A similar technique was performed by application of a tourniquet just below the level of the knee joint while the leg was elevated. The patient stood up and no veins were demonstrated filling in the posterior and posterolateral aspect of the calf. These findings suggested to the surgeon that there was also incompetence of the valve for the small saphenous system where it anastomoses with the popliteal vein.
Surgery was planned.
A small transverse incision was made below the level of the inguinal ligament where the great saphenous vein passes through the saphenous ring in the deep fascia. This can be easily palpated as a small circular defect in the fascia. The saphenofemoral junction was identified and the great saphenous vein was ligated, at its anastomosis with the femoral vein. The great saphenous vein was stripped using special surgical techniques and removed.
The patient was placed prone for the second part of the operation.
A small incision was made transversely at the level of the skin crease in the popliteal fossa. However, the surgeon had difficulty identifying the junction between the small saphenous vein and the popliteal vein. After considerable time the surgeon located what he thought was the small saphenous vein and the structure was ligated and the wound closed.
The following day the patient was sent home, but returned to the clinic after 2 weeks complaining of problems walking. On examination there was absence of dorsiflexion, a sensory disturbance over the lateral aspect of the leg and foot, and obvious wasting of the fibular muscles. As the patient walked, the foot was dragged between steps. A clinical diagnosis of footdrop was made and a common fibular nerve injury was diagnosed. The injury occurred at the time of surgery.
Within the popliteal fossa are the popliteal artery, popliteal vein, and sciatic nerve (and its divisions). The popliteal artery is the deepest structure. The popliteal vein is superficial to the artery and the sciatic nerve is superficial to the vein (eFig. 6.142). Importantly, the sciatic nerve divides at the apex of the popliteal fossa. The tibial nerve continues into the lower popliteal fossa. The common fibular nerve passes laterally adjacent to the biceps femoris muscle to become superficial and wrap around the fibula neck.
It was concluded that the surgeon had accidentally ligated the common fibular nerve rather than the small saphenous vein, thus producing this patient’s symptoms.
A 72-year-old woman was admitted to the emergency room after falling at home. She complained of a severe pain in her right hip and had noticeable bruising on the right side of the face.
On admission it was noted that the patient’s right leg was shorter than her left leg and externally rotated.
An initial series of investigations was carried out, including a plain radiograph of the pelvis.
The plain radiograph of the pelvis demonstrated a displaced fracture through the right neck of the femur.
The apparent shortening and external rotation of the leg on clinical examination were accounted for by spasm of the muscles connecting the pelvis to the trochanters and proximal femur. Of the muscles that surround the hip joint the largest group is the adductor group (adductor longus, brevis, and magnus) and the psoas major. The psoas major inserts onto the lesser trochanter and its action is to externally rotate and flex the hip. The fulcrum of action of the psoas major is the femoral head in the acetabulum. However, when the femoral neck is detached its overriding action pulls the femur proximally and into external rotation. The external rotation is exacerbated by the spasm in the adductor muscles.
Extensive medical testing was necessary before surgery. It is important to remember that elderly patients may have a number of coexisting diseases.
The patient then underwent a hemiarthroplasty.