Pseudoaneurysm of the Anterior Tibial Artery following Ankle Arthroscopy in a Soccer Player

Background: The anterocentral portal is not a standard portal in anterior ankle arthroscopy due to its proximity to the anterior neurovascular bundle. However, it provides certain advantages, including a wide field of vision, and portal changes become redundant. The purpose of this study was to evaluate the neurovascular complications after anterior ankle arthroscopy using the anterocentral portal. Methods: We retrospectively identified patients who had undergone anterior ankle arthroscopy with an anterocentral portal at our institution from 2013 to 2018. Medical record data were reviewed and patients were invited for clinical follow-up, where a clinical examination, quantitative sensory testing for the deep peroneal nerve, and ultrasonography of the structures at risk were performed. A total of 101 patients (105 arthroscopies) were identified and evaluated at a mean follow-up of 31.5 ± 17.7 months. Results: Leading indications to surgery were heterogeneous and included anterior impingement (48.6%), osteochondral lesions of the talus (24.8%), chronic ankle instability (14.3%), and fractures (8.6%). The overall complication rate was 7.6%, and no major complications were observed. In 1.9% (2/105) of the cases, the complications were associated with the anterocentral portal and included injury to the medial branch of the superficial nerve (1/105) and to the deep peroneal nerve (1/105). Injury to the deep peroneal nerve was associated with a loss of detection and nociception. There were no injuries to the anterior tibial artery. In 41.9% (44/105) of the cases, only 1 working portal was used in addition to the anterocentral portal, and in 19% (20/105) the anterolateral portal could be avoided. Ultrasonography confirmed the integrity of the deep peroneal nerve, the medial branch of the superficial peroneal nerve, and the anterior tibial artery in all patients. Patients with nerve injuries associated with the anterocentral portal showed no signs of neuroma or pseudoaneurysm. Conclusion: Using a standardized technique, the anterocentral portal in ankle arthroscopy is safe with a low number of neurovascular injuries and can be recommended as a standard portal. The anterolateral portal remains associated with a high number of injuries to the superficial peroneal nerve. Level of Evidence: Level III, retrospective cohort study.

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“… 3 Furthermore, case reports of pseudoaneurysms of the ATA following ankle arthroscopy have been reported. 5 , 15 , 16 , 18 , 25 …”

Section: Discussionmentioning

confidence: 99%

Anterocentral Portal in Ankle Arthroscopy

Stotter

Klestil

Chemelli³

et al. 2020

Foot Ankle Int.

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“…The most fatal complication of an untreated pseudoaneurysm of the peroneal artery is the rupture of this vital vessel. This is because the fibrous capsule of a pseudoaneurysm does not have the characteristic three-layered structure of a true aneurysm, and thus it continues to expand until restricted by neighboring structures [3]. This can result in further complications such as hemorrhage into the soft tissue and hemodynamic instability, ankle hemarthrosis, and compartment syndrome in severe cases [15].…”

Section: Discussionmentioning

confidence: 99%

“…Traction of the ankle during osteophyte debridement and synovectomy might be also involved, because structures like vessels can be easily injured due tightness or tautness from traction. In addition, strap placement during joint distraction also might be a factor, because this could compress the artery in the region of the anterior ankle joint capsule [3]. Furthermore, the pseudoaneurysm might have developed and increased in size due to weight bearing after the patient had the right foot in a cast 3 weeks after the arthroscopy.…”

Section: Discussionmentioning

confidence: 99%

“…In a pseudoaneurysm of the foot and ankle, the most frequently involved vessel is the ATA [2]. We have previously reported a case of aneurysm of the ATA [3], but a pseudoaneurysm of the peroneal artery, particularly around the ankle joint, is uncommon [4]. Peroneal artery aneurysm around the ankle joint has been reported following ankle sprain [5–10], fracture [11, 12], and ankle arthroscopy [13] and in hemophiliacs [14].…”

Section: Introductionmentioning

confidence: 99%

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Pseudoaneurysm of the Perforating Peroneal Artery following Ankle Arthroscopy

Tonogai

Fujimoto

Sairyo

2018

Case Reports in Orthopedics

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The use of standard anterolateral and anteromedial portals in ankle arthroscopy results in reduced risk of vascular complications. Anatomical variations of the arterial network of the foot and ankle might render the vessels more susceptible to injury during procedures involving the anterior ankle joint. The literature, to our knowledge, reports only one case of a pseudoaneurysm involving the peroneal artery after ankle arthroscopy. Here, we report the unusual case of a 48-year-old man in general good health with the absence of the anterior tibial artery and posterior tibial artery. The patient presented with a pseudoaneurysm of the perforating peroneal artery following ankle arthroscopy for traumatic osteoarthritis associated with nonunion of the medial malleolus. The perforating peroneal artery injury was repaired by performing end-to-end anastomosis. The perforating peroneal artery is at higher risk for iatrogenic injury during ankle arthroscopy in the presence of abnormal arterial variations of the foot and ankle, particularly the absence of the anterior tibial artery and posterior tibial artery. Before ankle arthroscopy, surgeons should therefore carefully observe the course of the perforating peroneal artery on enhanced 3-dimensional computed tomography, especially in patients with a history of trauma to the ankle joint.

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“…* However, excessive distraction of the ankle might put the ATA at greater risk of injury during removal of inflamed synovium using a shaver or during resection of osteophytes because, as this study shows, the distance between the anterior distal tibial edge and the ATA is decreased by distraction while injection of saline expands the joint space. Although distraction might be advantageous in terms of allowing direct access to the cartilage and the talar dome, releasing the distraction force on the ankle in dorsiflexion may help to increase the distance between the ATA and the anterior distal tibial edge, as well as decrease the risk of injury to the ATA during debridement of an anterior tibiotalar osteophyte, as Tonogai et al 28 and De Leeuw et al 9 have reported. Moreover, dorsiflexing the ankle may make the gutters and anterior joint line more safely accessible in the ankle, although this is likely to close the ankle joint space.…”

Section: Discussionmentioning

confidence: 99%