Nerve and vessel injuries during high tibial osteotomy combined with distal fibular osteotomy: a clinically relevant anatomic study

Based on our clinical experience and an anatomical study, we examined the c onditions under which injury to the popliteal artery, tibial nerve or peron eal nerve and its branches may occur during high tibial osteotomy. In 250 h igh tibial osteotomies performed in our department, we observed the followi ng in traoperative complications. (1) The popliteal artery was severed in 1 patient and repaired by the same surgical team using a microsurgical techn ique. (2) A tibial nerve paresis also occurred in I patient. (3) In 3 patie nts, temporary palsy of the anterior tibialis muscle was documented. (4) In 4 other patients, palsy of the extensor hallucis longus occurred. To inves tigate the causes of these complications in the popliteal artery, tibial ne rve and branches of the peroneal nerve, we dissected the neurovascular stru ctures surrounding the area of the osteotomy in 10 cadaveric knees and perf ormed a high tibial osteotomy in another 13 cadaveric knees. We concluded t he following. (1) The popliteal artery and tibial nerve are protected, at t he level of the osteotomy, behind the popliteus and tibialis posterior musc les. Damage can occur only by placing the Hohman retractor behind the muscl es. The insertion of the muscles is very close to the periosteum and can be separated only with a scalpel. (2) The tibialis anterior muscle is innerva ted by a group of branches arising from the deep branch of the peroneal ner ve. In two-thirds of the dissected knees, we found a main branch close to t he periosteum, which can be damaged by dividing the muscle improperly or du e to improper placement and pressure of the Hohman retractor. This may expl ain the partially reversible muscle palsy. (3) The extensor hallucis longus is also innervated by 2-3 thin branches, arising from the deep branch of t he peroneal nerve, but in 25% of the specimens, only one large branch was f ound. This branch is placed under tension by manipulating the distal tibia forward. Thus, it may be damaged by the Hohman retractor during distal scre w fixation, tensioned by hyperextension or directly injured during midshaft fibular osteotomy.