Tibial Artery Research Articles

Posterior Tibial Artery Perforator Based Propeller Flap for Reconstruction of 143 Skin and Soft Tissue Defect Around Ankle Joint

Background: Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this needs facility of microsurgery, may lead to donor site morbidity and is time consuming. With the introduction of perforator flap, management of small and medium size defects of distal leg and ankle region is easier, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180-degree, donor site can be closed primarily and increases the distance crossed by flap, thus increasing versatility. Objectives: To observe the outcome of soft tissue coverage of defects around ankle joint by posterior tibial artery perforator based propeller flaps. Methods: This was a prospective type of observational study carried out on 20 patients with skin and soft tissue defects in and around ankle joint for a period of 14 months in the Department of Burn and Plastic Surgery, Dhaka Medical College and Hospital. Results: Among 20 cases 17 were male and 3 females; age ranged from 11 to 60 years. Post operative outcome of flap were excellent in 11 cases, good in 6 cases, poor in 3 cases as per defined criteria. Uneventful outcome was observed in 14 cases and minor complications were observed in 5 cases; and total flap loss occurred in 1 case which required revision surgery. Conclusions: Perforator flap provides adequate soft tissue coverage for small & medium size wound around ankle. It is an easy, reliable & effective procedure with reasonable outcome. J Dhaka Med Coll. 2022; 31(2) : 243-250

Outcomes in Patients With Heel Ulcerations that Underwent Below the Knee Amputations Versus Vertical Contour Calcanectomy: Importance of Selection Criteria

The aim of the study was to compare preoperative factors and postoperative outcomes in patients with heel ulcerations that primarily had a transtibial (below the knee) amputation (N = 38) versus vertical contour calcanectomy (n = 62). The groups had no statistical difference between their Charlson Comorbidity Index Score, a prognostic score of 10-year survival in patients with multiple comorbidities. The odds of primary closure were 21.1 times higher in patients that underwent below knee amputation compared to patients that underwent vertical contour calcanectomy (OR 21.1 [95% CI 3.89-114.21]). The odds of positive soft tissue culture at time of closure were 17.1 times higher for patients that underwent vertical contour calcanectomy (OR 17.1 [95% CI 5.40-54.16]). The odds of a patent posterior tibial artery were 3.3 times higher for patients that underwent vertical contour calcanectomy (OR 3.3 [95% 1.09-10.09]). The secondary aim of the study was to evaluate preoperative factors and postoperative outcomes in patients with failed vertical contour calcanectomy, defined as needing a below knee amputation. The odds of vertical contour calcanectomy failure was 13.7 times higher in male patients (OR 13.7 [95% CI 1.80-107.60]). Vertical contour calcanectomy failure was 5.7 times higher in patients with renal disease (OR 5.7 [95% CI 1.10-30.30]), and vertical contour calcanectomy failure was 16.1 times higher for patients who needed additional surgery post closure (OR 16.1 [95% CI 1.40-183.20]).

Safety and Efficacy of Radial Artery Access for Peripheral Vascular Intervention: A Single-Center Experience

Radial artery (RA) access has been increasingly utilized for coronary procedures due to lower rates of access-site complications and improved patient satisfaction. However, limited data are available for RA access for peripheral vascular intervention (PVI). We performed a retrospective review of 143 patients who underwent PVI via RA access from February 2020 to September 2022 at a single institution. Baseline characteristics and follow-up data were ascertained from a prospectively maintained institutional database. Of 491 PVI, 156 (31.8%) were performed through the RA. Anatomical location for intervention were the femoral (44.8%), iliac (31.1%), popliteal (9.6%) peroneal (2.7%), tibial (9.9%), and subclavian (1.9%) arteries. Procedural access was obtained through the right RA (92.9%), left RA (4.5%), or right ulnar artery (2.6%) using the 6 French R2P Destination Slender sheath in 85 cm, 105 cm, and 119 cm lengths. Atherectomy was used in 34.7%. Mean contrast volume was 105.5 mL and the average fluoroscopy time was 18.5 minutes. Conversion to femoral access occurred in 3 cases (1.9%) due to arterial spasm and non-crossable lesions. Concomitant pedal access occurred in 2 cases (1.3%). Periprocedural complication rate was 3.84%, of which access-site hematoma was most common (3.2%); none required blood transfusion, surgical intervention, or additional hospital stay. There was 1 case (0.64%) of in-hospital stroke. The mortality rate at 30-day, 6-month, and 1-year was 1.4%, 2.8%, and 4.2%, respectively. In conclusion, RA access is feasible for diverse PVI, and future studies are needed to assess safety and benefit compared to femoral artery access.

Supra-Inguinal Inflow for Distal Bypasses Have Acceptable Patency and Limb Salvage Rates

There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets. The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into 3 cohorts based on outflow targets (above-knee [AK] popliteal, below-knee [BK] popliteal, and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival (AFS), and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes. Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the AK popliteal was used in 116 (28.8%), the BK popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. BK popliteal and tibial bypasses, compared to AK popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (69.5% and 69.9% vs. 48.3%; P<0.001). Vein conduit was more often used for tibial bypass than for AK and BK popliteal bypasses (46.3% vs. 21.9% and 16.3%; P<0.001). In the perioperative period, BK popliteal and tibial bypass patients had higher reoperation rates (16.9% and 13.2% vs. 5.2%; P=0.02) and lower primary patency (89.4% and 89% vs. 95.7%; P=0.04) than AK bypass patients. At 1year, compared with AK popliteal bypasses, BK and tibial bypasses demonstrated lower primary patency (81.9% vs. 56.7% vs. 52.4%, P<0.001) and freedom from MALE (77.6% vs. 70.2% vs. 63.1%, P=0.04), although AFS was not significantly different (89.7% vs. 90.6% vs. 83.8%, P=0.19).On multivariable analysis, compared with AK popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, P=0.04). Subanalysis of patients with chronic limb-threatening ischemia demonstrated significantly higher primary patency in the AK popliteal cohort at discharge and 1 year, but no difference in AFS or freedom from MALE between the cohorts at follow-up. LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE or AFS.

Intermittent Tibial Artery Compressibility in the Noninvasive Vascular Laboratory: Implications for Diagnosis and Follow-Up

Objective: There is limited evidence available regarding intermittent tibial artery compressibility in the published literature. This investigation looks to determine the existence of intermittent tibial artery compressibility, in the noninvasive vascular laboratory. Materials and Methods: Consecutive patients underwent noninvasive arterial physiologic testing. An ankle-brachial index (ABI) ≥1.40 was defined as noncompressible and classified into 4 subgroups: (1) noncompressible single occurrence (NC-S), (2) noncompressible multiple occurrence (NC-M), (3) compressible to noncompressible (C-NC), and (4) intermittently compressible (I-C) ABI. Normal patients were compared to these noncompressible subgroups. Selective risk factors were compared in the C-NC and I-C ABI patient groups. Results: Of the 13 881 patients that were evaluated, 89% had compressible tibial arteries and 11% were noncompressible. Intermittent tibial artery compressibility was present in 11.3% of the patients, with noncompressible arteries. There were 718 patients from the NC-M, C-NC, and I-C subgroupings that had 3014 follow-up exams, over mean duration of 38 ± 27.7 months. The C-NC and I-C subgroup patients averaged 3.3 and 3.6 calcification risk factors, respectively. Conclusion: A subset of patients with intermittent tibial artery compressibility was confirmed in the noninvasive vascular laboratory. Additional research is needed to substantiate these findings and investigate whether intermittent compressibility may be marker for increased cardiovascular risk.

RHEOLOGICAL THROMBUS EXTRACTION IN POSTOPERATIVE THROMBOSIS OF THE POPLITEAL-TIBIAL SEGMENT AFTER ENDOVASCULAR METHODS OF REVASCULARIZATION

Introduction. The use of endovascular methods of revascularization of the atherosclerotic stenotic-occlusive process of the femoral-distal arterial bed leads in 1/4 of the primary surgical interventions to the need for repeated surgical intervention, in 6-32% of cases it is complicated by the development of thrombosis of the reconstruction segment, restenosis of the surgical intervention segment [6, 7]. Aim. The main goal of the study was to improve the results of endovascular methods of revascularization of multi-level stenotic-occlusive femoral-distal arterial bed by performing rheological thrombus extraction with the Angiojet system in postoperative thrombosis of the popliteal-tibial segment. Materials and methods. 164 patients with multilevel stenotic-occlusive atherosclerotic lesions of the femoral-distal arterial bed were under observation. Thrombosis of the popliteal segment was diagnosed in 17 (73.9%) cases in patients with endovascular angioplasty of one of the tibial arteries, in 6 (26.1%) cases with endovascular angioplasty of two arteries of the tibial segment. Surgical treatment of thrombosis of the popliteal segment was performed by the method of minimally invasive rheological thrombus extraction using the Angiojet device (Possies, USA). Results. A patient with a multilevel stenotic-occlusive process of the femoral-distal arterial bed at clinical stage 3 (according to WIFI classification) had a two-level endovascular angioplasty of the infrainguinal arterial channel. Rheological thrombus extraction from the popliteal-tibial segment using the Angiojet system was used in 14 (60.9%) patients who underwent two-level endovascular angioplasty of the femoral-distal arterial bed. Rheological thrombus extraction from the popliteal-tibial segment with the Angiojet system was used in 9 (34.8%) patients who underwent revascularization of the infrainguinal arterial bed by the hybrid revascularization method. Conclusions. 1. Endovascular methods of revascularization of multilevel stenotic-occlusive femoral-distal arterial bed are complicated in 14.0% of observations by the development of postoperative thrombosis of the popliteal-tibial segment. The effectiveness of the application of rheological thrombus extraction by the Angiojet system of postoperative thrombosis from the popliteal-tibial segment after endovascular methods of revascularization of multilevel stenotic-occlusive femoral-distal arterial bed is at the level of 82.6%.

A proof-of-concept study of ultrasound-guided continuous parasacral ischial plane block for postoperative pain control in patients undergoing total knee arthroplasty

BackgroundContinuous peripheral nerve blocks are widely used for anesthesia and postoperative analgesia in lower limb surgeries. The authors aimed to develop a novel continuous sacral plexus block procedure for analgesia during total knee arthroplasty.MethodsThe study comprised two stages. In Stage I, the authors built upon previous theories and technological innovations to develop a novel continuous sacral plexus block method, ultrasound-guided continuous parasacral ischial plane block (UGCPIPB) and subsequently conducted a proof-of-concept study to assess its effectiveness and feasibility. Stage II involved a historical control study to compare clinical outcomes between patients undergoing this new procedure and those receiving the conventional procedure.ResultsThe study observed a 90% success rate in catheter placement. On postoperative day (POD) 1, POD2, and POD3, the median visual analog scale (VAS) scores were 3 (range, 1.5–3.5), 2.5 (1.6–3.2), and 2.7 (1.3–3.4), respectively. Furthermore, 96.3% of the catheters remained in place until POD3, as confirmed by ultrasound. The study revealed a significant increase in skin temperature and peak systolic velocity of the anterior tibial artery on the blocked side compared with those on the non-blocked side. Complications included catheter clogging in one patient and leakage at the insertion site in two patients. In Stage II, the novel technique was found to be more successful than conventional techniques, with a lower catheter displacement rate than the conventional procedure for continuous sciatic nerve block.ConclusionUGCPIPB proved to be an effective procedure and safe for analgesia in total knee arthroplasty.Chinese Clinical Trial Registry NumberChiCTR2300068902.

Staged treatment with arterial reconstruction and flap transplantation for ischemic mangled extremity: An observational study.

Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.

Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.

Comparison of outcomes of percutaneous deep venous arterialization in multiple practice settings

ObjectiveWe compared the efficacy of percutaneous deep venous arterialization (pDVA) in patients with no-option chronic limb-threatening ischemia in the hospital vs in office-based laboratory (OBL) settings. MethodsA retrospective chart review was performed of all patients who underwent pDVA using off-the-shelf devices from January 2018 to March 2023 in a hospital and an OBL. We identified 73 eligible patients, 41 from a hospital setting (59% male; median age, 72 years; interquartile range, 18 years) and 32 from an OBL setting (59% males; 67 years; interquartile range, 16 years). All eligible patients were deemed to have no-option critical limb ischemia, had at least one patent proximal tibial artery available for the creation of an arteriovenous anastomosis, and were classified as having Rutherford classification IV or higher peripheral arterial disease. Patients were ineligible if classified as Rutherford classification III or lower, had active infection, did not have at least one appropriate venous target, and/or had rapidly progressing wounds requiring immediate major amputation. The primary outcome was major amputation-free survival (AFS). Secondary outcomes included technical success, limb salvage, survival, primary patency, reintervention rate, adverse events, and partial and complete wound healing. Outcomes were evaluated using Kaplan-Meier method, log-rank, and two-stage procedure tests. ResultsTechnical success was achieved in 70 patients (96%) with 1 hospital (2.4%) and 2 OBL (6.3%) patients lost to follow-up. Major AFS estimates at 6 months, 1 year, and 2 years were 51.4%, 40.4%, and 30.2% in the hospital group and 69.4%, 54.0%, and 49.5% in the OBL group, respectively. Partial wound healing estimates at 6 months, 1 year, and 2 years were 27.5%, 71.7%, and 81.2% in the hospital group and 62.7% at all time points in the OBL group. Complete wound healing estimates at 6 months, 1 year, and 2 years were 6.7%, 33.3%, and 33.3% in the hospital group and 5.3%, 37.7%, and 41.6% in the OBL group, respectively. There was no significant difference in major AFS (P = .13), limb salvage (P = .07), survival (P = .69), primary patency (P = .53), partial (P = .08), or complete wound healing (P = .79) between groups. Reintervention was performed in 8 hospital (20.5%) and 14 OBL (45.2%) patients. ConclusionspDVA is a feasible and safe procedure for no-option critical limb ischemia in the hospital and OBL setting without significant differences in outcomes at ≤2 years.

Identification of peroneal artery perforators using non-contrast-enhanced T2prep multi-shot gradient echo planar imaging MRA.

The purpose of this study was to investigate the spatial resolution of non-contrast-enhanced (CE) T2prep multi-shot gradient echo planar imaging (MSG-EPI) magnetic resonance angiography (MRA) required to identify peroneal artery perforators and demonstrate its effectiveness in preoperative simulation. Twenty-six legs of 13 volunteers were scanned using non-CE T2prep MSG-EPI-MRA at three spatial resolutions: 1.0-, 0.8-, and 0.6-mm isotropic voxels. The location and number of peroneal artery perforators that could be candidates for free fibula flaps were identified by consensus among three plastic surgeons. Surgeons distinguished between septocutaneous and musculocutaneous perforators using MRA, and confirmed the accuracy of their presence and identification using ultrasonography (US). The ability to detect hypoplasia or stenosis of the anterior tibial, posterior tibial, and peroneal arteries was evaluated by confirming the consistency between the MRA and US results. The number of cutaneous perforators identified using MRA and confirmed using US was 39, 51, and 52 at each respective resolution. The discrimination accuracies between septocutaneous and musculocutaneous perforators were 92.3%, 96.1%, and 96.2%. The number of identified septocutaneous perforators was 1.3 ± 0.6, 1.6 ± 0.8, and 1.7 ± 0.8 at 1.0-, 0.8-, and 0.6-mm data, respectively. All the MRA results, including hypoplasia and stenosis, were consistent with the US results. Non-CE T2prep MSG-EPI-MRA with a spatial resolution of 0.8mm or less shows promise for identifying septocutaneous perforators of the peroneal artery, suggesting its potential as an alternative to conventional imaging methods for the preoperative planning of free fibula osteocutaneous flap transfers.

Posterior Tibial Artery Blood Flow Velocity Is Increased in Patients with Plantar Heel Pain.

Background/Objectives: This study aimed to investigate the relationship between posterior tibial artery blood flow velocity and plantar heel pain (PHP). Methods: The PHP group comprised patients diagnosed with plantar fasciitis with plantar heel pain during gait, and the control group comprised healthy participants without plantar heel pain. The peak systolic velocity of the posterior tibial artery was measured using ultrasonography; it was measured three times on each side, and the mean value was calculated. Receiver operating characteristic curve analysis was performed to calculate the peak systolic velocity cutoff value for plantar heel pain. Results: 23 patients (age 58.0 ± 16.5 years; 13 males and 10 females) and 23 healthy participants (age 51.3 ± 17.3 years; 10 males and 13 females) formed the PHP and control groups, respectively. Peak systolic velocity on the affected side was significantly greater in the PHP group (44.1 ± 13.1 cm/s) than in the control group (32.7 ± 5.9 cm/s). No significant difference was observed between the left and right sides in the PHP (7.1 ± 9.8 cm/s) and control (3.7 ± 3.0 cm/s) groups. A cutoff value of 38.2 cm/s was observed on the affected side. Conclusions: We quantified the increase in posterior tibial artery blood flow velocity in patients with plantar heel pain. Peak systolic velocity measurements can aid in quantitatively evaluating these patients. This study was registered as a clinical trial (UMIN000046875) on 1 October 2021.

Intravascular lithotripsy-assisted percutaneous deep vein arterialization for no-option chronic limb-threatening patients and heavily calcified tibial occlusive disease.

To report the first chronic limb-threatening ischemia (CLTI) patients who underwent an intravascular lithotripsy (IVL)-assisted percutaneous deep vein arterialization (pDVA). An 81-year-old patient presented with CLTI and a heavily calcified lesion of the popliteal artery and tibioperoneal trunk (TPT), with a distal tibial and foot arch occlusion. The patient underwent IVL and drug-coated balloon angioplasty for the distal popliteal artery and of the TPT to improve the inflow prior to pDVA. The wound situation remained stable without secondary procedure until the patient`s deaths due to complications of urosepsis 3months later. A 64-year-old patient with rest pain of the left limb with a single-vessel tibial run-off (peroneal artery) and occluded pedal arch was treated with 3.5mm IVL followed by a successful pDVA as mentioned above. IVL performed in the proximal posterior tibial artery to optimize the inflow to the circuit and change the compliance of the crossing point from the arterial to the vein system. The patient underwent repeat angioplasty of the plantar vein arch 5months after the index procedure and thereafter remained asymptomatic during 2years of follow-up. The combined use of IVL and pDVA could improve the patency of the reconstruction with clinical benefits in no-option CTLI patients.

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

BackgroundTibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study.Materials and methodsIn total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed.ResultsThe cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens.ConclusionsThe Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures.Level of evidenceIV.

Fourth consecutive emergency thrombectomy followed by femoral distal popliteal bypass in a patient with type VI popliteal artery entrapment syndrome: a case report

The article describes a case of the fourth consecutive emergency thrombectomy for popliteal and tibial artery thrombosis, followed by femoral distal popliteal bypass with a reversed vein in a patient with I. I. Zatevakhin grade 2B acute limb ischemia. The cause of repeated thrombosis type VI popliteal artery entrapment syndrome.

CT reconstruction based 3D model of the digital cushion's blood supply in the hind foot of an African savanna elephant (Loxodonta africana).

Foot health is crucial for elephants, as pathological lesions of the feet are a leading cause of euthanasia in captive elephants, which are endangered species. Proper treatment of the feet, particularly in conditions affecting the digits and the digital cushion, requires a thorough understanding of the underlying anatomy. However, only limited literature exists due to the small population and the epidemiological foot diseases which often precludes many deceased elephants from scientific study. The aim of this study was to provide a detailed anatomical description of the blood supply to the African elephant's hindfoot. The healthy right hindlimb of a 19-year-old deceased female African savanna elephant was examined using computed tomography. Following a native sequence, 48 mL of barium-based contrast agent was injected into the caudal and cranial tibial arteries, and a subsequent scan was performed. The images were processed with 3D Slicer software. The medial and lateral plantar arteries run in a symmetrical pattern. They each have a dorsal and a plantar branch, which reach the plantar skin before turning toward the axial plane of the sole to reach the digital cushion from the proximal direction. An accurate 3D model of the arteries and the bones of the foot, a set of labeled images and an animation of the blood supply have been created for ease of understanding. In contrast to domestic ungulates, the digital cushion of the hindlimb is supplied differently from that of the forelimb. The lack of large vessels in its deeper layers indicates a slow regeneration time. This novel anatomical information may be useful in the planning of surgical interventions and in emergency medical procedures.

Role of Retrograde Tibiopedal Access in Limb Salvage in Patients with Critical Lower Limb Ischemia

AbstractThe aim of this study was to assess the efficacy and safety of retrograde tibiopedal access as an alternative approach in cases of critical limb ischemia (CLI) when antegrade access has failed. A prospective study was conducted that included patients with CLI who underwent tibiopedal access after failed antegrade recanalization from January 2018 to June 2022. Follow-up was conducted at 6, 12, and 24 months. The primary outcomes evaluated were technical success rate and primary patency. Secondary outcomes included complication rate, mortality rate, and limb salvage rate (LSR). Forty-eight patients had CLI and Trans Atlantic Inter-Society Consensus infrainguinal lesions. The retrograde approach was used through the anterior tibial artery in 28 patients (58%), the posterior tibial artery in 18 patients (37.5%), and the peroneal artery in 2 patients (4.5%). Technical success was achieved in 90% of patients (43 patients). There was a significant increase in the anklebrachial index after the procedure with a mean follow-up of 22 months. Twenty-two months primary patency rate was 85.2%, while secondary patency rate was 100% and LSR was 96%, respectively. There was no mortality in the series. Retrograde tibiopedal approach is an alternative option for managing peripheral arterial disease and CLI. This method offers another means of crossing lesions when antegrade access failed, and the intervention can be completed either in an antegrade or retrograde approach. As the retrograde approach does not impact access site, considered a feasible safe treatment alternative which increase the success rate of endovascular treatment.

Challenging the angiosome concept: Delineating peripheral arterial disease patterns in diabetic foot ulcers.

The angiosome concept has significantly impacted diabetic foot ulcer management by highlighting the vascular anatomy's role in wound healing. However, its clinical applicability and validity remain debated due to complexities in foot blood supply and ulcer location determination. A cross-sectional study was conducted on 84 individuals with diabetic foot ulcers undergoing lower limb angiography. Demographics, ulcer characteristics, and angiographic data were collected and analyzed using descriptive statistics and relevant tests. Digital subtraction angiography assessed 89 limbs with diabetic foot ulcers; males comprised 54.8%, primarily type 2 diabetes (96.4%), averaging 64.36 ± 10.09 years. Of 129 angiosomes, angiosome 2 (40.3%) had the highest ulcer incidence. Posterior tibial artery (PTA) involvement was predominant (72.9%), while external iliac artery (EIA) and profunda femoris artery (PFA) were least affected (2.4% each). Posterior tibial artery showed 46.5% complete occlusion. Angiosome 2 correlated notably with anterior tibial artery (ATA), peroneal artery (CPA), and PTA, but categorizing angiosomes by supply patterns showed no significant artery correlation (p > .05). The research indicates inconsistent support for below-the-knee artery involvement correlating with foot ulcer locations in angiosomes. While aiding vascular comprehension, the angiosome concept may not fully elucidate lower limb vascular complexities and ulcer genesis. Factors like collateral circulation should be noticed to understanding ulcer localization and severity, extending beyond angiosomal arterial supply.

Computer Hexapod-assisted Orthopaedic Surgery for the Correction of Multiplanar Deformities throughout the Lower Limb.

Computerised hexapod-assisted orthopaedic surgery (CHAOS) is a method by which complex multiplanar, multilevel deformity can be corrected with a high degree of accuracy utilising minimally invasive techniques within a single operative event. This study's aim was to report the reliability, accuracy and magnitude of correction achieved, alongside patient-reported outcomes and risk factors for complications when using the CHAOS technique throughout the lower limb. Retrospective review of medical records and radiographs for consecutive patients who underwent CHAOS for lower limb deformity correction at a tertiary centre between 2012 and 2020. There were 70 cases in 56 patients, with the site of surgery being the femur in 48 cases, proximal tibia in 17 and distal tibia in 5 cases. Multiplanar correction was performed in 43 cases, and multilevel osteotomy was undertaken in 23 cases. Fixation was undertaken with intramedullary nailing (IMN) in 49 cases and locked plates in 21.The maximum corrections were 40° rotation, 20° coronal angulation, 51° sagittal angulation and 62-mm mechanical axis deviation (MAD). Deformity correction was mechanically satisfactory in all patients bar one who was undercorrected requiring revision. The mean patient global impression of change (PGIC) score was 6.2 out of 7.Overall complication rate was 12/70 (17%). Complications from femoral surgery included two nonunions, one case of undercorrection, one case of stiffness, one muscle hernia and one pulmonary embolism. Complications from tibial surgery were one compartment syndrome, one pseudoaneurysm of the anterior tibial artery requiring stenting, one transient neurapraxia of the common peroneal nerve, one locking plate fatigue failure, one seroma and one superficial wound infection. Computerised hexapod-assisted orthopaedic surgery can be used for accurate correction of complex multilevel and multiplanar deformities of both the femur and tibia. The risk profile appears to differ between femoral and tibial surgeries, and also to that of traditional circular frame correction. Patients remain highly satisfied with both the functional and symptomatic outcomes. French JMR, Filer J, Hogan K, et al. Computer Hexapod-assisted Orthopaedic Surgery for the Correction of Multiplanar Deformities throughout the Lower Limb. Strategies Trauma Limb Reconstr 2024;19(1):9-14.

Abstract 2035: In-Depth Analysis Of Tibial Artery Calcification Through Microct And Histology

Background: Peripheral artery disease (PAD) impacts over 200 million people worldwide. It is traditionally linked to atherosclerotic calcification, or intima arterial calcification (IAC). Recent findings emphasize the role of medial arterial calcification (MAC). Current studies have identified some factors in MAC and IAC, however, a comprehensive understanding of their distinct features and pathogenesis is lacking. This study addresses this gap by examining tibial arteries from PAD patients post-amputation. We characterized the calcification using microCT and histology. Methods: Human tibial arteries were obtained from PAD patients post amputation, and segmented into posterior, anterior, and peroneal arteries. The arteries were dissected, fixed in 4% paraformaldehyde, and stained with iodine. High-resolution microCT images were captured using a Scanco μCT40, and 3D models were reconstructed by ImageJ and Slicer3D. The samples were then processed for histological analysis, including Hematoxylin and eosin (H&amp;E) stain and Alizarin red staining. Results: The study design is shown in Fig. A, featuring the serial dissection of a posterior artery as an example. The microCT scan protocol is designed for imaging continuous sections under a specific orientation. The 3D models enable a comprehensive assessment of calcification and quantification for distinct categorization, and the peroneal artery showed the least calcified lesions (*P&lt;0.05, ***P&lt;0.001; Fig. B &amp; C). MAC/IAC or co-existing lesions were characterized by cross-sectional images and H&amp;E staining. The results indicated a predominance of MAC in the highly calcified group, comprising over 98% of the entire tissue (Fig. D &amp; E). Conclusions: We characterized calcified lesions in tibial arteries by microCT and histology. Calcification categories were determined through 3D models. Histology and cross-section images enabled the assessment and quantification of MAC/IAC or co-existing lesions.