Anatomy of the Peroneal Artery and its Role in Foot and Ankle Surgery

The objective of this study is to detail the terminal distribution of the peroneal artery, which may be at risk in a number of surgical procedures. Five per cent of the population presents with a dominant peroneal artery (arteria peronea magna), which is responsible for the entire foot vascularization.

Anatomic dissection of 54 specimens from 44 cadaveric donors was performed. Twenty belonged to women and 24 to men, whereas 10 lacked traceability data. Mean age of the donors was 75.01 ± 16.14 (range 38-101) years. Ten donors had bilateral extremities.

Six types on the terminal distribution of the peroneal artery were identified: type 1 (40.7%), terminal division into anterior perforating branch and posterior peroneal artery (bifurcation); type 2 (14.8%), proximal anterior perforating branch, distal bifurcation; type 3A (18.5%), terminal trifurcation into anastomosis, anterior perforating branch and posterior peroneal artery; type 3B (5.6%), terminal trifurcation where the anastomotic branch bows to join both posterior peroneal and posterior tibial arteries; type 3C (13%), proximal anterior perforating branch, distal trifurcation; type 3D (3.7%), proximal anterior perforating and anastomotic branches, distal trifurcation. Two specimens (3.7%) were nonclassifiable. The mean distance to the most distal anterior perforating branch was 69.37 ± 22.09 mm (from 35.69 to 146.40), whereas the mean diameter was 2.35 ± 0.71 mm (range 0.91-4.24). The most distal anastomosis branched off at 64.80 ± 21.49 mm (from 49.52 to 99.93). Horizontal distances from the fibula to the peroneal artery were, at 5 cm, 0.83 ± 1.21 mm (0-5.76); at 10 cm, 1.24 ± 1.16 mm (range 0-4.96); and at 15 cm, 1.63 ± 1.34 mm (0-5.2). No differences were found for side or gender. Three dominant peroneal arteries were found (5.56%), with a mean diameter of 3.78 ± 0.88 mm. These findings provide the most detailed classification to date and support incorporating peroneal artery mapping into preoperative planning for high-risk procedures.

Narrow proximity to the fibula, variation in branching, and dominance patterns suggest that identifying the peroneal vascular bundle intraoperatively is critical to avoid vascular complications. When performing posterior approaches to the ankle, it may be helpful to identify the peroneal vascular bundle and perform the necessary dissections and implant placement as distal as possible to avoid its injury.

Understanding the anatomy of the peroneal artery, its branches and anatomical variations, with special mention of the dominant peroneal artery (arteria peronea magna), may help to avoid iatrogenic injury to the peroneal vascular bundle during the varied and increasing number of foot and ankle surgical procedures performed, such as posterior open reduction internal fixation of ankle fractures, ankle arthrodesis, or ankle arthroscopy.