Has plantarflexion any positive impact on the clinical risk of vascular injury during ankle arthroscopy ?

Abstract

I have read with great interest the article by Basarir et al, “Medial and Lateral Malleolar Arteries in Ankle Arthroscopy: A Cadaver Study,” which appeared in the May-June 2007 issue of the Journal (1Basarir K. Esmer A.F. Tuccar E. Binnet M. Guclu B. Medial and lateral malleolar arteries in ankle arthroscopy: a cadaver study.J Foot Ankle Surg. 2007; 46: 181-184Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). I agree that routine plantarflexion of the ankle during portal placement and application of trocars is preferable because it increases the distance between the medial malleolar arteries, lateral malleolar arteries, and standard portals. In the last sentence of the article, the authors state that further studies are required to determine whether plantarflexion could have any positive impact on the clinical risk of vascular injury. I have performed a cadaveric dissection of an ankle (Figure 1) with the arthroscope located in the anteromedial portal. The examined ankle was plantarflexed. This position revealed that the main vessels, namely the tibial anterior artery and great saphenous vein, were taut in plantarflexion. I have performed a search on PubMed on features of the anterior vessels and nerves that trespass the ankle. This research allowed me to discover that the superficial peroneal nerve may be overstretched during inversion or plantarflexion injuries (2Accus R.W. Flanagan J.P. Perineural fibrosis of superficial peroneal nerve complicating ankle sprain: a case report.Foot Ankle. 1991; 11: 233-235Crossref PubMed Scopus (29) Google Scholar, 3Delfaut E.M. Demondion X. Bieganski A. Thiron M.C. Mestdagh H. Cotten A. Imaging of foot and ankle nerve entrapment syndromes: from well-demonstrated to unfamiliar sites.Radiographics. 2003; 23: 613-623Crossref PubMed Scopus (77) Google Scholar) and that the perforating peroneal artery is susceptible to marked stress with plantarflexion and inversion of the foot (4Maguire D.W. Huffer J.M. Ahlstrand R.A. Crummy Jr, A.B. Traumatic aneurysm of perforating peroneal artery Arterial bleeding—cause of severe pain following inversion, plantar flexion, ankle sprains.J Bone Joint Surg Am. 1972; 54: 409-412PubMed Google Scholar). Moreover, although vascular injuries after nonpenetrating, low-energy trauma to the lower limbs are rare, causes include traction injuries (5Rooney R.C.J. Rooney R.C. Anterior tibial aneurysm following inversion injury to the ankle.J Orthop Trauma. 1999; 13: 511-513Crossref PubMed Scopus (18) Google Scholar, 6Sriussadaporn S. Arterial injuries of the lower extremity from blunt trauma.J Med Assoc Thai. 1997; 80: 121-129PubMed Google Scholar). One of the injured vessels is the anterior tibial artery (6Sriussadaporn S. Arterial injuries of the lower extremity from blunt trauma.J Med Assoc Thai. 1997; 80: 121-129PubMed Google Scholar). Injuries to the anterior tibial artery are described after interventional procedures such as ankle arthroscopy; however, they remain very rare because of hyperplantarflexion or inversion of the ankle, with only a few similar cases reported in the literature (5Rooney R.C.J. Rooney R.C. Anterior tibial aneurysm following inversion injury to the ankle.J Orthop Trauma. 1999; 13: 511-513Crossref PubMed Scopus (18) Google Scholar, 7Sarungi M. Milassin P. Csaszar J. Sandor L. Arterial pseudoaneurysm of the ankle after plantar flexion-inversion injury A rare complication and its non-invasive diagnosis.Arch Orthop Trauma Surg. 1994; 113: 349-350Crossref PubMed Scopus (15) Google Scholar, 8Skudder P.A. Gelfand M.L. Blumenberg R.M. Fulco J. Tibial artery false aneurysm: uncommon result of blunt injury occurring during athletics.Ann Vasc Surg. 1999; 13: 589-591Abstract Full Text PDF PubMed Scopus (33) Google Scholar). Therefore, it is clear that when the ankle is plantarflexed, the risk for injury is lower than when the ankle is dorsiflexed. In fact, when an ankle arthroscopy is performed, because of the blunt end of the trochar when vessels are taut in plantarflexion, the vessels can be easily avoided while the trochar is being inserted rather than when they are relaxed. In my opinion, this is the reason that plantarflexion has a positive impact on the clinical risk of vascular injury. Medial and Lateral Malleolar Arteries in Ankle Arthroscopy: A Cadaver StudyThe Journal of Foot and Ankle SurgeryVol. 46Issue 3PreviewNeurovascular injury may occur during ankle arthroscopy. The majority of complications are neurological injuries; however, vascular injuries do exist. Neurovascular structures are especially vulnerable during portal placement and debridement of anterior structures. Routine anteromedial and anterolateral portals are generally accepted to be safe; this is different from the anterocentral portal, which is associated with a higher risk of injury. However, injuries may occur in these relatively safe portals. Full-Text PDF Dear Dr SalviThe Journal of Foot and Ankle SurgeryVol. 46Issue 6PreviewThere are certainly influences of ankle position to the risk of vascular injury in approximating the vessels to the portals and/or changing their tautness. Many reports have mentioned neurovascular injuries secondary to traction as cited by Dr Salvi (1,2). Neurovascular injuries, which account for the majority of the complications, were mostly related to portal placement (3,4). Full-Text PDF