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Concept: Anterior tibial artery

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Bone nonunion in the pediatric population usually occurs in the context of highly unfavorable biological conditions. Recently, the vascularized fibular periosteal flap has been reported as a very effective procedure for treating this condition. Even though a vascularized tibial periosteal graft (VTPG) was described long ago and has been successfully employed in one adult case, there has been no other report published on the use of this technique. We report on the use of VTPG, pedicled in the anterior tibial vessels, for the treatment of two complex pediatric bone nonunion case: a recalcitrant supracondylar femoral pseudarthrosis secondary to an infection in an 11-year-old girl, and a tibial nonunion secondary to a failed bone defect reconstruction in a 12-year-old girl. Rapid healing was obtained in both cases. In the light of the data presented, we consider VTPG as a valuable surgical option for the treatment of complex bone nonunions in children. © 2014 Wiley Periodicals, Inc. Microsurgery, 2014.

Concepts: Surgery, Report, Case, Complex analysis, Popliteal artery, Nonunion, Fibular artery, Anterior tibial artery

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This study characterized the anterior medial malleolar artery (AMMA) branching from the anterior tibial artery (ATA) to identify problems in anterior ankle arthroscopy possibly contributing to injury to the AMMA.

Concepts: Arteries of the lower limb, Anterior tibial artery, Anterior medial malleolar artery, Anterior lateral malleolar artery

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The majority of anterior tibial aneurysm cases described in the literature are pseudoaneurysms resulting from trauma1-6. Since 1967, only eight cases published on true anterior tibial artery aneurysms were atraumatic7-9,16,17. Recent experience with an atraumatic aneurysm of the anterior tibial artery prompted a literature review regarding their incidence, and accordingly, we feel the need exists for greater recognition and understanding of this entity.

Concepts: Atherosclerosis, Aneurysm, Cerebral aneurysm, Anterior tibial artery

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Posttumor excision defects can be very large, and many do require postoperative radiotherapy. It is therefore important to provide stable and durable wound coverage to provide ability to withstand radiotherapy as well as providing cover to vital structures.

Concepts: Osteoarthritis, Knee, Joint, Synovial joint, Joints, Popliteal artery, Code coverage, Anterior tibial artery

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Vascular deficiencies and reduced perfusion of the anterior tibial artery and the dorsalis pedis artery were suggested as causes of congenital talipes equino varus (CTEV). In this study, we assessed the prevalence of arterial abnormalities in patients with CTEV (50 patients; 74 feet) compared with a normal control group (16 patients; 32 feet) by Doppler ultrasound and Ankle Brachial Index. The flow was normal in the control group and was deficient in 39.19% of clubfoot patients. In severe clubfoot cases, the deficiency was found to an extent of 76.67%. In conclusion, the anterior tibial artery and dorsalis pedis artery are deficient in CTEV patients; to avoid postoperative skin sloughing, arterial supply must be protected using a judicious incision.

Concepts: Blood, Hospital, Blood pressure, Foot, Artery, Club foot, Dorsalis pedis artery, Anterior tibial artery

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A pediatric patient with critical limb ischemia secondary to antiphospholipid syndrome (APS) is reported. A 14-year-old male underwent extensive evaluation for worsening right lower extremity pain and ulcerative lesions of his right foot. He was discovered to have proximal occlusion of the superficial femoral artery (SFA), the distal popliteal artery, the anterior tibial artery at the mid-calf, and the posterior tibial artery at the ankle. Laboratory analysis revealed a diagnosis of APS, and he underwent a common femoral artery to above-knee-popliteal artery bypass with reversed greater saphenous graft. APS is a complex syndrome with a variety of clinical presentations. This case highlights arterial manifestations of APS and reviews the expanding literature to guide improved patient outcomes.

Concepts: Pulse, Femoral artery, Arteries of the lower limb, Popliteal artery, Posterior tibial artery, Fibular artery, Anterior tibial artery

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Although the foot and ankle derives its arterial supply from a combination of the anterior tibial artery (ATA), posterior tibial artery (PTA), and peroneal artery (PA), the focus of clinical examination techniques and noninvasive vascular testing is primarily on the ATA and PTA and not on the PA. The objectives of the present investigation were to evaluate the feasibility of incorporating an assessment of the PA into a noninvasive vascular testing protocol and to collect normative data of pressure measurements of the PA at the ankle. We attempted to locate a Doppler signal of the PA posterior to the lateral malleolus in consecutive patients undergoing our institution’s standard protocol for lower extremity noninvasive vascular testing using the ankle-brachial index and photoplethysmography. An audible signal of the PA with an available pressure measurement recording posterior to the lateral malleolus was found in a large majority (92.0%) of the studied legs with peripheral arterial disease. We also found pressure measurements in the PA generally equivalent to that of the ATA and PTA. The mean ± standard deviation systolic pressure of the PA was 130.33 ± 44.74 (range 54 to 255) mm Hg, with a corresponding ankle-brachial index of 0.92. The results of the present investigation provide unique information on a potentially underappreciated aspect of lower extremity vascular anatomy with the potential to affect rearfoot surgical decision making and planning.

Concepts: Blood pressure, Artery, Arteries of the lower limb, Pressure measurement, Popliteal artery, Posterior tibial artery, Fibular artery, Anterior tibial artery

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BACKGROUND Popliteal fossa pseudoaneurysms as a result of trauma are not uncommon. However, spontaneous pseudoaneurysms as a result of non-traumatic rupture of posterior tibial artery (PTA), anterior tibial artery (ATA), or tibioperoneal trunk (TPT) artery segment are extremely rare. We report a case of spontaneous popliteal fossa pseudoaneurysm resulting from spontaneous avulsion of the ATA and transection of the TPT. Despite a thorough workup, no underlying associated disease was found. The extreme rarity of this disease presentation prompted us to report this case. CASE REPORT A 53-year-old female patient presented with a 10-day history of sudden onset of non-traumatic left popliteal fossa pain and swelling. A popliteal fossa pseudoaneurysm was diagnosed by duplex ultrasound examination. Computed tomography angiography (CTA) was performed to confirm the diagnosis and to plan treatment. Surgical exploration revealed avulsion of the ATA and transection of the TPT leading to a pseudoaneurysm. Autogenous popliteal-tibioperoneal trunk bypass was performed with uneventful recovery. CONCLUSIONS A spontaneous popliteal fossa pseudoaneurysm caused by non-traumatic ATA avulsion and complete transection of TPT is extremely rare. Yet, it can be the cause of limb loss if not recognized early and treated promptly. Awareness by the medical community will help reduce the potential morbidity associated with this condition.

Concepts: Medical imaging, Arteries of the lower limb, Popliteal artery, Popliteal fossa, Posterior tibial artery, Fibular artery, Anterior tibial artery, Anterior tibial vein

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True aneurysms of the tibioperoneal trunk are rare. Given the scarcity of reports, the clinical presentation and treatment is not well defined. This is a case report of a 50-year-old male patient presenting with severe lower extremity swelling and compartment syndrome with neurological compromise secondary a tibioperoneal trunk aneurysm. He was also noted to have discrete ipsilateral popliteal and dorsalis pedis artery aneurysms. Given the location and size of the aneurysm, the severe leg swelling, and venous hypertension, aneurysmorrhaphy or aneurysm sac excision with arterial reconstruction was prohibitively dangerous. Thus, following fasciotomies, a hybrid repair utilizing a saphenous vein superficial femoral to anterior tibial artery bypass along with coil embolization of the aneurysm sac was performed. The patient recovered full function of his leg and follow-up CT angiogram demonstrated thrombosis and regression of the aneurysm sac with a patent bypass.

Concepts: Blood, Atherosclerosis, Heart, Blood pressure, Artery, Vein, Arteries of the lower limb, Anterior tibial artery

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Anterior tibial plateau fracture is fairly common. This study was aimed at introducing a type of severe anterior tibial plateau fracture (anterior tibial plateau fracture-dislocation) and evaluating its clinical characteristics and treatment strategies. In this study, 18 patients with severe anterior tibial plateau fracture (study group) were enrolled between November 2006 and August 2014, and their data were compared with those of 21 patients treated for normal Schatzker type VI tibial plateau fracture (control group) between January 2010 and August 2014. At the last follow-up, bony union had been achieved in both groups. The incidence of ligament injury was higher in the case of anterior tibial plateau fracture than control group. The average range of motion in the study group was 0.56 to 109 degrees, while that in the control group was 1.81 to 117 degrees. The average Hospital for Special Surgery scores and Lysholm scores in the study group were significantly lower than those in the control group. Further, the incidence of postoperative complications and reduction loss were higher for anterior tibial plateau fracture cases than for normal Schatzker type VI fracture. Our findings also showed a significantly higher rate (22.2%) of popliteal artery injury in the study group than in the control group. Anterior tibial plateau fracture-dislocation is a special type of Schatzker type VI fracture with very low incidence and most commonly characterized by the anterior subsidence of the tibial component, irreducible dislocation of the knee joint, and varying degrees of neurovascular and knee-joint peripheral ligaments injuries, as well as high incidence of complications during fixation surgery. The treatment of anterior tibial plateau fracture-dislocation is challenging even for experienced surgeons.

Concepts: Osteoarthritis, Knee, Anterior cruciate ligament, Joint, Popliteal artery, Meniscus, Popliteal fossa, Anterior tibial artery