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The Risk of Injury to the Peroneal Artery in the Posterolateral Approach to the Distal Tibia: A Cadaver Study

Objectives: The posterolateral approach to the distal tibia allows excellent visualization, direct reduction, and stabilization of posterior malleolar fractures. Concomitant fractures of the lateral malleolus may be internally fixed through the same approach. The approach may also be used for pilon fractures and for bone grafting in nonunions. This study aims to establish the safe zone of proximal dissection to avoid injury to the peroneal vessels when performing the posterolateral approach to the distal tibia. Methods: Twenty-six unpaired adult lower limbs were dissected using the posterolateral approach to the distal tibia. The peroneal artery was identified, as it coursed through the interosseous membrane on deep dissection and the level of its bifurcation was noted over the tibia. Perpendicular measurements were made from these points to the tibial plafond and distal fibula. Results: The peroneal artery bifurcated at 83 ± 21 mm (range, 41–115 mm) proximal to the tibial plafond and 103 ± 21 mm (range, 61–136 mm) from the distal fibula. The peroneal artery perforated through the interosseous membrane 64 ± 18 mm (range, 41–96 mm) proximal to the tibial plafond and 81 ± 20 mm (range, 42–113 mm) from the distal fibula. Conclusions: The posterolateral approach to the distal tibia allows direct reduction of posterior malleolus fractures. The peroneal artery may bifurcate and perforate through the interosseous membrane as little as 41 mm from the tibial plafond. Dissection around this region should be performed with care due to the wide variation in vasculature, however, once the peroneal artery is mobilized, a buttress plate can easily be placed beneath it.