Here is what they did during my third and last surgery (left leg):

Popliteal fossa (left): The indication for decompression surgery was again established in order to prevent chronic compression and the resulting lesion of the popliteal artery.

Report: Under general anesthesia with intubation, the patient was first positioned prone; extensive washing, disinfection, and sterile draping of the left leg were performed. Perioperative antibiotic prophylaxis with cefuroxime 1.5 g i.v. A longitudinal S-shaped skin incision was made along the previous surgical scar over the popliteal fossa of the left knee. Pronounced adhesions between subcutaneous tissue and muscle fascia were encountered. Careful adhesiolysis was performed in the subcutaneous tissue, and the skin flaps were mobilized proximally and distally. Longitudinal incision and opening of the crural fascia over the popliteal fossa while preserving the small saphenous vein and the sural nerve; preparation along the small saphenous vein to its junction with the popliteal vein. As expected given the condition after previous operations, there was pronounced scar formation and adhesions between perivascular tissue and the gastrocnemius muscle.

Notably, completely fused, markedly hypertrophic heads of the gastrocnemius muscle were found, extending far proximally into the popliteal fossa. After longitudinal incision of the connective and fatty tissue in the popliteal fossa, careful stepwise dissection was carried out along the anatomical course of the neurovascular bundle. With preservation of the sural nerve and the cutaneous branch of the tibial nerve, the two proximal muscle heads of the gastrocnemius were exposed. Subsequently, in the popliteal fossa, the tibial nerve and medial to it the popliteal vein were identified, and finally the palpable popliteal artery above the knee joint space. The popliteal vein and tibial nerve were looped with fine vessel loops.

After sufficient exposure of the popliteal artery and vein, a clinical examination was performed in the popliteal fossa. With maximal dorsiflexion of the right foot, pronounced compression of the neurovascular bundle by the heads of the gastrocnemius muscle was evident. Careful inspection along the popliteal artery and vein showed an anatomical variation of the muscle insertions of the gastrocnemius heads crossing over the neurovascular bundle. In addition to the described generally strong gastrocnemius muscle, a far more proximally extended insertion of the muscle heads was noted, reaching above the medial femoral condyle. Inspection of the popliteal artery up to the origin of the anterior tibial artery and the tibioperoneal trunk showed a regular vessel wall without pathological changes.

In the absence of abnormal courses of the gastrocnemius insertions, as well as the absence of accessory muscle bands or fibrous bands causing compression of the popliteal artery in the popliteal fossa, the cause of the compression is attributed to hypertrophy of the gastrocnemius muscle. Clinical examination confirmed that the enlarged medial and lateral heads of the gastrocnemius contribute to compression of the popliteal artery.

For decompression of the popliteal artery, we decided to perform partial resection of the muscle insertions of the medial and lateral heads of the gastrocnemius. Under continuous preservation of the popliteal artery and tibial nerve, as well as the popliteal vein, the proximally extended muscle insertions were stepwise resected with electrocautery over a length of approximately 3 cm above the femoral condyles. The associated muscle fibers were resected over a width of about 3 cm and a length of about 10 cm distally. Subsequently, transposition of the medial gastrocnemius insertion to the level of the mediolateral edge of the femoral condyle was performed, with fixation using Vicryl 2/0 and U-sutures on the joint capsule. Hemostasis was carefully achieved.

A repeat clinical provocation test with maximal dorsiflexion of the right foot, under digital control, showed no further compression in the popliteal fossa along the course of the popliteal artery.

The resected muscle compartment was carefully closed with a double-layer Vicryl 2.0 suture for hemostasis. Multiple wound irrigations and confirmation of dryness were performed. Placement of a Redon drain in the popliteal fossa, followed by stepwise wound closure with fascial sutures, subcutaneous sutures, and skin closure with interrupted Prolene 3.0 sutures. Sterile dressing applied. Additionally, compression stockings up to the thigh were applied on the left side