Traumatic Popliteal Artery Injury Research Articles

What is the Optimal Treatment Protocol for Traumatic Popliteal Artery Injury? A Comparative Study between Two Institutions

What is the Optimal Treatment Protocol for Traumatic Popliteal Artery Injury? A Comparative Study between Two Institutions

Efficacy of Orthoplastic Management in the Treatment of Traumatic Popliteal Artery Injury.

Popliteal artery injury (PAI) is a challenging condition. Even with appropriate initial treatment and reconstruction of the associated injuries, extensive soft-tissue necrosis may occur, requiring lower leg amputation. There are no reports on the effectiveness of orthoplastic surgery in treating traumatic PAI. However, orthoplastic surgery is also considered very effective in PAI treatment, which requires delicate handling of soft-tissue and blood vessels. This study aimed to examine the treatment outcomes of traumatic PAI at a trauma center with the capacity for orthoplastic management. Patients with PAI who were treated at our institution between August 2013 and December 2021 were included in this study. The surgeons included multiple orthoplastic surgeons with capabilities in vascular repair, bone and ligament reconstruction, and soft-tissue reconstruction. Patient demographics, injury characteristics, degree of ischemia, and treatment were investigated. We also investigated whether soft-tissue reconstruction and lower limb amputation were necessary as outcomes of treatment. Fifteen limbs of 14 patients with PAI met the inclusion criteria. Extensive soft-tissue necrosis was observed in three limbs. Two of these limbs were covered with a free latissimus dorsi flap and could be salvaged. In the remaining limb, lower limb amputation was unavoidable because of unexplained cardiac arrest during the initial surgery, but a fillet flap was used to successfully preserve the knee joint. Orthoplastic management has the potential to improve limb salvage rates and provide good outcomes for the treatment of traumatic PAI.

Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury

Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting (IVS) and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the cases series of traumatic PAI treated using CLS and verify the usefulness of CLS. All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. We used CLS for treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and four with grade 3. Amputation of the lower extremities was avoided except for one extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.

Traumatic popliteal artery spasm diagnosed using intraoperative angiography: A case report

There are few reports of traumatic arterial spasm in large-sized vessels in the extremities, and many surgeons are skeptical of its existence. We report a case of traumatic popliteal artery injury (PAI), which was later diagnosed as traumatic popliteal artery spasm on intraoperative angiography. A male patient, aged 54 years, was injured when a heavy object weighing approximately 100 kg fell on his right knee. Three hours after the injury, the patient was transported to our trauma center. The dorsalis pedis and posterior tibial arteries were not palpable, and his right lower leg was cold. However, he could move his ankle and toes completely and had no numbness or paresthesia in his right lower limb. Computed tomography angiography showed an interruption of the popliteal artery at the knee joint level and an enhancement on the distal side of the injury site. We diagnosed lower limb ischemia resulting from PAI and operated for revascularization. Under general anesthesia, the popliteal artery was explored via a posterior S-shaped incision in the prone position. No arterial abnormalities were observed macroscopically, and the injured area remained unidentified. Therefore, a contrast medium was injected into the popliteal artery using a 20-gauge intravascular needle, and angiography was performed, which revealed that the popliteal artery was patent; however, there was circumferential arterial stenosis at the level of the knee joint. At this point, the right lower limb's coldness had disappeared. Arterial spasm was speculated to cause the transient popliteal occlusion and lower leg ischemia. Immediate revascularization should be attempted when PAI is suspected. If no gross vascular abnormalities are confirmed, intraoperative angiography is useful for diagnosing arterial spasm.

Revisiting the Mangled Extremity Severity Score (MESS) in Popliteal Artery Injury: A Single-Centre Experience in Vietnam.

Popliteal artery injury is a severe condition that can lead to limb loss. Early intervention is essential to achieve optimal outcomes, including limb salvage. The Mangled Extremity Severity Score (MESS) is a scoring system used to predict amputation rates for mangled limb injuries. The effectiveness of the MESS in predicting amputationin patients with traumaticpopliteal artery injury is unclear, particularly in settings with a high prevalence of motorcycle accidents. This retrospective study was conducted at a single center in Vietnam between January 2018 and June 2020. The study included 120 patients who underwent surgical treatment for popliteal artery injury. Data were collected from electronic medical records, radiology reports, and operative notes. Logistic regression model and the area under the curve (AUC) were used to evaluate the predictive value of the MESS. Patients with a MESS score of ≥8 had a higher rate of amputation compared to those with a MESS score of <8. However, the predictive value of the MESS was limited, with an AUC of 0.68. Higher skeletal/soft tissue injury score, limb ischemia score, and shock score were associated with a higher risk of amputation. The age score of the MESS was unexpectedly higher in the limb salvage group. The MESS score can be useful in predicting amputation rates in patients with popliteal artery injury, but its predictive value is limited. A team approach involving experienced surgeons is recommended for decision-making regarding amputation.

Traumatic Popliteal Artery Occlusion Following Lower Extremity Crush Injury Presenting With Isolated Patellar Dislocation.

While traumatic popliteal artery injury historically has a low incidence, failure to acutely recognize the vascular insult poses a significant risk of limb loss and functional impairment. A 71-year-old male presented with left lower extremity pain in setting of a crush injury working underneath a vehicle resulting in an isolated lateral dislocation of his patella and complete occlusion of the distal popliteal artery. He was taken to the operating room for an in-situ bypass and four-compartment fasciotomy. His hospital stay included three staged washouts/debridements with eventual closure. He was discharged after 38days to a rehabilitation facility with ability to self-ambulate with assistance within one month. This patient's presentation is unique for his isolated patellar dislocation without associated injuries characteristically associated with a traumatic vascular injury of the popliteal artery and serves to remind the importance of complete examination in the setting of blunt trauma.

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

To report the experience of treatment on blunt traumatic popliteal artery injury (PAI) combined orthopedic injuries and determine the amputation-associated factors. From January 2008 to December 2019, 55 patients in level I trauma center with traumatic blunt PAI were retrospectively reviewed. Variables were retrospectively collected and statistically analyzed. Patients with PAI with limb selvage, primary amputation, and secondary amputation were retrospectively grouped and compared. A total of 55 patients with a median age of 41.4years (range 18-70), of which 45 were males (81.8%) and 10 were females (18.2%), were enrolled. The overall amputation rate was 36.4% because 88.6% of patients faced more than 6h of delay before treatment. The average injury severe score (ISS) and abbreviated injury score (AIS) were 10.4 (range 9-34) and 8.2 (range 5-16), respectively. Multivariate regression analysis showed that the number of hospitalization days was a significantly related factor to amputation. After a median follow-up of 56months (range 12-132), no death, another limb loss, or claudication was found in all patients. Patients with PAI are commonly accompanied by multiple injuries that increase the risk of amputation; therefore, timely treatments are urgently required. Reducing the severity of ischemia by fasciotomy, not losing time by performing preoperative imaging or diagnostic tests, and repairing the associated venous injury can help to optimize the rates of limb salvage. However, impact factors, such as the gender and age of the patient, injured mechanisms, concomitant injuries, AIS, ISS, and surgical times, are not associated with the outcomes of amputation. Nonetheless, endeavors to salvage the limbs as far as possible should be made.

Lower Extremity Staged Revascularization (LESR) as a new innovative concept for lower extremity salvage in acute popliteal artery injuries: a hypothesis

Popliteal artery injury following knee dislocation is associated with significant morbidity and high amputation rates. The complex and multi-disciplinary input required to manage this injury effectively can take time to arrange, prolonging the time to revascularization. Furthermore, open surgical bypass or interposition graft can be technically challenging in the acute setting, further prolonging ischemic time.Temporary intravascular shunts can be used to temporarily restore flow but require surgical exposure which takes time. Endovascular techniques can decrease the time to revascularization; however, endovascular popliteal stent-grafting is controversial because the biomechanical forces relating to flexion and extension of the knee may increase the risk of stent thrombosis. An ideal operation would result in rapid revascularization, eventually leading to a definitive and durable surgical solution.We hypothesize that a staged approach combing extracorporeal shunting, temporary endovascular covered stent placement, external fixation of bony injury, and definitive open repair provides for a superior approach to popliteal artery injury than current standard of care. We term this approach lower extremity staged revascularization (LESR) and the aim is to minimize the known factors contributing to poor outcomes after traumatic popliteal artery injury.

Popliteal Artery Injury After Fracture and/or Dislocation of the Knee: Risk Stratification for Revascularization Outcome.

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. 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. 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. 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.

Use of Medial Gastrocnemius Muscle Flap in Traumatic Popliteal Artery Injury Due to Posterior Dislocation of Knee Joint

Introduction: Injury to the popliteal region affects vascularity and soft tissue necrosis. The purpose of the study is to use the medial gastrocnemius muscle flap to enhance the soft tissue cover of the injured area. Materials and Methods: This retrospective study was conducted in the Department of Plastic surgery from January 2019 to December 2020. All patients admitted under the department with posterior dislocation of the knee with vascular compromise to the limb were enrolled in the study. Results: Five patients were included in the study. In all the five cases, the limb was salvaged with reverse saphenous vein graft harvested from the thigh region of the opposite limb with soft tissue cover of medial gastrocnemius muscle flap. Postoperative limb movements were satisfactory. The average duration of hospital stay was approximately 21 days. Conclusion: Usage of medial gastrocnemius flap serves an adequate soft tissue coverage in traumatic popliteal artery injury

Microsurgical Reconstruction of Lower Limb Using Thoracodorsal Artery Perforator Chimeric Free Flap after Popliteal Artery Revascularization: A Case Report

Although traumatic popliteal artery injury is uncommon, it can significantly increase the risk of limb amputation because of the anatomical complexity and delayed diagnosis and treatment. Various tools are available for treatment. Recently, an endovascular approach has been attempted for such injuries; however, open surgical repair remains the standard treatment. An integrated and stepwise procedure involving multidisciplinary specialists, including emergency department personnel for initial evaluation, orthopedic surgeons for treating accompanying fractures or dislocations, vascular and plastic surgeons for vessel repair, and interventional radiologists for immediate diagnosis and implementation of the endovascular approach, is needed. Covering wound defects due to skin and soft tissue necrosis and irreversible ischemic damage remains difficult despite successfully revascularizing the injured vessels. Here, we describe a case of revascularization after popliteal artery injury along with successful reconstruction of a complex defect with a thoracodorsal artery perforator chimeric free flap when recipient vessel selection was limited.

Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study

ObjectiveTraumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss. MethodsA multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P < .05) for amputation on univariate analysis were included in a multivariable analysis. ResultsA total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation. ConclusionsTraumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect.

Incidence and Outcome of Popliteal Artery Injury Associated with Knee Dislocations, Ligamentous Injuries, and Close to Knee Fractures: A Nationwide Population Based Cohort Study

Arterial injury in knee trauma is rare but can be devastating if the diagnosis is delayed. The frequency of concomitant arterial injury resulting from knee dislocations remains unclear, and from knee fractures it remains unknown. The primary aim was to investigate the incidence of arterial injury in knee trauma requiring hospitalisation. Secondary aims were to identify risk factors and describe outcome. Traumatic popliteal artery injury and knee trauma were identified by International Classification of Diseases (ICD)-10 codes from the Swedish National Inpatient registry (NPR), 1998-2014 and linked with data using the unique personal identification number with the National Registry for vascular surgery (Swedvasc). Risk factors for popliteal artery injury (PAI) such as cause of injury, comorbidities and injury severity were extracted from the NPR. Socio-economic status data and population count came from Statistics Sweden, and cause and date of death from the Swedish Cause of Death Registry. A total of 71149 admissions due to all knee trauma were identified, and 359 with simultaneous PAIs. Some of those injuries were non-orthopaedic. The proportion of PAI after knee dislocation ranged between 3.4% (46/1370 dislocations or multiligamentous injuries) and 8.2% (46/564 dislocations), and 0.2% after fracture close to the knee (60/36483). The most common causes of injury with PAI were falls causing knee dislocations and motor vehicle accidents (MVAs) causing fractures. The fact that all 46 injuries occurring after multiligamentous injuries were classified as knee dislocations is probably explained by the fact that the ICD codes are chosen retrospectively when the patient leaves the hospital. PAI after knee dislocation is not uncommon, and most frequently caused by a fall. PAI associated with knee fracture is rare and mostly caused by a MVA, while in low energy knee fractures PAI is practically non-existent.

Contemporary Outcomes of Traumatic Popliteal Artery Injury Repair

Contemporary Outcomes of Traumatic Popliteal Artery Injury Repair

Long-term functional outcomes after traumatic popliteal artery injury: A 20-year experience.

Traumatic popliteal arterial injury (TPAI) is associated with a risk of both limb loss and long-term morbidity due to prolonged ischemia and the often-associated musculoskeletal injuries. Long-term functional outcome following this injury has not been adequately studied. We evaluated patients with TPAI to determine if there was an improvement in functional outcome over time. We hypothesized that both the initial severity of ischemia and the associated injuries limited the ability of patients to improve functional outcome. Patients with TPAI for 20 years were identified. All patients had at least a 2-year follow-up. Functional outcomes were measured using the Boston University Activity Measure for Post-Acute Care to assess basic mobility (BM) and daily activity (DA). Multiple linear regression, adjusted for age, severity of injury and shock, operative complexity, associated injuries, ischemic time, and length of follow-up were used to identify predictors of functional outcome after TPAI. A total of 214 patients were identified: 123 penetrating (57%) and 91 blunt (43%). Overall mortality was 1.9% (all in-hospital), and amputation occurred in 10%. Of the 210 survivors, follow-up was obtained in 145 patients (69%). Median follow-up was 9.2 years (interquartile range, 5.7-15.7 years). Mean Activity Measure for Post-Acute Care scores for BM and DA were 78 and 75, respectively, both signifying mild impairment (normal, >84). Multiple linear regression failed to identify increasing length of follow-up as a predictor of improved functional outcomes. Only age, lower extremity fracture, and ischemic time were identified as predictors of decreased BM and DA. Increasing age, lower extremity fracture, and prolonged ischemic time worsened long-term functional outcomes. Functional outcome did not improve over time, suggesting that maximal recovery may be achieved within the first 2 years postinjury. Thus, early and effective revascularization remains the only potentially modifiable risk factor for improving functional outcomes following TPAI. Prognostic, level III.

Poster 350: Delayed Presentation of a Pediatric Traumatic Popliteal Artery Injury: A Case Report

Poster 350: Delayed Presentation of a Pediatric Traumatic Popliteal Artery Injury: A Case Report

A Case of Traumatic Popliteal Artery Injury with Knee Dislocation

A Case of Traumatic Popliteal Artery Injury with Knee Dislocation

Characteristics and clinical outcome in patients after popliteal artery injury

The treatment of popliteal artery injury (PAI) caused by blunt or penetrating mechanism is demanding. Concomitant injuries and prolonged ischemia are the major causes of lower extremity morbidity and poor rates of limb salvage. This study assessed the amputation rate and, subsequently, the therapeutic management and clinical outcomes regarding the affect of concomitant injuries among patients with PAI in a setting of central European trauma care. Sixty-four patients (20 female and 44 male), with an average age of 44 years (range, 17-79 years) at the time of injury, were evaluated for clinical characteristics, concomitant injuries, complications, amputation rates, and functional outcome after traumatic PAI. The mechanism of injury was blunt trauma in 35 patients (54.7%) and penetrating trauma in 29 (45.3%). The Mangled Extremity Severity Score and the Injury Severity Score were assessed initially and the modified Functional Independence Measure (FIM) Score at 12 months after the primary surgery. Thirty patients (47%) returned to their normal activity level within 1 year after trauma, and 16 (25%) were limited in their daily activity or suffered from chronic pain symptoms. Within the blunt trauma group 26 of 35 patients (74%) sustained severe concomitant injuries, whereas two of 29 patients (7%) in the penetrating group showed severe concomitant injuries (P < .046). Eleven patients (17%) had to undergo revision surgery due to their associated injuries. The median modified FIM score was 10.3, whereas patients with blunt trauma had significantly lower FIM score (P < .0082). The median Mangled Extremity Severity Score was 6 points (range, 6-16 points). Primary or secondary amputation was required in 18 patients (28%) due to failure of revascularization. Patients who sustained blunt trauma had significantly higher amputation rates than those with penetrating injuries (P < .035). Clinical outcome and limb salvage of patients with PAI were influenced by the mechanism of trauma, concomitant injuries, prolonged ischemia time, and the type of surgical procedure. Patients after blunt trauma had a higher incidence of concomitant injuries, and (comminuted) fractures or knee dislocations and severe soft tissue damage had the highest effect on the amputation rate.

Limb salvage and functional outcomes among patients with traumatic popliteal artery injury: a review of 64 cases.

Traumatic popliteal arterial injury carries the greatest risk of limb loss among all peripheral vascular injuries and is associated with high levels of morbidity and worse functional outcomes. The purpose of this study is to analyse the functional outcome among patients with popliteal artery injury (PAI) due to blunt and penetrating trauma and identify influencing factors. We critically reviewed 64 cases of PAI due to blunt and penetrating trauma treated at our institution over a 20-year period. We evaluated the influence of parameters, such as patient demographics, injury mechanism, initial ISS and performed interventions, on limb amputation rates and functional outcomes. Functional outcome was examined within the 12-months follow-up using the Functional Independence Measure (FIM) score for feeding, expression and locomotion. FIM scores for each category ranged from 1 (full assistance required) to 4 (fully independent), with a maximum total FIM score of 12 representing full independence. The mechanism of injury was blunt in 55 % and penetrating in 45 % of the patients. The overall amputation rate in our series was 28 %. Out of these, 83.3 % of all performed amputations in our series were due to blunt trauma and 88.6 % of all blunt trauma patients were severely injured (ISS > 9) or polytraumatized (ISS > 15). Blunt mechanism of injury has also shown a negative effect on the functional outcome. Analysis of the 1-year clinical follow-up showed that 30 patients (65.3 %) returned to their normal activity level within 1 year after trauma. A total of 16 patients (34.7 %) were recorded to have limited activity levels, 76.5 % of them sustained a blunt trauma. Using the FIM score to quantify the level of disability, we detected significantly worse results in both FIM total (8.8 vs. 10.4) and FIM locomotion score (3.1 vs. 2.7) following blunt trauma. The main findings of the present study were that PAI due to blunt trauma is associated with a high percentage of severely injured or even polytraumatized patients. Amputation rates following blunt trauma were significantly higher compared to penetrating trauma. Functional independence measurement, assessed 12 months after injury, also showed significantly worse results in both FIM total and FIM locomotion score after blunt trauma. Other factors that seem to have a negative influence on the outcome in terms of amputation rates after PAI are patient's age, presence of associated injuries and prolonged lower extremity ischemia.

Two Cases of Traumatic Popliteal Artery Injury

Two Cases of Traumatic Popliteal Artery Injury