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Concept: Fibular artery


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


We report a rare presentation of a ruptured pseudoaneurysm of the lateral plantar artery following tibiotalocalcaneal fusion with a retrograde nail at 1 month after the index surgery. Although case reports of pseudoaneurysms of larger arteries such as the anterior tibial artery and posterior tibial artery after ankle surgery (e.g., ankle arthroscopy, implant removal, Ilizarov application) have been reported, we report a rare complication of a pseudoaneurysm of the lateral plantar artery. We discuss the anatomic considerations of the lateral plantar artery in the foot and the entry point of the retrograde nail to avoid this unusual complication.

Concepts: Foot, Report, Arteries of the lower limb, Popliteal artery, Posterior tibial artery, Fibular artery, Anterior tibial vein, Lateral plantar artery


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


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


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


We report the case of a 65-year-old man with critical limb ischemia treated with popliteal-peroneal bypass via the posterior approach and endarterectomy of the P2 popliteal artery. The posterior approach is useful in a number of situations, such as cases of arteriosclerotic disease of the crural arteries, where the target artery is the distal posterior tibial artery or peroneal artery; where the inflow site is the popliteal artery; in cases of a poor-quality greater saphenous vein, limited length of vein, and a preferable lesser saphenous vein; and in reoperation after failed bypass via a medial approach. Vascular surgeons should consider the posterior approach as an alternative procedure in below-knee revascularization.

Concepts: Blood vessel, Artery, Great saphenous vein, Popliteal artery, Popliteal fossa, Popliteal vein, Posterior tibial artery, Fibular artery


Knowledge about branching pattern of the popliteal artery is very important in any clinical settings involving the anterior and posterior tibial arteries. This study aims to elucidate the anatomical variation patterns and common types of anterior tibial artery (ATA) and posterior tibial arteries (PTA) in the general population in China.

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


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.

Concepts: Knee, Anterior cruciate ligament, Anterior cruciate ligament reconstruction, Cruciate ligament, Hamstring, Popliteal artery, Fibular artery, Anterior tibial artery


A tendoachilles lengthening (TAL) is indicated in over 85 % of cases treated with the Ponseti technique. A percutaneous TAL is often performed in the clinic. Reported complications from a TAL performed in the clinic include: bleeding due to injury to the peroneal artery, posterior tibial artery, or lesser saphenous vein; injury to the tibial or sural nerves; and incomplete release. The purpose of the present study is to report the results and complications of a mini-open TAL performed in the operating room (OR).

Concepts: Great saphenous vein, Posterior tibial artery, Fibular artery


Distally based perforator sural flaps from the posterolateral or posteromedial lower leg aspect are initially a neurofasciocutaneous flap that can be transferred reversely to the foot and ankle region with no need to harvest and sacrifice the deep major artery. These flaps are supplied by a perforating artery issued from the deep peroneal artery or the posterior tibial artery, and the chain-linked adipofascial neurovascular axis around the sural/saphenous nerve. It is a versatile and reliable technique for soft-tissue reconstruction of the heel and ankle region with 180-degrees rotation. In this paper, we present its developing history, vascular basis, surgical techniques including flap design and elevation, flap variations in pedicle and component, surgical indications, and illustrative case reports with different perforating vessels as pivot points for foot and ankle coverage.

Concepts: Foot, Arteries of the lower limb, Ankle, Human leg, Popliteal artery, Posterior tibial artery, Medial plantar artery, Fibular artery