Vascular anatomy of the tibiofibular syndesmosis

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1 Washington University School of eicine Digital Open Access Publications Vascular anatomy of the tibiofibular synesmosis Kathleen E. ckeon Washington University School of eicine in St. Louis Rick W. Wright Washington University School of eicine in St. Louis Jeffrey E. Johnson Washington University School of eicine in St. Louis Jeremy J. ccormick Washington University School of eicine in St. Louis Sanra E. Klein Washington University School of eicine in St. Louis Follow this an aitional works at: Part of the eicine an Health Sciences Commons Recommene Citation ckeon, Kathleen E.; Wright, Rick W.; Johnson, Jeffrey E.; ccormick, Jeremy J.; an Klein, Sanra E.,,"Vascular anatomy of the tibiofibular synesmosis." The Journal of Bone an Joint Surgery.94, (2012). This Open Access Publication is brought to you for free an open access by Digital It has been accepte for inclusion in Open Access Publications by an authorize aministrator of Digital For more information, please contact

2 931 COPYRIGHT Ó 2012 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Vascular Anatomy of the Tibiofibular Synesmosis Kathleen E. ckeon, D, Rick W. Wright, D, Jeffrey E. Johnson, D, Jeremy J. ccormick, D, an Sanra E. Klein, D Investigation performe at the Department of Orthopaeic Surgery, Washington University School of eicine, St. Louis, issouri Backgroun: Injuries to the tibiofibular synesmosis commonly cause prolonge ankle pain anisability. Synesmotic injuries are associate with slower healing rates compare with rates for other ankle ligament injuries an typically result in longer time away from sports. To our knowlege, the vascular supply to the synesmosis an its clinical implication have not previously been stuie. The purpose of this stuy was to escribe the vascular supply to the tibiofibular synesmosis with use of a metho of chemical ebriement of caaveric specimens. ethos: Twenty-five matche pairs of ault caaver legs, fifty legs total, were amputate below the knee. Inia ink, followe by War Blue Latex, was injecte into the anterior tibial, peroneal, an posterior tibial arteries uner constant manual pressure to eluciate the vascular supply of the ankle synesmotic ligaments. Chemical ebriement was performe with 6.0% soium hypochlorite to remove soft tissue, leaving bones, ligaments, an casts of the vascular anatomy intact. The vascular supply to the synesmosis was evaluate an recore. Results: The anterior vascularity of the synesmosis was clearly visualize in forty-three of fifty specimens. The peroneal artery supplie an anterior branch (the perforating branch) that perforate the interosseous membrane, an average of 3 cm proximal to the ankle joint. This branch provie the primary vascular supply to the anterior ligaments in twenty-seven specimens (63%). The anterior tibial artery provie aitional contribution to the anterior ligaments in the remaining sixteen specimens (37%). Conclusions: The location of the perforating branch of the peroneal artery places it at risk when injury to the synesmosis extens to the interosseous membrane 3 cm proximal to the ankle joint. In the majority of specimens, injury to this vessel woul result in loss of the primary bloo supply to the anterior ligaments. Clinical Relevance: The vascular supply to the anterior synesmotic ligaments may be amage in ankle synesmotic injuries an may explain the elaye healing that is seen clinically. Injuries to the istal tibiofibular synesmosis account for up to 16% of all ankle sprains 1. This injury, commonly referre to as a high ankle sprain, is associate with a worse prognosis compare with other ligamentous injuries aroun the ankle. Patients frequently experience increase time away from sports, chronic pain, heterotopic ossification, ecrease ankle motion, an long-term isability after a synesmotic injury 2-4. In contrast to the treatment of nonsynesmotic ankle sprains, nonoperative treatment of synesmotic injuries necessitates prolonge perios of non-weight-bearing, immobilization, an rehabilitation 5,6. Early recognition an treatment of these injuries may improve prognosis. However, the reason for prolonge recovery time after synesmotic ligament injury is unclear. The istal tibiofibular synesmosis comprises four istinct ligaments (Fig. 1). The interosseous tibiofibular ligament is continuous with the interosseous membrane at its most istal aspect an runs obliquely from the tibia to the fibula in a lateral-istal-anterior irection. The ligament is pyramial in shape an spans 2 to 3 cm before it terminates approximately 1 cm above the level of the ankle joint 7. The anteroinferior tibiofibular ligament extens obliquely from the relatively large anterior tubercle of the istal tibia (the Chaput tubercle) to the anterior tubercle of the istal fibula. The posteroinferior tibiofibular ligament extens from the posterior malleolus to the posterior tubercle of the fibula an runs more horizontally than its anterior counterpart 7. The transverse tibiofibular ligament has been escribe as either a separate ligament or a Disclosure: None of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of any aspect of this work. None of the authors, or their institution(s), have ha any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. Also, no author has ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. J Bone Joint Surg Am. 2012;94:

3 932 VASCULAR A NATOY OF THE T IBIOFIBULAR SYNDESOSIS Fig. 1 Line rawing showing anterior synesmosis (Fig. 1-A) an posterior synesmosis (Fig. 1-B). eep component of the posteroinferior tibiofibular ligament 8. The fibers of the transverse ligament lie eep to the posterior ligament an run in a similar irection. In a biomechanical stuy, Ogilvie-Harris et al. foun the following contributions to ankle stability: the anteroinferior tibiofibular ligament, 35%; the interosseous ligament, 22%; the eep portion of the posteroinferior tibiofibular ligament or the transverse tibiofibular ligament, 33%; an the superficial fibers of the posteroinferior tibiofibular ligament, 9% 9. To our knowlege, no previous stuy has shown the vascular supply to the tibiofibular synesmosis, although the branching pattern of the peroneal artery at the level of the ankle synesmosis has been escribe 8,10,11. In 1941, Huber reporte a perforating, or anterior, branch of the peroneal artery (Fig. 2) that pierces the interosseous membrane an runs across the anteroinferior tibiofibular ligament beneath the peroneus tertius tenon 10. Bartonícek also mentione a perforating branch of the fibular artery that penetrates the interosseous membrane 7. Fig. 2 Fig. 3 Fig. 2 Photograph showing the anterior synesmosis in which the perforating branch (A) of the peroneal artery (B) travels through the interosseous membrane. Fig. 3 Photograph showing the peroneal artery (A) branching into a perforating branch (B) an a posterior branch (arrow). The perforating branch penetrates the interosseous membrane, an average of 3 cm proximal to the ankle joint.

4 933 VASCULAR A NATOY OF THE T IBIOFIBULAR SYNDESOSIS Fig. 4 Photograph (Fig. 4-A) an line rawing (Fig. 4-B) showing Anterior Type 1. The anterior synesmosis is supplie by the perforating branch of the peroneal artery (A) with multiple small branches (arrows) at the level of the synesmosis. There is no contribution of the anterior tibial artery (B) at the level of the synesmosis. Neither stuy showe specific branches from this artery running irectly to the anteroinferior tibiofibular ligament or any other arteries that were also in proximity to the anterior synesmosis. The purpose of this stuy was to escribe the vascular supply to the tibiofibular synesmosis with use of a metho of chemical ebriement of caaveric specimens. aterials an ethos Institutional review boar exempt status was grante by our university Human Research Protection Office after formal review of the research protocol. Twenty-five pairs of legs (a total of fifty legs) from twenty-five fresh ault human caavers were obtaine from a university-associate boy onation program. Only caavers of iniviuals who haie within seventy-two hours an that ha not been previously frozen or embalme were accepte. Caavers with evience of prior foot or ankle trauma, surgery, eformity, or congenital abnormalities were exclue. A history of ankle sprain or synesmotic injury was unknown for all specimens. The legs were amputate below the knee at the junction of the proximal an mile thirs of the tibial shaft. Skin incisions were mae on the orsal an plantar surfaces of each toe at the level of the proximal interphalangeal joint. The anterior tibial, peroneal, an posterior tibial arteries each were cannulate at the proximal aspect of the specimens by means of an 8-French triple lumen catheter an were manually injecte with saline solution until the effluent from the toes was clear. Any obvious atherosclerosis of the vessels at the level of the amputation was note. Inia ink was then injecte into each artery uner constant manual pressure until Inia ink staining was obvious on the cutaneous surface of the foot an Inia ink flowe from the skin incisions on the toes. War Blue Latex was then injecte in a similar fashion. After injection, the specimens were frozen for at least forty-eight hours. They were subsequently remove from the freezer an were allowe to thaw at room temperature for forty-eight hours. Once fully thawe, the specimens were amputate through the tibia 8 to 10 cm proximal to the ankle joint an the toes were amputate at the metatarsophalangeal joints. An axial pin was place from the tibia through both the talus an the calcaneus to maintain the integrity of the ankle joint uring chemical ebriement. The skin an subcutaneous tissues were sharply issecte away, an the specimens were submerge in 6.0% soium hypochlorite for four to six hours to complete the ebriement of the soft tissues. The specimens were checke every thirty minutes an the soium hypochlorite was refreshe as neee. The ebriement process was stoppe once the overlying soft tissues ha been ebrie aequately to allow examination of the vessels an ligaments of the tibiofibular synesmosis. Although the vessel walls were ebrie with the soium hypochlorite, casts of the vessel lumens fille by War Blue Latex remaine. At this point, the vascular supply to the synesmosis was carefully examine, ocumente, an photographe. Source of Funing There was no external funing source for this investigation. Results The vascular supply to the anterior tibiofibular synesmosis was clearly visualize in forty-three of the fifty specimens stuie. Seven specimens were exclue from the analysis of the anterior arterial supply after injection an chemical ebriement because of either vascular isease (two ankles) or poor injection results (five ankles). The two ankles that ha

5 934 VASCULAR A NATOY OF THE T IBIOFIBULAR SYNDESOSIS Fig. 5 Photograph (Fig. 5-A) an line rawing (Fig. 5-B) showing Anterior Type 2. The anterior synesmosis is supplie by the perforating branch of the peroneal artery (A) with multiple small branches (arrow) at the level of the synesmosis. The anterior tibial artery (B) also provies small branches to supplement the peroneal contribution to the anterior ligaments. been exclue for vascular isease were a matche pair from the same caaver with poor filling of the peroneal artery. These specimens ha atherosclerotic plaques note in the large vessels at the time of the injection. Poor filling ue to the injection technique may also explain the results seen in these specimens. The specimens that ha been etermine to have poor injection results ha obscuring of the vessels ue to leakage of Inia ink or War Blue Latex into the surrouning tissues in one ankle an limite soft-tissue ebriement in four ankles. The ankles in which the remaining soft tissues obscure the vessels ha a limite response to the chemical ebriement espite extening the time over which ebriement was allowe. In the forty-three specimens available for evaluation, there were three primary patterns of vascular supply to the anterior synesmosis. In each of these patterns, the perforating branch of the peroneal artery contribute branches to the anterior synesmosis (Fig. 3). These branches all arose istal to the point at which the vessel passe through the interosseous membrane, an averageof3cmproximaltotheanklejoint.threeistinctpatterns of bloo supply to the anterior ankle synesmosis were seen. The first an most common pattern, Anterior Type 1, was seen in twenty-seven (63%) of the forty-three specimens. In these specimens the perforating branch of the peroneal artery was the only vessel to supply branches to the anterior synesmotic ligaments. Occasional anastomotic vessels between branches of the perforating branch of the peroneal an the anterior tibial artery were seen istal to the anteroinferior tibiofibular ligament (Fig. 4). The secon pattern, Anterior Type 2, was seen in nine specimens (21%). In these specimens the peroneal artery supplie multiple branches to the anterior ligaments. The bloo supply was supplemente by branches of a lesser caliber arising from the anterior tibial artery, although the preominant bloo supply continue to arise from the perforating branch of the peroneal artery (Fig. 5). The thir an least common pattern, Anterior Type 3, was seen in seven specimens (16%). In these specimens the anterior tibial artery supplie branches of a caliber larger than that of the branches from the perforating branch of the peroneal artery. The perforating peroneal artery was note in each of these specimens as a relatively small vessel with few branches (Fig. 6). The vascular pattern was not always consistent in the matche caaver pairs. The anterior bloo supply was consistent in the right an left ankles in eleven matche ankle pairs consisting of twenty-two of the forty-three ankles evaluate. In nine matche ankle pairs (eighteen ankles) a ifference was recore in the vascular pattern in the right ankle compare

6 935 VASCULAR A NATOY OF THE T IBIOFIBULAR SYNDESOSIS Fig. 6 Photograph (Fig. 6-A) an line rawing (Fig. 6-B) showing Anterior Type 3. The anterior synesmosis is supplie primarily by larger branches (A) from the anterior tibial artery (B). The perforating branch of the peroneal artery (C) is a smaller vessel in these specimens. with the left ankle. In three aitional ankles the contralateral sie was exclue for either vascular isease or poor injection results. The vascular supply to the posterior tibiofibular synesmosis was elicite in thirty-eight of the fifty specimens stuie. Twelve specimens were exclue after injection an chemical ebriement because of either vascular isease (three ankles) or poor injection results (nine ankles). Similar to the anterior synesmosis, the ankles that ha been exclue for vascular isease ha poor filling of the posterior branch of the peroneal artery. The specimens that ha been exclue for poor injection results ha obscuring of the vessels ue to leakage of Inia ink or War Blue Latex into the surrouning tissues in five ankles an limite soft-tissue ebriement in four ankles. The vascular supply to the posterior synesmotic ligaments arose completely from the peroneal artery in twentyfour (63%) of thirty-eight specimens (Fig. 7), terme the Posterior Type-1 circulation. In fourteen specimens (37%) the posterior tibial artery also provie small branches to supply the posterior synesmosis (Fig. 8), terme the Posterior Type-2 circulation. There were no specimens in which the posterior tibial artery contribution was the ominant supply to the posterior ligaments. The anterior perforating branch of the peroneal artery i not contribute any branches to the posterior synesmosis, either proximal or istal to penetrating the interosseous membrane. Similar to the anterior finings, not all matche pairs ha the same posterior vascular pattern note on the right ankle compare with the left ankle. In eleven matche pairs consisting of twenty-two of the thirty-eight ankles evaluate, the pattern was consistent in the left an right ankles. Seven matche pairs (fourteen ankles) ha a ifference in the vascularity of the posterior synesmosis with one sie supplie by the peroneal artery only an the other sie supplie by both the posterior tibial artery an the peroneal artery. The contralateral sie was exclue for vascular isease or poor injection results for two ankles. Discussion This escriptive, anatomic stuy confirms the previous escriptions of the perforating branch of the peroneal artery traveling through the interosseous membrane of the istal tibiofibular synesmosis. Furthermore, in the majority of these caaver specimens, this perforating branch provie the primary bloo supply to the anterior ligamentous structures. Small branches supplie the anterior ligaments arising from the perforating branch after the artery penetrate the interosseous membrane. The anterior synesmotic ligaments are more commonly injure in ankle synesmotic injuries 12,13. On the basis of the

7 936 VASCULAR A NATOY OF THE T IBIOFIBULAR SYNDESOSIS Fig. 7 Photograph (Fig. 7-A) an line rawing (Fig. 7-B) showing Posterior Type 1. The posterior synesmosis is supplie by the posterior branch of the peroneal artery (A) with multiple small branches (arrows) at the level of the synesmosis. There is no contribution of the posterior tibial artery (B) at the level of the synesmosis. finings in this stuy, the perforating branch of the peroneal artery is a primary contributor of the vascular supply to these ligaments. A isruption to this branch in an ankle injury is possible given its close proximity to the interosseous membrane. In synesmotic isruptions that exten 3 cm proximal to the ankle joint, the perforating branch of the peroneal artery is in the zone of injury an vulnerable to rupture. The loss of this vessel may compromise the vascular supply to the anterior synesmosis in 63% of ankles on the basis of this analysis an may cause a ecrease in bloo supply in another 21% of ankles. An injury to this arterial branch at the time of a synesmotic injury may result in evascularization of the anterior synesmotic ligaments an is a possible contributing factor to the prolonge healing that is seen clinically. The posterior ligaments have a similar singularity to their vascular supply; however, the primary arterial supply oes not penetrate the ligament an may be less susceptible to injury. Aequate vascular supply is a known prerequisite for tissue healing. The limite bloo supply to a number of anatomic structures has been propose an investigate as a factor in elaye healing or importance when planning surgical exposure Surgical incisions in areas of skin with a known tenency for elaye woun-healing have been shown to have limitations in vascular supply. Borrelli an Lashgari escribe the vascular supply to the lateral hinfoot to offer an anatomic explanation for elaye healing of the corner of the flap with an extensile surgical approach to treat calcaneus fractures 15. Fractures in watershe areas of bone necessitate increase time an are more likely to necessitate surgical intervention for healing to occur. The fifth metatarsal Jones fracture has been an ongoing area of stuy because of the known tenency for nonunion that is thought to stem from isruption of or limitations to the bloo supply in the location of the fracture 17,18. Similarly, insufficient vascular supply to an area of ligamentous injury, specifically the tibiofibular synesmosis, may lea to elaye healing an increase rates of complications. Although it provie new insight into the anatomy of the tibiofibular synesmosis, this stuy ha several limitations.

8 937 VASCULAR A NATOY OF THE T IBIOFIBULAR SYNDESOSIS Fig. 8 Photograph (Fig. 8-A) an line rawing (Fig. 8-B) showing Posterior Type 2. The posterior synesmosis is supplie by the posterior branch of the peroneal artery (A) with multiple small branches at the level of the synesmosis. The posterior tibial artery (B) also provies small branches (arrow) to supplement the peroneal contribution to the posterior ligaments. First, as with any anatomic stuy, this stuy was limite by the quality of the specimens. Any specimen with atherosclerotic isease or peripheral eema with ilate vessels coul potentially have confuse stuy results. Any of these specimens may have ha a history of ankle sprain or synesmotic injury that coul have altere the observe vascular anatomy. There may have been other, less common patterns of vascularity that this stuy i not ientify because of a limite sample size. However, to our knowlege, the present stuy represents the largest number of specimens for which the vascular supply to the tibiofibular synesmosis has been escribe an the only stuy using injection methos with Inia ink followe by chemical ebriement. Also, these methos resulte in purely qualitative ata an lacke a way to quantify the vascular supply to the synesmosis. The component of vascular supply to the synesmotic ligaments irectly from their osseous attachments was not eluciate with this metho. This escriptive stuy escribe the vascular anatomy of the tibiofibular synesmosis. The location of the perforating branch of the peroneal artery places it at risk when injury to the synesmosis extens to the interosseous membrane 3 cm proximal to the ankle joint. Although there is no irect link to associate vascular injury with the clinical challenges of the healing of synesmotic injuries or high ankle sprains, improve unerstaning of the anatomy of the synesmosis may be an important factor in improving our treatment of these injuries. n Kathleen E. ckeon, D Rick W. Wright, D Jeffrey E. Johnson, D Jeremy J. ccormick, D Sanra E. Klein, D Department of Orthopaeic Surgery, Washington University School of eicine, One Barnes-Jewish Hospital Plaza, Suite West Pavilion, Campus Box 8233, St. Louis, O aress for S.E. Klein: kleins@wustl.eu References 1. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent isability associate with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19: Boytim J, Fischer DA, Neumann L. Synesmotic ankle sprains. Am J Sports e. 1991;19: Taylor DC, Englehart DL, Bassett FH 3r. Synesmosis sprains of the ankle. The influence of heterotopic ossification. Am J Sports e. 1992;20: Wright RW, Barile RJ, Surprenant DA, atava J. Ankle synesmosis sprains in national hockey league players. Am J Sports e. 2004;32:

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