Anterior Ankle Arthroscopy: Advantage of a Preoperative Ultrasound Mapping to Prevent Neurovascular Complications

The arterial risk posed by the posterolateral approach: An anatomical cadaveric study of the fibular artery and its variability

The posterior malleolus of the tibia is commonly accessed surgically through the posterolateral approach. This approach gives good access to the fibula and lateral aspect of the posterior tibia, however; there is little known on the vascular risks with this approach. The aim of this study was to assess and describe the anatomy of the fibular artery and its branches at the ankle region and relate it to the surgical access of the posterior malleolus. Eleven cadaveric foot and ankle specimens were dissected in layers, preserving the fibular artery, anterior tibial artery (ATA), and posterior tibial artery (PTA). Five distinct variations were found in the fibular artery: variable terminal branching with a hyperplastic fibular artery; a superficially located fibular artery; variation in the level and number of anastomoses; variation in the muscular branches; and a variable anterior perforating branch. The mean proximal distance from a horizontal line drawn through the medial protuberance of the medial malleolus of the tibia (horizontal line reference point-HLRP) to the posterior communicating branch of the fibular artery was 37.93 mm (range 19.03-85.43 mm). The mean proximal distance between HLRP and the anterior perforating branch of the fibular artery was 44.23 mm (range 35.44-62.32 mm). In 10 specimens, the fibular artery was immobile distal to its anterior perforating branch. The posterolateral approach specifically puts the fibular artery at risk and knowledge of its anatomy and variability is important when undertaking this approach. Understanding the common variations within the ankle's arterial anatomy can help surgeons protect these vessels from damage during the surgical approach.

A prospective case series to evaluate subcostal nerve injury with high-resolution ultrasound in posterior retroperitoneoscopic adrenalectomy

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy has several advantages over transabdominal laparoscopic adrenalectomy regarding operating time, blood loss, postoperative pain, and recovery. However, postoperatively several patients report chronic pain or hypoesthesia. We hypothesized that these symptoms may be the result of damage to the subcostal nerve, because it passes the surgical area.

METHODS

A prospective single-center case series was performed in adult patients without preoperative pain or numbness of the abdominal wall who underwent unilateral posterior retroperitoneoscopic adrenalectomy. Patients received pre- and postoperative questionnaires and a high-resolution ultrasound scan of the subcostal nerve and abdominal wall muscles was performed before and directly after surgery. Clinical evaluation at 6 weeks was performed with repeat questionnaires, physical examination, and high-resolution ultrasound. Long-term recovery was evaluated with questionnaires, and photographs from the patients were examined for abdominal wall asymmetry.

RESULTS

A total of 25 patients were included in the study. There were no surgical complications. Preoperative visualization of the subcostal nerve was possible in all patients. At 6 weeks, ultrasound showed nerve damage in 15 patients, with no significant association between nerve damage and postsurgical pain. However, there was a significant association between nerve damage and hypoesthesia (p = 0.01), sensory (p < 0.001), and motor (p < 0.001) dysfunction on physical examination. After a median follow-up of 18 months, 5 patients still experienced either numbness or muscle weakness, and one patient experienced chronic postsurgical pain.

CONCLUSION

In this exporatory case series the incidence of postoperative damage to the subcostal nerve, both clinically and radiologically, was 60% after posterior retroperitoneoscopic adrenalectomy. There was no association with pain, and the spontaneous recovery rate was high.

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.