Our patient is a 16-year-old otherwise healthy male who sustained an injury to the left leg while playing football, 2 years before presentation. He was found to have a left distal third oblique tibia fracture (Fig. 1) and was splinted in an outside emergency department that evening. Soon after, he was transitioned to a cast which remained in place for 6 weeks, and then to a boot for an additional 4 weeks. The patient then returned to playing football and did well, with mild occasional symptoms of aching pain for approximately 2 years.
Two years after the initial injury, the patient was tackled from the side while playing football. He had immediate pain in the left tibia in the same location of the previous fracture. The pain persisted for approximately 6 months. It was localized to the site of the prior tibia fracture and extended to the anterior aspect of the foot. The patient also noted occasional numbness and tingling in the tips of his toes.
Initial assessment at the time of presentation to our institution showed the left lower extremity to be grossly normal in appearance, with no swelling or deformity. The patient had tenderness to palpation along the left distal tibia. He had no neurologic deficit, with normal motor and sensory function throughout the lower extremities. Vascular exam was also normal.
Radiographs showed an apparent channel in the lateral aspect of the distal tibia, consistent with a partial nonunion; however, the remainder of the fracture appeared well-healed (Fig. 2).
A CT scan was obtained for further evaluation and showed a tubular channel running through the lateral cortex of the distal third of the tibia, at the previous fracture site (Fig 3). The appearance was consistent with entrapment of the neurovascular bundle, warranting further imaging with an magnetic resonance imaging (MRI) (Fig. 3).
MRI demonstrated the anterior tibial artery and deep peroneal nerve embedded within the lateral distal tibial cortex (Fig. 4).
Given the patient's persistent pain at the fracture site and concern for entrapment of the neurovascular bundle in the setting of partial nonunion, surgical intervention was offered. The decision was made to proceed with exploration and removal of the neurovascular bundle from within the cortical bone. We discussed that if the artery appeared to be coursing through the bone, it would likely not be functional. Given his foot remained well perfused, bypass was not planned (even if the anterior tibial artery was nonfunctional).
A longitudinal incision was made along the distal third of the anterior tibial crest of the left leg. Sharp dissection was carried down through the floor of the anterior tibialis tendon sheath. The periosteum was elevated using a Cobb elevator, to expose the anterior tibial artery and deep peroneal nerve. Exploration of the deep peroneal nerve showed it to be adherent to the periosteum, but not encased within the bone. The nerve was mobilized and neurolyzed throughout the entire zone of injury. The nerve was protected for the remainder of the procedure. The anterior tibial artery was encased in bone, entering the tibial cortex approximately 9 cm above the tibiotalar joint and exiting approximately 4 cm above the tibiotalar joint (Fig. 5).
An osteotome was used to create a trough in the tibia, extending from the entrance and exit points of the anterior tibial artery. The artery was easily removed from the bone after creation of the trough and was left in continuity. The artery was found to be non-pulsatile when the tourniquet was released. The patient was placed in a soft dressing and allowed to weight bear as tolerated in a walking boot.
The post-operative course was uncomplicated. The patient was seen at 6 weeks postoperatively. He reported significant improvement in his pain compared to preoperatively. He had been wearing the boot while out of the house. He had not yet returned to sporting activities. Examination at that time showed no motor or sensory deficits and a normal vascular exam. Radiographs showed the cortical defect along the lateral distal tibia with signs of ongoing healing at the fracture site (Fig. 6).
The patient was allowed to gradually return to his activities. He will be seen again at 6 months postoperatively.