The aberrant anterior tibial artery should be respected and can be protected in high tibial osteotomy surgery

We read with great interest the recent article ‘The presence of an aberrant anterior tibial artery does not depend on the patient's morphotype’ and would like to commend the authors for their important study [4]. Although the aberrant anterior tibial artery (ATA) occurred in only 2.1% of their cases, the authors have highlighted its importance in the clinical setting. Intraoperative injury to the ATA during high tibial osteotomy (HTO) can lead to pseudoaneurysms or even rupture with severe bleeding, challenging current management concepts for patients with an ATA [1, 5]. Schuster et al. present a case of a tibial closed wedge osteotomy and intraoperative ATA injury despite the presence of a posterior soft tissue retractor supposedly to protect the neurovascular structures [4]. The authors conclude that ‘the presence of an ATA may be a contraindication to HTO surgery’ [5]. Again, while we commend the authors for their very important study, we would like to challenge ATA as a contraindication to HTO surgery and present our concept for the management of affected patients. In a 24-year-old female patient with anterior cruciate ligament (ACL) re-re-rupture, medial meniscus deficiency, concomitant 2nd degree medial femoral chondromalacia, varus knee, and increased posterior tibial slope (PTS), leg axis and PTS correction were highly indicated, but associated with an increased risk of vascular injury during surgery (Figure 1). One of the most important prerequisites for a PTS-neutral HTO is a complete transection of the dorsal cortex [2]. Typically, oscillating saw blades angled 4.5° in each direction are used for HTOs. A 100 mm long saw blade (measured from the centre of rotation) is deflected 4 mm to each side, placing the posterior soft tissues at particular risk during HTO. The use of chisels instead of an oscillating blade, in addition to a sufficiently placed posterior soft tissue retractor may reduce the increased risk of vascular injury. The authors highlight that the distance of the ATA to the posterior cruciate ligament footprint was 2.7 ± 1.6 and 1.0 ± 0.6 mm below the tip of the fibula [3]. While this is very close, the authors were nonetheless able to show that the ATA is typically not directly attached to the bone. Therefore, careful placement of the posterior soft tissue retractor, even under direct visual control with an arthroscope, may adequately protect the posterior soft tissues (Figure 2). We believe that tibial osteotomies play an extraordinarily important role especially in young revision ligament insufficiency patients. Focusing on ATA appearance the authors have underscored its meaning in HTO and extensive preoperative planning is needed to adjust tibial osteotomy techniques in these patients. Hence, while ATA, amongst other risk factors, has been considered a potential contraindication to HTO careful placement of the posterior soft tissue retractor and the use of chisels instead of an oscillating saw blade could successfully decrease the risk of intraoperative vascular injury. MK, GS and KHF are consultans for Arthrex but have no COI with respect to the present article.