Peroneal Artery Danger Zone With Syndesmotic Screw Fixation: A Computed Tomography Angiography Study
Garrett K Berger1, Avinaash Korrapati1, Aaron Tran1
1Department of Orthopaedic Surgery, University of California-San Diego, San Diego, CA, USA.
Foot & Ankle International
|March 17, 2026
Summary
Trans-syndesmotic screws (TSS) pose a significant risk to the peroneal artery (PA) and its deep branch (dPA) in high-risk patients undergoing ankle fracture fixation. Identifying safe zones is crucial to prevent iatrogenic vascular injury during surgery.
Area of Science:
- Orthopedic Surgery
- Vascular Anatomy
- Radiology
Background:
- High-risk patients (e.g., with diabetes, obesity) undergoing unstable ankle fracture fixation often receive additional trans-syndesmotic screws (TSS).
- These patients face elevated complication risks, potentially linked to iatrogenic vascular compromise of the peroneal artery (PA).
Purpose of the Study:
- To investigate the anatomical range where the peroneal artery (PA) and its deep perforating branch (dPA) are vulnerable to injury from TSS fixation.
- To define safe zones for TSS placement, minimizing iatrogenic risk in high-risk patient populations.
Main Methods:
- Retrospective analysis of lower extremity CT angiograms (CTAs) in patients with comorbidities.
- Templating 3.5-mm syndesmotic screws onto CTA images to assess intersection with the PA and dPA.
- Measuring the proximal and distal extents of the PA and dPA relative to the tibial plafond and fibular tip.
Main Results:
- The PA was at risk in 98.5% of analyzed limbs.
- The critical "danger zone" for the PA extended from 7.5 cm proximal to the tibial plafond.
- The deep perforating branch (dPA) entered the syndesmotic plane at 3.6 cm proximal to the plafond, with both vessels exiting the danger zone approximately 2.5 cm proximal to the plafond.
Conclusions:
- The peroneal artery (PA) and its deep perforating branch (dPA) are frequently at risk during trans-syndesmotic screw (TSS) fixation, particularly in the distal limb.
- The critical zone for potential injury extends to approximately 2.5 cm proximal to the tibial plafond.
- Awareness of these anatomical findings is essential for surgical planning to avoid iatrogenic vascular injury in vulnerable patient groups.
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