a Current approaches to popliteal artery repair

JOHN T. MILES, MD, FRCS[C]; ALBERTO G. DE LA ROCHA, MD, FRCS(C]; RONALD J. BAIRD, MD, FRCS[C]

Trauma to the popliteal artery is In this paper we review the patho- who did not undergo amputation subse- potentially dangerous, and limb loss genesis of injury and management, and quently had contracture deformities and may result, especially with delayed describe an illustrative case of popliteal persistent paresthesias in the foot. Pop- diagnosis. Three anatomic factors artery injury. liteal artery injuries in civilians there- contribute to the seriousness of the fore appear to be as dangerous as those outcome: proximity of the artery to Background incurred by the military in combat. bone, superficial position of the artery The relative danger of popliteal vas- and consequent lack of protection, DeBakey and Simeone' found that cular injuries must be stressed. While and frequent associated injury to 49% of all arterial injuries in Amer- the amputation rate for popliteal ar- associated collateral blood vessels. ican troops in World War II resulted tery injuries is 32%, the rate for all Diagnosis of injury to the popliteal in limb loss and that the proportion other extremity injuries has been 7% .' artery rests on suspicion and vigilance; was 72.5% when popliteal arterial the Doppler transcutaneous flow detector injuries alone were considered. The ad- Pathogenesis of injury: and angiography are often useful aids vances in vascular techniques follow- anatomic factors to diagnosis. Methods of treatment ing World War II led to improvement that have been used include arterial in the treatment of vascular injuries, The popliteal artery is not intrinsic- repair, grafting and fasciotomy, together though Rich, Baugh and Hughes2 noted ally different from other peripheral ar- with management of associated that 32% of 150 patients with popliteal teries of its size. Failure of treatment injuries. The bypass principle of artery injuries required amputation dur- may be related to its unique anatomic vascular reconstruction may improve ing the Vietnam conflict, a proportion situation and on some occasions to overall results. not significantly different from that re- difficulty in diagnosis and the subse- ported for the Korean War some 15 quent delay in management. Three fac- years earlier by Hughes.' tors are important: the course of the Le traumatisme de l'artere poplitee Civilian experience has also been dis- artery in relation to bone proximally est potentiellement dangereux, et un couraging. Drapanas, Hewitt and Wei- and distally, the lack of protection af- retard dans son diagnostic peut chert4 in 1970 reported a 43% failure forded the artery by any overlying entrainer Ia perte dun membre. Trols rate in 14 cases of popliteal injury, and structures and the frequency with facteurs anatomiques contribuent a in Canada A.R. Downs (personal com- which collateral vessels also are dam- Ia gravite des r6sultats: Ia proximite munication, 1976) from Winnipeg re- aged. de I'artere avec l'os, Ia position en ported an amputation rate of 40% for The popliteal artery originates at surface de l'artere et le manque de 33 such cases. A review of 10 such the tendinous hiatus of the adductor protection qui en resulte, et les lesions cases at the Toronto General Hospital magnus, where it is held firmly against frequentes des vaisseaux sanguins (K.W. Johnston: personal communica- the distal femoral shaft (Fig. 1). It collateraux limitrophes. Le diagnostic tion, 1975) revealed that four patients passes freely through the popliteal d'une lesion de l'artere poplitee repose underwent amputation and two patients fossa, arriving beneath the tendinous sur Ia suspicion et Ia vigilance; le d6tecteur transcutane de debit Doppler et langiographie sont souvent des appoints precieux pour le diagnostic. Les modes de traitement qui ont ete ADDUCTOR MAGNUS utilises comprennent Ia reparation V POPLITEAL ART. de lartere, Ia greffe et l'aponevrotomie, ainsi que le traitement des blessures assoclees. Le principe de derivation SUPERIOR MEDIAL appllqu6 a Ia reconstruction vasculaire GENICULAR ART est susceptible dameliorer les SUPERIOR LATERAL resultats globaux. GENICULAR ART. Injuries to the popliteal artery are uniquely dangerous. Both limb loss and other major disabilities, includ- ing flexion contracture deformities, INFERIOR LATERAL persistent paresthesias and trophic ul- INFERIOR MEDIAL GENICULAR ART cers, are far more common with pop- liteal artery injuries than with arterial GENICULAR ART trauma at other sites. All physicians dealing with traumatized patients should be aware of the treacherous na- ture of this injury and the increased ANTERIOR TIBIAL ART. risk that it bears. Early recognition of POSTERIOR TIBIAL ART the injury is sometimes difficult and delay worsens the prognosis. / SOLEUS Reprint requests to: Dr. John T. Miles, Toronto western Medical Building, Ste. 202, 25 Leonard Ave., Toronto, Ont. M5T 2R2 FIG. 1-Posterior view of popliteal structuri 606 CMA JOURNAL/MARCH 19, 1977/VOL. 116 arch of the soleus muscle, where it is We have found the Doppler trans- tomoses are placed away from a once again held firmly against the un- cutaneous flow detector a useful in- contaminated area in the case of a derlying bone. Since the artery is an- strument in the initial assessment of compound wound. chored at either end, it is susceptible popliteal artery injuries. Angiography In the immediate postoperative pe- to stretching; long segments of vessel may be useful in determining the exact riod continued observation is necessary, may be damaged, though intimal rup- site and extent of the injury, but its specifically with reference to the return ture and thrombosis may only occur routine use in the preoperative assess- of pulses and perfusion of the foot. at one point. This may lead to under- ment of obvious popliteal arterial in- Doppler flow and ankle pressure anal- estimation of the extent of the injury jury is not obligatory. ysis is indicated for both detection of at operation. Stretching injuries to the return of blood flow and continuous artery are probably most common when Treatment monitoring of flow. Preoperative angio- dislocations of the knee or fracture dis- Arterial repair and graphy is also of value in difficult locations involving the upper tibia are grafting cases. also present. Popliteal arterial trauma Repair should be attempted as soon associated with this type of orthopedic as possible after injury. Success is un- Primary amputation injury appears to have the worst prog- likely after 12 hours,6 but successful There undoubtedly nosis; five of seven patients with repairs have been documented as late is a group of pa- such combined injuries reported by tients with popliteal injuries for whom as 48 to 72 hours after injury. Good primary amputation is the approach Kennedy5 required amputation. Late collateral circulation has probably been of diagnosis is a problem in relation to choice. Patients whose limbs are ob- responsible for favourable results in viously not viable or whose limbs with associated severe orthopedic these cases. We believe that attempts massive injuries because of both extensive swel- at repair should be made at any time soft tissue trauma makes lower limbs ling and the use of splints that may when limb viability is still possible. unsalvageable are in this group. obscure the overall picture. The techniques used to repair this Fasciotomy Another anatomic factor in the pa- artery have included lateral suture, end- thogenesis of the injury is the artery's to-end anastomosis with or without ex- The use of fasciotomy in association position: it lies posteriorly and is un- cision of a portion of artery, saphenous with arterial injuries is controversial. protected in this relatively superficial vein interposition graft and saphenous In several instances fasciotomy has position. Blunt trauma here produces vein bypass graft. Arterial prostheses been thought to contribute to the even- injury of greater magnitude than would have also been used. Lateral repair and tual need for amputation by becoming occur to a more protected artery sub- end-to-end anastomosis with or with- a focus for sepsis. Downs (personal jected to the same force. Also, the col- out excision are rarely suitable in view communication, 1976) has cautioned lateral network about the knee is par- of the usual mechanisms of such in- strongly against the use of routirre fasci- ticularly prone to injury because of juries and the length of artery involved. otomy; it made little difference to the the dearth of surrounding protective Suturing without tension and without outcome in his 33 cases. An intelligent soft tissue; hence the "back-up system" narrowing the anastomotic site can be decision about the use of fasciotomy may be injured at the same time as the a problem. More commonly, reversed probably cannot be made until more primary conduit for flow into the distal saphenous veins are used in grafting. sophisticated methods are developed to part of the leg. Damage to collaterals Arterial prostheses are clearly a second measure deep compartment tissue ten- may result at the time of injury or choice in the management of trauma in sion against arterial pressure. At pre- later during surgical intervention. this area, where structures are highly sent the need for fasciotomy should be A third factor is the difficulty of mobile and sepsis is a possibility. determined at the discretion of the surgical exposure. Despite its super- The classic repair of this lesion is operating surgeon; the use of fascio- ficial position in the mid-fossa, the ar- excision and reversed end-to-end saph- tomy is not recommended as a routine tery is difficult to expose over its full enous vein grafting. In spite of meticu- concomitant of repair in popliteal ar- length. A medial incision is usually per- lous technical care this procedure has tery injuries. formed but access to the portion of not been highly successful. We believe the artery directly behind the knee joint that the use of bypass grafting rather Management of associated injuries is not good. A posterior approach pro- than excision and grafting would im- Another contentious vides good access to the artery in the issue is the man- prove results. This view is supported agement of associated orthopedic trau- mid-fossa but exposure is poor above hy the work of Hartsuck, Moreland and and below this level because ma. Traditionally, internal fixation of the Williams,7 who reported no limb loss prior to vascular repair has been ad- muscles of thigh and calf. in five patients treated by bypass graft- vised, and this approach has recently ing for trauma distal to the popliteal been reinforced by Sher.8 On the other Diagnosis trifurcation. hand, extensive reports by McNamara Bypass grafting has several advan- and colleagues9 and by Connolly10 have The diagnostic techniques are similar tages. The graft may be placed in the suggested that internal fixation, either to those applicable to cases of injury artery proximal and distal to any pos- with plaster or pin traction, is as good to other arteries. Clinicians dealing with sible unrecognized injury - thus, the or possibly better. Certainly, any tech- leg trauma must consider the possibility danger of inadequate debridement of nique that tends to preserve the colla- of popliteal vascular damage, especially damaged artery is minimized. The sur- teral network of arteries at the knee is in the presence of severe orthopedic gical approach is simpler since only a attractive. Internal fixation not only trauma around the knee joint. It is not portion of the popliteal artery above potentially reduces the collateral circu- difficult to attribute changes in the limb and below the lesion must be exposed. lation but also increases the chance of to the extensive swelling caused by the Bypass grafting is more common in the sepsis, which may jeopardize the limb. injury. Splints may make the leg less treatment of obliterative vascular dis- Sullivan and associates" have em- available for frequent inspection. There- ease in general and is hemodynamically phasized the validity of repair of asso- fore, unless one suspects the injury and sound. Sacrifice of collateral vessels is ciated popliteal vein injuries when is vigilant from the moment the patient avoided since extensive popliteal dis- feasible. Short-term patency was dem- enters the emergency department, diag- section in the region of the genicular onstrated by venography and they nosis may be delayed. arteries is unnecessary, and both anas- reported that associated edema and CMA JOURNAL/MARCH 19, 1977/VOL. 116 607 chronic venous stasis were minimized. pressure of only 50 mm Hg. A femoral We support this approach. arteriogram confirmed the presence of Nerve injuries most often occur in persistent occlusion with poor distal continuity and can be treated expect- filling. In a second operation an ipsilateral antly. Ischemia itself may produce saphenous vein bypass graft was placed SEPTRA* numbness and paralysis below the level from above the region of the injury to of the injury, depending on the severity the popliteal artery below the knee. An- highly effective in of the arterial occlusive process. This terior and posteromedial fasciotomies were may make assessment of the associated performed. The ankle pulses returned to acute or recurrent nerve injury difficult. Massive soft- normal. tissue trauma is frequently present and Subsequent recovery was uneventful ex- cystitis, pyelitis and should be considered when assessing cept for moderate edema of the foot and the feasibility of limb salvage. lower leg, which later largely resolved. pyelonephritis A split-thickness skin graft was applied to * bactericidal against major G.U. The following case report illustrates the anterior fasciotomy site 3 weeks post- pathogens management of a patient with an injury operatively. Six weeks after injury the to the popliteal artery. patient returned to work. Subsequent * double blockade activity weakness in the flexor and extensor com- discourages development of A 20-year-old man sustained a blunt partments of the leg was minimal and resistance injury behind the right knee. His right there were no paresthesias. lower leg was cool and weak. No pulses * achieves therapeutic levels in both were detected in the right foot or right Despite two end-to-end interposition serum and urine popliteal fossa; the right femoral pulse grafts performed with specific attention * may be effective against was normal. There was no hematoma. to maintaining a widely patent anas- sulfonamide-resistant strains Doppler flow in the posterior tibial and tomosis, the patient's foot remained * convenient b.i.d. dosage schedule dorsalis pedis arteries was absent. Arteri- pulseless and cool. A consequent by- ography revealed occlusion of the popliteal pass graft, which was far simpler tech- * available in tablets or artery at the level of the knee joint (Fig. nically, was successful in restoring pleasant-tasting suspension 2). * SEPTRAPA Summary The limb was explored through a medial immediate pulses with excellent per- (Trimethoprim +Sultamethoxazole) fusion. Recently, two other patients INDICATIONSAND CLINICAL USES: Indicated tar the following incision. A 2-cm contused section of artery infections when caused by susceptible organisms: contained an intimal laceration with with similar injuries have been success- URINARY TRACT INFECTIONS -- acute, recurrent and chronic. thrombosis. A reversed saphenous vein fully treated by the bypass technique. GENITAL TRACT INFECTIONS - uncomplicated gonococcal urethritis. graft from the same leg was used to UPPER AND LOWER RESPIRATORY TRACT INFECTIONS - bridge the defect, narrowing at both particularly chronic bronchitis and acute and chronic otitis media. Conclusion GASTROINTESTINAL TRACT INFECTIONS. end-to-end anastomoses being carefully SKIN AND SOFT TISSUE INFECTIONS. avoided. However, the distal pulse was Popliteal artery injury carried a high- SEPTRA is not indicated in inteclions caused by Pseudomonas, considered inadequate when the clamps Mycoplasma or viruses. This drug has not yet been tully evaluated er risk than does injury of other peri- in streptococcal intections. were released so a fresh, slightly longer pheral arteries. Early recognition and CONTRAINDICATIONS: Patients with evidence of marked liver end-to-end graft was inserted. The pulse parenchymal damage, blood dyscrasias, known hypersensitivity to now seemed adequate and the incision was prompt treatment are mandatory. By- trimethoprim or sulfonamides, marked renal impairment where pass grafting has given results that have repeated serum .says cannot be carried out; premature or newborn closed. babies during the first few weeks of life. For the time being SEPTRA The foot continued to be cool and encouraged us to continue using this is contraindicated during pregnancy. It pregnancy cannot be technique. excluded, the possible risks should be balanced against the paresthetic. Doppler flow in the posterior expected therapeutic effect. tibial artery was present at an opening PRECAUTIONS: As with other sulfonamide preparations, critical appraisal of benefit versus risk should be made in patients with liver References damage, renal damage, urinary obstruction, blood dyscrasias, allergies or bronchial asthma. The possibility of a superinfeclion 1. DEBAKEY ME, SIMEoNE FA: Battle injuries with a non-sensitive organism should be borne in mind. of arteries in World War II; analysis of DOSAGE AND ADMINISTRATION: Adults and children over 12 2,471 cases. Trans South Surg Assoc 57: 65, years. 1946 Standard dosage: Two Seplra tablets or one Septra OS tablet twice daily (morning and evening). 2. RIcH NM, BAUGH JH, HUGHES CW: Popliteal Minimum dosage and dosage for tong-term treatment: One Septra artery injuries in Vietnam. Am I Surg 118: tablet or one-half Septra OS tablet twice daily. 531, 1969 Maximum dosage: 3. Huossas CW: Arterial repair during the Overwhelming infections: Three Septra tablets or one and one-half Korean War. Am I Surg 147: 555, 1958 Septra OS tablets twice daily. Uncomplicated gonorrhea: Two Septra tablets or one Septra OS 4. DRAPANAS T, Hitwrs-r RL, WEICHERT RF Its: tablet four times daily for 2 days. Civilian vascular injuries: a critical appraisal of three decades of management. Ann Surg Children 12 years and under A 172: 351, 1970 Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml pediatric suspension twice daily. 5. KENNEDY JC: Complete dislocation of the Children 210 5 years: One to two pediatric tablets or 2.5 to 5 ml knee joint. I Bone Joint Surg (Am] 45: 889, pediatric suspension twice daily. 1963 Children 610 12 years: Two to tour pediatric tablets or 510 10 ml pediatric suspension or one adult tablet twice daily. 6. MILLER HH, WELCH CS: Quantitative studies (Septra DS tablets should not be used for children under 12 years.) of the time factor in arterial injuries. Ann tIn children this corresponds to an approximate dose 016 mg Surg 130: 428, 1949 trimethoprim/kg body weight/day, plus 30mg sultamethooazole/kg 7. HARTSUCK JM, MORELAND HJ, WILLIAMS GR: body weight/day, divided into two equal doses. Surgical management of vascular trauma distal DOSAGE FORMS: SEPTRA TABLETS, each containing 80 mg to the popliteal artery. Arch Surg 105: 937, trimethoprim and 400 mg sulfamethoxazole, and coded 1972 WELLCOME Y2B. Bottles of 100 and 500, and unit dose packs of 100. SEPTRA OS TABLETS, each containing 160 mg trimethoprim and 8. SHEa MH: Principles in the management of 800 mg sulfamethoxazole, and coded WELLCOME 02C. Bottles of arterial injuries associated with fracture/dis- 50 and 250. locations. Ann Surg 185: 630, 1975 SEPTRA PEDIATRIC SUSPENSION, each teaspoonful (5 ml) 9. MCNAMARA JJ, BRIEF DK, STREMPLE JF, containing 40 mg trimethoprim and 200 mg sulfamethoxazole. et al: Management of fractures with asso- Bottles of 100 and 400 ml. ciated arterial injury in combat casualties. SEPTRA PEDIATRIC TABLETS, each containing 20 mg I Trauma 13: 17. 1973 trimethoprim and 100 mg sulfamethoxazole, and coded WELLCOME H4B. Bottles of 100. 10. CONNOLLY J: Management of fractures as- FIG. 2-Preoperative arterlogram, regIon sociated with arterial injuries. Am I Surg Product monograph available on request. of right knee: filling defect (arrow) proxi- 120: 331, 1970 mal to site of complete occlusion, indicat- 11. SULLIvAN WG, THORNTON FH, BAKER LH, . Burroughs Weilcome Ltd. et al: Early influence of popliteal vein repair ing probable site of intimal damage and in the treatment of popliteal vessel injuries. LaSalle, Qu6. thrombus. Am I Surg 122: 528, 1971 Trade Mark W-601 3 608 CMA JOURNAL/MARCH 19, 1977/VOL. 116