all knee flexion positions.Conclusion:Compared to values reported for supine individuals, upright passive popliteal venous return was observed to be markedly diminished at all knee flexion angles. Knee flexion had minimal effect on diameter, a small effect in further diminishing TAMV and TVF and a medium effect on diminishing TAPV. Hallux musculovenous pump activiation had a large effect on increasing flow at all knee flexion angles. Patients may well be counseled to use toe motion to counter the negative effects of gravity, and to a lesser extent knee flexion, when using crutches and knee scooters while their ankle is immobilized.