1Departments of Orthopaedic Surgery (E.-C.J., K.-S.S., H.-J.J., J.-S.L., and J.J.Y.) and Radiology (B.K.K.), Chung-Ang University Hospital, Heukseok-dong, Dongjak-gu, 224-1, Seoul, Republic of Korea. E-mail address for K.-S. Song: email@example.com
Most pseudoaneurysms forming after arthroscopic surgery have involved the popliteal vessels after knee arthroscopy1,2. However, the cases of five patients who had a pseudoaneurysm of the anterior tibial artery after ankle arthroscopy have been reported in the English-language literature and were found after a search of the PubMed database with use of three keywords: pseudoaneurysm, ankle, and arthroscopy1,3-6. Although the cases of two patients involved anticoagulation therapy5 and hemophilia3, which increase the risk of arterial injury, iatrogenic trauma may have occurred during portal placement or operative procedures, such as synovectomy and osteophyte resection. All five patients described in the literature were treated by different surgical techniques. We present the case of a patient who had delayed detection of an anterior tibial artery pseudoaneurysm with osseous erosion after ankle arthroscopy. The condition was treated effectively with ultrasound-guided compression therapy. The patient was informed that data concerning the case would be submitted for publication, and he consented.
A twenty-five-year-old man, in good general health, presented with a four-year history of pain and swelling in the anterolateral aspect of the right ankle. In addition, the ankle had sustained recurrent plantar flexion and inversion sprains that had been treated conservatively with rest, compression, and intermittent splinting. Physical examination revealed tenderness and moderate swelling of the anterolateral aspect of the right ankle with a positive anteromedial rotatory drawer maneuver7. Stress radiographs demonstrated a positive anterior drawer sign, and magnetic resonance imaging showed increased signal intensity in the anterior talofibular ligament and anterolateral synovitis of the right ankle. The patient underwent ankle arthroscopy with a 4.0-mm, 30° arthroscope with use of standard anteromedial and anterolateral portals under tourniquet control and noninvasive distraction of up to 20 lb (9 kg) with an ankle strap and foot traction. An arthroscopic pump was used for joint distension. The hypertrophic synovium was resected arthroscopically with use of a 3.5-mm motorized shaver, and anterior talofibular ligament repair was performed with use of a standard open Broström technique8. The portal sites and surgical wound were closed with skin sutures, and a short leg cast was applied to the leg immediately after the surgery. The patient complained of sustained, but tolerable, pain that was controlled well with intermittent analgesics while in the hospital, and there were no unusual findings upon removal of the sutures through a cast window on postoperative day 10. The short leg cast was removed at six weeks postoperatively.
Eight weeks after surgery, clinical examination showed indurated anterior swelling, a pulsatile anterior mass, and pain with range of motion of the right ankle. Needle aspiration of the mass yielded 30 mL of bright red blood. The color and duplex Doppler ultrasonography scan (Sequoia 512; Siemens Medical Solutions, Erlangen, Germany) showed a mosaic pattern of colors with “whirling” blood flow and “to-and-fro” motion typical of a pseudoaneurysm. The neck of the pseudoaneurysm was 8 mm in length, and it was attached to the posterior wall of the distal part of the anterior tibial artery (Fig. 1, A). Computed tomographic angiography (LightSpeed Pro 16; GE Medical Systems, Milwaukee, Wisconsin) of the lower limb vasculature demonstrated that the anterior tibial-dorsalis pedis artery was displaced anteriorly by a pseudoaneurysm that was 3.5 × 2.8 × 1.9 cm in size, and osseous erosion of the central-to-lateral side of the distal end of the tibia was detected (Fig. 1, B). The patient was referred to a vascular radiologist and was treated with nonoperative ultrasound-guided compression therapy on an outpatient basis.
The procedure was performed with the patient in the supine position. The neck of the pseudoaneurysm was localized with an ultrasonographic transducer, and the inflow portion of the proximal portion of the neck was marked with a pen. Next, a small bar was placed over the center of the mark, and direct pressure was applied to the small bar with just enough pressure to impede arterial flow into the pseudoaneurysm (Fig. 2). This amount of pressure was maintained with use of a 1.8-cm-wide compression band around the ankle. In order to preserve the distal blood flow to the foot, a splint and soft towel was applied beneath the compression band, particularly on the posteromedial side of the ankle to protect the posterior tibial artery. During the procedure, we confirmed the cessation of blood flow to the pseudoaneurysm sac by ultrasonography every thirty minutes. If flow into the sac was still present, the small bar was repositioned to impede flow completely. The compression was maintained for three hours per day with three to four-day intervals between the treatments, and four total treatments were given in the outpatient clinic. During the procedures, the patient had mild foot pain, which was tolerable without any medication. Mild swelling and mild cyanosis in the foot resolved within ten minutes after the compression band was removed. After each session, the patient was maintained on bed rest for one hour.
The pseudoaneurysm was completely obliterated after four sessions of compression. The ultrasonography scan performed just before the second session showed thrombus formation and thickening of the wall of the pseudoaneurysm, and the blood-filling portion was decreased to about 22% (2.28 × 1.37 ×1.30 cm) of the volume seen in the first session (Fig. 3, A). The sac was decreased to about 8% (1.14 × 1.21 × 1.07 cm) after the second session, 0.3% (0.52 × 0.36 × 0.26 cm) after the third session, and then completely obliterated after the fourth session (Fig. 3, B). The distal part of the anterior tibial artery showed stenosis, and the dorsalis pedis artery was weakly pulsatile with a weak flow of 4.52 cm/sec. The pseudoaneurysm sac changed from anechoic to isoechoic with a hypoechoic rim. There was no evidence of distal embolization of the thrombus to the foot. The symptoms subsided, and the patient recovered uneventfully after the four sessions of compression. He was examined eighteen months after ankle arthroscopy and remained free from pain and was participating in athletic activities such as football. Ultrasonography and computed tomographic angiography were performed again and demonstrated complete obliteration of the pseudoaneurysm without recurrence (Fig. 4).
A pseudoaneurysm likely originates from a partially damaged artery with hemorrhage into the surrounding soft tissues9. It usually occurs following trauma10, although other causes have been described.
Although the cause of pseudoaneurysm in this patient is not clear, aggressive shaving through the anterolateral portal could be a direct cause, considering that the vessel injury site was situated at the posterior wall of the anterior tibial artery. In addition, the ankle strap placement during joint distraction (even though the strap itself does not present a direct risk) and placement of the foot in plantar flexion during arthroscopy may have decreased the distance between the anterior tibial artery and the anterior ankle capsule. In order to reduce the risk of pseudoaneurysm during ankle arthroscopy, it may be helpful to partially release the distraction force on the ankle, which would decrease the tension on the anterior capsule. When shaving anteriorly, it is important to avoid the following situations: poor irrigation inflow, causing the capsule to be insufficiently distended; turning the shaver blades up into the soft tissues and capsule; and excising too much of the capsule.
In previous reports1,3-6, the postoperative time frame for detecting pseudoaneurysm after ankle arthroscopy has ranged from one week to two months. In our patient, pseudoaneurysm with osseous erosion was detected at eight weeks. The occurrence of osseous erosion suggests that the arterial injury probably occurred near the time of surgery. The cast applied to protect the ligament reconstruction might have hindered the early detection of the pseudoaneurysm and contributed to the osseous erosion of the distal portion of the tibia by pulsatile compression of the pseudoaneurysm. We now routinely remove the cast at two weeks to examine the ankle, remove the sutures, and evaluate the neurovascular structures and surrounding skin.
All five patients in the previous reports who had a pseudoaneurysm develop after ankle arthroscopy were managed operatively, by different surgical approaches (Table I). Although postoperative complications resulting from surgical repair were not reported, additional surgery may increase postoperative morbidity. In our patient, the relatively long neck of the pseudoaneurysm and the intact circulation of the posterior tibial artery and plantar arch were indications for nonoperative ultrasound-guided compression therapy. This method has been reported to be effective in the treatment of intervention-related femoral pseudoaneurysm11-13, and success rates have ranged from 60% to 90%14. To the best of our knowledge, this is the first report of ultrasound-guided compression therapy for an anterior tibial artery pseudoaneurysm. It is a simple, noninvasive, and safe technique performed on an outpatient basis14.
Ultrasound-guided compression therapy for pseudoaneurysm may be ineffective in patients with a coagulation deficit14 because the formation of a thrombus in the pseudoaneurysm is a very important step in this therapy. A successful outcome is usually forthcoming when there is no flow within the aneurysm during compression and a visible thrombus is observed during the first session. Ultrasound-guided compression therapy should be considered to be inappropriate if no substantial thrombus formation is seen within the pseudoaneurysm after repeated compressions or if the patient complains of intolerable pain during compression. Additionally, patients with rapid expansion of the pseudoaneurysm (with resulting compartment syndrome), vascular compromise, or other emergent complications should be treated surgically as soon as possible. Some authors10,15 have reported that ligation of the anterior tibial artery can be performed without ischemic consequences if the plantar arch is intact and has an alternative blood supply. In our patient, the pseudoaneurysm was completely obliterated after four sessions of compression, without recurrence or distal embolization, and the patency of the dorsalis pedis artery was preserved; however, stenosis and weak blood flow were observed. The reduced blood flow of the dorsalis pedis artery did not impede recovery or interfere with sports activities when the patency was evaluated eighteen months later.
When a pseudoaneurysm occurs at the anterior tibial artery, ultrasound-guided compression therapy is an effective nonoperative treatment alternative to surgery for patients with intact circulation of the posterior tibial artery and plantar arch who do not have a coagulation deficit.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Departments of Orthopaedic Surgery and Radiology, Chung-Ang University, College of Medicine, Seoul, Republic of Korea
1. Mariani PP, Mancini L, Giorgini TL. Pseudoaneurysm as a complication of ankle arthroscopy. Arthroscopy. 2001;17:400-2.
2. Guy RJ, Spalding TJ, Jarvis LJ. Pseudoaneurysm after arthroscopy of the knee. A case report. Clin Orthop Relat Res. 1993;295:214-7.
3. Kotwal RS, Acharya A, O'Doherty D. Anterior tibial artery pseudoaneurysm in a patient with hemophilia: a complication of ankle arthroscopy. J Foot Ankle Surg. 2007;46:314-6.
4. Darwish A, Ehsan O, Marynissen H, Al-Khaffaf H. Pseudoaneurysm of the anterior tibial artery after ankle arthroscopy. Arthroscopy. 2004;20:e63-4.
5. O'Farrell D, Dudeney S, McNally S, Moran R. Pseudoaneurysm formation after ankle arthroscopy. Foot Ankle Int. 1997;18:578-9.
6. Salgado CJ, Mukherjee D, Quist MA, Cero S. Anterior tibial artery pseudoaneurysm after ankle arthroscopy. Cardiovasc Surg. 1998;6:604-6.
7. Watson AD. Ankle instability and impingement. Foot Ankle Clin. 2007;12:177-95.
8. Broström L. Sprained ankles. VI. Surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966;132:551-65.
9. Dennis DA, Neumann RD, Toma P, Rosenberg G, Mallory TH. Arteriovenous fistula with false aneurysm of the inferior medial geniculate artery. A complication of total knee arthroplasty. Clin Orthop Relat Res. 1987;222:255-60.
10. Ozdemir H, Mahmutyazicioğlu K, Ozkökeli M, Savranlar A, Ozer T, Demirel F. Pseudoaneurysm of the dorsalis pedis artery: color Doppler sonographic and angiographic findings. J Clin Ultrasound. 2003;31:283-7.
11. Sorrell KA, Feinberg RL, Wheeler JR, Gregory RT, Snyder SO, Gayle RG, Parent NF 3rd. Color-flow duplex-directed manual occlusion of femoral false aneurysms. J Vasc Surg. 1993;17:571-7.
12. Schaub F, Theiss W, Heinz M, Zagel M, Schömig A. New aspects in ultrasound-guided compression repair of postcatheterization femoral artery injuries. Circulation. 1994;90:1861-5.
13. Cox GS, Young JR, Gray BR, Grubb MW, Hertzer NR. Ultrasound-guided compression repair of postcatheterization pseudoaneurysms: results of treatment in one hundred cases. J Vasc Surg. 1994;19:683-6.
14. Kang SS, Labropoulos N, Mansour MA, Michelini M, Filliung D, Baubly MP, Baker WH. Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg. 2000;31:289-98.
Copyright 2008 by The Journal of Bone and Joint Surgery, Incorporated
15. Yamaguchi S, Mii S, Yonemitsu Y, Orita H, Sakata H. A traumatic pseudoaneurysm of the dorsalis pedis artery: report of a case. Surg Today. 2002;32:756-7.