膝关节周围骨折、脱位伴血管损伤的诊疗分析

目的 探讨早期诊治膝关节周围骨折损伤的效果及影响因素.方法 回顾性分析2002年3月至2007年11月31例膝关节周围骨折、脱位伴血管损伤患者的临床资料.其中男性24例,女性7例,年龄21～62岁,平均41岁.结合临床体征,运用彩色超声、CTA、手术探查等明确血管损伤,分别采用外固定支架、钢板、螺钉固定骨折脱位,并根据具体情况对损伤血管进行取栓、修补、自体静脉或人造血管移植重建血循环,分析保肢指数(predictive salvage index,PSI评分)、早期诊断、治疗方法对预后的作用.结果 本组病例1例死亡,截肢6例,手术成功修复31例股动脉、胭动脉、胫前及胫后动脉,24例肢体存活患者分别随访1～4年,平均24.2个月.6例骨不连或感染骨缺损经二期植骨、骨转运骨折愈合,7例膝关节脱位患者进行二期韧带修复重建,功能优良率为71.4%.结论 PSI评分≤10分的膝关节周围骨折、脱位伴血管损伤患者应积极实施治疗,早期明确诊断、手术重建血循环是治疗成功的关键因素.     

膝部骨折脱位合并腘动脉损伤的治疗

目的探讨膝部骨折脱位合并腘动脉损伤的治疗。方法分析1998年以来对膝部骨折脱位合并腘动脉损伤18例的治疗资料。结果17例保肢,其中膝关节功能优10例,良4例,中2例,差1例。截肢1例。疗效满意。结论早期诊断是治疗腘动脉损伤的关键。术中选择合理骨折内固定是术后膝关节功能恢复的重要因素。血管损伤的处理,迅速恢复下肢有效循环是手术成功的保障,直接影响预后。     

膝关节周围骨折脱位合并腘动脉损伤诊治体会

目的 探讨膝关节周围骨折脱位合并腘动脉损伤的诊断与治疗效果.方法 16例膝关节周围骨折脱位合并腘动脉损伤患者中,行腘动脉端端吻合4例,自体大隐静脉或小隐静脉移植12例;同时修复腘静脉9例,胫神经吻合6例,腓总神经吻合2例.结果 肢体血循环重建时间4.5 ～26.5 h,例痊愈后肢体血循环恢复良好,例遗留小腿缺血性肌挛缩,例截肢.11例获得随访,时间12～18个月.术后1年时膝关节功能评定参照美国特种外科医院(HSS)膝关节评分标准:优5例,良2例,中1例,差3例.结论 膝关节周围骨折脱位合并腘动脉损伤早期诊断是挽救肢体的关键,尽早恢复肢体血循环、高质量修复损伤血管、有效复位固定骨折是降低致残率和促进肢体功能恢复的重要因素.     

腘动脉下段分叉部损伤的早期修复

文章报告了9例腘动脉下段分叉部损伤的治疗结果。除1例为土枪霰弹伤外,其余均为钝性暴力所致。早期截肢2例,后期截肢1例,截肢率33.3％。存活肢体中1例明显小腿缺血性挛缩,1例轻度小腿缺血性挛缩,4例功能基本正常。腘动脉下段分叉部损伤具有血管损伤范围广,远端缺血严重,常伴有骨、关节及皮肤、肌肉、神经等组织损伤等特点。尽早手术,同时重建胫前、胫后动脉血循环,尽量修复及保护伤肢静脉,常规行小腿深筋膜切开减压,骨折、脱位同时予以修复并可靠固定是提高治疗效果的必要措施。     

腓骨小头骨折合并腘动静脉损伤

目的:探讨腓骨小头骨折致腘动静脉损伤.方法:自1997年7月收治30余例腘动静脉损伤病人,有2例为单纯腓骨小头骨折致腘动静脉损伤.例1伤后3d入院.例2伤后4h入院.分别游离8cm和4cm伤肢小隐静脉移植修复.结果:例腘N动脉吻合后病人高热,2d后为保存生命,于股骨髁上截肢.例2腘动脉吻合后血管搏动良好,足背动脉可触及,伤肢存活.结论:单纯腓骨小头骨折可导致腘动静脉损伤,如早期诊断治疗明确,可挽救肢体保存生命,否则会造成严重后果.     

膝关节闭合骨折合并腘动脉损伤的诊疗体会

[目的]回顾性分析膝关节闭合骨折合并腘动脉损伤的治疗方法和效果.[方法]本组男18例,女3例.车祸伤15例,挤压伤5例,摔伤1例.X线片显示胫骨平台骨折10例,股骨远端骨折7例,二者合并损伤4例.腘部切口探查血管,见膝关节以远损伤8例,膝关节水平损伤6例,膝关节以近损伤7例.动脉挫伤后栓塞18例,破裂3例.术中采用大隐静脉移植修复4例.[结果]全部肢体成活.全部患者获得随访,随访时间12～18个月,平均15个月.骨折完全愈合时间4～6个月,平均5个月,肢端血运良好,足背动脉均可触及搏动.[结论]对于闭合性膝关节周围骨折患者,要高度警惕合并腘动脉损伤.要认真细致和全面检查,早发现,早手术,降低截肢率.     

腘血管不同平面损伤的临床意义

[目的]分析和总结腘血管损伤患者中不同损伤平面的临床特点,提高该损伤的临床认识和诊疗水平。[方法]回顾2014年1月～2016年12月本院收治的54例腘血管损伤患者,男43例,女11例,年龄6.5～75岁,平均(42.08±15.04)岁。分析患者的伤因、血管损伤平面、肢体缺血时间、手术方法、手术次数和随访时肢体功能等临床指标。[结果]据血管影像资料,损伤平面位于腘动脉发出腓肠动脉分支以上者(高位组) 12例,位于腘动脉发出腓肠动脉分支以下者(低位组) 42例。高位组12例,血管修复9例(术后溶栓2例),保肢成功9例,截肢3例,平均手术3.92次/例,保肢患者肢体功能优良率22.22%;损伤平面在腓肠动脉以下的患者(低位组) 42例,血管修复36例(术后溶栓3例),单纯溶栓治疗5例,保肢成功39例,一期截肢1例,二期截肢2例,平均手术2.91次/例,保肢患者肢体功能优良率66.67%。高位组患者在保肢率、保肢后肢体功能优良率等指标上显著差于低位组,两组差异有统计学意义(P0.05)。[结论]损伤平面在腓肠动脉分支平面以下者,保肢率及肢体功能明显优于损伤平面在腓肠动脉以上的患者。腓肠动脉的侧支代偿作用是腘血管不同损伤平面临床差异的主要原因。     

腘动脉损伤探查术中预后的判定

目的：探讨腘动脉损伤后，腘动脉远断端血流情况与伤肢转归的关系。方法：结合解剖和血流动力及生理学知识，通过13例术中探查，用肝素盐水灌注、轻柔按摩血管和切开3种方法。抽出腘动脉远断端血管内的血栓，根据损伤远端血流情况，判定小腿血管内血栓形成与否。结果：膝部软组织损伤轻，膝关节周围侧支循环佳，腘动脉远断端血栓取出后有活动出血的，伤肢可顺利成活，否则伤肢难以保全。结论：探查术中远断端血栓取出后的血流情况，是决定即刻截肢抑或保肢的可靠指标。     

闭合性腘动脉损伤的诊断与治疗

目的探讨闭合性腘动脉损伤的诊断与治疗。方法收治26例闭合性腘动脉损伤患者,13例采用彩色多普勒超声检查明确血管损伤部位,8例DSA检查明确损伤部位,5例直接手术探查。11例行断端吻合,14例大隐静脉移植,25例均行预防性小腿切开减张。术后应用激素、甘露醇等治疗。结果 22例15h内手术者均成功保肢,并且功能良好,3例24～36h内手术者2例保肢成功,1例截肢,72h明确诊断者肢体坏死直接行截肢手术。结论闭合性腘动脉损伤只要肢体不出现坏死,一旦确诊均应尽早修复血管以求保肢可能。     

腘动脉损伤手术修复与介入治疗的对比分析

目的 探讨腘动脉损伤手术修复术和介入治疗对急性腘动脉损伤的临床疗效.方法 收集2020年10月至2021年4月云南大学附属医院收治的6例急性腘动脉损伤(PAI)患者的临床资料,对救治时间、多学科团队(MDT)协作模式、传统手术和介入开通血管的方法等影响截肢率的因素进行分析.结果 6例急性PAI患者中,5例患者保肢成功,...     

Popliteal artery injuries associated with fractures and dislocations about the knee

The authors present the results of a retrospective review of popliteal artery injuries associated with fractures and dislocations about the knee. They treated 41 patients with popliteal artery injuries associated with either fractures about the knee or knee dislocations. Thirty-five of the patients were males, 6 females; the mean age was 23 years. The delay before accessing the hospital was 17 hours (range: 3 hours to 10 days). Thirty-two fractures were open. Together with the vascular injury, 12 femoral fractures, 20 tibial and fibular fractures, 5 knee dislocations, 4 femoral + tibial fractures were identified. Twenty-three patients underwent external fixation, 8 internal fixation, 6 plaster cast immobilization, 4 minimal osteosynthesis and plaster cast immobilization. The arterial injury was treated by end-to-end anastomosis in 5 cases, saphenous vein anastomosis in 29 cases and thrombectomy in 7 cases. Nine patients were amputated. Delay in surgery, blunt trauma, extensive soft tissue defect and bone fracture or dislocation, are associated with high amputation rate following popliteal artery injury. The influence of each of these factors alone on the amputation rate could not be evaluated in this study, as no statistically significant correlation could be demonstrated.     

膝关节周围骨折脱位合并腘动脉损伤

[目的]回顾性分析膝关节周围骨折、膝关节脱位合并胭动脉损伤的早期诊断、治疗。[方法]自1998年3月～2005年5月，共收治膝关节周围骨折、脱位合并有胭动脉损伤患者71例，通过临床检查、血管造影或（和）Doppler检查，及早明确诊断，及时手术探查，修复损伤的动脉、采用简单、快捷、可靠的方法稳定骨折，术后抗凝、解痉、预防感染治疗。[结果]15例伴有严重的小腿软组织毁损初期截肢，其余56例手术成功修复。骨折采用带锁髓内钉固定、钢板螺钉固定或外支架固定。术后吻合口处发生血栓形成2例，经Doppler检查证实后急诊切除血栓部，取自体大隐静脉逆转移植吻合成功。2例发生骨髓炎（均为开放性骨折），经病灶清除庆大霉素骨水泥链珠植入等处理后愈合。2例发生创伤性膝关节炎。其余骨折愈合良好，肢体功能恢复较好。[结论]膝关节周围骨折、脱位应高度怀疑合并有胭血管损伤，通过仔细临床检查，必要时结合Doppler、血管造影尽早明确诊断，及早手术探查修复损伤的血管，稳定骨折。     

Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage.

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.     

Vascular trauma to the lower extremity: the Lebanese war experience

The authors' experience with 386 patients who were operated on for vascular injuries to the lower extremities is reviewed. Of these, 118 had popliteal injuries, 252 had femoral injuries and 16 had tibial injuries. The overall mortality rate was 2.33% with no mortality in the popliteal and tibial injuries group whereas there were nine deaths in the femoral injuries group. The overall amputation rate was 5.95%, with 3.17% amputation rate for the femoral injuries group versus 11.86% for the popliteal injuries group and 6.25% for the tibial injuries group. Delay in repair (more than 6h from injury), associated femoral fractures and shocked condition on admission led to increased amputation rate. Prompt surgical repair, arterial as well as venous repair for popliteal and femoral injuries especially if femoral fracture is present, external skeletal fixation and/or traction, and fasciotomy when necessary led to improved limb salvage.     

外固定架在膝及小腿血管损伤修复中的应用

 目的 探讨外固定架在膝、小腿血管损伤中的应用效果。方法 回顾性分析2004年5月至2010年10月应用外固定架治疗的208例（234侧）膝及小腿血管损伤患者资料,男192例（217侧）,女16例（17侧）;年龄14~67岁,平均39.6岁。损伤血管：腘动脉84例（86侧）,胫前动脉36例（46侧）,胫后动脉41例（49侧）,胫前后动脉47例（53侧）。伤肢远端完全缺血129例（141侧）,不完全缺血79例（93侧）。所有患者均行急诊手术。采用AO通用外固定架164例,创生镶嵌式外固定架37例,组合式外固定器7例。血管采用直接或大隐静脉桥接吻合。创面采用一期包扎、植皮、皮瓣移植和VSD负压吸引治疗。结果 194例保肢成功, 14例因伤肢毁损严重及全身情况差于术后2~4 d截肢。术后43例患者创面自行愈合,127例二期行手术清创植皮或皮瓣治疗,24例一期行游离皮片或皮瓣移植覆盖。148例获得8个月~3年的完整随访,其中6例因患肢功能严重受限且伴发骨髓炎而自愿要求截肢。拆除外固定架时间1~18个月,平均7.2个月。102例骨折获得愈合,时间为3~13个月,平均5.6个月;40例出现骨折不愈合、骨缺损,行骨折内固定+植骨术或骨段滑移术,骨折均愈合。结论 外固定架具有固定可靠,可在短时间内复位骨折,减少肢体缺血时间等优点,利于膝、小腿血管损伤的修复。     

Popliteal artery trauma: a high risk injury

The clinical presentation and management of 28 popliteal artery injuries following penetrating and blunt trauma during a 6 year period is reviewed. Clinical and Doppler evaluation identified an arterial injury in 24 (85 per cent) patients. In eight (29 per cent) patients with arteriovenous fistulae or false aneurysms, pedal pulses were palpable during initial assessment. Three (10.7 per cent) patients had limb amputation attributable to delayed vascular repair, crush injury and sepsis. End-to-end arterial repair following blunt trauma resulted in early failure with thrombosis in two patients. Autogenous vein grafting was used in 12 patients and is advocated in all blunt popliteal arterial injuries. Routine repair of associated venous injuries and liberal criteria for early fasciotomy were used. Exoskeletal fixation or skeletal traction for compound and comminuted fractures is recommended for simplicity of application and wound management. The significant functional orthopaedic disability following blunt arterial trauma at the knee is emphasized.     

Popliteal vascular trauma. A community experience

Preventing amputation continues to be a significant challenge when popliteal vascular injuries occur. A retrospective review of cases from the San Diego County (California) Trauma System identified 108 patients with 76 blunt and 32 penetrating arterial injuries. The limb preservation rate was 88%; there were 13 amputations. The fracture-dislocated knee injury and close-range shotgun blasts were particularly limb threatening. In general, the trauma system achieved rapid evaluation of injuries and early operative intervention. All 13 patients who underwent amputations presented with signs of severe ischemia. Concomitant injuries to the popliteal vein, tibial nerves, and soft tissue were significantly more frequent in patients who underwent amputations. The importance of complete fasciotomy for compartment hypertension, early reconstructive management of soft-tissue injuries, and expeditious arterial repair, frequently without preoperative roentgenographic suite arteriography, is emphasized. An aggressive, multidisciplinary approach is required to achieve a functional extremity when popliteal vascular trauma occurs.     

Popliteal artery injuries in an urban trauma center with a rural catchment area: do delays in definitive treatment affect amputation?

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.     

The importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: A meta-analysis

Objective

The optimal sequence of surgical repair for lower extremity injury with associated vascular injuries is unclear. Lower extremity injury in our study is defined as femoral fracture, tibial fracture, and/or knee dislocation. Advocates of performing the vascular repair prior to lower extremity fixation argue that reversal of ischaemia in the limb is the most important factor in limb survival and should take precedence. Advocates of lower extremity fixation prior to revascularisation worry that the manipulation during fixation could disrupt the vascular repair and that total ischaemia time is more relative than absolute.

Methods

A literature search was performed to identify studies with the following criteria: adult population, femoral fracture, tibial fracture, and/or knee dislocation with associated vascular injury, an intervention of fracture fixation or knee stabilisation prior to revascularisation and/or revascularisation prior to fracture fixation, and amputation as an outcome measurement.

Results

934 articles were identified and narrowed to 14 articles through exclusion criteria. Meta-analysis of the data shows no statistical difference in regards to the incidence of amputation between lower extremity fixation prior to revascularisation and revascularisation prior to fracture fixation.

Conclusion

Lower extremity injuries with associated vascular injury are uncommon. There has been a widespread but unsupported belief that manipulation and traction during lower extremity fixation will disrupt the vascular repair. Ischaemic time should be considered a relative, but not absolute predictor of amputation. Soft tissue injury and neurologic deficits have been found highly correlated with disability and amputation. Surgical sequence has not been shown to affect the rate of amputations in lower extremity fractures.     

Popliteal pseudoaneurysm and arteriovenous fistula after arthroscopic anterior and posterior cruciate ligament reconstruction: A case report

IntroductionVascular injuries are a well recognised but very rare complication of surgery or trauma around the knee, especially associated with arthroscopic anterior and posterior cruciate ligament reconstruction.Presentation of caseThis report describes a case of a Popliteal pseudoaneurysm and arteriovenous fistula after Arthroscopic anterior and Posterior Cruciate Ligament Reconstruction. An 57-year-old male who complained of pain and swelling around the left lower extremity after the ACL and PCL reconstruction using a semitendinosus graft from the two limbs caused by bicycle accident. He was diagnosed with the popliteal pseudoaneurysm and arteriovenous fistula by the Doppler ultrasonographic examination and CTA, and transferred to the interventional radiology suite where a successful vascular stent implantation was made. There was no postoperative complication.DiscussionThe most important finding of the present case were a popliteal pseudoaneurysm and arteriovenous fistula after the ACL and PCL reconstruction. To our knowledge, very few cases reporting an arteriovenous fistula with popliteal pseudoaneurysm following arthroscopy have been described. Vascular injury is a very rare complication of knee surgery, but surgeons should always consider this possibility in patients who have undergone knee arthroscopy. If the patient has symptoms of pain in the popliteal area and unexplainable swelling following arthroscopic ACL and PCL reconstruction, a popliteal vascular injury should be suspected.ConclusionsIn order to minimize the risk of vascular complications in ACL and PCL reconstructive surgery, we advise to look for less traumatizing instruments and to limit the amount of riskful actions, precise attention should be paid in the establishment of the tibial tunnels.