Fanter Nathan J, Inouye Sandra E, Beiser Christopher W
1 Department of Orthopaedic Surgery, Edward Hines Jr. VA Hospital, Hines, IL, USA.
2 Department of Anatomy, Midwestern University, Downers Grove, IL, USA.
J Orthop Surg (Hong Kong). 2017 Jan;25(1):2309499016684471. doi: 10.1177/2309499016684471.
Tibial intramedullary nailing remains a common tibial fracture fixation method. Tibial nailing indications continue to expand. Neurovascular complications from tibial nailing have been described; however, the proximity of distal tibial locking bolts to the anterior tibial artery (ATA) variants has not.
52 cadaveric legs were dissected identifying three common ATA variants. Each ATA variant received an intraluminal wire to facilitate fluoroscopic identification. Three different intramedullary tibial nails were inserted in each of the three ATA variant specimens. With fluoroscopy, the proximity of the distal locking holes of each tibial nail to the intraluminal wire representing the ATA variant course was measured.
Of the 40 measurements, the intraluminal wire was directly in the bolt insertional path in 8 of 40 (20%) and within 5 mm in 16 of 40 (40%). All specimens had the wire cross the locking bolt insertional path at least once in each of the nails. The ATA variant taking a more lateral course deep to the extensor digitorum longus and peroneus tertius to overlay the lateral malleolus had the highest occurrence of measurements less than 5 mm.
The close proximity of tibial nail distal locking bolt holes to ATA variants presents a risk for iatrogenic vascular injury during insertion. The coronal locking bolts pose the greatest iatrogenic risk to the most laterally positioned ATA variant.
胫骨髓内钉固定仍是一种常见的胫骨骨折固定方法。胫骨钉的适应证不断扩大。胫骨钉固定的神经血管并发症已有报道；然而，胫骨远端锁定螺栓与胫前动脉（ATA）变异的接近程度尚未见报道。
解剖52条尸体下肢，确定三种常见的ATA变异。每种ATA变异均置入一根腔内导丝，以利于透视识别。在三种ATA变异标本中分别插入三种不同的胫骨髓内钉。通过透视，测量每根胫骨钉远端锁定孔与代表ATA变异走行的腔内导丝的接近程度。
在40次测量中，腔内导丝直接位于螺栓插入路径上的有8次（20%），在5mm范围内的有16次（40%）。所有标本中，每根钉子的导丝至少有一次穿过锁定螺栓插入路径。在趾长伸肌和第三腓骨肌深面走行更偏外侧并覆盖外踝的ATA变异，测量值小于5mm的发生率最高。
胫骨钉远端锁定螺栓孔与ATA变异距离较近，在插入过程中存在医源性血管损伤风险。冠状面锁定螺栓对最外侧位置的ATA变异造成的医源性风险最大。
