Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 77-80

Use of medial gastrocnemius muscle flap in traumatic popliteal artery injury due to posterior dislocation of knee joint


1 Department of Plastic Surgery and Burns, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
2 Department of Plastic Surgery, Apollo Hospital, Chennai, Tamil Nadu, India

Date of Submission24-Jul-2021
Date of Decision09-Nov-2021
Date of Acceptance16-Nov-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Pradeoth Mukundan Korambayil
Department of Plastic Surgery and Burns, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_85_21

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  Abstract 


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

Keywords: Knee joint, medial gastrocnemius muscle flap, popliteal artery injury, posterior dislocation


How to cite this article:
Korambayil PM, Dilliraj VK, Babu EM, Varkey PA. Use of medial gastrocnemius muscle flap in traumatic popliteal artery injury due to posterior dislocation of knee joint. Indian J Vasc Endovasc Surg 2022;9:77-80

How to cite this URL:
Korambayil PM, Dilliraj VK, Babu EM, Varkey PA. Use of medial gastrocnemius muscle flap in traumatic popliteal artery injury due to posterior dislocation of knee joint. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:77-80. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/77/340511




  Introduction Top


Injury to the popliteal artery due to trauma to lower extremity ranges from 27% to 47%.[1],[2],[3] Timely revascularization of the limb is almost necessary to prevent vascular complication and to ensure limb preservation. During posterior dislocation of the knee, due to its anatomical relationship, the popliteal artery is more susceptible to contusion, segmental disruption of flow, or rupture.[4] The condition requires immediate efforts to revascularize the limb by either bypass graft or segmental vascular reconstruction of the injured vessel. Some surgeons prefer a bypass graft from the lower femoral artery to the posterior tibial vessels or just above the trifurcation area of the popliteal vessels without disturbing the zone of injury. Some surgeons tend to explore the injured area and reconstruct the injured segment with a saphenous vein graft. Each method has its own advantages and disadvantages. In this study, we emphasize on an approach of usage of medial gastrocnemius muscle flap for coverage of vascular graft following segmental reconstruction of the popliteal vessels.


  Materials and Methods Top


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 a vascular compromise to the limb were enrolled in the study. After primary and secondary surveys, the patients were shifted to the operating room after evaluation with Doppler study for vascular flow to the limb. Orthopedic team was involved in the procedure for bony stabilization.

Surgical procedure

After harvesting the saphenous vein graft, all the cases were done in a semi-prone position. The patient was kept in the position turned to the side of injury, which is comfortable for the exposure of the injured vascular site and medial gastrocnemius muscle. A curvilinear incision was made from the lower thigh to the upper third of the leg, exposing the popliteal fossa and the medial gastrocnemius muscle [Figure 1] and [Figure 2]. After exposure of the vessel, the popliteal artery contusion and adjacent nerve injury were examined. For proper exposure of the contused popliteal artery, medial gastrocnemius muscle is split from lateral gastrocnemius and detached from its insertion. After the removal of the contused segment, revascularization of the limb was done by reconstruction of the artery with reversed saphenous vein graft from the opposite limb. The reconstructed vascular segment was covered with medial gastrocnemius muscle to prevent graft blowout or vascular graft exposure due to soft tissue loss in the contused posterior segment popliteal fossa [Figure 3]. The gastrocnemius muscle has medial head and lateral head, supplied, respectively, by the medial and lateral sural artery and by branches of the popliteal artery. We utilize the supply from the medial sural artery, which arises from the popliteal artery at a higher level than the knee joint, and hence, they are spared from injury due to posterior dislocation of knee.
Figure 1: Line of incision for popliteal vessel and medial gastrocnemius muscle

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Figure 2: Anatomical representation of popliteal fossa

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Figure 3: Utilization of medial gastrocnemius muscle for vascular cover

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Cases

Case 1

A 35-year-old female sustained injury due to a road traffic accident left leg with contusion over the popliteal fossa region and absent distal pulsations. The patient presented to the emergency room 2 h following the injury. Following Doppler examination, the patient was immediately shifted to the operation room. Dislocation of the joint was stabilized by orthopedic team by means of an external fixator. A curvilinear incision was made to expose the arterial segment [Figure 1] and medial gastrocnemius muscle was elevated for adequate exposure [Figure 4]a. Contused segment was removed and reconstructed with a saphenous vein graft from the opposite limb. Elevated muscle was used to cover the vascular graft [Figure 4]b. There was no concomitant venous injury. Wound closed in layers. Postoperative period was uneventful.
Figure 4: (a) Injured popliteal artery exposure. (b) Repair with reverse saphenous vein graft and medial gastrocnemius muscle cover

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Case 2

A 27-year-old male suffered injury to the right leg due to road traffic accident presented in the emergency room with contusion and hematoma over the popliteal fossa region. The patient presented to the emergency room 3 h following the injury. After confirmation of absent blood flow to the leg by means of Doppler scan, the patient was shifted to the operation room. The joint was stabilized by an external fixator by orthopedic team. A curvilinear incision was made for arterial and muscle exposure. Reverse saphenous vein graft from the opposite limb was used for reconstruction of the contused segment. Vascular graft was well covered by the medial gastrocnemius muscle and the wound closed in layers [Figure 5]. There was no concomitant venous injury. The overall procedure of revascularization took around 3 h. Postoperative period was uneventful.
Figure 5: Medial gastrocnemius muscle flap for popliteal vessel cover

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  Results Top


There were three male and two females in the study. In all the five cases, the limb was salvaged with a reverse saphenous vein graft harvested from the thigh region of the opposite limb. Postoperative limb movements were satisfactory. The average duration of the hospital stay was approximately 21 days.


  Discussion Top


Trauma to the knee due to road traffic accidents is most common in India, which results in injury the popliteal vessels in 47% of cases.[1],[2],[3] Timing of intervention is almost a necessity as amputation rates are higher in delayed repair or reconstruction. Posterior dislocation of the knee is the most common injury and may be associated with venous injury and nerve injury as well.[5] There are high chances of missing the injury as the posterior dislocation may spontaneously be reduced. Early suspicion, exploration, and revascularization are mandatory for salvage of the limb. In our center, we usually confirm the vascularity with duplex ultrasonography, and if absent or reduced flow with clinical suspicion, the patient will be taken up to the operation room. Two types of surgical approach are followed.

Some surgeons prefer to do a bypass graft with reverse saphenous vein away from the zone of injury with thrombectomy at the injury site. The advantage is the collateral circulation which is not disturbed and the graft passes through the healthy zone. The disadvantage of this procedure is that the requirement of a long graft which may get occluded due to edema or inflammation when it passes through the bottleneck knee region. Tissue necrosis in and around the knee joint is common in posterior dislocation injury which results in fat necrosis. The chance of infection through the area where the graft is tunneled is another risk for this preferred method.

In this particular series, the incision is made on to the lower thigh, popliteal fossa, and to curve along the medial gastrocnemius muscle [Figure 1]. This incision provides adequate exposure of the injured vascular segment, and the nerve injuries could be examined simultaneously. A small segment of saphenous vein is required at the area of injury and end-to-end anastomosis is preferred than the end-to-side long segment anastomosis, as described in previous method. In case of any nerve injury, the nerve was examined under a microscope, simultaneously repaired with a sural nerve graft from the opposite leg. Medial gastrocnemius muscle is useful to cover both vascular and nerve grafts reconstructed in popliteal graft. In case of fat necrosis or soft tissue loss in the popliteal fossa, the grafts are well guarded by the medial gastrocnemius muscle placed over the grafts which prevent the vascular blowout or loss of nerve graft in the reconstructed area. Even if the skin loss is anticipated in the injured site or difficult closure in the edematous injured region, the situation could be handled by skin grafting over the vascularized gastrocnemius muscle rather than direct exposure of grafts.

The goal of popliteal artery injury due to posterior dislocation of the knee is to restore the continuity of the artery without any stenosis or tension. Most of the studies have depicted that thrombectomy alone is insufficient for establishing the flow and approximately 70% of the patient required proper revascularization procedure.[6] Along with reconstruction of vascular and nerve structures, it is almost necessity to provide proper soft tissue coverage at the injured area. Soft tissue injury due to posterior dislocation may manifest as bruise, contusion, hematoma, and fat necrosis. Since the vascular and neural structures are superficial in the popliteal fossa, a proper soft tissue cover is a mandate for limb survival. Limb may present with gross edema due to vascular injury, which may prevent the closure of the incision site. In case of difficulty in closure of the primary incision, with medial gastrocnemius muscle as the underlying structure, the wound could either be closed secondarily or skin grafted without compromising the vascularity of limb. Simultaneously, the compartment syndrome release of the posterior leg could also be addressed by utilizing medial gastrocnemius muscle flap. The procedure could be selectively applied in patients according to the clinical condition. If the surgeon does not have any difficulty in soft tissue cover and if there is adequate padding around the vascular graft, then the technique could be altered. However, the superficial position of the popliteal artery, chances of fat necrosis at popliteal fossa at the site of injury, wound infection, dehiscence of wound, and vascular graft exposure are some of the factors which trigger the surgeon to keep in reserve an alternative viable tissue for safer outcomes.

Early diagnosis, accurate initial treatment, and proper planning are important in popliteal artery injury due to posterior dislocation of knee.[7] Good multidisciplinary coordination and clear communication is key for salvage of the limb in case of popliteal artery injury.


  Conclusion Top


Usage of medial gastrocnemius flap serves an adequate soft tissue coverage in traumatic popliteal artery injury due to posterior dislocation of knee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chapman JA. Popliteal artery damage in closed injuries of the knee. J Bone Joint Surg Br 1985;67:420-3.  Back to cited text no. 1
    
2.
Drapanas T, Hewitt RL, Weichert RF 3rd, Smith AD. Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 1970;172:351-60.  Back to cited text no. 2
    
3.
Steele HL, Singh A. Vascular injury after occult knee dislocation presenting as compartment syndrome. J Emerg Med 2012;42:271-4.  Back to cited text no. 3
    
4.
Abou-Sayed H, Berger DL. Blunt lower-extremity trauma and popliteal artery injuries: Revisiting the case for selective arteriography. Arch Surg 2002;137:585-9.  Back to cited text no. 4
    
5.
Imerci A, Özaksar K, Gürbüz Y, Sügün TS, Canbek U, Savran A. Popliteal artery injury associated with blunt trauma to the knee without fracture or dislocation. West J Emerg Med 2014;15:145.  Back to cited text no. 5
    
6.
Wilson JS, Miranda A, Johnson BL, Shames ML, Back MR, Bandyk DF. Vascular injuries associated with elective orthopedic procedures. Ann Vasc Surg 2003;17:641-4.  Back to cited text no. 6
    
7.
Godfrey AD, Hindi F, Ettles C, Pemberton M, Grewal P. Acute thrombotic occlusion of the popliteal artery following knee dislocation: A case report of management, local unit practice, and a review of the literature. Case Rep Surg 2017;2017:5346457.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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