Borrelli Joseph, Prickett William, Song Edward, Becker Devra, Ricci William
Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri 63110, USA.
J Orthop Trauma. 2002 Nov-Dec;16(10):691-5. doi: 10.1097/00005131-200211000-00002.
To describe the extraosseous blood supply of the tibia and how the blood supply of the distal tibia is influenced by different plating techniques.
Microdissection of cadaveric adult hip disarticulation specimens following sequential arterial injections of india ink and Ward's Blue Latex was performed. Readily identifiable arterioles measured approximately 0.5 mm in diameter. Their artery of origin was identified, and their position along the medial, lateral, and posterior aspects of the tibia was documented relative to the tibial plafond. Additionally, six matched pairs of limbs were used to assess the effects of different plating techniques on the extraosseous blood supply along the medial aspect of the distal tibia.
University anatomy laboratory.
PATIENTS/PARTICIPANTS: Nine matched pairs ( = 18) of randomly obtained, adult cadaveric hip disarticulation specimens.
India ink followed by Ward's Blue Latex was injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. The skin, subcutaneous tissue, and muscles were dissected from the leg, exposing the arterial system and the extraosseous vessels of the tibia. MEAN OUTCOME MEASUREMENTS: The extraosseous blood supply of each aspect of the tibial diaphysis was determined. Each extraosseous arteriole was identified, and the locations of each documented relative to the tibial plafond. Changes in the filling of these vessels along the medial aspect of the distal tibia were documented in a separate group of specimens ( = 12), which had undergone two different plating techniques.
The proximal metaphysis of the tibia was found to have a rich extraosseous blood supply provided primarily from vessels from the popliteal artery, the anterior tibial artery (ATA) laterally, and the posterior tibial artery (PTA) medially. In comparison, the tibial diaphysis was found to have relatively few extraosseous vessels and a considerably hypovascular region, posteriorly. Branches of the ATA were found to supply the posterior aspect of the diaphysis with these branches passing through the interosseous membrane. The diaphysis also received a variable contribution from the PTA. The lateral aspect of the diaphysis was supplied by branches of the ATA. An anastomotic network of arteries from the ATA and PTA formed the rich extraosseous blood supply of the medial distal aspect of the tibia. Open plating of the medial aspect of the distal tibia caused a statistically significant ( < 0.05) greater disruption of the extraosseous blood supply of the metaphyseal region than did percutaneously applied plates. In each specimen, open plating prevented filling of each periosteal vessel in the region as opposed to percutaneous plates, which permitted filling of the extraosseous vessels up to the edge of the plate.
The proximal and distal metaphyseal areas of the tibia have a rich extraosseous blood supply provided primarily by branches of the ATA and the PTA. Open plating of the medial aspect of the distal tibia caused a greater disruption of this extraosseous blood supply than did percutaneously applied plates. Disruption of these extraosseous vessels following fracture and subsequent operative stabilization may slow healing and increase the risk of delayed union and nonunion. These findings support current efforts to develop less invasive methods and implants for operative stabilization of distal tibia fractures.
描述胫骨的骨外血液供应以及不同钢板固定技术如何影响胫骨远端的血液供应。
对成年尸体髋关节离断标本进行显微解剖，先依次向动脉注射印度墨水和沃德氏蓝色乳胶。可轻易识别的小动脉直径约为0.5毫米。确定其起源动脉，并记录它们在胫骨内侧、外侧和后侧相对于胫骨平台的位置。此外，使用六对匹配的肢体来评估不同钢板固定技术对胫骨远端内侧骨外血液供应的影响。
大学解剖实验室。
患者/参与者：九对（共18个）随机获取的成年尸体髋关节离断标本。
在清洁动脉系统后，于腹股沟皱襞水平将印度墨水随后是沃德氏蓝色乳胶注入股浅动脉。从腿部解剖皮肤、皮下组织和肌肉，暴露动脉系统和胫骨的骨外血管。
确定胫骨干各方面的骨外血液供应。识别每个骨外小动脉，并记录其相对于胫骨平台的位置。在另一组（共12个）接受两种不同钢板固定技术的标本中记录这些血管沿胫骨远端内侧的充盈变化。
发现胫骨近端干骺端有丰富的骨外血液供应，主要来自腘动脉的分支，外侧为胫前动脉（ATA），内侧为胫后动脉（PTA）。相比之下，发现胫骨干的骨外血管相对较少，后侧有相当大的低血运区域。ATA的分支穿过骨间膜为骨干后侧供血。骨干也接受来自PTA的不同程度的供血。骨干外侧由ATA的分支供血。ATA和PTA的动脉吻合网络形成了胫骨远端内侧丰富的骨外血液供应。与经皮应用钢板相比，胫骨远端内侧的开放钢板固定导致干骺端区域的骨外血液供应受到统计学上显著（P<0.05）更大的破坏。在每个标本中，开放钢板固定阻止了该区域每个骨膜血管的充盈，而经皮钢板则允许骨外血管充盈至钢板边缘。
胫骨的近端和远端干骺端区域有丰富的骨外血液供应，主要由ATA和PTA的分支提供。与经皮应用钢板相比，胫骨远端内侧的开放钢板固定对这种骨外血液供应造成的破坏更大。骨折后及随后手术固定时这些骨外血管的破坏可能会延缓愈合并增加延迟愈合和不愈合的风险。这些发现支持目前为开发用于胫骨远端骨折手术固定的侵入性较小的方法和植入物所做的努力。
