Calf pain in runners may be caused by venous insufficiency

Sportsman complaints in the legs are most often associated with diseases and/or trauma of the musculoskeletal system. More rarely disturbances of the vascular system, e.g., popliteal artery entrapment have been reported in sportsman. Venous entrapment or venous claudication is mainly observed in cases of deep venous thrombosis. We report a case of venous claudication in the right leg of a sportsman (long distance runner) without any history of venous thrombosis who presented himself to the Praxisklinik Sauerlach. After running one to two km the man had to stop running due to increasing numbness in the lower leg, aching muscles in the calf and finally pain. An orthopaedic evaluation including magnetic resonance imaging of the leg by two orthopaedic specialists did not reveal any disturbance in the musculoskeletal system being responsible for the pain. - At the first clinical evaluation in ambulatory surgery clinic in Sauerlach there were no visible signs of varicose veins in the legs. B-mode and duplex-sonographic investigation of the right leg revealed an enlarged (0.63 cm) insufficient sapheno-popliteal junction with reflux in the right leg, the investigation of the venous system in the left leg was normal. A popliteal artery entrapment was excluded by colour duplex sonography. The operative procedure, ligation of the sapheno-popliteal junction with segemental saphenous vein stripping, has been well tolerated. 2-3 weeks after ligation of the sapheno-popliteal junction and segmental saphenous vein stripping the patient resumed his running program and could run without any painful disturbances. Conclusion: Athletes, e.g., runners with complaints in the leg should be investigated for musculoskeletal defect but also for vascular disease,e.g., small saphenous vein insufficiency. The choice of treatment is ligation of the sapheno-popliteal junction with segmental saphenous vein resection which gives the patient optimal results and allows practicing long-distance running shortly after the operation.     

成功抢救血管再通综合征一例报告

本文报告一例右侧总股动静脉严重损伤,在血管重建术后发生了血管再通综合征。经过多次人工肾透析和筋膜切开,挽救了生命,获得了血管重建手术的成功。由于此征是血管损伤的严重并发症和致死的主要原因,故对其发病机理,预防及治疗进行了讨论。     

COMBINED BILATERAL FREE LATISSIMUS D()RSI SKIN FLAP TRANSPLANTATION

The authors creatively performed a combined bilateral free latissimus dorsi myocutaneous flap transplantation for an eight-year-old girl to repair a skin defect measuring 26X18 cm encircling the entire left leg between the knee and foot. Two free latissimus dorsi myocutaneous flaps were joined to form a single flap with only one common vascular pedicle - the right subscapular artery and vein. The left subscapular artery is anastomosed to the right circumflex scapular artery and the left subscapular vein connected with the right circumflex scapular vein. The left circumflex scapular artery and vein being redundant, are ligated. Cross-bridge vascular anastomosis was employed due to the absence of blood vessels available for anastomosis at the reci pient site. The flaps survived and the patient can bear weight and walk with the affected leg. There has been no functional impairement of the upper limbs after the removal of both latissimus dorsi myocutaneous flaps.     

Chronic ischemia presenting as muscular groin pain

A 66-year-old man was admitted to a hospital rehabilitation unit for the management of chronic groin pain. Since the groin pain began, he had been unable to bear weight on his right foot. During a podiatric examination, the patient reported sharp pain at the apex of his right hallux. A full podiatric assessment was undertaken to evaluate his vascular, neurologic, and biomechanical status. The patient's ankle-brachial index was found to be 0.34 in the right lower limb and 0.68 in the left lower limb. After vascular assessment, the patient was diagnosed as having chronic ischemia of the right leg. He underwent left-to-right femoral-to-femoral bypass graft surgery to salvage the right lower leg and foot.     

CsA对CCI大鼠触诱发痛和热痛敏影响的实验研究

目的:研究免疫抑制剂环孢素A(CsA)对大鼠神经性慢性病理性疼痛的影响。方法:16只Wistar大鼠随机分为CsA组和生理盐水(NS)组,每组8只。结扎大鼠右侧坐骨神经建立坐骨神经压榨性损伤(CCI)模型,建模术后第3天,CsA组大鼠腹腔注射CsA(6 mg/kg),NS组注射等量生理盐水,均1次/d,连续给药4周。在CCI术前(当天)和术后3、7、10、14、21、28天测量2组大鼠手术侧(右侧)及对侧触诱发痛针刺-缩足强度和热刺激-缩足时间。结果:成功建立CCI大鼠模型。2组在术后3天手术侧针刺-缩足强度和热刺激-缩足时间与术前比较均明显降低或缩短(P均<0.05)。CsA组手术侧热刺激-缩足时间到10天后逐渐增加,28天基本恢复,但针刺-缩足强度变化不明显。结论:CsA能影响CCI大鼠的热痛敏,对大鼠神经性慢性病理性疼痛有一定程度的干预作用,与触诱发痛敏无关。     

Ruptured superficial femoral artery aneurysm treated by simple ligation

A 79-year-old man, with a background of peripheral vascular disease, presented to the emergency department with a sudden increase in the size of his swelling in the right thigh, indicating rupture of his right superficial femoral artery aneurysm. His past medical history included having had a left femoropopliteal bypass (1986), abdominal aortic aneurysm repair (1991), repair of false aneurysm on the right (1992) and repair of left common femoral artery aneurysm (1995). On surgical exploration, four contiguous aneurysms in the right superficial femoral artery were identified, which measured around 25 cm in total length. After achieving control of the aneurysm, it was noted that the popliteal artery was unsuitable for anastomosis. However, the leg was still adequately perfused via collaterals in spite of the ligation, so nothing further was done. The patient was put on a heparin infusion postoperation, and had an uneventful recovery with a viable limb on discharge. It is a useful reminder that ligation can still be an option in vascular emergencies in some situations.     

Differential diagnosis of leg pain in the athlete

Leg pain in the athlete is common and has many different etiologies. The most common causes include muscle or tendon injury, medial tibial stress syndrome, stress fracture, and exertional compartment syndrome. Less common causes of leg pain include lumbosacral radiculopathy, lumbosacral spinal stenosis, focal nerve entrapment, vascular claudication from atherosclerosis, popliteal artery entrapment syndrome, and venous insufficiency. This article reviews the essential history and physical examination findings and the various causes of leg pain to help the clinician pinpoint the diagnosis and facilitate the athlete's return to sport participation.     

Determination of blood flow of the lower leg in patients with diabetes mellitus and the effects of treatment with the principle of vitalizing blood and solubilizing thrombus

This paper reports the determination of blood flow of the lower leg in 50 cases of non-insulin dependent diabetes mellitus (NIDDM) using an XLJ-2 Bipolar Rheoencephalometry Impedance Rheogram. In patients with leg pain (but without obvious vascular pathological changes, 85 legs) the blood flow was decreased. In male patients the blood flow of the left leg (9 legs) was 3.28 +/- 0.47 ml/100ml.tissue.min (mean +/- S), while that in the right leg (11 legs) was 3.88 +/- 0.80; in females, the blood flow of the left leg (32 legs) was 2.72 +/- 0.8; while that in the right leg (33 legs) was 2.94 +/- 0.66. These figures were significantly (P less than 0.01-0.001) lower than those obtained from normals. In diabetic feet (15 painful legs) the decrease of blood flow of the lower leg was more apparent: it averaged 1.87 +/- 0.79 for the left leg (7 legs) and 2.66 +/- 0.87 for the right leg (5 legs) in male patients. The values were significantly different when compared with those of normals (P less than 0.001) or with those of the diabetic patients with leg pain (P less than 0.05). These results demonstrated that determination of the blood flow of the lower leg of diabetic patients might aid in early discovery of the abnormal changes of blood supply to the lower legs in diabetes mellitus and judge the degree of ischemia. Of the 50 cases of diabetics 32 were Qi-Yin deficiency with blood stasis while the remaining 18 cases were deficiency of both Yin and Yang with blood stasis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Rare complications of a low lying median arcuate coeliac ligament

Pancreaticoduodenal artery aneurysm is a rare complication of coeliac artery stenosis secondary to a low lying median arcuate coeliac ligament. This article reports the case of a 69-year old man who presented with left arm and leg weakness, clinically in keeping with right hemisphere stroke. Initial CT brain scan was within normal limits. The patient did not receive thrombolysis as he was outside the time window. 3 hours later the patient experienced sudden onset epigastric pain and acute shock. CT aorta abdominal was diagnostic of a ruptured inferior pancreaticoduodenal artery aneurysm. Repeat CT brain the following day showed subacute infarction within the right frontal lobe. Embolisation of the aneurysm was successfully performed. It is well documented that ischaemic stroke can cause acute hypertension. This acute hypertension probably contributed to the rupture of the pancreaticoduodenal artery aneurysm. The patient was well on discharge and remains well 2 months on.     

Internal iliac artery pseudo aneurysm occlusion using amplatzer vascular plug

Pseudoaneurysm of the internal iliac artery is a rare occurrence. Our patient presented with pain over the lower abdomen which also radiated to the back. An Angiogram of the aorta and the iliac arteries showed a pseudoaneurysm of the right internal iliac artery which measured about 8 x 8 cm with a proximal branch of the internal iliac artery distended. Initial efforts of trying to embolize the pseudoaneurysm revealed that there was a connection between the pseudoaneurysm and the interanal iliac vein where foam was getting dislodged into the venous system. Subsequently, we decided to use a vascular plug which has just been recently being introduced. Post procedure there was no more flow into the right internal iliac artery pseudoaneurysm.     

CROSS-BRIDGE TRANSPLANTATION OF FREE LATISSIMUS DORSI SKIN FLAP IN ONE CASE

Extensive skin and soft tissue defect accom- panied by damage and/or absence of blood vessels in the local and adja.cent regioins is a formidable problem which often cannot be effectively solved by conventional means as skin tube transfer,, crossed skin flap or free skin grafting. An original operative procedure des;igned by our group and applied successfully to repair a Inassive left leg defect with extensive scarring measuring 30xi25 cm and extending deep into the periosteum is presented in this paper. The left anterior tibial vessels and great saphenous vein were also ba.dly damaged. A free latissimus dorsi skin flap is excised and transplanted onto th.ei defect, while the right leg is flexed so the ankle crosses over and lies just behind the upper end of the left leg forming a 600 angle betweeaa the 2 legs A pedicle skin flap is mobilized from the right ankle region and sutured to the le.ft leg wound ma.rgin to form the "floor" of the skin bridge. The right anteriorr tibial artery and its continuation, the dorsal pedal artery, the continuation of the great saphenous vein, and the dorsal pedal vein were mobilized and severed. They ar'e anastomosed end-to-end respectively with the thoracodorsal artery and vein of the free latissimus dorsi skin flape Finally, the free latissimus dorsi skin flap is sutured to the right ankle skin incision edge to form the "surface" of the skin bridge. The vascular pedicle of the free latissimus dorsi skin flap is made to span the crossed legs, serving as a skin bridge through which flows the t.em- porary blood, supply to the free skin flap. After vascular training to promote new circulation formation, t.he skin bridge is severed 6 weeks postoperatively. The free skin flap survives The succes^s of this procedure makes pos- sible the plastic reconstructive repair in pa- tients with large area skin and compound tissue defects, broa.dening the range of reconstructive surgery and the operative indicat.ions for large area skin and compound tissue loss.     

Protein S deficiency and lower-extremity arterial thrombosis: complicating a common presentation

A 42-year-old woman presented to the emergency department with progressive painful discoloration of the digits of her right foot and symptoms previously diagnosed as neuroma. She was admitted to the hospital for dorsalis pedis arterial occlusion and ischemic foot pain. Despite attempts to restore perfusion to the right leg, ischemia of the right foot persisted and progressed to digital gangrene. The patient subsequently required right transmetatarsal amputation and eventually below-the-knee amputation. After extensive inpatient vascular and hematologic work-up of this otherwise healthy woman, test results revealed that she had protein S deficiency, hepatitis C, and human immunodeficiency virus type 1. In addition to describing this patient's evaluation and treatment, we review protein S deficiency, including its correlation with human immunodeficiency virus type 1 infection and laboratory diagnosis. This case promotes awareness of protein S deficiency and serves as a reminder to the physician treating patients with vascular compromise and a history of human immunodeficiency virus type 1 to include protein S deficiency in the differential diagnosis.     

改进的桥式吻合血管背阔肌穿支皮瓣移植的临床应用

应用改进的桥式吻合血管背阔肌穿支皮瓣移植方法,修复5例小腿软组织缺损。皮瓣切取连带肩胛下与旋肩胛血管,与健侧小腿胫后动脉行端端吻合。皮瓣全部成活,术后随访8个月～3．5年（平均2．7年）,无明显的供区功能障碍。健侧小腿经临床观察与Doppler检查,胫后动脉通畅。此术式适宜修复伤肢软组织缺损仅有1条主要动脉者,行桥式游离皮瓣移植保存了对侧肢体胫后动脉通畅。     

铬制肠线与丝线制作CCI模型效果比较

目的比较利用铬制肠线和丝线制作CCI疼痛模型痛阈变化的区别。方法将30只健康雄性SD大鼠随机分为铬制肠线组、丝线组和假手术组,每组10只。铬制肠线组和丝线组分别用铬制肠线和丝线对大鼠右侧坐骨神经进行松结扎,假手术组只暴露右侧坐骨神经但不进行任何处理。建模后测量各组大鼠热缩足反射阈值（TWT）和机械性缩足反射阈值（MWT）。结果铬制肠线组和丝线组均能引起大鼠痛阈的降低（与假手术组比较P〈0.05）,铬制肠线组和丝线组间MWT无明显区别（P〉0.05）,铬制肠线组TWT低于丝线组（P〈0.05）。结论铬制肠线制作CCI模型较之丝线制作CCI模型能引起更为明显的热痛阈降低。     

硬膜外应用虎纹镇痛肽-Ⅰ对大鼠外周神经挤压再生模型脊髓背角c-fos表达影响的研究

目的通过观察硬膜外给予虎纹镇痛肽-Ⅰ对大鼠外周神经挤压模型机械痛阈与脊髓背角c-fos表达的影响,探讨虎纹镇痛肽-Ⅰ对再生神经神经性疼痛的影响。方法雄性Wistar大鼠60只随机均分成3组,A组为坐骨神经挤压模型组;B组为坐骨神经挤压模型＋虎纹镇痛肽-Ⅰ治疗组;C组为假手术组。分别制成模型后,术后21d起检测机械刺激阈值及c-fos表达计数。结果A、B组各项指标与C组比较有显著差异;A组与B组比较c-fos表达阳性细胞计数及机械痛阈均有显著差异。结论虎纹镇痛肽-Ⅰ能有效减轻再生神经的神经性疼痛程度,促进神经的完善修复。     

AN ANATOMIC STUDY OF ADIPOFASCIAL FLAP OF THE LEG

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GDNF在慢性收缩性损伤大鼠脊髓背根神经节中的蛋白表达

目的探讨胶质细胞源性神经营养因子（GDNF）在慢性收缩性损伤（CCI）所致神经病理性疼痛大鼠的L4背根神经节中的蛋白表达。方法实验1：24只SD大鼠,随机分为正常组（Naive组）、假手术组（Sham组）和CCI组（每组n=8）。Naive组不做任何手术;Sham组仅暴露坐骨神经;CCI组按Bennett法结扎右侧坐骨神经主干制备CCI模型。分别测定Sham组和CCI组术前2天（基础值）及术后第1、3、5、7、14、21天（Naive组则在相对应的时间点）大鼠同侧（本实验为右侧）后足机械缩足反射阈值（MWT）和热缩足反射潜伏期（PWL）。实验2：18只SD大鼠随机分为正常组（Naive组）、假手术组（Sham组）和CCI组（每组n=6）。CCI组制备CCI模型,术后第7天处死大鼠,取同侧L4背根神经节;Naive组不做任何手术,直接取右侧L4背根神经节;Sham组仅暴露坐骨神经,术后第7天处死大鼠,直接取右侧L4背根神经节。采用Western blot法检测脊髓L4背根神经节GDNF的蛋白表达。结果实验1：与Sham组相比,CCI组大鼠从术后第3天开始至术后21天内各时间点MWT和PWL均显著降低（P〈0.05或P〈0.01）。实验2：与Sham组相比,CCI组在L4背根神经节的GDNF表达明显减少（P〈0.01）。结论CCI大鼠的L4背根神经节的GDNF表达减少,可能参与CCI所致神经病理性疼痛的发病机制。     

Clinics in diagnostic imaging (107)

A 90-year-old woman was admitted for progressively increasing lower abdominal pain. There was no history of prior surgery, and physical examination was non-specific. The supine abdominal radiograph revealed an abnormal collection of air over the right obturator foramen. Computed tomography showed a right obturator hernia with incarcerated bowel in the hernial sac, and a right sciatic hernia containing the right ovary. The anatomy of obturator and inguinal hernias is reviewed, and the use of various imaging modalities in evaluation of abdominal hernias is discussed.     

完全性血管环的产前超声诊断及鉴别诊断

目的研究产前超声在诊断及鉴别诊断完全性血管环中的价值。方法本文总结了5例在我院产前超声诊断、并经产后影像学复查确诊或引产后病理解剖确诊的完全性血管环胎儿的产前超声表现。结果 1例双主动脉弓构成的完全性血管环,4例右位主动脉弓、迷走动脉（3例迷走左锁骨下动脉、1例迷走左无名动脉）及左位动脉导管构成的完全性血管环。在三血管气管切面上,双主动脉弓构成的完全性血管环超声特点是：升主动脉于气管前分叉为左右两支绕行于气管两侧,左右两支在气管后汇合延续为降主动脉,血管环呈＂O＂型;右位主动脉弓、迷走动脉及左位动脉导管构成的完全性血管环的超声特点是：右位主动脉弓、迷走血管及左位动脉导管围绕食管形成＂U＂型;按照右位主动脉弓的分支数目、第一分支走行及迷走动脉分支,可鉴别迷走动脉是左锁骨下动脉或者左无名动脉。结论三血管气管切面是诊断先天性完全性血管环的重要切面,产前超声能诊断常见的完全性血管环,并且可以鉴别常见的完全性血管环。     

探讨急性下壁心肌梗死的心电图对判断心肌梗死相关动脉和闭塞位置的作用

目的：探讨急性下壁心肌梗死的心电图情况对判断心肌梗死相关动脉及闭塞位置的作用。方法选取该院收治的急性下壁心肌梗死患者80例,观察该组患者心电图情况,并研究心电图情况对心肌梗死相关动脉和闭塞位置判断影响。结果血管闭塞在右冠状动脉发生率为86.25%,回旋支发生率为13.75%,合并右心室心肌梗死发生率41.25%%。急性下壁心肌梗死右冠状动脉是心肌梗死相关动脉的时候,血管闭塞的位置发生于右心室支开口以远占73.75%,合并RVI的时候,其闭塞多数发生在第1右心室只开口前占65.00%。结论下壁急性心肌梗死的心电图情况与心肌梗死相关动脉及闭塞位置相关,具有一定的预测价值。