A novel approach to the treatment of functional popliteal artery entrapment syndrome in college athletes.

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 problematic in 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 to 2023. The popliteal fossa was entered by a 10- to 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 (ABIs), and lower extremity arterial duplex. Results: Twenty-four patients were included, 23 of whom underwent bilateral repair (47 limbs total). The mean age was 21.9 years (standard deviation, 7.7 years). Most patients were female (83.3%), 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, 0.94). Lower extremity arterial duplex revealed a nearly two-fold increase in mean blood velocity among patients after exercise (mean velocity at rest, 65.8 cm/s; mean velocity during plantarflexion, 120.9 cm/s). Nine patients (36.2%) had prior operations related to exertional compartment syndrome in the lower extremities. The median length of stay was 1 day. Postoperative exercise ABI showed marked improvement compared with preoperative values in all athletes. Twenty-one of 24 patients (87.5%) resumed competitive sports without restriction at a median of 59 days after surgery. Of the three patients who did not return to competition, one died of an unrelated malignancy, and two had symptomatic recurrences that were subsequently treated for causes other than FPAEs. 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.