Saphenous Branch Research Articles

Oblique or short incisions reduce the risk of saphenous nerve damage during hamstrings harvesting. A model for mapping nerve pathways at the harvest site.

Hamstring autografts are frequently used for ligament reconstruction surgery. Twelve to 84% of patients describe hypo or dysaesthesia secondary to injury of the saphenous nerve or one of its branches after hamstring harvesting. Type of incision (orientation and length) is subject of much debate to limit the risk of nerve damage. A cadaveric study was performed to determine which type of incision limits the risk of injury to the saphenous nerve or one of its branches, based on an anatomic model for mapping nerve pathways at the harvest site. An anatomical study was performed on 20 knees from 12 embalmed bodies. Distance between saphenous nerve branches and 4 points of interest along the tibial crest was measured. Based on these measurements, a digital model of the saphenous nerve and its branches was created. A model of three common types of incision (vertical, horizontal and oblique) was overlaid. Each incision was modelled for three lengths (2, 3 and 4cm). Percentage of collision between nerve course model and incision model was then calculated to determine the risk of nerve damage for each type of incision. Based on the nerve course model, a "low collision risk" safe zone was identified. Nerve damage risk after an oblique incision was significantly lower than for a horizontal or vertical incision, for incision lengths of 3 and 4cm (p<0.05). For a specific incision orientation, the length of the incision did not affect the risk of nerve damage. A trapezoidal space close to the tibial crest and distal to the anterior tibial tuberosity appears to reduce risk of nerve damage. This cadaveric study suggests that during hamstring harvesting, incisions shorter than 2cm reduce the risk of saphenous nerve's branches injuries. For incisions longer than 2cm, using an oblique incision may reduce the risk compared to vertical or horizontal incisions. Level of evidence not applicable: Laboratory experiments.

Anatomical variation types of the deep femoral vein and its tributaries

BackgroundThe deep femoral vein generally has individual differences in origin, course, tributary, caliber, and quantity. However, systematic research on deep femoral vein variations remains insufficient. Given this, this study used anatomical observation to reveal the types and ratios of variations in the deep femoral vein and its tributaries. MethodsThis study selected 63 gross specimens of intact lower extremities and dissected their 126 lower limbs layer by layer to explore variations in the deep femoral vein and its tributaries. ResultsA total of 15 lower limbs exhibit variations in the deep femoral vein and its tributaries, of which 93% were unilateral. No correlation was found between the mutations and gender. They can be generally classified into three types: variations in the small saphenous vein branch of the deep femoral vein (7.14%), variations in the popliteal vein branch of the deep femoral vein (3.96%), and multiple deep femoral vein variations (0.79%). ConclusionsVariations in the deep femoral vein and its tributaries are not rare and can achieve a variation rate of 11.9%. Moreover, 93% of the variations involve tributaries of the deep femoral vein, among which 60% occur in the small saphenous vein branch, and approximately 30% are related to the popliteal vein branch. The variation diversity can lay a theoretical foundation for clinical diagnosis and treatment.

Peripheral nerve stimulation for the treatment of chronic knee pain

The average age of our population is increasing, resulting in a high incidence of chronic degenerative knee pathologies. Several treatment options, including surgical procedures are available to help mitigate these pathologies. However, the percentage of subjects with chronic post-surgical knee pain is still estimated at 16–20%. Neuromodulation techniques such as spinal cord stimulation and dorsal root ganglion stimulation (DRGS) are treatment options for subjects with chronic knee pain. The evidence for peripheral nerve stimulation (PNS) is minimal due to a limited number of neuromodulation systems capable of targeting the distal part of the lower limbs. This study aimed to investigate the safety and efficacy externally powered PNS systems for the treatment of chronic intractable knee pain targeting the saphenous nerve. Patients suffering from chronic intractable post-surgical knee pain received landmark-guided peripheral nerve stimulation of the branches of the saphenous nerve. All implants were performed with an externally powered PNS system to avoid lead migration as a result of cross-joint lead positions tunneling towards an Implantable Pulse Generator to the trunk. Data were collected retrospectively. Subject-reported outcome was measured via numerical rating scale values on a 10-point scale measuring pain intensity at rest and in motion. Additional data were collected for the subjects treated at the Charité location, including quality of life with the SF-36 form, quality of sleep with the Pittsburgh Sleep Quality Index and mood states with the short form of the General Depression Scale. Thirty-three patients received direct to permanent implant, landmark-guided peripheral nerve stimulation of the saphenous nerve branches. Six (18.2%) subjects reported non-sufficient initial benefit from the therapy and were explanted. Two subjects were explanted due to wound infections. The total study population reported included 25 patients. These subjects reported significant improvements related to pain, quality of life, mood quality, and quality of sleep. Additionally, subjects were able to reduce their opioid medication significantly after PNS therapy. Externally powered PNS at the saphenous nerve branches is a straightforward, selective and safe technique for patients with chronic knee pain. The landmark-guided implantation technique is less invasive than classical neuromodulation techniques such as spinal cord or DRGS and complication rates remain low. Short-term results are promising and show considerable reductions in pain scores and opioid intake. Long-term results are pending.

Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes.

Background:Most free-flap phalloplasty reports describe the femoral artery and great saphenous vein as recipient vessels, with the deep inferior epigastric artery and venae comitantes (DIEA/V) only rarely reported. We review our experience with preferentially using the DIEA/V as recipient vessels in gender-affirming free-flap phalloplasty, with DIEV as primary venous outflow.Methods:We retrospectively reviewed consecutive patients who underwent gender-affirming free-flap phalloplasty at our single institution from June 2017 through June 2021. The DIEA/V was used as recipient vessels, with the DIEA/V pedicle externalized via a passageway made through the external inguinal ring.Results:Thirty-eight consecutive free flaps (26 radial forearm free-flap phalloplasties, 10 anterolateral thigh phalloplasties, and two radial forearm free-flap urethroplasties) were performed. Mean age was 37.3 years; mean BMI was 25.7. Mean follow-up was 17.9 months. All flaps were anastomosed to the DIEA/V, without use of vein grafts. Most flaps (89.5%) had at least two veins anastomosed. To augment outflow, a saphenous vein branch was used in one of 38 (2.6%) cases and other superficial veins were used in two of 38 (5.3%) cases. One of 38 (2.6%) cases (early in our experience) resulted in total flap loss.Conclusions:Advantages of the DIEA/V as free-flap phalloplasty recipient vessels include a short, direct pathway for vessels, excellent donor-recipient vessel size match that allows end-to-end anastomoses, and elimination of risks associated with arterialized interposed veins. When venous outflow appears compromised, we recommend a low threshold to use additional local or saphenous veins, though this is rarely needed given the DIEV’s reliability.

A laparoscopic radical inguinal lymphadenectomy approach partly preserving great saphenous vein branches can benefit for patients with penile carcinoma

BackgroundInguinal lymphadenectomy (iLAD) is effective for penile carcinoma treatment, but usually results in many complications. This study aims to clinically evaluate the feasibility and clinical significance of a laparoscopic radical iLAD approach partly preserving great saphenous vein branches for penile carcinoma patients.MethodsA total of 48 patients with penile cancer who underwent laparoscopic radical iLAD with retention of the great saphenous vein in Henan Cancer Hospital from 2012 Jan to 2020 Dec were included in this study. Sixteen penile carcinoma patients who underwent laparoscopic radical iLAD preserving parts of superficial branches of the great saphenous vein were identified as the sparing group, and the matched 32 patients who incised those branches were identified as control group. This new procedure was performed by laparoscopy, preserving parts of superficial branches of the great saphenous vein, superficial lateral and medial femoral veins. Clinicopathological features and perioperative variables were recorded. Postoperative complications, including skin flap necrosis, lymphorrhagia, and lower extremity edema were analyzed retrospectively.ResultsWe found that the operative time of the sparing group is significantly longer than the control group (p = 0.011). There was no statistical difference in intraoperative blood loss, the lymph node number per side, average time to remove the drainage tube and postoperative hospital stay between the two groups. Compared to the control group, the sparing group showed a significantly decreased incidence of lower extremity edema (p = 0.018). The preservation of parts of superficial branches of the great saphenous vein was mainly decreased the incidence of edema below ankle (p = 0.034).ConclusionsThis study demonstrated that the iLAD with preserving parts of superficial branches of the great saphenous vein, with a decreased incidence of postoperative complications, is a safe and feasible approach for penile cancer.

Outside-in technique versus inside-out semitendinosus graft harvest technique in ACLR: a randomised control trial

BackgroundParaesthesia after hamstring graft harvest is a ubiquitous complication in the early post-operative period, and its correlation with vertical versus horizontal skin incision are well documented. The purpose of the study is to evaluate the incidence and extent/area of sensory loss of saphenous nerve branches occurring with the outside-in (OI) versus inside-out technique (IO) of semitendinosus graft harvest from the sartorius fascia and to determine a better method of graft harvest.MethodsSixty patients who underwent isolated semitendinosus graft harvest during anterior cruciate ligament reconstruction (ACLR) between 2016 and 2017. Patients were randomised into two groups depending on the graft harvest technique: 30 in the OI group and 30 in the IO group. The area of sensory loss was mapped on the patients’ skin using tactile feedback from the patients at each follow-up (10 days, 1 month, 3 months, 6 months and 1 year). Then, the area of sensory changes for the infrapatellar branch (IPBSN) and sartorial branch (SBSN) of the saphenous nerve, incision length, graft harvest duration, and graft length were analysed statistically between the groups.ResultsIn groups 1 and 2, 18/30 (60%) and 19/30 (63%) of patients, respectively, developed sensory changes, with no significant difference between the groups (p = 0.79). Isolated SBSN and IPBSN paraesthesia occurred in 2/60 (3%) and 19/60 (32%), respectively. Combined SBSN and IPBSN paraesthesia was present in 16/60 (27%) of patients. There was no significant difference in the area of the sensory deficit between OI and IO groups on the 10th post-operative day or at 1-month, 3-month or 1-year follow-up (p = 0.723, p = 0.308, p = 0.478, p = 0.128, respectively). However, at 6-month follow-up, the area of paraesthesia was significantly higher in the IO group (p = 0.009). The length of incision and duration of graft harvest was higher in the OI group than in the IO group (p = 0.002 and p = 0.007, respectively), and the total length of the graft was greater in the IO group (p = 0.04).ConclusionIncidence is equally distributed, area of iatrogenic saphenous nerve injury gradually decreases, and recovery is seen in the majority of the patients in both graft harvest techniques. IO graft harvesting technique is better in terms of graft harvest time and cosmetics and yields longer graft; however, area of paraesthesia, though not significant, was two-fold higher than the OI technique at 1-year follow-up.Clinical relevanceIO graft harvest technique would enable the surgeon to adopt quicker graft harvest, smaller surgical scar and lengthier graft than the OI technique.Level of evidenceTherapeutic randomised controlled prospective study, Level II.

495 New-onset left ventricular dysfunction and critical coronary artery disease: an MRI can help—a clinical case

Abstract Aims Understanding the aetiology of heart failure is crucial for treatment. Gadolinium cardiac magnetic resonance (CMR) is a powerful technique to distinguish dilated cardiomyopathy (DCM) from left ventricular (LV) dysfunction related to coronary artery disease (CAD). Methods and results Clinical case: a 61 years old Caucasian woman with a history of hypertension and dyslipidaemia presented to the emergency department of our hospital with pulmonary oedema and hypertensive crisis, requiring non-invasive ventilatory support. She complained about shortness of breath and exertional angina for almost one year. On admission, the echocardiography showed severe LV systolic dysfunction and severe functional mitral regurgitation (FMR). Troponin levels were slightly increased, and NT-proBNP was 2809 pg/ml. Once obtained clinical stability, anti-remodelling cardiac therapy was introduced and up titrated. Due to the history of angina and the new-onset severe LV systolic dysfunction, coronary angiography was performed, showing critical stenosis of the left main (LM) and of the proximal tract of the left anterior descending artery (LAD). In deciding the best treatment pathway for the patient evaluate myocardial viability and characterize myocardial tissue was of paramount importance. Subsequently, a CMR confirmed severe LV systolic dysfunction and severe functional mitral regurgitation but demonstrated myocardial viability, with no late gadolinium enhancement. Therefore the patient underwent surgical myocardial revascularization with triple coronary artery bypass grafts (left internal mammary artery-LAD, saphenous vein graft-obtuse marginal artery, saphenous vein graft-diagonal branch of LAD) and mitral valve repair (annuloplasty). The patient underwent a period of cardiac rehabilitation asymptomatic and in good clinical status. Three months later, echocardiography demonstrated an initial recovery of LV systolic dysfunction with signs of reverse cardiac remodelling and a good result of mitral valve repair. The patient is now on optimal medical therapy, free of symptoms and in good clinical and functional condition. Conclusions Cardiovascular magnetic resonance (CMR) is an excellent diagnostic tool in heart failure. This clinical case can be formative, confirming once again the importance of an accurate and complete diagnostic workup and a subsequent therapy of aetiology in heart failure.

Cadaveric and Angiographic Anatomical Considerations in the Genicular Arterial System: Implications for Genicular Artery Embolisation in Patients with Knee Osteoarthritis.

Genicular artery embolisation (GAE) is a novel treatment for patients with knee osteoarthritis (OA). Cadaveric dissection was undertaken to provide a complete description of the relevant arterial anatomy in order to perform safe and effective GAE. Twenty human lower limb specimens were dissected. The morphology of the genicular arteries and presence of anastomotic connections was recorded and compared with angiographic images from patients having undergone GAE. Vessels were measured to investigate the risk of non-target embolisation (NTE), taking a diameter of 300 microns as the threshold for significance. The descending genicular artery (DGA) is the dominant vessel in medial OA, with 95% of cases revealing vessel division into muscular, saphenous and osteoarticular branches from a single pedicle. The superior medial genicular artery (SMGA) had a shared origin with the middle genicular artery (MGA) in 25% of cases. NTE to the MGA may damage the cruciate ligaments. In 85% of cases, there was an anastomosis between the DGA and SMGA, often encountered at angiography. The mean diameter of the anastomoses was 850 micron, presenting a risk for NTE. An anastomosis between the Inferior Medial Genicular Artery (IMGA) and medial sural artery was found in 5% of cases; the medial sural artery supplies blood to the tibial nerve and should be avoided. The IMGA and inferior lateral genicular artery provided supply to the patellofemoral joint in 69% and 88% of cases, respectively. An in-depth knowledge of genicular artery anatomyis requiredfor interventional radiologists to perform safe and effective GAE in patients with knee osteoarthritis.

Free extended posterior tibial artery perforator flap with the neurovascular plexus of a saphenous nerve branch for large soft tissue and sensory reconstruction: Anatomic study and clinical application.

The posterior tibial artery perforator (PTAP) flap is a useful tool for reconstruction of soft tissue defects in the leg. However, the size and reliability of the flap largely depends on the quality of the perforator by which the flap is supplied, and the sensory recovery of the flap is limited. In this study, the anatomy of the saphenous nerve branches and their accompanying vessels was investigated, and a free extended PTAP flap with the neurovascular plexus of a saphenous nerve branch was designed for large soft tissue and sensory reconstruction in a series of clinical cases. Sixteen adult cadaveric legs perfused with red latex in the femoral artery were dissected. The number and location of the saphenous nerve branches and the features of their accompanying vessels were dissected and studied. From January 2016 to December 2017, six patients with soft tissue defects ranged from 8 × 2.5 cm to 21 × 4 cm were repaired by the free extended PTAP flap. The patients' average age was 48 years. The causes of the defects included machine injuries in three patients and traffic injuries in the other three. The defects located at the hand in three cases, foot in two cases, and ankle in one case. The flap was designed based on the perforators of the posterior tibial artery and included a branch of saphenous nerve. The perforator pedicle and the nerve branch were connected to the vessels and nerve in the recipient site, respectively. The saphenous nerve gave off 5.8 ± 1.1 branches, with a relatively constant one issuing 8.1 ± 0.7 cm distal to the medial femoral condyle. Every nerve branch had an accompanying vessel, which connected with the PTAPs and supplied the skin. The size of the flap ranged from 10 × 3.5 cm to 23 × 5 cm. All of the flaps survived completely without complications. Follow-up varied from 6 to 12 months. All the patients obtained cold/hot sensation and pain sensation. The results of Semmes-Weinstein monofilament test ranged from 4.31(2 g) to 5.46 (26 g), and the 2-point discrimination test varied from 20 to 35 mm. The free extended PTAP flap, containing the saphenous nerve branch and its accompanying vessels, may be an alternative for large soft tissue reconstruction with improved sensation recovery.

Pseudoaneurysm following hamstring tendon harvest in arthroscopic anterior cruciate ligament reconstruction: a case report

BackgroundVascular injury is a very rare complication following arthroscopic knee surgery. This is the first report of pseudoaneurysm at the saphenous branch of the descending genicular artery complicating semitendinosus tendon harvest in arthroscopic anterior cruciate ligament reconstruction.Case presentationA 19-year-old male had developed large ecchymosis, focal swelling and tenderness around his posteromedial knee after an arthroscopic anterior cruciate ligament reconstruction. Compartment syndrome of the lower leg and deep vein thrombosis were ruled out. A pseudoaneurysm formation was confirmed through an angiography and coil embolization was performed. At one year follow up, the patient reported improved functional outcome with good stability of the knee. However, mild paresthesia over the posteromedial calf was noted due to the compression injury of the saphenous nerve by the hematoma.ConclusionsThe pseudoaneurysm was presumed to result from accidental vascular injury while dissecting the accessory bands of the semitendinosus and was successfully treated by coil embolization. Care must be taken to section the expansions of the hamstring tendon, especially when the patient presents with underlying coagulopathy or vascular disease.

The ACL of the Ankle Joint: A Cadaveric Evaluation of the Subtalar Intrinsic Ligaments and Optimal Surgical Approach

Category:Ankle; Basic Sciences/Biologics; SportsIntroduction/Purpose:The biomechanics of ankle sprains involves a multiplanar-supination motion and not the strict inversion as is often described. During supination, calcaneal inversion occurs at the anatomic subtalar joint. The intrinsic subtalar ligaments include a series of broad thick ligaments situated in the tarsal canal that separate the anterior and posterior compartments. The subtalar intrinsic ligaments are damaged in an estimated 25% to 80% of all lateral ankle sprains. We hypothesize that the intrinsic subtalar ligaments have a multiplanar role in ankle joint stabilization similar to that of the anterior cruciate ligament at the knee. The purpose of this study is to evaluate the efficacy of four surgical approaches to the subtalar ligaments through cadaveric dissection.Methods:Four fresh-frozen cadaveric ankle specimens were utilized. Ability to access the extrinsic lateral ankle ligament (anterior talofibular), the extrinsic subtalar ligaments (calcaneofibular, lateral talocalcaneal) and the intrinsic subtalar ligaments (interosseous talocalcaneal, cervical) was evaluated. The first cadaveric specimen was dissected as a baseline to identify the extrinsic and intrinsic subtalar ligaments. The three remaining cadaveric specimens were utilized to evaluate the efficacy of three standard surgical approaches (a curvilinear incision made over the distal anterior border of lateral malleolus, a posterolateral longitudinal incision, and an extensile sinus tarsi approach) to access both the extrinsic ankle and subtalar ligaments as well as the intrinsic subtalar ligaments. Ability to access all ligaments as well as identification of neurovascular structures at risk during the dissection was recorded for each approach.Results:The curvilinear incision made over the distal anterior border of the lateral malleolus provided access to the anterior talofibular, calcaneofibular ligaments. Branches of the superficial peroneal nerve were noted to be at direct risk. The posterior longitudinal incision provided access to the calcaneofibular, lateral talocalcaneal ligaments. Branches of the sural nerve were noted to be at direct risk with this approach. An extensile posterolateral incision improved access to the anterior talofibular ligament. An extensile sinus tarsi approach provided the most direct access to the interosseous talocalcaneal and cervical ligaments. Visualization of the calcaneofibular and lateral talocalcaneal was also provided with this incision. The saphenous and superficial nerve branches and the sinus tarsi artery were noted to be at risk.Conclusion:We hypothesize that the intrinsic subtalar ligaments have a multiplanar role in ankle joint stabilization similar to that of the anterior cruciate ligament at the knee. Accurate identification and optimal surgical approach to these structures has not been well described in the orthopaedic foot and ankle literature. This cadaveric study provides evidence that an extensile sinus tarsi approach can provide access to the extrinsic ankle and subtalar ligaments as well as the intrinsic ligaments of the subtalar joint.

Anatomical study of the descending genicular artery and implications for image-guided interventions for knee pain.

The descending genicular artery (DGA) has recently been mentioned as accompanying some nerves in the medial aspect of the knee joint. This could be clinically relevant as the arteries could serve as landmarks for accurate nerve capture during ultrasound-guided nerve blockade or ablation. The aim of this cadaveric study was to investigate the anatomical distribution of the DGA, assess the nerves running alongside its branches, and discuss the implications for regional anesthesia and knee pain interventions. We dissected the femoral artery (FA) all along its course to identify the origin of the DGA, from which we carefully dissected all branches, in 27 fresh-frozen human specimens. Simultaneously, we systematically dissected the nerves supplying the medial aspect of the knee from proximally to distally and identified those running alongside the branches of the DGA. The surrounding anatomical landmarks were identified and measurements were recorded. The DGA was found in all specimens, arising from the FA 130.5 ± 17.5 mm (mean ± SD) proximally to the knee joint line. Seven distribution patterns of the DGA were observed. We found three consistent branches from the DGA running alongside their corresponding nerves at the level of the medial aspect of the knee: the artery of the superior-medial genicular nerve, the artery of the infrapatellar branch of the saphenous nerve, and the saphenous branch of the DGA. The consistent arteries and surrounding landmarks found in this study could help to improve the capture of the targeted nerves during ultrasound-guided interventions.

Estudo anatômico do ramo infrapatelar do nervo safeno em humanos

Objective To perform an anatomical study of the location of the infrapatellar branch of the saphenous nerve in relation to the structures of the knee. Methods An anatomical study was performed by dissection of 18 humans knees (9 right and 9 left knees). After exposure of the infrapatellar branch and its direct and indirect branches, they were then measured. We adopted a quadrant in the medial region of the knee delimited by two transversal planes as a parameter of the study. Results In 17 of the 18 knees (94.4%) studied, a single infrapatellar branch was observed. The infrapatellar branch emerged as fibers of the womb of the sartorius muscle in 17 of the 18 knees (94.4%). In relation to the branch, we observed that in 100% of the knees the infrapatellar branch had at least one primary branch, resulting in a superior branch and an inferior branch. In 9 limbs (50% of the cases) this branch occurred outside the proposed quadrant, and, in the remaining limbs, it occurred within the quadrant. Conclusion The infrapatellar saphenous nerve branch was found in all dissected knees, and, in 94.4% of the cases, it was of the penetrating type; in 100% of the cases, it originated two primary direct branches. The direct and indirect branches presented great variability regarding their path.

Four-year Duplex Ultrasound Follow-up of Trunk Incompetent Saphenous Veins Treated with High Ligation and Reversed Catheter-directed Foam Sclerotherapy

Introduction: Ultrasound-guided foam sclerotherapy (UGFS) is an alternative and supplementary method for endovenous thermal ablation (EVTA) to treat incompetent saphenous reflux (ISR) and branch varicose veins (BVV).[1] The long-term result is not as satisfactory as EVTA, even while administered by catheter-directed method with or without tumescent local anesthesia.[2,3,4] Combined high ligation(HS) of sapheno-femoral junction(SFJ)/ sapheno-popliteal junction (SPJ) and reversed catheter-directed foam sclerotherapy (rCDFS) to treat ISR is an idea to assure SFJ/SPJ closure, avoid foam leaking into deep vein and enhance foam-endothelium interaction to improve safety and surgical results in less invasive and lower cost way. Midterm sonographic changes of target saphenous veins (TSV), clinical severity improvement and re-intervention rate are our concerns. Methods: From Jan. 2015 to Nov. 2018, 37 patients, 38 limbs treated with HS+rCDFS were retrospectively reviewed. The TSVs, CEAP severity, life quality scores, presence of venous leg ulcers (VLU), previous procedures for ISR or BVV, ongoing surgical procedures and following procedures were recorded. All enrolled patients were called back for re-evaluation of CEAP severity, life quality scores and VLU healing. The sonographic changes of TSV and BVV were focused. Results: 37 patients, 70.3% female, aged 29-85(mean 62.4), received HS+rCDFS because of unsatisfactory results of previous interventions (UGFS 21%, others 22.2%) or reluctant to EVTA. The severity above C4a was 76.3% (figure 1), including 26.3% with VLU. The TSVs included 30 great saphenous veins(GSV), 1 anterior accessory great saphenous vein (AAGSV) and 7 small saphenous veins (SSV). 71.1% surgeries were proceeded under local anesthesia. 23.7% surgeries combined with miniphlebectomy and 28.9% with sclerotherapy to BVV and 10.5% with sclerotherapy to reticular/spider veins. 63.2% patients needed following sclerotherapy, 18.4% needed following miniphlebectomy. 70.3% patients were followed from 57 to 1316 (mean 248) days. 76.9% TSVs were fibrotic or sealed. There were 4 small caliber recanalization, 1 large caliber recanalization(LCR), 1 neovasculization and 1 collateralization.(table 1) The VLU healing rate was 100%. The mean AVVQ and VCSS were 2.4, 1.9 respectively. There was one re-intervention for LCR with 1% polidocanol microfoam, Varithena. Conclusion: The severity of this series of patients was high but HS+rCDFS still permitted satisfactory midterm results to treat de novo or relapsed ISR and BVV and achieved 100% VLU healing, not inferior to EVTA or open saphenous vein stripping. The follow-up sonographic findings were surprisingly well without evident neovasculization as expected. Only 4% significant collateralization or LCR might need re-intervention. Disclosure: Nothing to disclose

Combined effect of chronic partial occlusion and orthostatic load on the saphenous vein network: A varicosity model in the rat.

We tested the combined effects of chronic flow obstacle and gravitation on the saphenous vein network of rats. A narrowing clip (500 µm, partial occlusion) was administered on the saphenous vein main branch for 4, 8 and 12 weeks, either separately or in combination with chronic orthostatic load (tilted tube-cages for four weeks). Resulting network changes were studied on plastic casts, by video-microscopy, histochemistry-immunohistochemistry and image analysis. A rich collateral venous network developed containing newly formed masses of retrograde conducting small veins. Their walls had less dense elastica, less contractile protein, increased cell division activity and macrophage invasion, and were more sensitive to chronic gravitational load. Hemodynamic disturbance induces remodeling of the saphenous vein network. Walls of veins being in the process of flow-induced morphological remodeling are weak and more sensitive to gravitational load. Reticular vein conglomerates, veins with local dilations, and convoluted courses were observed.

Clinical application of posterior tibial artery perforator flap within saphenous nerve branch for sensory reconstruction

Objective To explore the operative technique and clinical results of posterior tibial artery perforator flap within saphenous nerve branch for sensory reconstruction. Methods From January, 2016 to June, 2018, 9 patients suffered from soft tissue defect were treated by the posterior tibial artery perforator flap containing saphenous nerve branch. Seven patients were males and 2 were females, with age ranged from 31 to 62 years. Soft tissue defects located in hands in 5 patients, plantar in 2 patients, ankle in 1 patient and dorsal foot in 1 patient. The size of soft tissue defects ranged from 8.0 cm×2.5 cm to 21.0 cm×4.0 cm. The regular post-operative followed-up was performed. Results All flaps survived without complications. The size of flap ranged from 10.0 cm×3.5 cm-23.0 cm×5.0 cm. Donor sites were primarily closed in 5 patients and secondary closed in 4 patients. Followed-up ranged from 6 to 15 months with 10 months in average. The contour of flaps were satisfied and the sensory function of the donor sites were normal. At 6 months followed-up, SW test reached 5.07 in all flaps, and 2PD ranged from 14 to 35 mm. Conclusion The novel sensory flap can provide satisfied sensory outcome without sacrificing main artery and saphenous nerve, and is a good candidate for sensory reconstruction of soft tissue defects. Key words: Posterior tibial artery; Perforator flap; Saphenous nerve; Sensory reconstruction; Soft tissue defect

Reappraisal of Perforasomes of the Superficial Femoral, Descending Genicular, and Saphenous Arteries and Clinical Applications to Locoregional Reconstruction.

The superficial femoral artery and medial thigh region has been an underused donor site for perforator flaps. This study evaluated perforasomes of the superficial femoral artery and its principal branches to review the clinical applications for locoregional reconstruction. Twenty-six fresh cadaveric lower extremities were dissected. Perforator size and anatomical course from the superficial femoral artery, descending genicular artery, and saphenous artery branch were documented. Perforators were selectively injected with iodinated contrast to assess vascular territories using computed tomography. A retrospective chart review was conducted on consecutive patients (2014 to 2015). One hundred thirty perforators were mapped in the medial thigh region. Eleven extended medial thigh perforator flaps and 15 hemicircumferential flaps were harvested. The mean distance from the joint line was 16.7 ± 7.3 cm. Perforators arose from the superficial femoral artery (62 percent), saphenous artery branch (23 percent), and descending genicular artery (15 percent). Superficial femoral artery perforators were located around the mid and proximal thigh region (p < 0.001). The median perforasome surface area was 244 cm, representing 36 percent in hemithigh flaps with preferential filling in the anteromedial region. Proximal perforasomes were the smallest. Perforasome areas based on vessel origin were comparable; however, saphenous artery perforators had a broader perforasome compared with descending genicular (p = 0.01) and superficial femoral artery perforators (p = 0.04). Six clinical case examples were presented for knee, thigh, and lower leg reconstruction. The superficial femoral artery or its branches can provide nontraditional reconstructive perforator flap options in regional reconstruction. They can be simple to harvest using a free-style approach, do not require preoperative imaging, offer a one-stage reconstructive method with low morbidity, and obviate the need for microsurgery or muscle flaps.

Analgesic strategies for day-case knee surgery.

Analgesic strategies for day-case knee surgery.

Cell Adhesion Molecule Close Homolog of L1 (CHL1) Guides the Regrowth of Regenerating Motor Axons and Regulates Synaptic Coverage of Motor Neurons.

The close homolog of L1 (CHL1) is a cell adhesion molecule involved in regulation of neuronal differentiation and survival, neurite outgrowth and axon guidance during development. In the mature nervous system, CHL1 regulates synaptic activity and plasticity. The aim of the present study was to evaluate the influence of CHL1 on peripheral nerve regeneration after trauma. Using the established model of mouse femoral nerve regeneration, CHL1 knock-out mice were investigated in comparison to the wild type littermates. First, non-injured mice of both genotypes were compared regarding the synaptic phenotypes in the corresponding spinal cord segment. While no differences in phenotypes were detectable in the femoral nerve, corresponding segments in the spinal cord were observed to differ in that inhibitory perisomatic innervation of motor neurons was increased in CHL1-deficient mice, and numbers of perisomatic cholinergic synapses on motor neuronal somata were reduced. Regarding the femoral nerve after injury, CHL1-deficient mice demonstrated preferential motor axon regrowth into the saphenous vs. quadriceps branch after nerve transection upstream of the nerve bifurcation by 8 weeks after transection, indicating decreased preferential motor re-innervation. Furthermore, in injured wild-type mice, enhanced CHL1 expression was observed in regenerating axons in the proximal nerve stump upstream of the bifurcation at days 1, 3, 5, 7 and 14, and in the distal stump at days 7 and 14 after injury, when compared to non-injured mice. Injury-related upregulation of CHL1 expression was more pronounced in axons than in Schwann cells. Despite a more pronounced capacity for preferential motor axon regrowth in wild-type vs. mutant mice, only a tendency for difference in recovery of motor functions was observed between genotypes, without statistical significance Taken together, these results indicate that CHL1 is involved in peripheral nerve regeneration, because it guides regrowing axons into the appropriate nerve branch and regulates synaptic coverage in the spinal cord.

Anatomical Features of the Descending Genicular Artery to Facilitate Surgical Exposure for the Subvastus Approach—A Cadaveric Study

BackgroundThe purpose of this cadaveric study was to clarify the proximal limit for the subvastus approach (SVA) in total knee arthroplasty to decrease potential vascular injury. MethodsSeventy embalmed knees underwent a modified SVA using a 14-cm oblique medial incision. Anatomical features of the descending genicular artery (DGA) were investigated with regard to variation, distance of the vessels from surgical landmarks, and sex differences. ResultsThe DGA was identified in 62 knees (89%), while it was absent in 8 knees (11%); in the latter, the articular, saphenous, and muscular branches arose separately from the femoral artery. The mean distances from the tibial tuberosity and medial joint line to the origin of the DGA were 15.5 ± 1.6 cm and 12.6 ± 1.6 cm, respectively. Both distances were significantly longer in males than in females (P < .01, respectively). A strong positive correlation was found between the distance from the tibial tuberosity to the origin of the DGA and the distance from the medial joint line to the origin of the DGA (Spearman's correlation coefficient, R2 = 0.72, P < .01). A weak positive correlation was found between the distance from the tibial tuberosity to the origin of the DGA and lower leg length (R2 = 0.13, P < .01). No vascular injuries were observed in this surgical exposure. ConclusionThe DGA showed several variations and was absent 11% of the time. An oblique medial incision within 14 cm from the tibial tuberosity followed by arthrotomy is considered a safe zone for the SVA.