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

Complications of ankle arthroscopy: frequency, prevention, and treatment

The complication rate of ankle arthroscopy (AA) ranges from 3.5% to 14%. To avoid such complications, it is essential to have a thorough understanding of the anatomy of the ankle, to perform the procedure very carefully and with appropriate instrumentation, and to use a non-invasive distraction technique. The most frequent complications are neurological (cutaneous nerve injuries), which are usually caused by direct injury during arthroscopic portals or by a distracting pin when using an invasive distraction technique. They usually resolve spontaneously within a few months. The iatrogenic formation of a pseudoaneurysm is a severe but extremely rare complication (an incidence of 0.008%). There are several treatments for pseudoaneurysms: external compression; direct thrombin injection, surgical intervention (resection of the damaged segment of the artery and reconstruction with a reversed long saphenous vein interposition graft), and endovascular embolisation. Other rare complications include wound infections (localised superficial infection), problems at the portal incisions (prolonged portal drainage, residual pain in the portal, portal scar dehiscence, cyst at the portal site), type I complex regional pain syndrome, instrument breakage, painful scars and nodules, and a number of other rarer complications. In conclusion, when performing AA, it is important to remember the potential complications and try to avoid them. When they do occur, it is essential to diagnose and treat them appropriately.

Into a brave new world: Haemophilia A & von Willebrand Disease Surgery with novel therapies

INTRODUCTION

Haemophilia & von Willebrand disease are both recognised inherited bleeding disorders. With increased access to highly efficient and safe replacement and novel therapies, management of surgical interventions in this group can be safely managed by experienced multidisciplinary teams.

AIM

To review the evidence for managing surgery in the era of novel therapies.

METHOD

We explore four cases and establish the role of the clinical nurse specialist within the surgical pathway.

RESULTS

All of these cases evidence the continued important role of both the multidisciplinary planning prior to any surgical interventions in people with bleeding disorders and the key role of the Nurse Specialist in ensuring this plan is then implemented. Key focuses of communication with all parties involved in the patient journey, performing education for the patient, family and wider healthcare team about the underlying bleeding disorder and the importance of time critical medicines being given on time is essential.

CONCLUSION

These cases demonstrate that individuals with bleeding disorders are at risk of developing other rare conditions alongside their life long condition, in addition to comorbidities associated with ageing. Evidence for rare plus rare is likely to be minimal as demonstrated within the cases, and recognition of how to reach out to international peers in the field is important. Sharing complex case management at national & international meetings and in publication has never been so important.

Large anterior tibial artery pseudoaneurysm as a rare complication to vascular surgery

A pseudoaneurysm is a rare complication to vascular reconstruction and may be limb threatening if not treated. A patient previously treated for an aneurysm of the left popliteal artery presented to our outpatient clinic with swelling and reduced active movement. Computed Tomography Angiography revealed an 8.1 cm large pseudoaneurysm of the anterior tibial artery (ATA). The pseudoaneurysm was successfully treated with an interposition vascular graft to the patent ATA. Open surgical repair was the only option with resection of the pseudoaneurysm and insertion of an interposition vascular graft with and end-to-side anastomosis. The giant ATA pseudoaneurysm was successfully treated with insertion of a new end-to-side graft anastomosis with interposition to the old patent vascular graft.

Anterocentral Portal in Ankle Arthroscopy

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.

Pseudoaneurysm of the Perforating Peroneal Artery following Ankle Arthroscopy

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.

Pseudoaneurysm following ankle arthroscopy: a systematic review of case series

BACKGROUND/OBJECTIVE

Pseudoaneurysms (PA) are rare complications following ankle arthroscopy (AA). Delay in diagnosis is reported to be frequent and could lead to serious complications. Evidence synthesis on the clinical context of such complication lacks in the literature.

METHODS

A systematic review is conducted to locate all relevant papers. In total, 23 case reports were included in the review. Data of 23 patients with a mean of 40.9 ± 10.3 years were extracted and analyzed. Outcomes included comorbidities, portals and procedure types performed during AA, PA location and size, time to diagnosis and treatment, and therapeutic modalities.

RESULTS

The results showed that d-ATA and the dorsal pedis artery (DPA) were involved in 18 and 4 cases, respectively. A single case of PA of the fibular artery was described. The mean PA size was found to be 4.2 × 3.9 × 2.1 cm. Five of the 14 patients (35.7%) with a reported detailed medical history were treated for a cardiovascular or hemostasis condition. Delay in PA diagnosis was found to be at a mean time of 50.45 ± 74.6 days. The most commonly reported surgical indications were anterior synovectomy and removal of anterior osteophytes. Ligation was the most common procedure in treating PA.

CONCLUSION

While portal placement might be a minor factor, the variability of the d-ATA and/or DPA anatomical position and its affection with foot position and distraction during AA could play a role in the arterial injury. Synovectomy and removal of anterior, particularly big-sized, osteophytes could be considered as risk factors as well. A state of hypocoagulability might affect injury healing and consequently PA formation. PA diagnosis should be raised whenever a non-resolving or pulsatile swelling over a portal incision is observed.