Peronea Magna Artery Challenging Proximal Fibula Resection of Ewing’s Sarcoma, Report of a Case

Surgical resection of the fibula is commonly done for either to obtain structural bone graft or to respect the fibula if involved by bone tumor. The vascular anatomy around the popliteal fossa is complex and has to be studied prior to any attempt of surgical resection. We present a case of 11 years old female patient who was diagnosed as a Ewing’s sarcoma of the fibula and her pre-operative CT angiography showed a vascular anomaly of Peronea magna artery. Following adjuvant chemotherapy, the patient was treated by wide local resection and the surgical procedure has to be modified in order to save the dominant peroneal artery the vascularity of the limb.

The congenital popliteal vasculature patterns in fibular free flap reconstruction by means of surgical anatomy in cadavers

Fibular free flap (FFF) is frequently used for reconstruction requiring vascularized bone. Thus, understanding its vasculature variation is crucial. This study investigates the popliteal artery branching variations in Thai cadavers and compares them with previous studies. One hundred and sixty-two legs from 81 formalin-embalmed cadavers were dissected. The popliteal artery branching patterns were classified. The previous data retrieved from cadaveric and angiographic studies were also collected and compared with the current study. The most common pattern is type I-A (90.7%). For the variants, type III-A was the majority among variants (6.2%). Type IV-A, hypoplastic peroneal artery, was found in one limb. A symmetrical branching pattern was found in 74 cadavers. Compared with cadaveric studies, type III-B and III-C are significantly common in angiographic studies (p = 0.015 and p = 0.009, respectively). Type I-A is most common according to previous studies. Apart from this, the prevalence of type III-A variant was higher than in previous studies. Furthermore, type III-B and III-C are more frequent in angiographic studies which might be from atherosclerosis. Thus, if the pre-operative CTA policy is not mandatory, the patients at risk for atherosclerosis and population with high variants prevalence should undergo pre-operative CTA with cost-effectiveness consideration.

Degrees of Arterial Stenosis and Other Factors Related with Diabetic Foot Wound Severity

Background: Few studies have addressed which blood vessels are affected by arterial stenosis in patients with diabetic foot (DF) and the severity thereof. Furthermore, whether the severity of arterial stenosis is significantly correlated to DF severity was yet to be established. We analyzed the association between the severity of arterial stenosis and DF wound severity, along with a variety of relevant factors.Methods: Seventy-one cases hospitalized with DF were evaluated. To assess the degree of arterial stenosis of the five major arteries of the lower extremity (femoral, popliteal, anterior tibial, posterior tibial and peroneal artery), we performed computed tomography angiography, and quantified arterial stenosis using Bollinger scores. We then assessed DF severity and calculated self-reported wound scores. We also analyzed factors that can affect DF severity and the degree of arterial stenosis in the lower extremities.Results: There was no significant association between the mean total Bollinger score and wound severity. Albumin, protein, and Bollinger scores of femoral arteries showed significant association with wound severity, and age and ankle-brachial index (ABI) showed significant association with mean total Bollinger scores (P<0.05). Albumin and Bollinger scores of femoral arteries had significant association with wound severity, and age and ABI showed significant association with mean total Bollinger scores (P<0.05).Conclusion: There was no significant association between the degree of vascular obstruction and the severity of DF. Our results indicate that surgeons should consider the other factors above to ensure appropriate management of patients with DF and assess the prognosis.

Anatomical Variability of System of Popliteal Artery Branches in the Human Fetus of 4-6 Months

The study of topographical variations of the branches of the popliteal artery in human fetuses from a macroscopic point of view in modern anatomy is considered relevant and promising. The need to study the anatomy of the terminal branches of the popliteal artery in fetuses of different ages is due to the rapid development of fetal surgery and the improvement in the performance of surgical procedures on the structures of the knee and lower leg areas, since the establishment of the anatomical variability of the vessels of the lower extremities allows choosing the optimal tactics of surgical intervention. In the literature, there are fragmentary data on the fetal topography of the popliteal artery and its branches. The purpose of the study. The study aimed to establish the topographic and anatomical features of the branches of the anterior and posterior tibial arteries in human fetuses of 4-6 months. Material and methods. The study of the fetal anatomy of the popliteal artery was carried out on 34 preparations of human fetuses (81.0-230.0 mm parietococcygeal length) using the methods of anatomical preparation, vascular injection, and morphometry. Results and discussion. In 21 examined fetuses, the classic variant of the branching of the anterior and posterior tibial arteries was observed both on the right and on the left extremity. In other fetuses, atypical variants of the origin and topography of the branches of the popliteal artery were found. The most interesting, from our point of view, was the anatomical variants of the terminal branches of the popliteal artery in fetuses of 160.0, 180.0, and 195.0 mm parietococcygeal length. A high variant of the branch of the peroneal artery from the popliteal artery; a rare variant of doubling the peroneal artery is trifurcation of the popliteal artery into the anterior and posterior tibial and peroneal arteries, doubling of the branches of the tibioperoneal trunk, as well as the formation of anastomoses between them were revealed. Among the most frequent atypical variants of the onset of the peroneal artery in the studied human fetuses was its branch from the tibioperoneal trunk. Conclusion. To obtain a clear idea of the spatial orientation of the peroneal artery in human fetuses, fetal surgeons should distinguish three segments in the peroneal artery trunk: segment I of the peroneal artery (it is proximal part) is the passage of the peroneal artery trunk in the ankle-popliteal canal; segment ІІ (middle part) corresponds to the topography of the peroneal artery in the inferior muscular-peroneal canal; the third segment of the peroneal artery (distal part) is a segment of its trunk from the point of exit from the inferior muscular-peroneal canal to the level of its division into terminal branches

Anatomical variant of physeal blood supply to the fibula

Vascularised epiphysial fibula bone transfers in the paediatric population provides a solution to growth suppression in extremity reconstruction. We report a case of an anatomical variant to the epiphysial blood supply that has never been reported in literature. A 6-year-old girl underwent a free vascularised fibula flap for reconstruction of her right humerous following osteosarcoma resection. While identifying and dissecting the recurrent epiphysial branch, a large branch from the peroneal artery was identified which directly entered the head of the fibula. No dominant supply from the anterior tibial (AT) vessels to the head of the fibula was seen. This led to the need for a bipedicled flap with diaphyseal supply from the AT vessels and the epiphysial transfer based on the peroneal artery. The patient made an uneventful recovery from the procedure. The same technique may be used by surgeons that may encounter this unique variant in clinical practice.

Two-point flap blood glucose measurement for monitoring propeller flap perfusion – a case report

Monitoring flap perfusion is a helpful method of postoperative care allowing for proper early intervention in and salvage of a flap. The basic means of blood supply monitoring include the assessment of color, warmth, skin tension, and a pin-prick examination. Along with advances in microvascular surgery, methods of flap blood circulation assessment have been also developed. This paper presents the case of a peroneal artery propeller perforator flap for the treatment of a secondary wound resulting from an orthopedic complication of ankle arthrodesis. Blood glucose level (BGL) was used to monitor flap perfusion as an early indicator of possible venous congestion. It is well known that in case of vascular compromise, whether arterial or venous, the flap salvage rate depends on how fast the vascular problem is resolved. Arterial insufficiency is easily detectable, and the arterial flow may be also monitored with minidoppler, however venous insufficiency causes symptoms less dynamically. This fact emphasized the importance of early prediction of venous insufficiency before clinical symptoms appear. It is crucial that the time between pedicle impairment and clinical signs is as short as possible.

Clinical Application of the Peroneal Artery Perforator Flap for Reconstruction of Lateral Malleolus Defects

The reconstruction of defects of the lateral malleolus involving the exposed fibular bone or tendon is challenging. This study aimed to evaluate the clinical application of the peroneal artery perforator flap with or without split-thickness skin grafting for soft tissue reconstruction of the bony defect of the lateral malleolus of the ankle joints. Reconstruction using a peroneal artery perforator flap with or without split-thickness skin grafting was performed for 15 patients (10 men, 5 women) between January 2007 and December 2018. The mean age was 53.7 years, and the mean size of the flaps was 40 cm2. The flaps were elevated in the form of a perforator flap, and split-thickness skin grafting was performed over the flaps and adjoining raw areas. The flaps survived in all cases; however, partial necrosis was observed in 3 cases. In cases of small-sized defects of the lateral malleolus of the ankle joints where a flap is required for the exposed bone or tendon, reconstruction using the peroneal artery perforator flap is advantageous, since the morbidity rate of the donor site is low and soft tissue is reconstructed.