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During tibial plateau leveling osteotomy (TPLO), the laceration of the cranial tibial artery (LCTA) may occur, and the ligation of the cranial tibial artery might lead to impaired blood supply to the osteotomy site. The present case-control study aimed to evaluate the effect of LCTA on TPLO healing and the occurrence of perioperative complications. The incidence and predisposing factors to LCTA were also investigated. Fourteen cases experiencing LCTA were retrospectively enrolled from medical records of two veterinary teaching hospitals (LCTA group), whereas 28 randomly selected TPLOs that did not experience LCTA were included in the control group. Signalment data, proximal tibial epiphysis conformation, osteotomy features, perioperative complications, and bone healing were compared between the two groups. Bone healing was evaluated using the modified radiographic union scale for tibial fracture and the visual analog scale. The mean incidence was 9.6%. Bodyweight was significantly higher in the LCTA group compared to the control group (P = 0.009). Dogs belonging to the LCTA groups were significantly younger (P = 0.01). Intraoperative hypotension was significantly overreported in the LCTA group (P = 0.0001). None of the other variables differed significantly between the two groups. Dogs' size seems to be a predisposing factor, with dogs weighing >15 kg having 22 times more chance of experiencing LCTA. Due to the well-developed collateral blood supply of the canine hindlimb, LCTA and the closure of the cranial tibial artery did not appear to delay the radiographic bone healing or affect the incidence of perioperative complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Disclosures None.

Background: Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma., Methods: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3)., Results: Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar., Conclusions: In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique., Methods: 116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate., Results: The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens., Conclusions: The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

A pseudoaneurysm, or false aneurysm, is a haematoma that is formed secondary to a leaking hole in an artery. This haematoma is contained by surrounding fascia. In contrast, a true aneurysm contains all three layers of vessel wall, namely intima. Pseudoaneurysms are scarce and can arise consequential of numerous iatrogenic influences, including but not limited to, blunt or penetrating trauma, orthopedic procedures like tibial nailing or ankle arthroscopy, and sports injury. A thorough history taking focusing on the recent history of trauma or instrumentation and clinical examination should raise the suspicion of a pseudoaneurysm. In doubtful cases, imaging modalities such as an ultrasound and doppler examination of the lower limb can be utilized to confirm the diagnosis. Our case was a 37-year-old gentleman presented with progressive swelling in the anterior aspect of his left leg for the past two weeks. The patient had a atypical presentation, with absence of classic signs of a pseudoaneurysm such as a pulsatile mass, absence distal pulses or a thrill or bruit. However, these injuries albeit rare can be sinister and prompt diagnosis is critical, so that pertinent treatment can be delivered. Our case highlights the importance of sonographic approaches for suspected vascular injuries.

Objective: No vascular implant is commercially available in the United States to treat post-angioplasty dissections in below-the-knee (BTK) arteries. The Tack Endovascular System (Intact Vascular, Wayne, Pa) is purpose-built to repair postpercutaneous transluminal angioplasty (PTA) BTK dissections. A trial was conducted to investigate the safety and efficacy of the first-of-a-kind implantable BTK device to treat post-PTA dissections in the setting of critical limb ischemia., Methods: The present prospective, single-arm, multicenter study evaluated the Tack Endovascular System for treating post-PTA dissections in the mid/distal popliteal, tibial, and peroneal arteries. The primary safety endpoint was major adverse limb events (MALE) plus perioperative death (POD), assessed at 30 days after the index procedure. The primary efficacy endpoint was a composite of MALE at 6 months and POD. The unpowered secondary endpoint was primary patency at 6 months. With no available on-label comparator, the primary endpoints of the present trial were determined using objective performance goals from a systematic literature search. The secondary endpoints included Tacked segment patency and target limb salvage at 6 months. The 6-month results are reported., Results: Of the 233 patients enrolled, 117 (50.2%) had Rutherford class 5 and 78 (33.5%) had Rutherford class 4. A total of 341 post-PTA dissections were treated. Each patient received at least one Tack implant, and 100% of the dissections resolved according to the angiographic core laboratory findings. The primary safety and efficacy endpoints were both met. The rate of MALE plus POD at 30 days was 1.3% (3 of 228) and freedom from MALE at 6 months plus POD at 30 days was 95.6% (196 of 205). The 6-month Tacked segment patency was 82.1% (247 of 301) and target limb salvage was 98.5% (202 of 205). The Kaplan-Meier freedom from clinically driven target lesion revascularization and amputation-free survival at 6 months was 92.0% and 95.7%, respectively. Rutherford improvement was reported in 79.4% (158 of 199). Most (90 of 122; 73.8%) preexisting wounds had healed or were improving., Conclusions: The Tack Endovascular System is safe and effective for treating post-PTA BTK dissections through 6 months, with favorable rates of MALE plus POD, patency, clinically driven target lesion revascularization, limb salvage, and wound healing., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of this study was to investigate the location and distribution patterns of neurovascular structures and determine the effective injection point in the tarsal tunnel for heel pain., Methods: Fifteen adult non-embalmed cadavers with a mean age of 71.5 years were studied. The most inferior point of the medial malleolus of the tibia (MM) and the tuberosity of the calcaneus (TC) were identified before dissection. A line connecting the MM and TC was used as a reference line. The reference point was expressed in absolute distance along the reference line using the MM as the starting point. For measurements using MRI, the depth from the skin was measured to inferior at an interval of 1 cm from the MM., Results: The posterior tibial artery, lateral plantar nerve, and medial plantar nerve were located from 29.0 to 37.3% of the reference line from the MM. The distribution frequencies of the medial calcaneal nerve on the reference line from the MM were 0%, 8.60%, 37.15%, 37.15%, and 17.10%, respectively. The mean depth of the neurovascular structures was 0.3 cm., Discussion: This study recommended an effective injection site from 45.0 to 80.0% of the reference line.

We report a case of an 18-year-old woman who developed a delayed pseudoaneurysm of the right anterior tibial artery (ATA), 14 days after a knife accidental trauma. The patient was admitted to our emergency department for acute onset of pain in the right limb after a domestic trauma. At a physical examination, the limb was tense and tender, with a pulsatile mass in the anterior compartment. Femoral, popliteal, and distal pulses were palpable on both limbs. Duplex ultrasound scan (DUS) and computed tomography angiography showed the presence of an ATA pseudoaneurysm. An urgent endovascular treatment was performed under local anesthesia via percutaneous access. Pseudoaneurysm was excluded implanting 2 coronary covered balloon-expandable stents (BeGraft; Bentley Innomed GmbH, Hechingen, Germany). Postoperative course was uneventful and the patient was discharged on the second postoperative day under dual antiplatelet therapy. One- and 13-month scheduled follow-up visits and DUS revealed the presence of a normal pedal pulse, complete pseudoaneurysm exclusion, and patency of the stent grafts and the entire ATA with triphasic waveforms. In conclusion, endovascular treatment of an ATA pseudoaneurysm seems to be a feasible option. Further experience with this technique is needed to validate its safety and long-term patency, especially in young and healthy subjects., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Pseudoaneurysm of the ankle involving the posterior tibial artery is a rare presentation with only four paediatric cases previously reported in English literature. We report a new case following blunt trauma with the clinical presentation and management strategy. A 6-year-old boy presented with a pulsatile swelling at the medial aspect of ankle following a history of blunt trauma 3 weeks ago. Imaging confirmed pseudoaneurysm involving the distal posterior tibial artery. Excision of the pseudoaneurysm was performed without any complication., Competing Interests: Competing interests: None declard., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background:: The extensile lateral calcaneal approach is a standard method for accessing a joint depression calcaneal fracture. However, the operative wound complication rate is high. Previous studies showed a calcaneal branch of the peroneal artery contributing to the calcaneal flap blood supply. This study focuses on the location of the vertical limb in this approach correlating to the aforementioned artery and flap perfusion., Methods:: Ten pairs of fresh-frozen cadaveric lower extremities were used. Extensile lateral calcaneal approach (ELCA) was carried out on both calcanei, where the vertical limb was placed at the line between the posterior border of lateral malleolus and lateral edge of the Achilles tendon for the right side (standard ELCA; sELCA) and at the lateral edge of the Achilles tendon for the left side (modified ELCA; mELCA). The identified vessel in the vertical limb incision was ligated and cut, and the horizontal limb of the incision was carried out as usual. After completion of flap elevation, 80°C water was injected into the popliteal vessel. In addition, thermal images were taken pre- and postinjection. Dye was injected subsequently, and perfusion was recorded in video format., Results:: Mean pre- and postinjection skin flap temperature difference was significantly higher in mELCA (5.36°C vs 0.72°C, P = .0002). Dye perfusion patterns were significantly better in mELCA ( P = .0013). The calcaneal branch of peroneal artery was found in the vertical incision in 9 of 10 sELCA, with average distance 22.04 mm anterior to the calcaneal tuberosity and 8.22 mm proximal to superior border of the calcaneus, whereas one was found in mELCA, in which perfusion tests still appeared normal., Conclusion:: The vertical limb of incision during extensile lateral calcaneal approach should be placed at the lateral edge of the Achilles tendon to avoid injuring the calcaneal branch of peroneal artery, which supplies the lateral calcaneal flap. However, further clinical research might be needed to confirm the results of this study., Clinical Relevance:: This study demonstrates a likely safest position for the proper incision for exposing the lateral calcaneus.

True infrapopliteal aneurysms occur very rarely; the majority of reported cases are secondary to trauma or infection. We report the development of a tibioperoneal trunk aneurysm 6 months after atherectomy and angioplasty and describe subsequent open surgical repair via a great saphenous vein bypass graft., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Open tibia fractures are commonly stratified by the Gustilo classification, an orthopedic grading system that does not incorporate the presence of arterial injury when limb perfusion is intact. In the authors' experience, however, the presence of arterial injury appears to negatively impact microsurgical outcomes., Methods: In a retrospective review of 806 lower extremity reconstructions between 1979 and 2016, 361 soft-tissue flaps performed for Gustilo type IIIB/C coverage met inclusion criteria. Patient demographics, flap characteristics, and outcomes were analyzed., Results: Most patients suffered type IIIB [n = 332 (91.9 percent)] injuries; 29 (8.0 percent) had type IIIC injuries. Preoperative angiography [n = 243 (67.3 percent)] demonstrated arterial injury in 126 (51.8 percent); 27 arterial injuries were identified intraoperatively; and the overall incidence was 153 of 361 (42.4 percent). Complications occurred in 143 flaps (39.6 percent) and included 37 partial losses (10.2 percent) and 31 total losses (8.6 percent). Injured recipient arteries [n = 62 (17.2 percent)] had more complications (p = 0.004); specifically, increased take-backs (p = 0.009). Decreasing vessel runoff increased the risk of complications (p = 0.025), take-backs (p = 0.007), and total flap failures (p = 0.024) accordingly. Specifically, among grade IIIB injuries, controlling for age, sex, time since injury, and vein number, single-vessel runoff was associated with higher rates of complications (relative risk, 3.07; p = 0.012), take-backs (relative risk, 3.43; p = 0.013), and total flap failures (relative risk, 4.80; p = 0.010) compared with three-vessel runoff., Conclusions: Arterial injury was common among Gustilo type IIIB patients and correlated with increased reconstructive complications. Nonischemic arterial injury appears to negatively impact reconstructive outcomes and should be accounted for when considering free tissue transfer for lower extremity salvage. The authors propose a 3-2-1 modification of the Gustilo type IIIB classification to incorporate degree of arterial injury, as it appears to add prognostic value and certainly influences the reconstructive plan., Clinical Question/level of Evidence: Risk, IV.

Background: The purpose of this study was to assess the risk of iatrogenic injury to plantar neurovascular structures of the foot during insertion of a curved retrograde tibiotalocalcaneal (TTC) fusion nail., Material and Methods: Ten below-knee thawed fresh-frozen cadaveric specimens underwent curved retrograde nailing of the ankle. The shortest distance between the nail and the main plantar neurovascular branches and injured structures were recorded during dissection. We also evaluated the relative position of these structures along 2 lines (AB, connecting the calcaneus to the first metatarsal, and BC, connecting the first and fifth metatarsal)., Results: The lateral plantar artery was found to be in direct contact with the nail 70% of the time, with a macroscopic laceration 30% of the time. The Baxter nerve was injured 20% of the time, as was the lateral plantar nerve. The medial plantar artery and nerve were never injured. The most proximal structure to cross line AB was the Baxter nerve followed by the lateral plantar artery, the nail, the lateral plantar nerve, and the medial plantar nerve., Conclusion: Our cadaveric anatomic study found that the most common structures at risk for iatrogenic injury by lateral curved retrograde TTC fusion nails were the lateral plantar artery and nerve, and the Baxter nerve., Clinical Relevance: Determination of a true neurovascular safe zone is challenging and therefore warrants careful operative dissection to minimize neurovascular injuries.

Objective: The aim of this report was to present the use of flow-through free fibula osteocutaneous flap for the repair of complex tibial bone, soft tissue, and main artery segmental defects., Patients and Methods: Five patients with bone, soft tissue, and segmental anterior tibial artery defects were included. The lengths of injured tibial bones ranged from 4 to 7 cm. The sizes of impaired soft tissues were between 9 × 4 and 15 × 6 cm. The lengths of defect of anterior tibial artery segments ranged from 6 to 10 cm. Two patients had distal limb perfusion problems. Flow-through free fibula osteocutaneous flap was performed for all 5 patients., Results: Patients were followed for 12 to 18 months. All wounds healed after 1-stage operation, and all flow-through flaps survived. The distal perfusion after vascular repair was normal in all patients. Superficial necrosis of flap edge was noted in 1 case. After the local debridement and partial thickness skin graft, the flap healed uneventfully, and the surgical operation did not increase injury to the donor site. Satisfactory bone union was achieved in all patients in 2 to 4 months postoperation. Enlargement of fibula graft was observed during follow-up from 12 to 18 months. The functions of adjacent joints were recovered, and all patients were able to walk normally., Conclusions: Flow-through free fibula osteocutaneous flap was shown to be an effective and efficient technique for repairing composite tibial bone, soft tissue, and main artery segmental defects. This 1-stage operation should be useful in clinical practice for the treatment of complex bone, soft tissue, and vessel defects.

Pure ankle dislocation is a rare event that primarily results from high-energy trauma. Predisposing anatomical factors such as talar hypoplasia, ligament laxity, and previous sprains may play a key role. This report presents the case of a 55-year-old man with fatal anterior and posterior tibial artery tears following a pure anterolateral dislocation of the right ankle. To the best of our knowledge, no such cases have previously been reported in the English-language literature.

Introduction: Tibial intramedullary nailing remains a common tibial fracture fixation method. Tibial nailing indications continue to expand. Neurovascular complications from tibial nailing have been described; however, the proximity of distal tibial locking bolts to the anterior tibial artery (ATA) variants has not., Materials and Methods: 52 cadaveric legs were dissected identifying three common ATA variants. Each ATA variant received an intraluminal wire to facilitate fluoroscopic identification. Three different intramedullary tibial nails were inserted in each of the three ATA variant specimens. With fluoroscopy, the proximity of the distal locking holes of each tibial nail to the intraluminal wire representing the ATA variant course was measured., Results: Of the 40 measurements, the intraluminal wire was directly in the bolt insertional path in 8 of 40 (20%) and within 5 mm in 16 of 40 (40%). All specimens had the wire cross the locking bolt insertional path at least once in each of the nails. The ATA variant taking a more lateral course deep to the extensor digitorum longus and peroneus tertius to overlay the lateral malleolus had the highest occurrence of measurements less than 5 mm., Conclusions: The close proximity of tibial nail distal locking bolt holes to ATA variants presents a risk for iatrogenic vascular injury during insertion. The coronal locking bolts pose the greatest iatrogenic risk to the most laterally positioned ATA variant.

Arthroscopy of the foot and ankle is a common orthopedic procedure with low complication rates. Arterial injuries from these procedures are an even more rare subset of the complications. Hemophilia A is a genetic disorder of aberrant coagulation, which leads to increased risk of bleeding even after minor trauma. We present the second case of anterior tibial artery pseudoaneurysm formation secondary to ankle arthroscopy in a hemophiliac patient and suggest that these individuals are at higher risk for developing complications associated with arterial injury. Furthermore, potential risk factors include port placement, anatomic variation of the vessels, and nature of the arthroscopic procedure. We recommend steps to prevent complications in hemophiliac patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We report a case of entrapment of the deep peroneal nerve as well as the anterior tibial artery and vein by a spiral distal tibial shaft fracture, causing partial non-union. The authors describe the utility of MRI in making the diagnosis of this post-traumatic complication, which may potentially result in a permanent neurovascular deficit and adverse functional outcome if left undetected. The importance of recognizing the distinct possibility of entrapment and injury to the deep peroneal nerve as well as the anterior tibial vessels, when managing a fracture involving the distal third of the tibial shaft is emphasized. Absence of clinical symptoms or signs of neurovascular entrapment should not deter one from performing the relevant investigations to exclude this complication, in particular when surgical fixation is being contemplated, or in the presence of a non-healing fracture.

Many complications have been reported during or after anterior cruciate ligament (ACL) reconstruction, including infection, bleeding, tibial tunnel widening, arthrofibrosis, and graft failure. However, arterial injury has been rarely reported. This paper reports a case of an anterior tibial arterial injury during bicortical tibial drilling in arthroscopic ACL reconstruction, associated with an asymptomatic occlusion of the popliteal artery. The patient had a vague pain which led to delayed diagnosis of compartment syndrome and delayed treatment with fasciotomy. All surgeons should be aware of these rare but critical complications because the results may be disastrous like muscle necrosis as in this case.

Pseudoaneurysms remain a rare complication of knee and leg trauma. They may go unnoticed and manifest late after the initial trauma; they are often associated with arteriovenous fistula. No standard treatment is recognized. We report a case of post-traumatic pseudoaneurysm of the inferior articular artery of the knee, treated by coil embolization and a case of post-traumatic pseudoaneurysm of the anterior tibial artery associated with an arteriovenous fistula, treated with coil embolization and decompression surgery. Follow-up in both patients was satisfactory., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: Pediatric post-traumatic pseudoaneurysms are a rare complication of arterial limb injuries. Management modalities in children are poorly defined. We report on a case of post-traumatic pseudoaneurysm of the right anterior tibial artery after minimal penetrating trauma, treated with surgery., Case Report: A 14-year-old boy presented in consultation with a limp and right calf pain 3 months after a penetrating trauma. On physical examination, a painful mass in the middle third of the right leg was found, without inflammatory signs, but with a pulsatile character and a palpable thrill. Ultrasonography revealed a hypoechoic cystic structure, adjacent to the anterior tibial artery with a characteristic ying-yang flow on color Doppler, suggesting a post-traumatic pseudoaneurysm. The diagnosis was confirmed by CT angiography. The treatment was surgical, including flattening of the pseudoaneurysm and interposition of an autologous graft., Conclusion: Management of pediatric post-traumatic pseudoaneurysm of the limbs is surgical. Currently however, new alternatives exist: endovascular techniques, ultrasound-guided compression, and embolization by thrombin injection., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Purpose of the Study: Purpose of this anatomic study was to develop a new and safe technique of minimal invasive dorsal plate osteosynthesis for tibia shaft fractures., Material and Methods: Sixteen paired adult lower limbs of eight different cadaveric specimens were examined. Anatomical prebending for each plate was done. Plates were inserted percutaneously, following plate fixation the neurovascular bundle was dissected out. The distance between the neurovascular bundle (posterior tibial nerve, posterior tibial artery) and the plate was measured at two different positions. The distance to the origin of the flexor digitorum longus muscle and the arch of the soleus muscle was measured., Results: The mean distance between the neurovascular bundle and the plate amounted 1.4 cm (±0,2 cm; 1.0-1.7 cm) at hole number six and 1.1 cm (±0.4 cm; 0.6-2.0 cm) at hole number ten. The nerve was never directly in contact with the plate. The flexor digitorum longus muscle had its origin along the plate and was between the plate and the neurovascular bundle in all cases., Conclusions: Dorsal percutaneous plate insertion is a safe and easy method for osteosyntesis of tiba shaft fractures. Especially in case of poor skin and soft tissue conditions this technique offers a good alternative.

Endovascular treatment of posttraumatic pseudoaneurysms has become a viable less-invasive option when compared with open repair. In this study, we present a case of a posttraumatic pseudoaneurysm of the posterior tibial artery in a 34-year-old man treated with endovascular stent grafting. An extensive review of the literature has been performed., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: The posterolateral approach to the distal tibia allows excellent visualization, direct reduction, and stabilization of posterior malleolar fractures. Concomitant fractures of the lateral malleolus may be internally fixed through the same approach. The approach may also be used for pilon fractures and for bone grafting in nonunions. This study aims to establish the safe zone of proximal dissection to avoid injury to the peroneal vessels when performing the posterolateral approach to the distal tibia., Methods: Twenty-six unpaired adult lower limbs were dissected using the posterolateral approach to the distal tibia. The peroneal artery was identified, as it coursed through the interosseous membrane on deep dissection and the level of its bifurcation was noted over the tibia. Perpendicular measurements were made from these points to the tibial plafond and distal fibula., Results: The peroneal artery bifurcated at 83 ± 21 mm (range, 41-115 mm) proximal to the tibial plafond and 103 ± 21 mm (range, 61-136 mm) from the distal fibula. The peroneal artery perforated through the interosseous membrane 64 ± 18 mm (range, 41-96 mm) proximal to the tibial plafond and 81 ± 20 mm (range, 42-113 mm) from the distal fibula., Conclusions: The posterolateral approach to the distal tibia allows direct reduction of posterior malleolus fractures. The peroneal artery may bifurcate and perforate through the interosseous membrane as little as 41 mm from the tibial plafond. Dissection around this region should be performed with care due to the wide variation in vasculature, however, once the peroneal artery is mobilized, a buttress plate can easily be placed beneath it.

Objective: To evaluate possibility of screw-related vascular injury at proximal tibia while using medial narrow tibial locking plate., Material and Method: Cross-sectional images of CTangiographs (33 samples) at levels corresponding with the screw holes of a narrow locking plate were used to evaluate the risk of vascular injury relating to screw insertion. This was performed by measuring the distance and angle between the screw trajectory in each hole and the columns of arteries at the proximal tibia., Results: There is a higher risk of injury to the anterior tibial artery than to the posterior tibial artery in cases of perfect placement of a medial locking plate for osteosynthesis of the tibial shaft fracture. In instance of plate tilting, thus causing a deviation ofscrew trajectory of up to 20 degrees from the perpendicular axis of the middle 1/3 of medial tibial surface, the posterior tibial artery is also at risk of being injured., Conclusion: Vascular injury relating to locking screw insertion from the medial aspect of the tibia is still a risk. To prevent vascular injury, the plate should be positioned in the middle 1/3 and parallel to the medial tibial surface. Attachment of the instrument beyond the far cortex of the tibia stillpresents a risk of injuring the tibial artery.

Trans-syndesmotic screws are commonly used to repair syndesmosis ruptures and stabilize the ankle joint. Just as with any surgery, the neurovascular structures can be compromised, causing complications. We evaluated the position of the perforating branch of the peroneal artery to define the risk of arterial compromise during placement of 2 trans-syndesmotic screws. In 37 cadaveric specimens, 2 trans-syndesmotic screws were inserted 2 and 4 cm proximal to the ankle joint. The distances between the perforating branch of the peroneal artery and the screws and the other anatomic landmarks were measured. Significant differences were calculated between the male and female limbs, and regression analysis was used to determine the significant associations between the tibial length and screw location. The perforating branch of the peroneal artery passed through the interosseous membrane 3.42 ± 0.6 cm proximal to the tibial plafond. The artery was located up to 4 mm from the superior and inferior screws 51.4% and 10.8% of the time, respectively. A greater percentage of male specimens displayed close proximity between the artery and the superior screw, and the distance of the artery from the distal fibula was statistically significant compared with the distance in the female specimens. Regression analysis revealed that the greater the tibial length, the closer the superior screw was to the artery, with a negative correlation discovered for the inferior screw. We concluded that superior screw placement increased the risk of injuring the perforating branch of the peroneal artery injury, and the likelihood of injuring the artery with the inferior screw increased as the length of the tibia decreased., (Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the role of CT angiography in the evaluation of patients with lower extremity gunshot wounds in the emergency room., Materials and Methods: Eighty patients (73 male, 7 female, mean age 26 years) underwent CT angiography for the evaluation of lower extremity gunshot injuries. Imaging was conducted on the basis of standardized protocols utilizing 16-slice and 64-slice multidetector systems and images were qualitatively graded and assessed for various forms of arterial injury., Results: CT angiography findings indicative of arterial injury were observed in 24 patients (30%) and a total of 43 arterial injuries were noted; the most common form was focal narrowing/spasm (n = 16, 37.2%); the most common artery involved was the superficial femoral artery (n = 12, 50%). In qualitative assessment of images based on a 4-point grading system, both readers considered CT angiography diagnostically excellent (grade 4) in most cases. Surgical findings were consistent with CT angiography and follow-up of patients' medical records showed no arterial injuries in patients with normal findings on initial imaging., Conclusion: Our findings demonstrate that CT angiography is an effective imaging modality for evaluation of lower extremity gunshot wounds and could help limit more invasive procedures such as catheter angiography to a select group of patients., Key Points: • CT angiography efficiently evaluates lower extremity gunshot wounds. • CT angiography provides image quality sufficiently reliable for assessment of gunshot injuries. • CT angiography could help limit invasive procedures to select patients.

Purpose of the Study: Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. The aim of this study was to analyze structures that are at risk during this approach., Material and Methods: Thirteen unpaired adult lower limbs were used for this study. Thirteen, 15-hole LCP anterolateral distal tibial plates were percutaneously inserted according to the recommended technique. Dissection was performed to examine the relation of the superficial and deep peroneal nerves and anterior tibial artery relative to the plate., Results: The superficial peroneal nerve was found to cross the vertical limb of the LCP plate at a mean distance of 63 mm (screw hole five) but with a wide range of 21 to 105 mm. The neurovascular bundle (deep peroneal nerve and anterior tibial artery) crossed the plate at a mean of 76 mm (screw hole six) but also with a wide range of 38 to 138 mm. The zone of danger of the neurovascular structures ranges from 21 to 138 mm from the tibial plafond. In one specimen, a significant branch of the deep peroneal nerve was found to be entrapped under the plate., Conclusion: Caution is advised when using anterolateral minimally invasive technique for plate insertion and screw placement in the distal tibia due to great variability in the neurovascular structures that course distally in the lower leg and cross the ankle.

Pseudoaneurysms developing around the foot and ankle are known to be an uncommon complication following surgery. We present a case of a pseudoaneurysm following ankle surgery for a tibial plafond fracture and comprehensively review the literature with emphasis on their anatomic location, aetiology and treatment options., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

Background: Posterolateral tibial plateau shear fractures often require buttress plating, which can be performed through a posterolateral approach. The purpose of this study was to provide accurate data about the inferior limit of dissection., Methods: Forty unpaired cadaver adult lower limbs were used. The anterior tibial artery was identified because it coursed through the interosseous membrane. The perpendicular distance from the lateral joint line and fibula head to this landmark was measured., Results: The anterior tibial artery coursed through the interosseous membrane at 46.3 ± 9.0 mm (range 27-62 mm) distal to the lateral tibial plateau and 35.7 ± 9.0 mm (range 17-50 mm) distal to the fibula head., Conclusions: Displaced posterolateral tibial plateau fractures require anatomic reduction and stabilization with a buttress plate. This can be achieved by gaining access to the posterolateral tibial cortex. The distal limit of this dissection can be as little as 27 mm distal to the lateral tibial plateau. Dissection in this region should be carried out with caution.

Pseudoaneurysms of the posterior tibial artery are rare, but a high index of suspicion should be maintained in evaluating patients who present with a painful swelling after arterial trauma. We report a case of a posterior tibial artery pseudoaneurysm in a young patient sustained from a laceration and associated profuse arterial bleeding. Because of the risk of rupture and the presence of an infection and high venous flow, an embolization of the aneurysm proximally and distally was carried out after verifying that distal collateral circulation ensured foot vascularization. Endovascular treatment of a pseudoaneurysm seems to be a safe therapeutic and noninvasive choice, particularly in young patients in whom the presence of collaterals guarantees distal vascularization and in whom the procedure can be safely performed in the presence of a superficial wound infection.

Blunt traumatic arteriovenous fistulae of the extremities are rare in children. We report the case of a 10-year-old boy with a traumatic infrapopliteal arteriovenous fistula and concomitant pseudoaneurysm diagnosed 2 months after he was struck by a car. It was definitively managed with coil embolization. Postprocedure, the vascular anatomy of the patient's right calf was well preserved. He had complete resolution of his symptoms immediately after the intervention and continues to do well 6 months later., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Pseudoaneurysm of the anterior tibial artery (ATA) after ankle arthroscopy is an uncommon complication but can cause unexpected consequences. However, its contributing factor is not fully understood., Hypothesis: Anatomic factors, such as ATA variations and the distance between the ATA and joint capsule, may contribute to the occurrence of pseudoaneurysm., Study Design: Case series; Level of evidence, 4., Methods: The magnetic resonance images and medical records of 358 ankle cases were analyzed. According to locations of the ATA in relation to the peroneus tertius (PT) and the extensor digitorum longus (EDL) tendon on axial magnetic resonance imaging, patients were classified as type 1 (safe type), type 2 (increased risk type), or type 3 (high-risk type). In addition, distances between the anterior joint capsule and the ATA were measured to evaluate the thickness of the anterior fat pad, which contains the ATA and anterior compartment tendons., Results: In 336 cases (93.8%), the ATA was located medial to the EDL (type 1, safe). In 7 cases (2.0%), the ATA was located lateral to the EDL and PT tendon (type 2, increased risk); and in 15 cases (4.2%), the branching artery was observed lateral to the EDL and PT tendon and the ATA was in the normal position (type 3, high risk). The mean distance between the anterior joint capsule and the ATA was 2.3 ± 1.1 mm., Conclusion: In 22 (6.2%) of the 358 cases, the ATA and its branches were located near the anterolateral ankle portal, which introduces the risk of vascular damage during arthroscopic surgery. Furthermore, the mean distance between the ATA and the joint capsule was only 2.3 ± 1.1 mm, and thus the ATA is very close to the anterior working space of the ankle joint. Careful preoperative evaluation and an intra-articular procedure may reduce the risk of vascular complications attributable to ankle arthroscopy.

Arteriovenous fistula formation after a closed extremity fracture is rare. We present the case of an 11-year-old boy who developed an arteriovenous fistula between the anterior tibial artery and popliteal vein after closed fractures of the proximal tibia and fibula. The fractures were treated by closed reduction and casting. A fistula was diagnosed 12 weeks after the injury. It was treated by embolisation with coils. Subsequent angiography and ultrasonography confirmed patency of the popliteal vein and anterior and posterior tibial and peroneal arteries, with no residual shunting through the fistula. The fractures healed uneventfully and he returned to full unrestricted activities 21 weeks after his injury.

The formation of an arterial pseudoaneurysm as a complication of ankle arthroscopy is extremely rare, with a reported incidence of 0.008%. Pseudoaneurysm is especially unlikely after ankle arthroscopy by means of standard anteromedial and anterolateral portals. In this report, we describe a case of a pseudoaneurysm of the anterior tibial artery detected 2 weeks after ankle arthroscopy in a 63-year-old woman. The diagnosis was confirmed with a Doppler ultrasonography scan of the right ankle, after which the patient was referred to an interventional radiologist, who performed an angiogram. Endovascular embolization of the pseudoaneurysm was performed thereafter, and the patient experienced an uneventful recovery after the intervention. The potentially catastrophic sequelae of delayed diagnosis or misdiagnosis of the complication, like hemarthrosis of the ankle and compartment syndrome, are dangerous and must not be underestimated. Therefore, a high degree of suspicion for a pseudoaneurysm should be maintained in the postarthroscopy period when a patient presents with abnormal swelling and pain. Potentially preventative measures include careful dissection while making the portals and preoperative mapping of the vascular structures with a duplex or handheld Doppler., (Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

We report the case of a 38-year-old man who developed a false aneurysm of the anterior tibial artery after a true-cut needle biopsy of the shinbone. Although arterial damages are a known theoretical risk of such a procedure, to our knowledge, this is the first case to be reported. Repair was achieved by means of an arterial resection and anastomosis., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Three cases of blunt trauma to the anterior tibial artery in professional footballers are described. Each case was managed conservatively, allowing the players to promptly return to competitive fixtures. We hope the outcomes of the cases described might be helpful for teams facing the challenge of managing similar injuries.

Arterial perforation is a well-recognized complication of attempted percutaneous revascularization of a chronic totally occluded tibial artery and typically necessitates termination of the procedure. This report describes a step-by-step approach on how to perform a direct posterior tibial artery puncture and a sheathless wire introduction, to salvage a case of tibial artery perforation induced during attempted anterograde recanalization of an occluded tibial artery. After control of blood loss, retrograde wire passage and balloon inflation can facilitate relocation of the anterograde wire in the true lumen allowing uneventful completion of the procedure. © 2010 Wiley-Liss, Inc.

Traumatic arterial spasm is a phenomenon that has long been questioned by clinicians. Indeed, some would argue that surgical exploration is mandatory whenever there are signs of distal ischaemia following limb trauma. We present a case of angiographically demonstrated tibial artery spasm following gunshot injury. Exploration was unnecessary and distal perfusion was reestablished spontaneously. This case demonstrates the existence of traumatic arterial spasm as a genuine clinical entity and suggests that immediate surgical exploration may not be necessary in all cases.

Objective: Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury., Methods: The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation., Results: Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P < .01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score >5 (hazard ratio [HR], 2.7; P = .01) and amputation., Conclusions: This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status., (Published by Mosby, Inc.)

Tibial artery pseudoaneurysms can occur in the setting of trauma. Operative exposure and repair of these injuries can be challenging, and surgical management options include direct arterial repair, interposition grafting, or arterial ligation. Other techniques including duplex-guided compression, thrombin injection, and endovascular intervention have been described. We present the case of a 39-year-old man who sustained blunt trauma to his right lower extremity and developed a delayed symptomatic pseudoaneurysm of the posterior tibial artery. He was successfully managed with endovascular stent graft exclusion of the pseudoaneurysm. Endovascular stent-grafting techniques can be successfully applied to the management of traumatic tibial pseudoaneurysms.