The Effect of Knee Flexion on Active and Passive Popliteal Venous Flow When Using Crutches or Knee Scooter While Immobilized
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Category: Trauma; Other Introduction/Purpose: Knee flexion has been demonstrated to impede popliteal venous return with large effect size among patients lying supine for surgery. Passive popliteal flow impedance has also been suggested to occur with knee scooter usage due to knee flexion. This study compared the effect of knee flexion angles on popliteal venous return between upright, crutch and knee scooter positioning when immobilized. Further, the countervailing effect of standardized hallux musculovenous pump activation was observed. Methods: This was an IRB approved study of young, healthy volunteers. Popliteal venous diameter and flow metrics were assessed with venous ultrasonography and compared between straight leg, crutch, and knee scooter positioning while wearing a walking boot and nonweightbearing. Flow was assessed with muscles at rest and with hallux musculovenous pump activation via active oscillation between hallux metatarsophalangeal joint extension and flexion at one motion per second (0.5 Hz) as paced by a metronome. Observer consistency was assessed. Paired-sample Student’s t-test and the Wilcoxon signed rank tests were used to assess within-subject differences for diameter and venous flow parameters, respectively. Knee flexion and musculovenous pump activation effects sizes were calculated. A priori sample size indicated 24 subjects were needed to achieve 80% power to detect a significant ( p < 0.006 ) difference in medial flow for any of 8 comparisons, assuming large effect sizes. Results: 16 of 24 (67%) subjects were female. Twelve limbs (50%) were right sided. The mean age was 21.9 years (SD 3.0 years) and the mean body mass index was 21.9 (SD 1.9). Observer consistencies were excellent (0.93 to 0.99). No significant differences in mean vessel diameter, time-averaged mean velocity, and total volume flow occurred. Corresponding knee flexion effect sizes were small (range -0.04 to -0.26). A significant decrease (-24%) in active median time-averaged peak velocity (TAPV) occurred between upright and crutch position (20.89 cm/s vs. 15.92 cm/s, p < 0.001) with a medium effect size (-0.51). Hallux musculovenous pump increased all flow parameters (all p< 0.001) and effect sizes were comparatively larger (>0.6) across all knee flexion positions. Conclusion: Compared to values reported for supine individuals, upright passive popliteal venous return was observed to be markedly diminished at all knee flexion angles. Knee flexion had minimal effect on diameter, a small effect in further diminishing TAMV and TVF and a medium effect on diminishing TAPV. Hallux musculovenous pump activiation had a large effect on increasing flow at all knee flexion angles. Patients may well be counseled to use toe motion to counter the negative effects of gravity, and to a lesser extent knee flexion, when using crutches and knee scooters while their ankle is immobilized.Keywords:
Crutch
Supine position
Popliteal artery
Popliteal vein
Knee flexion
A 63-year-old asymptomatic man with unlimited exercise tolerance is investigated for suspected popliteal aneurysms, due to absent pedal pulses and prominent popliteal pulsations. Contrast-enhanced computed tomography (CT) shows occlusion of the left popliteal artery with geniculate collaterals surrounding the popliteal vein (A). The medial head of gastrocnemius separates the popliteal vein and the occluded (entrapped) popliteal artery. CT also shows entrapment of the right popliteal artery, due to extrinsic compression by the abnormally sited tendon of the medial head of gastrocnemius, which separates the artery and vein, mirroring the muscular anatomy on the left (B). A second 55-year-old man, normally walking 10-12 miles per day without restriction, presents with acute right leg claudication at 200 m. Contrast-enhanced CT demonstrates left popliteal artery stenosis with post-stenotic dilatation and right distal popliteal embolic occlusion due to a popliteal aneurysm with thrombus secondary to bilateral popliteal entrapment syndrome (PAES) (C). Axial balanced flow fast field echo magnetic resonance images and corresponding CT axial images demonstrate that the left medial head of gastrocnemius passes between the popliteal artery and popliteal vein. However, the aneurysmal right popliteal artery and the right popliteal vein are both located medial to, and are not separated by, the medial head of gastrocnemius (D). PAES is an uncommon cause of occlusive arterial disease, which is often bilateral. It is caused either by abnormal muscular insertions, typically of the medial head of gastrocnemius or the popliteus muscle, or by anomalous fibrous bands (types II, III, and IV, according to the modified Whelan classification).1Rich N.M. Collins G.J. McDonald P.T. Kozloff L. Clagett G.P. Collins J.T. Popliteal vascular entrapment: its increasing interest.Arch Surg. 1979; 114: 1377-1384Google Scholar Less commonly, an abnormal course of the popliteal vessels around normally inserted muscles is responsible for the entrapment (type I). Arteriovenous (type V) and functional entrapments have also been described. As illustrated, cross-sectional studies are very useful in demonstrating the abnormal anatomy. These two cases also show that muscular abnormalities are not always symmetrical in bilateral PAES (all limbs presenting as type II, except for the right leg of the second patient, which can be classed as type I, due to the medial course of the artery around a normal insertion of the medial head of gastrocnemius). Both patients consented to the publication of the case details and relative images.
Popliteal artery
Popliteal vein
Gastrocnemius muscle
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Objective To observe the popliteal artery anatomy courses at different levels of knee using computed tomography angiography(CTA)scan,so as to explore the best CTA monitoring level in lower limb popliteal artery.Methods A retrospective analysis of popliteal artery images was conducted in 47(94sides)diabetic patients from May 2012to April 2013.The image data were divided into three groups,namely,the upper edge(group A),the middle portion(group B)and the lower edge(group C)of the patella.The relation between popliteal artery and popliteal vein was analyzed and the occurrence of popliteal artery plaques was evaluated.Results In group A,76sides of popliteal artery were observed in the anteromedian of the popliteal vein,11sides in the front,1side in the anterolateral,1side in the lateral of the popliteal vein, and 5sides were unclear due to disturbance by other vessels.In group B,68sides of popliteal artery were recorded in the anteromedian of the popliteal vein,10sides in the front,3sides in the anterolateral,1side in the posterior of the popliteal vein,and 12sides were unclear due to disturbance by other vessels.In group C,41sides of popliteal artery were found in the anteromedian of the popliteal vein,17sides in the front,4sides in the anterolateral,1side in the lateral,2sides in the posterior of the popliteal vein,and 29sides were unclear due to disturbance by other vessels.Results ofχ 2 test indicated that the stability of the popliteal artery in group A and B was significantly higher(P0.05)and the vascular disturbance was significantly less(P0.05)than those in group C.The incidence of plaque in group A(44.68%,42/94)was significantly higher than that in group B(25.53%,24/94,P0.05).Conclusion The median patella level is the best CTA monitoring level for lower limb popliteal artery.When the popliteal artery at the median patella level is hard to identify,the upper edge level of the patella can be chosen as an alternative.
Popliteal artery
Popliteal vein
Computed Tomography Angiography
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Abstract The results of treatment in 34 cases of penetrating injury to the popliteal vein are presented. In 26 cases there was associated damage to the popliteal artery. Satisfactory venous repair by lateral suture was achieved in 11 of 12 limbs. Autogenous vein grafts were used to repair the damaged popliteal vein in 10 limbs. In 4 the saphenous vein was anastomosed directly to the popliteal vein; in 6 cases it was used as a wide-bored panel or compilation graft. Three popliteal veins were ligated. Major postoperative limb oedema and chronic venous insufficiency were not a problem in those cases where the veins were repaired. Fasciotomy was performed in 19 of the 34 cases of venous injury. In 12 of these cases fasciotomy, performed as part of the original operation to repair the vascular injury, led to an excellent clinical result.
Popliteal vein
Popliteal artery
Fasciotomy
Femoral vein
Great saphenous vein
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Popliteal artery
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Popliteal artery
Popliteal vein
Concomitant
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Objective: To provide anatomical basis for the way of isolatin g small sapheonus vein to repair injuried popliteal artery. Methods: Small saphe onus veins and popliteal arteries on 50 sides of adult cadaveric lower extremiti es were observed and measured. Results: Small sapheonus vein and popliteal arter y had steady anatomic relationship. The average diameters of popliteal artery we re 6.6±0.9 mm at the original segment, 5.9 ±1.0 mm at the middle segment, 4.9 ±0.9 mm at the branch part. While the average diameters of small sapheonus vein were 3.1±0.1mm at the areas of the entrance, 2.9±0.1 mm at the middle segment and the external malleolus part. The appearance of rate was low in the communic ating branches of small sapheonus vein and popliteal artery. Conclusion: Both sm all sapheonus vein and popliteal artery system have a constant anatomical positi on and their diameters were similar. Removing a segment of small sapheonus vein to repair the injuried popliteal artery is possible.
Popliteal artery
Popliteal vein
Cadaveric spasm
Medial malleolus
Malleolus
Great saphenous vein
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Popliteal vein compression caused by popliteal cyst was detected in 53-year-old man with venostasis of the lower limb. Deviation of the popliteal artery was also demonstrated by arteriography. The cyst communicating with the knee joint and partly covered by the lining of synovial cells was totally excised without damage to the vein. An analysis revealed hyaluronic acid to be the major component of glycosaminoglycan in the cyst and was 3 or 4 times in excess of that in the synovial fluid. The postoperative course was uneventful and symptoms were almost relieved.
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Popliteal vein
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Introduction This study aimed to determine the incidence, management, and outcomes of popliteal artery injury, popliteal vein injury, and concomitant popliteal artery injury and vein injury. Methods A retrospective analysis was completed using the 2000–2010 Nationwide Inpatient Sample utilizing International Classification of Diseases-9 codes to select patients with isolated popliteal artery injury (904.41), isolated popliteal vein injury (904.42), and isolated concomitant popliteal artery and vein injury (958.92). Variables included demographics, procedure type, and outcome during hospital course. Statistical analysis was with chi-square, Fisher exact test, and multivariate analysis. Results A total of 2216 patients presented with injury to the popliteal system; 71% (1568) presented with isolated popliteal artery injury, 14% (306) with isolated popliteal vein injury, and 15% (342) with concomitant popliteal artery and vein injury. Amputation was significantly increased in popliteal artery injury and concomitant popliteal artery and vein injury ( P < 0.001) as compared to popliteal vein injury. Ligation of the vein was more common in concomitant popliteal artery and vein injury when compared to popliteal vein injury ( P < 0.05). The rate of amputation was 9.8% for popliteal artery injury, significantly greater than for popliteal vein injury (0.7%, P < 0.001) but not different than for concomitant popliteal artery and vein injury (8.2%, P = NS). Conclusion Evidence-based management of popliteal vasculature may increase rates of limb salvage. Within the limitations of the data set used, conclusions appear to be that patients with popliteal vein injury or concomitant popliteal artery and vein injury may be managed with vein ligation without increased amputation rates as compared to popliteal artery injury.
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Unlike the venous compression associated with larger popliteal artery aneurysms, which frequently is associated with deep vein thrombosis, the venous compression caused by the moderate sized (greater than 2 cm and less than 3 cm) aneurysms in the reported cases is not associated with thrombosis. The extrinsic compressive effect of these moderate sized popliteal artery aneurysms on the adjacent vein is shown to vary with the patient's leg position. Three of the four patients with unilateral leg swelling discussed here had bilateral popliteal artery aneurysms. In these cases, the contralateral leg had a small popliteal aneurysm (less than 2 cm) and no leg swelling was present. The cases suggest that popliteal artery aneurysm size is an important factor in determining the type of venous obstruction that results from the extrinsic compression of the ipsilateral popliteal vein. The described phenomenon of a popliteal artery aneurysm having the effect of restricting flow in the ipsilateral popliteal vein must be included as a differential diagnosis among the causes of unilateral leg swelling in the absence of deep vein thrombosis.
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Popliteal vein thrombosis secondary to popliteal artery aneurysmPE Giustra, JA Root, SE Mason and PJ KilloranAudio Available | Share
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Popliteal vein
Venography
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