Unilateral arteria peronea magna associated with bilateral replaced dorsalis pedis arteries

Free gracilis end-to-side microanastomosis to a peronea arteria magna: a case report

BACKGROUND

Complex orthoplastic lower limb trauma in individuals with multiple injuries requires considerable resources and interdisciplinary collaboration for good outcomes. We present the first reported end-to-side free flap microanastomosis for lower limb trauma reconstruction involving a peronea arteria magna without radiographic collaterals.

CASE PRESENTATION

A 55-year-old Caucasian gentleman involved in road traffic collision sustained an open tibial fracture on the anteromedial distal third of the left lower leg with local degloving and a subtotal right foot and ankle degloving. Both injuries were reconstructed with free tissue transfer. A left lower limb peronea arteria magna successfully received a free gracilis muscle flap by end-to-side microanastomosis and perfusion of the foot was preserved. This rare anatomical variant and its anatomy is reviewed, as well as a description of the suggested preoperative planning and technique for reconstruction.

CONCLUSIONS

Successful free flap reconstruction may be performed to a lower limb with a peronea arteria magna recipient as the lone vessel supplying the foot in trauma, although preoperative counseling of the risks, benefits, and options are essential.

LEVEL OF EVIDENCE

Level V, case report.

Standardize routine angiography assessment of leg vasculatures before fibular flap harvest: lessons of congenital and acquired vascular anomalies undetected by color Doppler and physical examinations

BACKGROUND

Fibular flaps have been widely used for mandibular and maxillary reconstructions. On occasion, anatomical variants of fibular arteries (FA) will be encountered.

PURPOSE

Although anatomical variants of FA during fibular harvest have been reported, controversy exists regarding whether simple color Doppler ultrasonography (CDU) and physical examinations (PE) are sufficient for early preoperative detection.

MATERIAL AND METHODS

A 10-year retrospective analysis in our department was performed to find the patients with various FA anomalies confirmed by computed tomography angiography (CTA) or intraoperative findings.

RESULTS

A total number of 19 FA anomalies were found either pre- or intraoperatively in 16 patients, in whom three cases were with bilateral FA variants. Type IIIC variants, also called arteria peronea magna (great peroneal artery), were confirmed in two legs, while the majority (13 legs) had type IIIA hypoplastic/aplastic posterior tibialis arteries (PTA). Four legs had new type IIID (low FA and PTA bifurcations). Preoperative CDU and PE only suspected anomalies in two legs. Six cases proceeded with using the affected fibulas, within whom vascular grafts were used in half of them for lengthening the FA pedicle. Local ischemia, partial soleus muscle necrosis, and claudication were reported in one.

CONCLUSIONS

Routine CTA before every fibular harvest, rather than simple PE and CDU, should be added for screening contraindications and ensuring safety for fibular flap harvest.

Safety of ankle trans-syndesmotic fixation

BACKGROUND

Ankle syndesmosis fixation is often employed with the utilization of many variable methods and implants. Complications secondary to trans-syndesmotic fixation have been described, yet the proximity of a single trans-syndesmotic screw to the perforating branch of the peroneal artery (PBPA) has not.

MATERIALS AND METHODS

Sixteen cadaveric legs received a single trans-syndesmotic screw using standard AO technique. The PBPA was identified and the following distances were measured using photographic images and morphometric software: the tip of lateral malleolus to the PBPA, the tibial plafond to the PBPA, tip of lateral malleolus to the screw, and the PBPA to the screw. Average distances were calculated and statistically compared.

RESULTS

The location of the trans-syndesmotic screw inserted 2 cm proximal to the tibial plafond was on average less than 1.3 cm distal to the PBPA. In six out of the 16 specimens, the screw was less than 1 cm from the PBPA. In one specimen, the screw came within 0.22 cm of the PBPA.

CONCLUSION/CLINICAL RELEVANCE

The placement of trans-syndesmotic fixation places the PBPA at risk. In order to avoid injury to the PBPA with trans-syndesmotic fixation, fixation should be avoided 2.3 to 4.1 cm proximal to the tibial plafond or 4.5 to 6.2 cm proximal to the tip of the lateral malleolus in females and 2.8 to 5.9 cm proximal to the tibial plafond or 5.1 to 7.2 cm proximal to the tip of the lateral malleolus in males.

Clinical implications of peroneal artery variation

Vascular anatomy has a strong influence on the choice of surgical approach. Anomalies of vascular patterns may explain uncharacteristic physical or clinical findings. We present a case of an anomalous peroneal artery not previously described. The anomalous anatomic pattern is the peroneal artery replacing the posterior tibial artery in the medial ankle and providing the primary blood supply to the plantar foot.