Vascular dangers of the posterolateral approach in a peroneal artery dominant leg

Video Description

?? ????Vascular dangers of thye PL approach in a Peroneal dominant or Posterior Tibial Artery absent leg ????

Over the last 2 weeks I have been posting cases to encourage discussion on treatment of posterior malleolar ankle fractures. After over a decade of research, which initially involved the movement away from the percentage joint argument, the last 5 years has been on how to get the best results. One main factor has been the moving away from the posterolateral approach. One major factor is the vascular risk. The knowledge of the importance of the peroneal artery to both FHL blood supply, and sometime the entire limb, is seriously underestimated.

This video highlights a case of a two vessel leg (ie no Posterior tibial artery) which is then supported by the communicating branch between peroneal and PT. This unfortunately lies exactly where your plate sits if doing a PL or PM approach. The Medial Posteromedial (MPM) approach is a safer alternative, as it elevates both arteries off, including the communicating branch, and allows access anterior to the danger.

This case has been given by Togay Koç, an excellent example of a two artery leg, where the initial plate caused foot ischemia because it was inadvertently placed on the communicating branch. This would have not been an issue in a three vessel leg (and we have all probably done this many times!). Also note the blush at the injured peroneal perforator’s to FHL. If all these are damaged, the FHL will become avascular and possibly form a Volkmanns contracture.