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pseudoaneurysm is a rare complication reported after any surgery such as orif of fracture , plate removal , ankle or knee arthroscopy or arthroplasty . to our knowledge ,
we report a case of a 18-year - old male patient who had pseudoaneurysm of posterior tibial artery following plate removal .
a 18-year - old male was referred to our outpatient clinic because of mass - like lesion in his left calf .
he had a history of car accident and left isolated tibia fracture 30 months ago that was treated by open reduction and internal fixation with dcp plate .
after union in radiograph , the plate was removed 7 months ago on the patient request .
finally , pseudoaneurysm was diagnosed and was repaired in a common surgery with a vascular surgeon without any difficulty .
pseudoaneurysms of the posterior tibial artery after tibial plate removal are an extremely rare phenomenon .
this complication in most cases follows penetrating injuries but it has been reported following blunt trauma .
in fact , in most of these patients the diagnosis was initially missed because the large hematoma concealed the underlying pseudoaneurysm and its pulsations .
hence , the surgeon should be suspicious to this complication following plate removal when he / she is doubtful about the sign and symptoms .
implant removal in orthopaedic procedures have more frequently been a subject of controversy [ 1 , 2 ] . some surgeons prefer to remove the implant routinely in skeletally immature patients and also in adults , others do this by patient s request or when complications such as infection , pain , breakage , malunion , delayed or nonunion occurs .
we present a 18-year - old male patient with isolated pseudoaneurysm of the posterior tibial artery ( proximal third ) after plate removal in tibia .
the patient presented to our outpatient department with complaints of a firm , pulse less , non - tender swelling on the posterior aspect of the leg which gradually increased in size by overtime .
a 18-year - old male patient was referred to our outpatient clinic because of masslike lesion in his left calf .
he had a history of car accident and left isolated and closed tibia fracture 30 months ago that was treated by open reduction and internal fixation with 4.5 mm broad dcp plate ( fig . 1 , 2 ) .
the surgical approach was through 1 cm lateral to tibial crest and plate was in lateral aspect of tibia . in this period ,
after 2 years , union was obvious in ap and lateral radiographs , and removal of tibial plate was decided .
the plate had been removed 7 months ago on patient s request . at the time of surgery
plate and screw removal was done without any complication ( eg , plate or screw break down ) .
, the bone in radiograph was completely united and the patient was discharged when we find near 50 - 100 cc collection in the drain at the second day post operation.(fig .
post - operation radiograph after plate removal shows the bone was completely united . at the first post operation visit
about 4 weeks after plate removal , he came back with mild paresthesia in the left foot at the plantar surface .
also , he had firm , pulse less and non - tender swelling with unclear border on the posterior aspect of the leg which gradually increased over time . position of ankle was plantigrade . in vascular examination , we found the dorsalis pedis and the posterior tibialis pulses were equal to the opposite leg .
we followed this patient without further investigation . at about 3 months after plate removal ,
thus , we thought that paresthesia was due to iatrogenic tibial nerve injury ( eg , bennet tip ) .
approximately 5 months after surgery , he returned with calf muscle firmness and occasional spasm like pain .
paresthesia remained mild and distal pulses were normal and swelling was more firm and fixed . in physical exam , the skin over the mass was intact and we did nt see ecchymosis or discoloration in this area .
we found no tenderness at the fracture site and patient did nt compliant from pain similar the previous fracture .
mri was requested for this patient for calf muscle evaluation . at 1 month after mri request ,
the patient came back and discovered a large ( 5 x 7 cm ) soft tissue mass that was enhanced with probable diagnosis of hemotoma or pseudoaneurysm ( fig .
after the patient was systemically heparinized with 5000 units of unfractionated heparin , angiography showed the widening between the anterior and posterior tibial artery which confirmed the pseudoaneurysm of the posterior tibial artery ( fig.7 , 8) .
coronal magnetic resonance imaging ( mri ) of the left leg reveals the pseudoaneurysm of the posterior tibial artery .
sagittal mri of the left leg confirmed the diagnos is of the pseudoaneurysm arising from the posterior tibial artery in this patient .
, clots and hemotoma was evacuated and the posterior tibial artery perforation was repaired ( fig . 9 , 10 ) . at the operation time , clots and hemotoma was evacuated .
this photograph that was taken at the operation time shows pseudoaneurysms of the posterior tibial artery .
to our knowledge , pseudoaneurysms of the posterior tibial artery after tibial plate removal are too rare phenomenon [ 4 , 5 ] .
this branch of popliteal artery begins at the lower border of the popliteus , descends obliquely and supplies the posterior compartment of the leg and plantar surface of the foot .
along its course , it accompanied by the posterior tibial vein [ 6 , 7 ] .
pseudoaneurysms in most cases follow penetrating injuries but in our case it has been reported following blunt trauma [ 8 , 9 ] . indeed , the literature showed that in most of these patients the diagnosis was initially missed because the large hematoma concealed the underlying pseudoaneurysm and its pulsations .
thus , delay in the diagnosis is usual in this phenomenon [ 8 , 10 ] .
maxwell - armstrong and his co - author reported pseudoaneurysm of the anterior tibial artery following removal of tibial plate .
fung and his coauthors also reported pseudoaneurysm of the radial artery following plate removal in radius .
although this complication can be seen after fixation of leg , distal radius , clavicle and femur fracture with plate , total knee arthroplasty , the overall pseudoaneurysm incidence after plate removal is unknown but in our knowledge it is too rare [ 13 - 17 ] . in this manuscript
, we present a 18-year - old male patient with a mass in his left calf that was diagnosed pseudoaneurysm of the posterior tibial artery .
the time for the diagnosis of pseudoaneurysm in the literature is seen to vary from hours to years , depending on the location of pseudoaneurysm and clinical signs and symptoms .
the signs and symptoms include a pulsatile mass , pain , swelling , bruit , blood and neurologic deficit .
repair of tibial artery pseudoaneurysm can be challenging and a different surgical operation was described in the recent manuscripts such as direct arterial repair , interposition grafting or arterial ligation , duplex - guided compression and finally endovascular intervention [ 17 - 19 ] . during surgery ,
left leg is elevated for 2 minutes and then the tourniquet turned on and inflated to 280 mm hg .
the present surgery was done through the incision over the line that had greatest firmness .
a perforation was found in posterior tibial artery at the proximal third which was repaired with prolin 5 - 0 ( fig.9,10 ) . in this patient , it was not obvious whether this injury was caused by direct tearing of the artery or due to plate removal , but it s important to note that we should turn off the tourniquet and carefully find bleeding origin in any operation in the proximity of major vessels .
another point that we should say is this complication may be a pulsless mass , thus pulslessness could nt rule out the pseudoaneurysm .
we suggest having this complication in mind and being familiar with the presentation of the signs and symptoms .
it seemed vital to release the tourniquet before closing the wound to prevent this complication rate .
incidence of this complication is unknown , but has been reported after any surgery such as orif of fracture , plate removal , ankle or knee arthroscopy , or following arthroplasty .
although in most cases we find a pulsatile soft tissue mass , but we should know that the mass may be pulseless which may cause misunderstanding and delay in the diagnosis . in most cases , the diagnosis is delayed initially owing to slow progression in sign and symptoms .
an important key in the diagnosis is that the surgeon should have a high degree of suspicion when the patient compliants of a mass , with paresthesia and pain that was inappropriate to the operation and soft tissue swelling .
further assessment should be carried out carefully . when the diagnosis is confirmed , patient should be referred to a vascular surgeon . at a final result
, we should release the tourniquet before wound closure for accurate hemostasis and decrease this complication rate .
orthopaedic surgeon should consider pseudoaneurysm in his / her mind even if this complication is too rare after plate removal .
introduction : pseudoaneurysm is a rare complication reported after any surgery such as orif of fracture , plate removal , ankle or knee arthroscopy or arthroplasty . to our knowledge , 
 pseudoaneurysms of the posterior tibial artery after tibial plate removal are a rare phenomenon . 
 we report a case of a 18-year - old male patient who had pseudoaneurysm of posterior tibial artery following plate removal.case presentation : a 18-year - old male was referred to our outpatient clinic because of mass - like lesion in his left calf . 
 he had a history of car accident and left isolated tibia fracture 30 months ago that was treated by open reduction and internal fixation with dcp plate . 
 after union in radiograph , the plate was removed 7 months ago on the patient request . 
 four weeks after surgery , the patient had complaints of pain and swelling . finally , pseudoaneurysm was diagnosed and was repaired in a common surgery with a vascular surgeon without any difficulty.conclusion:pseudoaneurysms of the posterior tibial artery after tibial plate removal are an extremely rare phenomenon . 
 this complication in most cases follows penetrating injuries but it has been reported following blunt trauma . 
 in fact , in most of these patients the diagnosis was initially missed because the large hematoma concealed the underlying pseudoaneurysm and its pulsations . 
 thus , a delay in the diagnosis is common in this phenomenon . 
 hence , the surgeon should be suspicious to this complication following plate removal when he / she is doubtful about the sign and symptoms .