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

Abstract

Ankle arthroscopy carries a lower risk of vascular complications when standard anterolateral and anteromedial portals are used. However, the thickness of the fat pad at the anterior ankle affords little protection for the thin-walled anterior tibial artery, rendering it susceptible to indirect damage during procedures performed on the anterior ankle joint. To our knowledge, only 11 cases of pseudoaneurysm involving the anterior tibial artery after ankle arthroscopy have been described in the literature. Here we reported a rare case of a 19-year-old soccer player who presented with pseudoaneurysm of the anterior tibial artery following ankle arthroscopy using an ankle distraction method and underwent anastomosis for the anterior tibial artery injury. Excessive distraction of the ankle puts the neurovascular structures at greater risk for iatrogenic injury of the anterior tibial artery during ankle arthroscopy. Surgeons should look carefully for postoperative ankle swelling and pain after ankle arthroscopy.

Figure 1

(a) Plain radiograph and (b) three-dimensional computed tomography scan acquired at initial consultation indicating osteophytes at the anterior edge of the distal tibial end and the dorsal side of the talar neck ((a) white arrow, (b) black arrow).

Figure 2

Photographs taken during ankle arthroscopy showing (a) large osteophytes at the anterior edge of the distal tibial end (arrow). (b) After excision using a bone cutter (arrow).

Figure 3

(a) A plain radiograph and (b) a three-dimensional computed tomography scan after ankle arthroscopy showing resection of osteophytes at the anterior edge of the distal tibial end and at the dorsal talar neck ((a) white arrow, (b) black arrow).

Figure 4

Photograph of the ankle and foot showing swelling between the anteromedial portal and the anterolateral portal (arrow) 3 days after ankle arthroscopy.

Figure 5

Magnetic resonance images showing a pseudoaneurysm 25 × 22 × 13 mm in size arising from the anterior tibial artery (arrow) at the level of the ankle joint. The pseudoaneurysm is seen as a mass with a heterogeneous (a) low-intensity to isointensity signal on T2-weighted imaging and (b) high-intensity signal on T2 star-weighted imaging.

Figure 6

Color and duplex Doppler ultrasonography showing flow through the anterior tibial artery (black arrow) at the anterior ankle joint, with decreased flow through the dorsalis pedis artery, suggesting a pseudoaneurysm (white arrow) leaking into the ankle joint (black arrow head). Flow towards and away from the transducer is indicated by red and blue, respectively.

Figure 7

Angiographic image showing a pseudoaneurysm originating from the anterior tibial artery and passing on the anterior side of the ankle joint. Predominantly anterograde filling from the anterior tibial artery is seen (arrow). Flow from the posterior tibial artery and the plantar collateral was also detected. The dorsalis pedis artery is filled by a plantar arch.

Figure 8

Photographic images taken during repair of the anterior tibial artery injury demonstrated that the pseudoaneurysm was caused by disruption of the posterior third of the anterior tibial artery wall (arrow) on the anterior side of the ankle joint (a). The injured anterior tibial artery wall was repaired using an end-to-end anastomosis longitudinally (arrow head), without compromising the blood supply to the foot (b).