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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 4  |  Page : 153-155

Popliteal artery thrombosis caused by osteochondroma: Arare presentation


Department of Cardiology, Government Medical College, Kozhikode, Kerala, India

Date of Web Publication20-Dec-2016

Correspondence Address:
Kailash Kumar Goyal
Department of Cardiology, Government Medical College, Super-Specialty Block, Kozhikode - 673 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449x.196287

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  Abstract 

Popliteal entrapment syndrome should be considered as a cause of lower limb vascular insufficiency in young adults. It is often caused by musculotendinous structures and bony abnormalities are rarely implicated. Early diagnosis and prompt surgical treatment are the key factors for a better prognosis. This report describes a rare case of popliteal artery thrombosis cause by an osteochondroma treated by surgical resection with good results.

Keywords: Exostoses, osteochondroma, popliteal artery thrombosis, popliteal entrapment syndrome


How to cite this article:
Muneer K, Goyal KK, Gupta H, Sajeev CG. Popliteal artery thrombosis caused by osteochondroma: Arare presentation. Heart India 2016;4:153-5

How to cite this URL:
Muneer K, Goyal KK, Gupta H, Sajeev CG. Popliteal artery thrombosis caused by osteochondroma: Arare presentation. Heart India [serial online] 2016 [cited 2020 Jul 15];4:153-5. Available from: http://www.heartindia.net/text.asp?2016/4/4/153/196287


  Introduction Top


Popliteal entrapment syndrome (PES) refers to a group of symptoms caused by mechanical compression of popliteal artery, vein, or tibial nerve in the popliteal fossa.[1] Popliteal artery entrapment usually occurs in young adult males and presents with intermittent claudication mimicking atherosclerotic peripheral vascular disease. This is usually described with relation to musculotendinous structures and there are very few case reports where bony exostoses of the popliteal fossa causing popliteal artery entrapment syndrome have been described. These exostoses can present as solitary osteochondroma or as a familial form known as hereditary multiple exostoses. Pseudoaneurysms are the most common vascular complications caused by exostoses [2] and thromboembolic complications are rare. We herein report a case of popliteal artery thrombosis caused by osteochondroma presenting with lower limb ulcer. Our case is rare in the sense that there are very few reports of lower limb ischemia caused due to bony exostosis of the popliteal fossa and compression leading to popliteal artery thrombosis and lower limb ulcer is even rarer.


  Case Report Top


A 23-year-old male presented with complaint of a nonhealing ulcer [Figure 1] on the plantar aspect of the fourth toe of left lower limb. He also gave a history of intermittent claudication of the left calf on walking <200 m for the last 6 months, for which he was not evaluated previously. There were no risk factors such as diabetes, smoking, or any family history of premature atherosclerotic heart disease. An arterial Doppler of left lower limb was done which showed popliteal artery thrombus with no distal flow. On examination, popliteal and distal pulses were absent on the left side. While palpating for popliteal artery, a hard nontender lump was felt in the popliteal fossa. This arouses the suspicion of a bony exostosis, and so, an X-ray of the bilateral knee joint was done [Figure 2]a and [Figure 2]b. The X-ray showed multiple well-defined varying-sized sessile and pedunculated bony lesions arising from bilateral distal femur, proximal tibia, and fibula. Computed tomography (CT) angiogram of the lower limb was done which showed thrombosis involving left popliteal artery and anterior tibial artery. It also showed multiple irregular exophytic bony projections continuous with the medullary cavity of the bone and arising from the metaphyses of lower end of femur, upper end of tibia, and fibula bilaterally [Figure 3]a and [Figure 3]b. The projections appeared to stretch the popliteal artery on the left side. The patient underwent a surgical resection in the orthopedic department of our hospital along with a Fogarty embolectomy. During surgery, a large bony spur arising from distal femoral metaphysis was identified which appeared to be impinging on the popliteal artery. Osteochondroma was resected in multiple fragments with the largest measuring 5 cm × 3.5 cm × 1.5 cm. Two of the pieces also showed a smooth glistening cap [Figure 4]a and [Figure 4]b. Histopathological examination of the resected specimen showed a fibrous capsule covering the cartilaginous cap suggestive of osteochondroma [Figure 5]. The patient was discharged on the 8th postoperative day. Distal pulses were present at discharge and follow-up visit is awaited.
Figure1: A nonhealing ulcer on the plantar aspect of the fourth toe

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Figure2:(a) X-ray of bilateral knee joint anteroposterior view.(b) X-ray of bilateral knee joint lateral view

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Figure3:(a) Computed tomography angiogram showing popliteal artery thrombosis.(b) Computed tomography scan showing multiple exophytic bony projections

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Figure 4: (a) Resected fragment of osteochondroma. (b) Resected fragment showing smooth glistening cap

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Figure 5: Histopathological slide of the resected specimen

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  Discussion Top


Peripheral arterial disease causing limb claudication is a common disease of elderly population and is commonly caused by atherosclerosis and embolism. In young patients presenting with claudication or vascular insufficiency, alternative causes such as trauma, tumors, thromboangiitis obliterans, fibromuscular dysplasia, vasculitis, and PES should be suspected.

Popliteal artery entrapment syndrome is caused due to abnormal relation of popliteal artery and its surrounding structures in popliteal fossa.[3] Embryologically, it results due to abnormal development of popliteal artery or excessive cranial migration of head of gastrocnemius muscle.[4] A total of five types of PES have been described based on the relationship of popliteal artery and vein with respect to attachment of gastrocnemius and popliteus muscle. A separate functional variety with no definitive anatomic abnormality has also been described.[5],[6] Osseous abnormalities of popliteal fossa have not been categorized as a cause of PES.

Osteochondromas are most common benign tumors representing about 35%–45% of all benign tumors of bone.[7] They are generally solitary but sometimes may be associated with hereditary multiple exostoses. These tumors are usually asymptomatic. Symptoms, when present, are due to mechanical compression, fracture, or malignant transformation. Vascular complications caused by osteochondromas include pseudoaneurysm, phlebitis, and venous thrombosis. Ischemic complications however are relatively rare and may sometimes be the presenting complaint as seen in our case. Most common age of presentation is in the early 20s which is also the age group for PES.

Diagnosis of PES is based on clinical history, physical examination, and various noninvasive and invasive diagnostic procedures. It should always be suspected in a young patient below aged 50 years, presenting with lower limb claudication and absent traditional cardiovascular risk factors. Doppler ultrasonography with provocative maneuvers is a useful screening test for PES. Plain radiography is useful if a vascular compromise due to external compression by tumorous lesion is suspected as in our case. Angiography used to be the gold standard test for diagnosis of PES. However, magnetic resonance imaging (MRI) is considered to be the best investigation for PES nowadays as it is noninvasive and allows for a complete evaluation of anatomical relationships between the vessels and musculotendinous structures. A CT can also be useful if MRI is not available and osseous tumors are suspected to be the pathogenetic lesions causing PES.

The management of PES, whether due to muscular or bony pathology, consists of surgical release of entrapped artery and dealing with local arterial pathology to restore flow. Early surgical treatment provides better results, and hence, a high index of suspicion is required to diagnose and treat this condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sinha S, Houghton J, Holt PJ, Thompson MM, Loftus IM, Hinchliffe RJ. Popliteal entrapment syndrome. J Vasc Surg 2012;55:252-62.e30.  Back to cited text no. 1
    
2.
Vasseur MA, Fabre O. Vascular complications of osteochondromas. J Vasc Surg 2000;31:532-8.  Back to cited text no. 2
    
3.
Iwai T, Konno S, Soga K, Hatano R, Sato S, Yamada T, et al. Diagnostic and pathological considerations in the popliteal artery entrapment syndrome. J Cardiovasc Surg (Torino) 1983;24:243-9.  Back to cited text no. 3
    
4.
Lambert AW, Wilkins DC. Popliteal artery entrapment syndrome. Br J Surg 1999;86:1365-70.  Back to cited text no. 4
    
5.
Love JW, Whelan TJ. Popliteal artery entrapment syndrome. Am J Surg 1965;109:620-4.  Back to cited text no. 5
    
6.
Rich NM, Collins GJ Jr., McDonald PT, Kozloff L, Clagett GP, Collins JT. Popliteal vascular entrapment. Its increasing interest. Arch Surg 1979;114:1377-84.  Back to cited text no. 6
    
7.
Vanhoenacker FM, Van Hul W, Wuyts W, Willems PJ, De Schepper AM. Hereditary multiple exostoses: From genetics to clinical syndrome and complications. Eur J Radiol 2001;40:208-17.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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