Ratnayake Amila, Samarasinghe Bandula, Bala Miklosh
Military Hospital, Colombo 5, Sri Lanka.
Department of surgery, University of Peradeniya, Peradeniya, Sri Lanka.
Injury. 2014 May;45(5):879-84. doi: 10.1016/j.injury.2014.01.003. Epub 2014 Jan 15.
Traumatic injury to the popliteal vascular zone remains a challenging problem on the modern battlefield and is frequently associated with more complications than other vascular injuries. Limb salvage and morbidity (graft infection, thrombosis and delayed haemorrhage) were studied.
All popliteal vascular injuries over an 8 month period admitted to the Military Base Hospital were analyzed. Local limb evaluation included confirmation of the presence of ischaemia, extent of soft tissue damage, muscle viability after calf fasciotomy, and neurological injury. Ischaemic time was recorded from the time of injury to definitive revascularization. If there was a prior attempt at reconstruction, the amputation was considered delayed.
For a series of 44 patients with popliteal vascular injury average time to presentation was 390min, 46% were completely ischaemic. Of those 39 (89%) had popliteal artery injuries. There were 24 (62%) complete popliteal artery transections and associated venous (69%) and osseous (46%) injuries. The preferred technique of repair was inter-position venous graft (IPVG) (54%). Eleven immediate amputations were performed (28%). There were 13 wound infections (33%), 5 early graft thromboses (5 of 21 IPVG, 238%), 2 anastomotic disruptions (2 of 21 IPVG, 9%), which resulted in 4 delayed amputations. Mortality was 5% (2 patients).
In this case series of popliteal artery injury early identification of limbs at risk, early four compartment fasciotomy, temporary intra-luminal shunting, definitive repair of concomitant venous injuries and aggressive treatment of haemodynamic instability were shown to be beneficial in achieving reasonable outcome in an austere environment with limited recourses.
腘血管区域的创伤性损伤在现代战场上仍是一个具有挑战性的问题，且与其他血管损伤相比，常常伴有更多并发症。本研究对肢体挽救及发病率（移植物感染、血栓形成和延迟性出血）进行了探讨。
对军事基地医院8个月期间收治的所有腘血管损伤病例进行分析。对局部肢体的评估包括确认是否存在缺血、软组织损伤程度、小腿筋膜切开术后肌肉活力以及神经损伤情况。记录从受伤至确定性血管重建的缺血时间。如果之前有过重建尝试，则将截肢视为延迟性截肢。
在这组44例腘血管损伤患者中，平均就诊时间为390分钟，46%的患者完全缺血。其中39例（89%）存在腘动脉损伤。有24例（62%）腘动脉完全横断，并伴有静脉损伤（69%）和骨损伤（46%）。首选的修复技术是静脉移植术（IPVG）（54%）。进行了11例即刻截肢（28%）。发生13例伤口感染（33%），5例早期移植物血栓形成（21例IPVG中有5例，23.8%），2例吻合口破裂（21例IPVG中有2例，9%），这导致4例延迟性截肢。死亡率为5%（2例患者）。
在本系列腘动脉损伤病例中，早期识别有风险的肢体、早期进行四室筋膜切开术、临时腔内分流、确定性修复伴发的静脉损伤以及积极治疗血流动力学不稳定，在资源有限的严峻环境中被证明有助于取得合理的治疗结果。
