de Cesar Netto Cesar, Johannesmeyer David, Cone Brent, Araoye Ibukunoluwa, Hudson Parke William, Sahranavard Bahman, Johnson Michael, Shah Ashish
1 Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
Foot Ankle Int. 2017 Oct;38(10):1139-1145. doi: 10.1177/1071100717715909. Epub 2017 Jul 21.
The purpose of this study was to assess the risk of iatrogenic injury to plantar neurovascular structures of the foot during insertion of a curved retrograde tibiotalocalcaneal (TTC) fusion nail.
Ten below-knee thawed fresh-frozen cadaveric specimens underwent curved retrograde nailing of the ankle. The shortest distance between the nail and the main plantar neurovascular branches and injured structures were recorded during dissection. We also evaluated the relative position of these structures along 2 lines (AB, connecting the calcaneus to the first metatarsal, and BC, connecting the first and fifth metatarsal).
The lateral plantar artery was found to be in direct contact with the nail 70% of the time, with a macroscopic laceration 30% of the time. The Baxter nerve was injured 20% of the time, as was the lateral plantar nerve. The medial plantar artery and nerve were never injured. The most proximal structure to cross line AB was the Baxter nerve followed by the lateral plantar artery, the nail, the lateral plantar nerve, and the medial plantar nerve.
Our cadaveric anatomic study found that the most common structures at risk for iatrogenic injury by lateral curved retrograde TTC fusion nails were the lateral plantar artery and nerve, and the Baxter nerve.
Determination of a true neurovascular safe zone is challenging and therefore warrants careful operative dissection to minimize neurovascular injuries.
本研究的目的是评估在插入弯形逆行胫距跟（TTC）融合钉过程中，医源性损伤足部足底神经血管结构的风险。
对10例膝下解冻的新鲜冷冻尸体标本进行踝关节弯形逆行穿钉。在解剖过程中记录钉子与主要足底神经血管分支及损伤结构之间的最短距离。我们还评估了这些结构沿两条线（AB，连接跟骨与第一跖骨；BC，连接第一和第五跖骨）的相对位置。
发现外侧足底动脉70%的时间与钉子直接接触，30%的时间出现肉眼可见的撕裂伤。巴克斯特神经和外侧足底神经20%的时间受到损伤。内侧足底动脉和神经从未受损。越过AB线的最近端结构是巴克斯特神经，其次是外侧足底动脉、钉子、外侧足底神经和内侧足底神经。
我们的尸体解剖研究发现，外侧弯形逆行TTC融合钉造成医源性损伤的最常见结构是外侧足底动脉和神经以及巴克斯特神经。
确定真正的神经血管安全区具有挑战性，因此需要仔细的手术解剖以尽量减少神经血管损伤。
