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OJHAS: Vol. 5, Issue
4: (2006 Oct-Dec) |
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Squatting -An Unusual
Cause Of Popliteal Artery Thrombosis |
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Marya KM
Ex-Lecturer, Department of Orthopaedics, Paraplegia
& Rehabilitation, Pt. BD Sharma Postgraduate Institute of
Medical Sciences, Rohtak, India
Yadav V
Department of Orthopaedics, Paraplegia
& Rehabilitation, Pt. BD Sharma Postgraduate Institute of
Medical Sciences, Rohtak, India |
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Address For Correspondence |
#986, Sector 15,
Faridabad - 121007,
INDIA
E-mail:
drkmmarya@yahoo.com |
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Marya KM, Yadav V. Squatting -An Unusual
Cause Of Popliteal Artery Thrombosis
Online J Health Allied Scs.2006;4:5 |
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Submitted Dec 22, 2006; Accepted
Mar 22, 2007; Published Mar 26, 2007 |
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| Abstract: |
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We report a case of acute
popliteal artery occlusion in a young male farmer as a result of prolonged squatting
Key Words:
Popliteal artery, Thrombosis |
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We report a hitherto un-described cause of acute
popliteal artery occlusion in a young male farmer free from any other medical
condition. The occlusion was caused by a thrombus of 10.6mm length, which formed
in situ in the popliteal artery, as a result of prolonged squatting by the
farmer in the fields in the harvesting season. Prolonged periods of squatting
are very commonly endured by farmers in tropical countries during harvesting
season. The hyperflexion induced kink of the artery probably caused arterial
stasis and intimal endothelial damage. Extreme flexion of the knee, as in
squatting, has been implicated as a major cause of common peroneal nerve
palsy1. We could not find any report in the literature surveyed
describing squatting induced spontaneous popliteal arterial
thrombosis.
A 27-years-old man reported
to our institute with painful, swollen, discoloured and cold left leg, for the
last 24 hours. He had been engaged in manual harvesting activities in his fields
the previous day. After squatting for 7 hours at a stretch, he noticed numbness
in his left leg. Assuming it to be a mild problem, he remained confined to his
home and did not seek any medical attention. Gradually his limb started becoming
pale and bluish and he noticed weakness of ankle movements. He then reported to
our institute.
On examination, his left
limb had signs of ischaemia below the knee and paraesis of ankle extensors,
flexors, evertors and invertors was noticed as well. The limb was colder as
compared to the other side. Gangrenous patches were present in the first, second
and third toes and also on plantar surface of sole in an area of 5 by 7cms. No
popliteal pulse was palpable and all distal pulses were also absent. Capillary
circulation was present but was sluggish. A detailed investigation was carried
out. He was found to suffer from no other medical condition. Echocardiography
was within normal limits. Tests to rule out systemic infection as a source of
infective emboli were negative. Serum cholesterol, blood pressure, AST and ALT
enzyme levels, blood lipid profile, coagulation profile were all within normal
limits.
Doppler study of the limb
showed decreased peak flow velocity in the femoral artery, a 10.6mm thrombus
completely occluding the lumen of popliteal artery with no flow distally apart
from a few collaterals (Fig 1a & 1b).
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Fig. 1a & b: Doppler study of popliteal artery showing
no flow pattern. Femoral artery flow is sluggish with peak flow velocity of
102cms/second; anterior and posterior tibial arteries and dorsalis pedis artery
shows no flow. Few collaterals maintain the distal
circulation. |
Immediate open surgical
thrombectomy was performed. Per-operatively, intima of the arterial wall was
found damaged. At the last follow-up, the patient had recovered completely,
apart from mild sensory deficit over the plantar aspect of the left foot and a
mild motor deficit with power grade 4/5 on MRC scale in ankle
dorsiflexors.
Squatting, a posture
commonly adopted by manually harvesting farmers in many countries, is a known
cause of common peroneal nerve palsy.1,2 This posture involves
hyper-flexion at the knee and not only unilateral, even bilateral peroneal nerve
palsy is known to occur after prolonged squatting.3 The mechanism
involves hyper-flexion at the knee, which causes an acute kinking of popliteal
vessels in addition to putting pressure on the common peroneal nerve. Prolonged
squatting in the present case probably caused stasis of blood flow secondary to
an acute kink in the popliteal artery resulting in development of thrombosis.
Possibly, the extreme flexion attitude also caused micro trauma to the
endothelium, initiating the coagulation cascade and culminating in a thrombus
that totally occluded the arterial lumen.
Acute arterial thrombosis
in situ occurs most frequently in atherosclerotic vessels at the site of
stenosis or aneurysm, and in arterial bypass grafts. Less frequent causes
include trauma to an artery, thoracic outlet syndrome, entrapment of popliteal
artery by abnormal placement of medial head of gastrocnemius muscle,
polycythemia and hypercoagulable disorders. Acute arterial occlusion has also
been reported as the presenting feature in acute promyelocytic
leukaemia.4 Awareness should also be created amongst Orthopaedic
surgeons performing knee arthroplasty as acute popliteal artery occlusion has
occurred after a total knee arthroplasty.5 None of these aetiological
factors could be found in the present case. A review of the available literature
did not reveal any report of squatting induced spontaneous popliteal artery
thrombosis.
Over the past several
decades, preferred treatment options for acute limb ischaemia have alternated
between medical and surgical approaches. More recently, direct intra-arterial
thrombolysis became the standard of care after several randomised trials
demonstrated the benefit of this approach as compared with acute surgical
intervention. Despite all of the experience with direct intra-arterial
thrombolysis for the treatment of acute limb ischaemia, the optimal thrombolytic
approach has not been clearly established.6 Percutaneous techniques
reportedly offer excellent early and mid-term results in selected patients
presenting with acute ischaemia with popliteal and/or tibial arterial
occlusion.7 Surgical thrombectomy is the method of choice for
treating a large sized thrombus, although controversy still exists regarding the
use of thrombolytic therapy and anticoagulants. For traumatic injuries, however,
interposition vein grafting using the long saphenous vein is a better
alternative. Appropriate handling of acute ischaemic conditions implies the use
of both thrombolysis and appropriate surgical procedures, including distal
bypass grafts.8 Mechanical thrombectomy might offer a useful
alternative as a first-line treatment for arterial occlusion when the procedure
is performed during the early phase.9
Farmers, especially of
tropical countries, who engage in manual harvesting practises should be made
aware of this potentially disastrous complication, and advised to intermittently
extend their knees while harvesting, so that such situations can be averted.
- Katirji B. Peroneal neuropathy.
Neurol Clin. 1999;17:567-91.
- Sangwan SS, Marya KM, Kundu ZS,
Yadav V, Devgan A, Siwach RC. Compressive peroneal neuropathy during
harvesting season in Indian farmers. Tropical Doctor 2004:
34(4):244-46.
- Togrol E, Çolak A, Kutlay M,
Saraçoğlu M, Akyatan N, Akin ON. Bilateral peroneal nerve palsy induced by
prolonged squatting. Mil Med. 2000; 165:240-2.
- Kalk E, Basu S, Rose P, Chachlani N.
Acute arterial occlusion as the presenting feature in acute promyelocytic
leukaemia. Br J Haematol. 2001;115:2.
- Ohira T, Fujimoto T, Taniwaki K.
Acute popliteal artery occlusion after total knee arthroplasty. Arch
Orthop Trauma Surg. 1997;116:429-30.
- Laird JR. The management of acute
limb ischemia: techniques for dealing with thrombus. J Interv
Cardiol. 2001;14:539-46.
- Desgranges P, Kobeiter K,
d'Audiffret A, Melliere D, Mathieu D, Becquemin JP. Acute occlusion of
popliteal and/or tibial arteries: the value of percutaneous treatment.
Eur J Vasc Endovasc Surg. 2000;20:138-45.
- Nilsson L, Albrechtsson U, Jonung T,
Ribbe E, Thorvinger B, Thorne J, Astedt B, Norgren L. Surgical treatment
versus thrombolysis in acute arterial occlusion: a randomised controlled
study. Eur J Vasc Surg. 1992;6:189-93.
- Kasirajan K, Marek JM, Langsfeld M.
Mechanical thrombectomy as a first-line treatment for arterial occlusion.
Semin Vasc Surg. 2001;14:123-31.
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