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Objective - A patient presented with life threatening hemorrhage from a ruptured posterior tibial artery pseudoaneurysm following an attempted endoscopic gastrocnemius recession (aponeurosis transection) for a diabetic foot ulcer. This is the first such reported complication associated with this procedure.
Methods - Case report.
Results - This 48 year old diabetic patient had undergone an aborted endoscopic gastrocnemius recession by a podiatrist to improve ankle dorsiflexion and healing of a plantar first metatarsal ulcer. The procedure was stopped due to excessive bleeding and the wound closed. The incision subsequently opened and was treated with local dressing changes. Two months later, the patient developed acute arterial bleeding at home and was found by EMS to be awake but in hypovolemic shock with a blood pressure of 82/36 and later hematocrit of 22%. A pressure dressing was applied and he was taken directly to the operating room from the emergency department. With a proximal calf tourniquet applied, the wound was opened and a pseudoaneurysm cavity was explored. The posterior tibial artery was cleanly transected and the ends separated along with a partially transected and thrombosed vein. As the patient had a palpable dorsalis pedis pulse with the tourniquet deflated, the arterial ends were dissected to normal tissue and suture ligated. The chronic wound was debrided and partially closed. Postoperative noninvasive vascular studies confirmed a normal ABI of 1.2 and good PVR waveforms. The wound was treated with local wound care and healed uneventfully. It remains healed and the patient asymptomatic three months later.
Conclusions - Minimally invasive endoscopic procedures, such as gastrocnemius recession and Achilles tendon lengthening, are at risk for arterial injury due to close proximity of the vessels. Awareness of these anatomic relationships may help prevent such complications. Should unexpected vascular injury occur, early vascular surgery consultation should be obtained.