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Aytekin K, Çakır İM, Taşdemir MN, Balta O. Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography. Arch Orthop Trauma Surg 2024; 144:2119-2125. [PMID: 38492060 PMCID: PMC11093777 DOI: 10.1007/s00402-024-05258-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 02/18/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.
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Affiliation(s)
- Kürşad Aytekin
- School of Medicine, Department of Orthopedics and Traumatology and Department of Anatomy, University of Giresun, Giresun, Turkey.
| | - İsmet Miraç Çakır
- School of Medicine, Department of Radiology, University of Giresun, Giresun, Turkey
| | - Merve Nur Taşdemir
- School of Medicine, Department of Radiology, University of Giresun, Giresun, Turkey
| | - Orhan Balta
- Department of Orthopaedics and Traumatology, Gaziosmanpasa University Hospital, Kaleardı District Muhittin Fisunoglu Street, 60100, Tokat, Turkey
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Stella M, Santolini E, Sanguineti F, Felli L, Vicenti G, Bizzoca D, Santolini F. Aetiology of trauma-related acute compartment syndrome of the leg: A systematic review. Injury 2019; 50 Suppl 2:S57-S64. [PMID: 30772051 DOI: 10.1016/j.injury.2019.01.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute compartment syndrome (ACS) is characterised by abnormal pressure inside a compartment, resulting in ischemia of muscles and nerves. Most orthopaedic surgeons, especially those who work in major trauma centres, have been or will be facing a case of ACS in their clinical activity. Fortunately, complications related to untreated compartment syndrome have become less frequent thanks to a better understanding of pathogenesis and to early recognition and prompt surgical treatment. The aim of this study is to identify the existing evidence regarding aetiology of trauma-related ACS of the leg. METHODS A systematic review of the literature was undertaken using PubMed Medline, Ovid Medline and the Cochrane library, extended by a manual search of bibliographies. Retrieved articles were eligible for inclusion if they reported data about aetiology of trauma-related compartment syndrome of the tibia. RESULTS Ninety-five studies that fulfilled the inclusion criteria were identified. By dividing the studies into three groups according to the traumatic aetiology, we were able to classify traumatic ACS as fracture related, soft tissue injury related and vascular injury related. Fracture related was the most represented group, comprising 58 papers, followed by the soft tissue injury related group which includes 44 articles and vascular injury related group with 24 papers. CONCLUSIONS Although traditionally ACS has been associated mainly with fractures of tibial diaphysis, literature demonstrates that other localisations, in particular in the proximal tibia, are associated with an increased incidence of this serious condition. The forms of ACS secondary to soft tissues injuries represent an extremely variable spectrum of lesions with an insidious tendency for late diagnosis and consequently negative outcomes. In the case of vascular injury, ACS should always be carefully considered as a priority, given the high incidence reported in the literature, as a result of primitive vascular damage or as a result of revascularisation of the limb. Knowledge of aetiology of this serious condition allows us to stratify the risk by identifying a population of patients most at risk, together with the most frequently associated traumatic injuries.
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Affiliation(s)
- Marco Stella
- Orthopaedics and Trauma Unit, Ente Ospedaliero Ospedali Galliera, Mura delle Cappuccine 14, 16148, Genoa, Italy
| | - Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy.
| | - Francesca Sanguineti
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Lamberto Felli
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Giovanni Vicenti
- Department of Neuroscience and Sense Organs, Orthopaedics Section, University of Bari Aldo Moro, Bari, Italy
| | - Davide Bizzoca
- Department of Neuroscience and Sense Organs, Orthopaedics Section, University of Bari Aldo Moro, Bari, Italy
| | - Federico Santolini
- Orthopaedics and Trauma Unit, Emergency Department, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy
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Acute Exertional Compartment Syndrome in Young Athletes: A Descriptive Case Series and Review of the Literature. Pediatr Emerg Care 2018; 34:76-80. [PMID: 27248777 DOI: 10.1097/pec.0000000000000647] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Acute exertional compartment syndrome (AECS) is a rare presentation of acute compartment syndrome (ACS) after exertion without injury. Unfamiliarity with this entity can lead to delay in diagnosis. The purpose of this study was to increase awareness of AECS and illustrate the morbidities associated with delayed diagnosis. METHODS With institutional review board approval, we conducted a retrospective chart review of all patients who underwent emergent fasciotomies for AECS from 1997-2013 at our institution. Male patients with sports-related closed fractures of the tibia leading to ACS were identified for comparison. Demographic variables, patient-specific factors, treatment, and outcome characteristics were analyzed. RESULTS Seven male patients (mean age, 17 years) presented to our institution with AECS from 1997-2013, and 9 patients with fracture-related ACS were selected for comparison. All cases of AECS occurred in the leg. In the AECS group, the mean time from symptom onset to diagnosis was 97 hours. Four patients initially had a missed diagnosis. On presentation, 6 of 7 patients experienced neurologic symptoms (motor or sensory deficit), although none had perfusion deficits. The mean compartment pressure was 91 mm Hg. They all underwent isolated anterior and lateral compartment releases (except for 1 patient who required a 4-compartment release) and required a mean of 4 surgeries. The mean follow-up was 270 days. Of the 4 patients with missed diagnoses, 2 had significant neurologic and functional deficits at final follow-up. The other 5 patients had a full recovery. Fracture-related ACS patients were younger, with quicker time from symptom onset to surgery, and required more compartments to be decompressed at surgery. CONCLUSIONS Despite the rarity of AECS, orthopedists as well as primary care, emergency medicine, and sports medicine physicians should maintain a high index of suspicion when examining a patient with leg pain out of proportion to examination after exertion. Delay in diagnosis of AECS is associated with substantial muscle necrosis and morbidity.
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Abstract
Ankle sprains fall into two main categories: acute ankle sprains and chronic ankle instability, which are among the most common recurrent injuries during occupational activities, athletic events, training and army service. Acute ankle sprain is usually managed conservatively and functional rehabilitation failure by conservative treatment leads to development of chronic ankle instability, which most often requires surgical intervention. Enhancing the in-depth knowledge of the ankle anatomy, biomechanics and pathology helps greatly in deciding the management options.
Cite this article: Al-Mohrej OA, Al-Kenani NS. Acute ankle sprain: conservative or surgical approach? EFORT Open Rev 2016;1:34-44. DOI: 10.1302/2058-5241.1.000010.
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Affiliation(s)
- Omar A Al-Mohrej
- King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia
| | - Nader S Al-Kenani
- King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia
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Chen YP, Ho WP, Wong PK. Acute compartment syndrome secondary to disruption of the perforating branch of the peroneal artery following an acute inversion injury to the ankle. Int J Surg Case Rep 2014; 5:1275-7. [PMID: 25460492 PMCID: PMC4275801 DOI: 10.1016/j.ijscr.2014.11.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 11/08/2022] Open
Abstract
Vascular disruption and compartment syndrome, although rare, can be severe sequelae of an inversion ankle injury. The perforating branch of the peroneal artery passes anteriorly through a hiatus in the interosseous membrane, and is susceptible to stresses in inversion injury of the ankle. Acute compartment syndrome related to vascular lesions may rapidly present in hours after ankle sprain.
INTRODUCTION Although ankle sprain by inversion is common in daily practice, acute compartment syndrome following ankle inversion injury is unusual. Only a few cases of this uncommon entity have been reported. PRESENTATION OF CASE This report describes a case of acute compartment syndrome following severe inversion of an ankle injury secondary to disruption of the perforating branch of the peroneal artery 3 h after the trauma. Although emergent fasciotomy was performed, residual weakness of ankle dorsiflexion still presented six months after surgery. DISCUSSION To the best of our knowledge, this case is the third in literature on an acute compartment syndrome following severe inversion ankle injury secondary to disruption of the perforating branch of the peroneal artery. CONCLUSION This report underscores the importance of considering compartment syndrome when individual has an inversion ankle injury, even when no fracture exists.
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Affiliation(s)
- Yu-Pin Chen
- Department of Orthopaedic Surgery, Taipei Medical University-Wan Fang Hospital, School of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Wei-Pin Ho
- Department of Orthopaedic Surgery, Taipei Medical University-Wan Fang Hospital, School of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Poo-Kuang Wong
- Department of Orthopaedic Surgery, Taipei Medical University-Wan Fang Hospital, School of Medicine, Taipei Medical University, Taipei, Taiwan, ROC.
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Veger HTC, Bosman WM, van den Broek MA, Ritchie ED, Hedeman Joosten PP. A traumatic false aneurysm of the ankle: an unusual bump on the forefoot. BMJ Case Rep 2014; 2014:bcr-2014-205955. [PMID: 25281250 DOI: 10.1136/bcr-2014-205955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Hugo T C Veger
- Department of Surgery, Rijnland Ziekenhuis, Leiderdorp, The Netherlands
| | | | | | - Ewan D Ritchie
- Department of Surgery, Rijnland Ziekenhuis, Leiderdorp, The Netherlands
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Abstract
Compartment syndrome is a rare but severe complication of lower extremity trauma. This article provides an extensive review of the literature, including incidence, physical examination findings, pathophysiology, compartment pressure evaluation, and surgical decompression techniques. Most of the recent compartment syndrome literature shows case reports of atypical causes of this limb-threatening disorder. Although the emphasis of this article is traumatic compartment syndrome, recent literature on chronic lower extremity compartment syndrome, secondary to exercise or activity, is also discussed.
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Affiliation(s)
- Michael Murdock
- Covenant Medical Center, 3420 West 9th Street, Waterloo, IA 50720, USA
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Kemp MA, Barnes JR, Thorpe PL, Williams JL. Avulsion of the perforating branch of the peroneal artery secondary to an ankle sprain: a cause of acute compartment syndrome in the leg. J Foot Ankle Surg 2010; 50:102-3. [PMID: 21106410 DOI: 10.1053/j.jfas.2010.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Indexed: 02/03/2023]
Abstract
In this report, we describe the case of an adult male who developed an acute compartment syndrome localized to the anterior compartment of the leg following an ankle sprain. Compartment syndrome in association with ankle sprain is unusual, and has been previously described in association with avulsion of the perforating peroneal artery. Because of the potential for severe morbidity, we feel that it is important to make foot and ankle surgeons aware of this unusual injury.
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Affiliation(s)
- Mark A Kemp
- Musgrove Park Hospital, Taunton, Somerset, UK.
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Abstract
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.
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Affiliation(s)
- Nathan J Fanter
- St. Vincent Mercy Medical Center, Osteopathic Medical Education, Toledo, OH 43608-2691, USA.
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Abstract
We present a case of a pseudoaneurysm of the anterior tibial artery following ankle arthroscopy with synovectomy, an extremely rare complication when standard anteromedial and anterolateral portals are used. The patient was diagnosed and treated with appropriate interventions which led to an uneventful recovery. Nevertheless, the potential sequelae of delayed diagnosis or misdiagnosis of the complication are dangerous; therefore, a high index of suspicion for a pseudoaneurysm must be maintained in the postoperative period.
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Affiliation(s)
- Olubusola A Brimmo
- Department of Orthopaedic Surgery, St. John's Mercy Medical Center, St. Louis University, St. Louis, MO, USA
| | - Selene G Parekh
- Fuqua Business School, Duke University, Durham, NC, USA,Address for correspondence: Dr. Selene G Parekh, Adjunct Faculty, Fuqua Business School, Duke University, Durham, NC, USA. E-mail:
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Lee RY, Colville JM, Schuberth JM. Acute compartment syndrome of the leg with avulsion of the peroneus longus muscle: a case report. J Foot Ankle Surg 2009; 48:365-7. [PMID: 19423039 DOI: 10.1053/j.jfas.2009.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Indexed: 02/03/2023]
Abstract
UNLABELLED A rare case of avulsion of the peroneus longus origin associated with acute lateral compartment syndrome is presented. Pain on passive stretch of the peroneus longus was not reported owing to the lack of proximal attachment of muscle. Other less reliable signs of compartment syndrome were relied on make an accurate and timely diagnosis. The surgical decompression and clinical course are presented. LEVEL OF CLINICAL EVIDENCE 4.
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Affiliation(s)
- Ryan Y Lee
- Private Practice, San Diego Podiatry Group, San Diego, CA, USA
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