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A Novel Approach to the Treatment of Functional Popliteal Artery Entrapment Syndrome in College Athletes
Connor W. Smith, James H. Black, III
Johns Hopkins University School of Medicine, Baltimore, MD
BACKGROUND: Functional popliteal artery entrapment syndrome (FPAES) is a rare disorder that results from hypertrophy and overuse injury of calf muscles, which thereby compress neurovascular structures in the popliteal fossa. The majority of FPAES cases are found in young athletes who present with symptoms during exercise. Most commonly, FPAES is surgically treated with muscle debulking utilizing a posterior S-shaped incision, but wound healing and neuropathy remain concerns with this approach. Here, we present our case series of college athletes undergoing FPAES repair using a novel medial calf approach that avoids surgical incision across the joint space.
METHODS: This is a retrospective analysis of all FPAES repairs performed at our institution from 2016-2023. The popliteal fossa was entered by a 10-12 cm incision on the medial aspect of the calf. Exploration of the popliteal artery, vein, and neurovascular bundle was performed. Tenotomy of the soleus and tenotomy and debulking of the medial gastrocnemius were performed. We studied postoperative wound complications, pain, neurovascular symptoms during in-hospital and long-term follow-up periods, postoperative analgesia use, length of stay, pre- and postoperative ankle-brachial indices (ABI), and lower extremity arterial duplex.
RESULTS: Twenty-three patients were included, 21 of whom underwent bilateral repair (44 limbs total). The mean age was 22.1 years (SD ± 7.9). Most patients were female (82.6%) and all patients reported exercise-induced lower extremity pain. Most patients had a reduction in preoperative ABI after exercise (Mean preoperative resting ABI: 1.19; mean preoperative exercise ABI: 0.93). Seven patients (30.4%) had prior operations related to exertional compartment syndrome. The median length of stay was 1 day (IQR 1). Postoperative hematoma was not observed in any patients. Postoperative exercise ABI showed marked improvement compared to preoperative values in all athletes (Mean preoperative exercise ABI: 0.93; mean postoperative exercise ABI: 1.07). At the three-year follow-up, all patients returned to athletics, but two patients experienced symptom recurrence. Both of these patients were then treated for non-FPAES etiologies after.
CONCLUSIONS: We demonstrate favorable clinical and hemodynamic results and a low rate of complications for release of FPAES utilizing the medial approach. This surgical approach avoids the complications of delayed wound healing and neuropathy inherent to the posterior approach and may provide comparable functional outcomes for patients with FPAES.
Figure 1. Ankle Brachial Indices (ABI) measured pre- and post-operatively, at rest and after exercise. A decrease in pre- and post-operative ABI was observed with exercise, but the drop was attenuated after surgery.
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