Popliteal Area Research Articles

Tumor-Induced Sentinel Lymph Node Lymphangiogenesis and Increased Lymph Flow Precede Melanoma Metastasis

Lymphangiogenesis is associated with human and murine cancer metastasis, suggesting that lymphatic vessels are important for tumor dissemination. Lymphatic vessel alterations were examined using B16-F10 melanoma cells implanted in syngeneic C57Bl/6 mice, which form tumors metastasizing to draining lymph nodes and subsequently to the lungs. Footpad tumors showed no lymphatic or blood vessel growth; however, the tumor-draining popliteal lymph node featured greatly increased lymphatic sinuses. Lymph node lymphangiogenesis began before melanoma cells reached draining lymph nodes, indicating that primary tumors induce these alterations at a distance. Lymph flow imaging revealed that nanoparticle transit was greatly increased through tumor-draining relative to nondraining lymph nodes. Lymph node lymphatic sinuses and lymph flow were increased in mice implanted with unmarked or with foreign antigen-expressing melanomas, indicating that these effects are not due to foreign antigen expression. However, tumor-derived immune signaling could promote lymph node alterations, as macrophages infiltrated footpad tumors, whereas lymphocytes accumulated in tumor-draining lymph nodes. B lymphocytes are required for lymphangiogenesis and increased lymph flow through tumor-draining lymph nodes, as these alterations were not observed in mice deficient for B cells. Lymph node lymphangiogenesis and increased lymph flow through tumor-draining lymph nodes may actively promote metastasis via the lymphatics.

Common Peroneal Nerve Palsy after Excision of a Skin Mass in the Posterolateral Popliteal Fossa Region

The aim of this article is to report a patient with an iatrogenic injury of the common peroneal nerve (CPN) caused by compression due to tight fascial closure after surgical excision of a skin mass in the posterolateral popliteal fossa area. Injury to the CPN results in significant disability with foot drop. Palsy of the CPN is a most frequent complication of various orthopedic or other surgical procedures in the lower leg. The clinicians must keep in mind the complications of the nerve and profound knowledge of anatomy around the posterior popliteal region to minimize an unwanted complication. (J Kor Neurotraumatol Soc 2007;3:103-106)

The nonsaphenous vein of the popliteal fossa: Prevalence, patterns of reflux, hemodynamic quantification, and clinical significance

A large tortuous vein coursing over the posterior aspect of the knee and the upper calf may give rise to a constellation of varicose veins unrelated to the great (GSV) or small (SSV) saphenous veins. Designated the popliteal fossa vein (PFV), it perforates the deep popliteal fascia and empties into the deep system. We examined the prevalence, anatomic reflux patterns, hemodynamic role, and clinical significance of the PFV. We examined 543 patients (818 limbs) with venous disease, aged 14 to 94 years (median, 55 years). The study consisted of group A, comprising limbs with a PFV, and group B, formed by the remaining limbs. The history, clinical examination, and venous duplex scan findings were analyzed retrospectively. Venous clinical severity and venous segmental disease scores of group A were compared with those of an equal number of CEAP-, sex-, and age-matched control limbs. In situ venous hemodynamics of the PFV obtained with duplex scan are reported. A PFV was found in 24 (2.93%) of 818 limbs (95% confidence interval [CI], 1.8%-4.1%); 24 (4.4%) of 543 subjects (95% CI, 2.7%-6.2%), 12 men and 12 women aged 23 to 82 years (median, 54 years) had a PFV. CEAP clinical classes in limbs with a PFV were as follows: C2, 15 limbs; C3, 5 limbs; C4, 2 limbs; C5, 1 limb; and C6, 1 limb. Proximal and distal (92%), superficial (100%), perforator (87.5%), and complex-pattern (41.7%) reflux occurred more often in group A (P < .01). Incompetence in the GSV (75%), posterior arch, and posteromedial and saphenous tributaries was also more frequent in group A (P < .05). SSV reflux in group A (29%) matched that in group B. The PFV terminated at the deep system (96% in the popliteal vein) above the SSV (median distance, 1.5 cm; 95% CI, 0.5-2 cm). The odds ratio for a PFV in limbs with prior SSV disconnection was 5.68. Deep reflux was evenly distributed in group A (41.7%) and group B (27%). The prevalence of incompetent perforators was 283% (95% CI, 194%-373%) in group A and 96% (95% CI, 95%-98%) in group B (P < .001). PFV tributaries were distributed at the popliteal area (100%); the posterior (87.5%), medial (62.5%), and lateral (37.5%) upper calf; and the posterior distal thigh (17%), often projecting to the posterior GSV arch (50%). The (median) peak velocity of reflux in the PFV was 82.6 cm/s, the mean velocity was 17.7 cm/s, the duration was 2.4 seconds, the volume flow was 231.5 mL/min, and the expelled volume was 9.3 mL. The median diameter of the PFV at the crossing of the fascia was 0.527 cm. Venous clinical severity (range, 2-17; median, 5.5) and venous segmental disease (range, 0.5-8; median, 2.75) scores in limbs with a PFV exceeded (P <or= .04) those of the control limbs. With a prevalence of 4.4%, the PFV presents in limbs featuring complex reflux patterns involving all three venous systems proximally and distally. Limbs with a PFV have a higher propensity for GSV and superficial tributary reflux and have perforator vein incompetence three times more often than limbs without this vein. The PFV perforates the deep popliteal fascia terminating at the deep system (ie, the popliteal vein in 96%) distinctly above the SSV. In light of its reflux dynamics, nearing or exceeding those of severely impaired perforator veins, and the complex patterns of reflux (venous segmental disease) and venous clinical severity (high venous clinical severity scores) of the affected limbs, clinical and investigational awareness of the PFV is warranted.

Migration of a Kirschner wire from the greater trochanter to the popliteal fossa: a case report

Migration of Kirschner (K) wires from the upper extremity joints has often been reported, but it is less common from the lower extremities. In this report, we describe an 85-year-old man treated, during a hip replacement procedure, with a K-wire because of a trochanteric fracture; after one year, the K-wire was found in the popliteal fossa. This report illustrates the first case of K-wire migration in the popliteal area of the knee and suggests avoiding the use of free K-wires without any tension banding.

Diagnosis of deep vein thrombosis after operation for fracture of the proximal femur: comparative study of ultrasonography and venography

BackgroundWe compared investigative methods to study the diagnostic capability of ultrasonography. Subjects were 75 patients with proximal femur fractures who underwent surgery rom March 2002 to December 2003. MethodsBiochemical assays were carried out on days 3 and 7, and D-dimer levels were investigated as a time series. Ascending lower limb venography and ultrasonography were carried out nearly simultaneously in all cases on day 7. ResultsThe incidence of deep vein thrombosis (DVT)- positive findings on venography was 61.3% (46/75). Venography results demonstrated a diagnostic sensitivity of 95.5% and specificity of 91.4% using a D-dimer cutoff of 10μg/ml on postoperative day 7. By ultrasonography, diagnostic sensitivity for DVT was 78.3%, and specificity was 96.5%. Among all proximal area cases, there were 18 limbs with DVT seen on venography among which were 17 limbs in cases demonstrating DVT at the same site on ultrasonography, a correct diagnosis rate of 94.4%. ConclusionsFor the diagnosis of a thrombus more proximal than the popliteal area, a location at high risk for occurrence of pulmonary embolism, ultrasonography provided results nearly on par with those obtained by venography. Thus, we believe that ultrasonography allowed a more noninvasive, accurate diagnosis and more rapid treatment in cases where Ddimer values were 10μg/ml or more on postoperative day 7.

Rocky form giant synovial chondromatosis: a case report

We report a case of painless synovial chondromatosis with an extremely large mass at the popliteal area related to the right knee joint. A hard mass at the posterior aspect of the knee was the only complaint reported by the patient. Plain X-ray studies revealed punctuated calcifications both intra-articularly and around the knee joint. With the surgical procedure performed subsequently, multiple rocky-hard giant chondroid nodules were excised from the posterior aspect of the knee. After 9 months following the surgery, the patient had full range of motion, and no complaints. We emphasize on the importance this case because these lesions may simulate tumors, and lead to misdiagnosis.

Effect of leg elevation on healing, venous velocity and ambulatory venous pressure in venous ulceration

Objective: Current treatment of venous leg ulcers (VLU) includes four-layer bandaging, appropriate superficial venous surgery and leg elevation. The aims of this study were to: investigate a device designed to measure leg elevation; assess how long patients elevate; and to assess the effect of elevation on ulcer healing, femoral vein velocity (FVV) and popliteal vein cross-sectional area (PVCSA), and venous pressure. Patients and methods: A datalogger and accelerometer were manufactured to measure leg elevation. The device was validated in eight control subjects; elevation was measured in 24 patients with VLU. Ulcers were traced over six weeks in 29 patients and elevation measured to correlate healing with elevation. Ten patients and 10 controls underwent duplex measurement of FVV and PVCSA to measure flow in relation to posture; nine patients underwent measurement of venous pressure with postural changes. Non-parametric statistical analysis was used. Results: The datalogger accurately recorded all episodes of elevation. Median (range) elevation time was 53 (0–350) mins/24 h; correlation between ulcer healing and elevation was poor at 0.103 ( P=0.616, Spearman); change in posture from sitting to supine produced a significant increase in median (range) FVV from 11 (7–24) to 34 (22–66) in VLU ( P=0.005) and 15 (12–34) to 38 (16–69) in controls ( P=0.005, Wilcoxon). Change in posture from supine to 25 degrees elevation produced no change in FVV in either group ( P=0.173 in VLU, P=0.327 in controls, Wilcoxon). In VLU, sitting PVCSA was 1.07 (0.51–1.45) cm2. Supine position significantly reduced the area to 0.46 (0.27–1.01) cm2 ( P=0.005, Wilcoxon). On elevation to 25°, PVCSA was further reduced to 0.28 (0.07–0.63) cm2 ( P=0.058, Wilcoxon). In controls, sitting PVCSA was 0.79 (0.31–1.56) cm2, supine was reduced to 0.46 (0.27–1.09) cm2 ( P=0.047, Wilcoxon) and on elevation was reduced to 0.23 (0.10–0.44) cm2 ( P=0.005, Wilcoxon). Venous pressure standing was 99 (73–116) mmHg, reduced to 76 (53–113) mmHg on sitting ( P=0.084), and further reduced to 23 (7–36) mmHg supine ( P=0.008, Wilcoxon). Conclusions: Leg elevation in patients with VLU is poor but can be accurately measured. Elevation in the presence of compression may not improve ulcer healing. Postural changes of the leg can produce an increase in deep venous flow and a reduction in venous pressure.

How to deal with difficult microsurgical end‐to‐side anastomoses

Although unexplained thrombotic failures still exist, the majority of free-flap failures are due to identifiable technical failures, indicating that an excellent operative technique remains the key point. However, some clinical circumstances, such as damaged or deeply located vessels, are related to a higher thrombotic risks, demanding refinements of the microsurgical procedure to avoid higher failure rates. We reviewed 195 free flaps in the lower leg in order to quantify these situations and how we dealt with them. In total, six flaps were performed with a T-interposition to cope with difficult end-to-side anastomoses on damaged vessels. In two cases, the use of a funnel-shaped vein graft facilitated difficult end-to-side anastomoses in the popliteal area. The authors believe that these refinements of microsurgery should not be first-choice procedures, but they have proven to be a useful tool for certain microsurgical reconstructions.

Dermite livedoïde de Nicolau après sclérothérapie de varices

The accidental intra arterial injection of a sclerosing drug is a rare but well known accident, which can cause ischemia of the limb. The aspect of Nicolau livedoid dermatitis is less acknowledged. The ignorance of this entity or the confusion between the latter and an extravasation of the injected drug can delay an urgent treatment. A 39 year-old woman went to outpatients consultation, after sclerotherapy of a varicose vein of the right popliteal area, for the occurrence of a purpuric, painful plaque of the right popliteal area and the right calf. In spite of the late institution of a treatment including a potent vasodilator (iloprost) and an anticoagulant (calcic nadroparin), the patient recovered without important after effects. Nicolau livedoid dermatitis during sclerotherapy of a varicose vein has rarely been described before. Our case emphasizes the fact that these apparently superficial injections might involve this complication. Using an echo-Doppler device for targeting the varicose vein did not prevent the accident. Successive punctures on one site before injection might favor this event. Prevention relies on guidelines for the injection technique. Respecting these guidelines reduces the risk of complication without completely preventing it.

Microneurographic study of C fiber discharges induced by CO 2 laser stimulation in humans

We investigated C-fiber discharges and cerebral potentials evoked by weak CO 2 laser beams applied to a tiny skin area in five healthy subjects. Microneurography was performed from the peroneal nerve in the right popliteal area. Cerebral potentials were recorded from the Cz electrode referred to linked earlobes. The mean conduction velocity of five stable single units was 1.1±0.3 m/s. The mean latency of the positive peak of cerebral potentials was 1327.4±46.2 ms. These findings indicated that this new stimulation method selectively activated C-fiber nociceptors of the skin.

Microneurographic study of C fiber discharges induced by CO2 laser stimulation in humans

We investigated C-fiber discharges and cerebral potentials evoked by weak CO 2 laser beams applied to a tiny skin area in five healthy subjects. Microneurography was performed from the peroneal nerve in the right popliteal area. Cerebral potentials were recorded from the Cz electrode referred to linked earlobes. The mean conduction velocity of five stable single units was 1.1±0.3 m/s. The mean latency of the positive peak of cerebral potentials was 1327.4±46.2 ms. These findings indicated that this new stimulation method selectively activated C-fiber nociceptors of the skin.

Broken Blade in the Knee: A Complication of Arthroscopic Meniscectomy

Arthroscopic surgery has a very low incidence of intraoperative complications. However, while the authors were using a No. 11 blade to resect the anterior horn of a meniscus, the blade broke and the fragment flew into the posterior knee compartment. The only way to remove it was to make an incision over the popliteal area. We describe this complication to show that improvisation and use of inappropriate surgical instruments can lead to serious problems and the failure of arthroscopic procedures.

Multiple Pterygium Syndrome: Report of One Case

Multiple pterygium syndrome is a rare autosomal recessive disease which is characterized by multiple pterygium across the major joint and other associated anomalies. In this article, we report a male premature infant who was born with bizarre appearance: mask face with low set ear and micrognathia; pterygium of neck, antecubital, popliteal and intercrural area with four extremities flexion contracture. He was thought to be the first case report in Taiwan. Besides, we review medical literature about this disease.

Clinical investigation of the pressure and shear stress on the trans-tibial stump with a prosthesis

A system for measuring pressures and bi-axial shear stresses at the body support interfaces has been developed. This system has been used, in five unilateral trans-tibial amputees, to investigate the stresses at multiple points on the residual limb and prosthetic socket interface during standing and walking. The subjects investigated regularly used a patellar-tendon-bearing socket. The maximum peak pressure at the measured points was 320 kPa over the popliteal area during walking. The maximum shear stress was 61 kPa over the medial tibia area. Variable wave-forms of stress during walking were observed at the different measured points. The influence of the angular alignment on the stresses was investigated on one subject. It was found that a miss-alignment of ±8° produced a change in peak longitudinal shear stress of between 8% and 11.5%.

One Case of Sparganosis Infestation of the Thigh and Popliteal Area Combined with Avascular Necrosis of the Femoral Head

One Case of Sparganosis Infestation of the Thigh and Popliteal Area Combined with Avascular Necrosis of the Femoral Head

Recurrent Varicose Veins after Short Saphenous Vein Surgery: A Duplex Ultrasound Study

Recurrent venous reflux in the popliteal fossa of patients with recurrent varicose veins following short saphenous vein surgery was assessed in 70 limbs using a duplex scanner. Incompetence of the short saphenous vein was found to be the main source (61%) of venous reflux in the popliteal fossa (43/70). The recurrence or persistence of the short saphenous vein was subdivided into four types: an intact saphenopopliteal junction, as well as an intact short saphenous vein in 20 limbs (type I); varicosities in the popliteal fossa communicating with a short saphenous vein stump in 11 limbs (type II); a residual short saphenous vein communicating with the popliteal vein via a tortuous recurrent vein in eight limbs (type III); and a segment of residual short saphenous vein with no communication with the popliteal vein in four limbs (type IV). Incompetence of a gastrocnemius vein was involved in 24 cases (34%), an incompetent popliteal area vein in one (1.4%), popliteal vein incompetence in 15 (21%), and popliteal fossa varicosities communicating with the long saphenous system in two (3%). Of 12 limbs tested pre- and postoperatively, a high termination of the short saphenous vein was demonstrated in four of seven residual incompetent short saphenous veins. Duplex scanning is recommended to assess recurrent venous reflux in the popliteal fossa. It can be used to determine the level of an incompetent saphenopopliteal junction and the level of the termination of any other incompetent vein in the management of varicose veins recurring after a short saphenous vein operation. Copyright © 1996 Published by Elsevier Science Ltd.

Recurrent varicose veins after short saphenous vein surgery: a duplex ultrasound study

Recurrent venous reflux in the popliteal fossa of patients with recurrent varicose veins following short saphenous vein surgery was assessed in 70 limbs using a duplex scanner. Incompetence of the short saphenous vein was found to be the main source (61%) of venous reflux in the popliteal fossa ( 43 70 ). The recurrence or persistence of the short saphenous vein was subdivided into four types: an intact saphenopopliteal junction, as well as an intact short saphenous vein in 20 limbs (type I); varicosities in the popliteal fossa communicating with a short saphenous vein stump in 11 limbs (type II); a residual short saphenous vein communicating with the popliteal vein via a tortuous recurrent vein in eight limbs (type III); and a segment of residual short saphenous vein with no communication with the popliteal vein in four limbs (type IV). Incompetence of a gastrocnemius vein was involved in 24 cases (34%), an incompetent popliteal area vein in one (1.4%), popliteal vein incompetence in 15 (21%), and popliteal fossa varicosities communicating with the long saphenous system in two (3%). Of 12 limbs tested pre- and postoperatively, a high termination of the short saphenous vein was demonstrated in four of seven residual incompetent short saphenous veins. Duplex scanning is recommended to assess recurrent venous reflux in the popliteal fossa. It can be used to determine the level of an incompetent saphenopopliteal junction and the level of the termination of any other incompetent vein in the management of varicose veins recurring after a short saphenous vein operation.

Cost-effectiveness of routine screening for proximal deep venous thrombosis in acquired brain injury patients admitted to rehabilitation

Objective: Determine the prevalence of proximal deep venous thrombosis (DVT) among acquired brain injury patients on admission to rehabilitation and assess cost-effectiveness of routine ultrasound screening for proximal DVT in those patients. Design: Prospective study, sequential case series. Setting: University tertiary care rehabilitation center. Data Set: One hundred sixteen traumatic brain injury patients (TBI) and 48 nontraumatic brain injury patients were admitted to our brain injury (BI) unit over a 21-month period and screened for a DVT on admission to rehabilitation utilizing real time, spectral Doppler, and color Doppler ultrasound. Patients with a previous clinically recognized and treated DVT were excluded. No patients had been treated with prophylactic anticoagulation or intermittent anticoagulation since their BI and all patients were within 4 months of the original injury. Results: Fourteen patients in total (8.5%) were found to have a DVT in the thigh or popliteal area, 9 of the 116 patients in the TBI group (7.8%), and 5 of the 48 patients in the nontraumatic BI group (10.4%). Statistically, there was no significant difference in the total number of detected proximal lower extremity DVT's between the TBI and the nontraumatic BI groups (Fisher's exact test). In the TBI group 22 patients had associated lower extremity or pelvic fractures, but this factor appeared not to be significant, because only 1 of the 22 patients was discovered to have a DVT. The average admission Glascow Coma Score (GCS) of the TBI group was 8.6 but there was no correlation with the GCS and the prevalence of DVT. The additional cost of screening for and treating the additional DVTs utilizing color Doppler ultrasound is conservatively estimated to be $674.84 per patient admitted to the BI rehabilitation unit. It can be estimated the cost of saving one life is $129,527.83. Conclusion: DVT screening in this patient population appears to be more cost-effective than mass screening programs for either breast cancer or colorectal cancer. The cost per year of life saved, estimated at only $2,977.65 ($129,527.83/43.5 years) for DVT screening for brain injury patients on admission to rehabilitation, is lower than those costs proposed for comparable programs with significant social support.

Arthroscopic allograft: Posteriorcruciate ligament reconstruction

Posterior cruciate ligament (PCL) injuries are less frequent in the athletic population than injuries to theanterior cruciate ligament. Some reports indicate a ratio of 13 to 1 in these injuries. Recent reports on traumatic/nonathletic injuries detects a high percentage of primary PCL injuries that may go undetected or unattended because of severity of associated traumatic conditions. Arthroscopic technique of reconstructing the PCL regardless of substitute used seems to be superior to standard open technique and offers less morbidity, better visualization, and more precise placement of the graft. However, because of the closeness of the delicate neurovascular structure in the popliteal area meticulous attention to detail and precision technique is mandatory. This technique is not for the casual arthroscopist, a high level of arthroscopic skills are necessary to perform the procedure safely and accurately.

Gastrocnemius Muscle Herniation at the Knee Causing Peroneal Nerve Compression Resembling Sciatica

This was a case report. This is a case report of common peroneal nerve compression resembling sciatica caused by muscle herniation through the gastrocnemius muscle fascia in the popliteal area. A review of the literature revealed various causes of nerve compression of the lower extremity that resembles symptoms of sciatica (pseudoradiculopathy). There is, however, no report of pseudoradiculopathy caused by gastrocnemius muscle herniation in the popliteal area. The diagnosis of muscle herniation was confirmed during an exploratory operation of the common peroneal nerve in the popliteal area after other possible causes for L5 radiculopathy such as disc herniation and nerve root compression in the lumbar spine were ruled out by various imaging tests. Complete relief of symptoms was obtained after the torn gastrocnemius fascia was repaired. An unusual case of pseudoradicular symptoms is presented caused by compression of the common peroneal nerve in the popliteal area by gastrocnemius muscle herniation.