PMC6280239_01
(a) Plain radiography and (b) 3-dimensional computed tomography image indicating nonunion of the medial malleolus. Arrow shows nonunion site of the medial malleolus.
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Plain radiography and three-dimensional computed tomography (3D-CT) of the right ankle confirmed that there was no bony bridge formation of the medial malleolar fragment (Figures 1(a) and 1(b)); osteophytes were noted at the anterior edge of the distal end of the tibia with joint space narrowing.
Photograph of the ankle and foot showing swelling around the anterolateral portal (arrow) 4 weeks after ankle arthroscopy.
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Following cast removal 4 weeks after surgery, slight tenderness and a pulsatile swelling was noted in the anterolateral aspect of the ankle (Figure 2); the DPA pulse was, however, palpable.
Enhanced three-dimensional computed tomography (CT) images show the perforating peroneal artery (arrow) with the absence of the anterior tibial artery and posterior tibial artery (a) and the pseudoaneurysm of the perforating peroneal artery (arrow) at the lateral aspect of the ankle joint (b). Enhanced CT images also show the size of the pseudoaneurysm (arrow) 15 x 20 x 30 mm on the sagittal (c) and axial planes (d).
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The absence of the ATA and PTA was seen on enhanced 3D-CT imaging (Figure 3(a)), with an associated pseudoaneurysm in continuity with the perforating peroneal artery at the level of the anterolateral ankle joint (Figure 3(b)) and with dimensions of 15 x 20 x 30 mm (Figures 3(c) and 3(d)).
Color and duplex Doppler ultrasonography showing flow through the perforating peroneal artery (arrow) at the anterolateral ankle joint, suggesting a pseudoaneurysm (arrowhead) leaking into the ankle joint. Flow toward and away from the transducer is indicated by red and blue, respectively.
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Color and duplex Doppler ultrasonography displayed a mosaic pattern with pathognomonic "whirling" blood flow and "to-and-fro" motion indicative of a pseudoaneurysm on the wall of the perforating peroneal artery (Figure 4).
Photographic images taken during repair of the perforating peroneal artery injury. (a) Pseudoaneurysm (arrow) caused by disruption of the perforating peroneal artery wall on the anterolateral side of the ankle joint. Arrow indicates the main trunk of the perforating artery proximally and distally. (b) Pseudoaneurysm is cut (arrowhead) followed by removal of the hematoma-like content within the pseudoaneurysm. Arrow indicates the main trunk of the perforating artery proximally and distally. (c) Repair of the injured perforating peroneal artery wall using end-to-end anastomosis (arrow), without compromising blood supply to the foot.
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There was disruption of the posterolateral 1/3 of the perforating peroneal artery wall with leakage of blood into the ankle, resulting in the pseudoaneurysm (Figure 5(a)). The pseudoaneurysm was cut, and some hematoma-like content seen within the lumen was removed (Figure 5(b)). The injured arterial walls adjacent each other were sutured using end-to-end anastomosis, and blood flow was preserved distally (Figure 5(c)).