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

Introduction

The peroneal artery originates from the posterior tibialis artery, 2 cm distal from the inferior border of the popliteus muscle under the tendinous arch of the soleus. ¹³ Its proximal diameter measures around 3 mm.² It runs down the deep posterior compartment of the leg alongside 2 accompanying veins, posterior to the fascia over the tibialis posterior muscle, toward the fibula until its terminal division, which is traditionally regarded as a bifurcation between the anterior perforating branch and the posterior peroneal artery. The anterior perforating branch pierces the interosseous membrane just proximal to the posterior tibiofibular syndesmosis and descends over the anterior tibiofibular ligament to anastomose to the anterolateral malleolar artery, branch of the anterior tibialis artery. Accordingly, the posterior peroneal artery is a continuation of the peroneal artery once the anterior perforating branch has branched off and continues to descend, supplying the fibular malleolus, where it concludes as the lateral calcaneal artery. ²⁵

The peroneal artery vascularizes the fibula (middle and distal thirds), talus (posterior process) and calcaneus (52% of its blood supply).^5,19,27 Concerning soft tissues, it irrigates the ankle’s lateral ligament complex, both peroneus longus and brevis muscles and tendons and the skin of the ankle (anterolateral) and heel (plantar and lateral).^9,26

Despite being quite constant, the role of the peroneal artery in the vascularization of the foot is variable, and depends on the posterior and anterior tibial arteries. Specifically, if the anterior tibial artery does not exist, the anterior perforating branch of the peroneal artery will form the dorsalis pedis artery. ¹⁰ On the other hand, if the posterior tibial artery is hypoplastic or absent, the peroneal artery will form the plantar arteries. ¹³ It has been estimated that the peroneal artery is the foot’s main blood supply in 5% of the population, a variation known as dominant peroneal artery or arteria peronea magna. ¹ Consequently, in about 5% of the surgical procedures performed at the fibula or posterior aspect of the distal leg and ankle, not only the peroneal artery and its branches are at risk, but also the entire foot vascularization. Common examples of these surgical procedures include posterior-based approaches for open reduction and internal fixation of fibular and posterior malleolus fractures during ankle or pilon fracture surgery, ankle arthroscopy, osteotomies, Achilles lengthening, and ankle arthrodesis or flaps, where complications concerning the peroneal artery have already been reported.^{4,12,20,21,28}

The study’s primary objective is to describe and classify the various patterns of the peroneal artery terminal distribution through a cadaveric study. The secondary objectives are to correlate these findings, explicitly noting the dominant peroneal artery, with the potential iatrogenic injury to the artery and its branches during commonly performed surgical procedures.

Methods

All procedures performed on human participants in the present study complied with ethical standards according to the Helsinki Declaration of 1964 and its subsequent modifications.

Fifty-four embalmed specimens from 44 cadaveric donors were anatomically dissected from 2022 to 2024. Twenty belonged to women and 24 to men. Ten specimens lacked traceability data. The mean age of the donors was 75.01 ± 16.14 (range 38-101) years. Ten donors provided bilateral samples. Specimens had been previously embalmed by a femoral injection containing methanol (62.5%), glycerin (17.5%), 80% phenol (12.5%), and 37% formaldehyde (7.5%). All dissected specimens were included in the study. No extremities had clinical data of previous vascular or orthopaedic conditions, which were also confirmed macroscopically at the time of dissection.

Dissection Technique

Specimens were positioned prone. Skin and subcutaneous tissue were removed from the posterior aspect of the leg and ankle until the superficial fascia was exposed. The Achilles tendon was transected from the posterior calcaneal tuberosity and the sural triceps was lifted off medially by blunt dissection to expose the transverse intermuscular septum (Figure 1A). Deep fascia was divided, exposing the flexor hallucis longus (FHL) muscle (Figure 1B). The FHL tendon was identified distally, then transected for its elevation, releasing its attachments from the interosseous membrane and fibula while exercising extreme caution to avoid damaging the peroneal vascular bundle, which contains both the peroneal artery and its accompanying veins (Figure 1C). Once the peroneal vascular bundle was exposed (Figure 2A), the artery was isolated by excising the veins and the adventitial layer of the artery using magnification and microsurgery instruments (Figure 2B). If the peroneal artery had medially directed branches, they were also dissected to determine whether they were anastomoses to the posterior tibial artery, muscular branches, or periosteal branches for the posterior tibial metaphysis.

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Figure 1.

Dissection technique to expose the peroneal artery on a left leg. (A) The Achilles tendon (at) has been transected, and the sural triceps (t) is medially reflected to reveal the transverse intermuscular septum. Proximally, note how the peroneal bundle (yellow arrowhead) enters into the muscle belly of the flexor hallucis longus (fhl). (B) By dividing the transverse intermuscular septum, the flexor hallucis longus muscle belly and tendon, the tibial nerve (tn), and the posterior tibialis vascular bundle (white arrowhead) are exposed. (C) The flexor hallucis longus (fhl) tendon is distally identified and transected, and its muscular attachments are released for lateral mobilization, exposing the peroneal vascular bundle (yellow arrowhead). Peroneus longus (pl). [See online article for color figure.]

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Figure 2.

Deep dissection on a left leg. (A) Proximally, the peroneal vascular bundle, which contains both the peroneal artery and accompanying veins, has been exposed. The peroneal artery (yellow arrowhead) has been isolated distally. (B) Final dissection of the peroneal artery and its branches: anterior perforating branch (white arrowhead) and posterior peroneal artery (black arrowhead). AT, Achilles tendon. F, fibula. PL, peroneus longus. TN, tibial nerve, posterior tibial artery (red arrowhead). [See online article for color figure.]

We did not dissect the cutaneous perforators that arise from the peroneal artery to vascularize the skin of the distal leg. When the term “perforator” or “perforating branch” appears in this article, it always refers to those branches arising from the peroneal artery that pierce the interosseous membrane from posterior to anterior.

Each dissection took on average 3-4 hours. All samples were photographed. Some were manually ink-painted, whereas others were digitally colored using the software Procreate (Savage Interactive Pty Ltd).

Results

Classification

The peroneal artery was present in all specimens (n = 54). A new classification was established based on the terminal distribution of the peroneal artery (bifurcation, trifurcation) as well as the presence and number of anastomotic branches and anterior perforating branches. The samples were categorized primarily into 6 types (Figure 3):

- Type 1 (40.7%). The peroneal artery divides into anterior perforating branch and posterior peroneal artery (bifurcation) (Figure 4)

- Type 2 (14.8%). The peroneal artery gives proximally an anterior perforating branch and bifurcates distally in anterior perforating branch and posterior peroneal artery

Number 3 indicates terminal trifurcation (anterior perforating branch, posterior peroneal artery, anastomotic branch) of the peroneal artery within a distance of 2 cm (40.8%) (Figure 5A).

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Figure 3.

Classification scheme of the terminal distribution of the peroneal artery (red). 1. The terminal division into the anterior perforating branch (blue) and posterior peroneal artery (orange). 2. The proximal anterior perforating branch, distal bifurcation. 3A. The terminal trifurcation into anastomotic branch (green) to the posterior tibial artery, anterior perforating branch and posterior peroneal artery. 3B. The terminal trifurcation, but the anastomotic branch bows to anastomose with posterior peroneal and tibial arteries. 3C. The proximal anterior perforating branch, distal trifurcation. 3D. The proximal anterior perforating and anastomotic branches, distal trifurcation.

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Figure 4.

(A) Posterior view of a left leg dissection, showing the terminal bifurcation of the peroneal artery (pa) into the anterior perforating branch (yellow arrowhead) and posterior peroneal artery (white arrowhead) (type 1). The artery also gives off branches for the peroneus muscles (black arrowhead). (B) Same dissection, but picture from a different angle and in color. Note how a medially directed branch terminates at the tibialis posterior (tp) muscle belly, indicating it is not an anastomotic branch. FDL, flexor digitorum longus; FHL, flexor hallucis longus; PB, peroneus brevis; PL, peroneus longus. [See online article for color figure.]

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Figure 5.

(A) The posterior view of a left leg illustrates the terminal trifurcation of the peroneal artery (pa) into the perforating branch (yellow arrowhead), anastomosis (black arrowhead) and posterior peroneal artery (white arrowhead). (B) The posteromedial view of a left leg depicts a type 3B, in which the anastomotic branch (black arrowhead) curves laterally to eventually anastomose with the posterior peroneal artery (white arrowhead) and posterior tibial artery. FDL, flexor digitorum longus; FHL, flexor hallucis longus; PB, peroneus brevis; PL, peroneus longus; TN, tibial nerve. TP, tibialis posterior tendon. [See online article for color figure.]

- Type 3A (18.5%). The peroneal artery trifurcates into the anterior perforating branch, the posterior peroneal artery that descends closely with the fibular malleolus, and a horizontal anastomotic branch to the posterior tibial artery.

- Type 3B (5.6%). The peroneal artery trifurcates into the anterior perforating branch, the posterior peroneal artery, and anastomotic branch, but the latter goes inside the peroneal retinaculum, making a bow to anastomose with the posterior peroneal artery distally and ultimately with the posterior tibial artery (Figure 5B).

- Type 3C (13%). The peroneal artery gives proximally an anterior perforating branch and trifurcates distally (anterior perforating branch, posterior peroneal artery, and anastomotic branch).

- Type 3D (3.7%). The peroneal artery gives off an anterior perforating branch and an anastomotic branch to the posterior tibial artery proximally, and distally trifurcates into the anterior perforating branch, posterior peroneal artery, and anastomotic branch.

Two specimens did not fit in any of the previous categories (3.7%). One of these had a very proximal anastomosis while distally producing a first anterior perforating branch and bifurcating into the second anterior perforating branch and posterior peroneal artery, which will later anastomose with the posterior tibial artery. The other is discussed in the dominant peroneal artery section.

Statistical Analysis

The most frequent pattern in the sample was type 1 (40.7%), followed by types 3A (18.5%) and 2 (14.8%). No significant differences were found when adjusted for gender (χ² = 7.174, P value = .305) or side (χ² = 6.454, P value = .374). Descriptive statistics are summarized in Table 1.

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Table 1.

Descriptive Statistics for Peroneal Artery Terminal Division Classification.

Type	Frequency (n)	Percentage (%)	Female	Male	Left	Right
1	22	40.7	8	9	11	11
2	8	14.8	2	5	5	3
3A	10	18.5	6	3	4	6
3B	3	5.6	1	2	2	1
3C	7	13.0	1	4	2	5
3D	2	3.7	2	0	0	2
4	2	3.7	0	1	2	0
Total	54	100.0	20	24	26	28

The mean distance to the most distal anterior perforating branch was 69.37 ± 22.09 mm (range 35.69-146.40) from the fibular malleolus, whereas the mean diameter of the peroneal artery at this level was 2.35 ± 0.71 mm (range 0.91-4.24).

The most distal anastomotic branch between the peroneal artery and posterior tibial artery branched off at 64.80 ± 21.49 mm (range 49.52-99.93).

The mean distance from the fibular malleolus to the most proximal anterior perforating branch was 90.68 ± 42.67 mm (range 44.26-278.01). At this level, the mean diameter of the peroneal artery was 2.59 ± 0.78 mm (1.42-4.65).

Mean horizontal distances from the fibula to the peroneal arteries and diameters are summarized in Table 2. This information may assist in locating the peroneal vascular bundle using a reliable reference such as the fibula.

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Table 2.

The Horizontal Distance Between the Fibula and the Peroneal Artery, As Well As the Mean Diameters at Specified Heights From the Peroneal Malleolus.

Height From Fibular Malleolus, cm	Horizontal Distance From Fibula to Peroneal Artery, mm, Mean ± SD	Range, mm	Peroneal Artery Diameter, Mean ± SD	Range, mm
5	0.83 ± 1.21	0-5.76	1.76 ± 0.64	0.57-3.61
10	1.24 ± 1.16	0-4.96	2.59 ± 0.72	1.19-4.54
15	1.63 ± 1.34	0-5.2	3.12 ± 0.78	1.85-5.77

Of the 10 donors with bilateral samples, only 3 (2 female, 1 male) had the same type on both sides (n = 2 type 1, n = 1 type 3A).

The Spearman test revealed a significant correlation between the proximal and distal diameters of the peroneal artery (larger proximally) and the horizontal distance between the fibula and the peroneal artery, which ranged from 10 to 15 cm (closer distally).

A few anterior perforating branches had a long posterior course before perforating the interosseous membrane, rather than following the most common pattern of perforating it soon after (less than 1 cm) its origin from the peroneal artery. In many cases, accessory and frequently small-diameter (less than 0.5 mm) anastomotic or perforating branches were discovered beyond the bounds established for being considered terminal division (more than 2 cm).

The 3 dominant peroneal arteries found were the anatomical variations of more interest (5.56% of the sample). Their mean diameter was 3.78 ± 0.88 mm (range 2.9-4.65), located proximal to the most significant anastomotic branch. The posterior tibial artery was present in all cases but hypoplastic. Division occurred at 77.31 ± 16.73 mm (range 59.91-93.27). All 3 dominant peroneal arteries exhibited asymmetry. A description of each case is detailed in Table 3 and Figure 6.

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Table 3.

Characteristics of Dominant Peroneal Arteries Include the Height of Division Measured From the Tip of the Lateral Malleolus. ^a

Dominant Peroneal Artery Type	Laterality	Diameter (mm)	Division (mm)	Donor: Age [y], Gender	Contralateral Extremity Peroneal Artery Type	Features	Figure
3C	Right	3.79	59.91	56 M	1	Diameter of the anastomotic branch is 4.56 mm	6A
NC	Left	4.65	93.27	76 M	3C	Proximal anterior perforating branch at 113.87 mm. Proximal origin of posterior peroneal artery.	6B
1	Right	2.90	78.75	80 F	3A	High anastomotic branch, 186.07 mm from the lateral malleolus	6C

Abbreviations: F, female; M, male; NC, for nonclassifiable.

a

The terms anastomotic branch and anterior perforating branch are noted. Additionally, the posterior peroneal artery is mentioned.

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Figure 6.

Dominant peroneal arteries (pa), also known as arteria peronea magna. (A) Posterior view of a right leg, showing a distal trifurcation (type 3C) into anastomotic branch (black arrowhead), anterior perforating branch (yellow arrowhead) and posterior peroneal artery (white arrowhead). (B) Posterior view of a left-sided dominant peroneal artery (pa), classified as type 4 due to the anomalous and proximal origin of the posterior peroneal artery (white arrowhead). (C) Posterior and proximal view of a right leg, depicting a dominant peroneal artery (pa) with a high anastomotic branch (black arrowhead). Observe in all images how the posterior tibial artery descends hypoplastic previous to the anastomosis. TP, tibialis posterior, FDL, flexor digitorum longus. [See online article for color figure.]

Discussion

A new and comprehensive classification of the peroneal artery terminal distribution has been developed, detailing the anterior perforating branches and anastomoses to the posterior tibial artery up to 15 cm proximal to the lateral malleolus, along with the relative location of the artery concerning the fibula in the distal leg. The peroneal artery was also present in all cases, confirming that is the most constant artery of the leg. Lippert and Pabst classified the terminal distribution of the peroneal artery. ¹⁶ According to them, the terminal trifurcation would be by far the most common type (88%), when in our sample the terminal trifurcation accounted for 40.8% (summation of types 3A, B, C, and D), almost the same to the peroneal artery bifurcation (type 1, 40.7%).

Regarding the peroneal artery branches, at least 1 anterior perforating branch was found in each dissection, consistent with previous reports. ⁴ However, the presence of more than one anterior perforating branch has rarely been reported, whereas in our study 59.3% (n=32) of dissections had at least another proximal anterior perforating branch. Most of these branches were small in diameter and might had been overlooked in other anatomic studies and not identified in radiologic studies. Additionally, anastomotic branches between the peroneal and posterior tibial arteries have been documented before, but with variable or unreported frequencies.^15,16 In our sample, 25 specimens had 1 anastomosis (46.30%) whereas 5 had 2 (9.26%). These frequencies resemble the one found in a previous anatomic study. ²⁹

Open reduction and internal fixation of posterior malleolus fractures through a posterolateral approach is standard practice.^6,11 When using this approach, one of the most crucial factors to prevent injury to the peroneal vascular bundle is the height at which the terminal division of the peroneal artery occurs, which in our sample was 69.37 ± 22.09 mm (range 35.69-146.40). The literature regarding this parameter, which is highly variable, is summarized in Table 4.^8,15,18

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Table 4.

Recent Publications on the Terminal Division of the Peroneal Artery, Which Include an Anatomical Study Through Cadaveric Dissection and a Radiologic Study via Retrospective Analysis of CT Angiography.

Author, Year	n	Study Type (Methods)	Terminal Division of the Peroneal Artery From the Fibular Malleolus (mm) and Range
Lidder (2014)	26	Anatomic	103 ± 21 (61-136)
Galanakis (2021)	115	Radiologic	65.3 ± 11.7 (40.71-100.2)
Mousa (2022)	142	Radiologic	81.8 ± 24.15 (54.0-142.0)
This study (2025)	54	Anatomic	69.37 ± 22.09 (35.69-146.40)

Abbreviation: CT, computed tomography.

Lidder et al ¹⁵ performed the posterolateral approach in 26 specimens, in an attempt to describe a safe zone for treating ankle fractures. They observed a wide variation in the vasculature of the peroneal artery and concluded that “once the artery is mobilized, a buttress plate can easily be placed beneath it.” Our findings suggest a different interpretation, as mobilizing the peroneal vascular bundle is extremely challenging. Its location is very deep, requiring an extensive approach, and it is embedded within the flexor hallucis longus muscle, alongside many other muscular, periosteal, and peroneal branches that had been omitted to ease our classification. Still, it may be difficult to identify in live surgery. The peroneal artery is also in close proximity to the fibula, as indicated by our results on the horizontal distance from the fibula to the peroneal artery, with the maximum values around 5 mm. Nevertheless, unless it is a dominant peroneal artery, we accept that the injury risk might be acceptable from 5 cm proximal to the joint line, where the encountered vessel is the posterior peroneal artery, whose diameter is small and, if injured, could successfully be electrocauterized. Therefore, our specific recommendations to avoid injury to the peroneal artery when performing a posterolateral approach involve using not prominent hardware for posterior malleolus fixation and identifying the peroneal vascular bundle. The use of nonprominent hardware, such as posterior to anterior screws if the fragment permits, and/or minifragment plates (2.4-2.7 mm), should be kept as short and distal as possible (Figure 7). ⁷ Based on our research, we believe that the frequent complication rate (20%-30%) concerning the surgical wound in the posterolateral approach may be attributable to the unnoticed vascular injury to the peroneal artery or its branches. ¹⁷ Secondly, identifying the peroneal vascular bundle provides direct visualization and assessment of its size, particularly when managing large posterior malleolus fractures, whose apex is located proximal to the syndesmosis. To achieve this, at 10 cm from the fibular tip, the peroneal artery will have a considerable diameter (2.59 ± 0.72 mm) and will be in close contact with the medial side of the fibula (1.24 ± 1.16 mm). At this distance, the artery would most likely not have divided yet (69.37 ± 22.09 mm). If the peroneal vascular bundle stands out because of its size, meaning approximately 10 mm, it should warn of being a dominant peroneal artery (arteria peronea magna) (Figure 8). Our findings of this anatomical variation align with its 5% estimated prevalence. Currently, there are no established guidelines to address this finding in orthopaedic surgical procedures, such as in ankle or tibial pilon osteosynthesis, as amputation rates in case a dominant peroneal artery is injured oscillate between 5% and 65%. ²² Amputation resulting from dominant peroneal artery injury following open reduction internal fixation of a trimalleolar fracture via a posterolateral approach has already been reported. ²⁴ In our sample, 2 of the 3 dominant peroneal artery replaced the posterior tibial artery by crossing between 50 and 80 mm from the fibular malleolus.^13,14 In the third case, the crossing occurred very proximal, at 186.07 mm from the fibular malleolus.

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Figure 7.

Posteromedial views of the relationship between standard-diameter peroneal artery (pa) and different plates used for posterior malleolus fixation in a right leg: (A) one-third tubular plate (DePuy Synthes); (B) anatomic posterior malleolus plate (Acumed); (C and D) 2.4-mm and 2.7-mm plates, Variax 2 minifragment (Stryker). Longer plates may likely increase the risk of injury to the peroneal artery, particularly the anastomotic branch to the posterior tibial artery. Posterior peroneal artery (white arrowhead). Anterior perforating branch (yellow arrowhead). Pta, posterior tibial artery. [See online article for color figure.]

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Figure 8.

Posterior views of the relationship between a dominant peroneal artery (pa) and different plates used for posterior malleolus fixation in a right leg: (A) one-third tubular plate (DePuy Synthes); (B) anatomic posterior malleolus plate (Acumed); (C and D) 2.4-mm and 2.7-mm plates, Variax 2 minifragment (Stryker). Anastomotic branch (black arrowhead). Posterior peroneal artery (white arrowhead). Anterior perforating branch (yellow arrowhead). Pta, posterior tibial artery. [See online article for color figure.]

Another potential injury to the peroneal artery in ankle fracture surgery, specifically regarding the distal anterior perforating branch, may occur during transsyndesmotic screw placement. In a 2014 article, where 37 anatomic dissections were performed, the anterior perforating branch was found to be anterior to the interosseous membrane at 3.42 ± 0.6 cm from the joint line. Its position was also evaluated in relation to the placement of 2 transsyndesmotic screws at 2 and 4 cm from the joint line. ²³ In another study, 100 CT-angio were used to create simulations of transsyndesmotic screw placement. ³ Potential injury to the peroneal artery was found in 38.9% of all simulated screws. The authors noted that the risk increased with larger-diameter screws, more proximal placement, and 20° of inclination. Both studies largely align with ours, where the most distal anterior-perforating branch was identified in most cases proximal to the syndesmosis. Additionally, a more superior screw placement increases the risk of injuring the peroneal artery, as its diameter will be larger, according to the correlation tests.

This anatomical mapping provides a practical tool for surgeons to anticipate vascular variation and optimize surgical planning, particularly when operating in the posterior ankle and distal leg. By presenting a detailed and structured classification of the terminal distribution of the peroneal artery—including branching patterns, proximity to the fibula, and prevalence of dominant variants—this study enhances anatomical understanding and may help minimize the risk of iatrogenic vascular injury during commonly performed foot and ankle procedures.

Conclusion

The peroneal artery demonstrates considerable anatomical variation in its terminal distribution and proximity to the fibula, including in 5% of cases where it becomes the dominant arterial supply to the foot. These findings underscore the importance of intraoperative identification of the peroneal vascular bundle—especially in posterior ankle or fibular procedures—to minimize iatrogenic injury. Accurate classification of branching patterns may assist in optimizing surgical planning, hardware placement, and patient outcomes.

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