Proximal Locking in Intramedullary Tibial Nailing: A Cadaveric Study

Abstract

Purpose: Vascular complications associated with locked intramedullary tibial nailing are rare but always serious. The purpose of this cadaveric study is to define the risk of vascular complications after proximal locking in intramedullary tibial nailing.
Material and Methods: Seven fresh cadaver legs were obtained from the University Hospital of Ioannina. The Grosse & Kempf Tibial Locking Nail was used with anterior-posterior locking. Each procedure was performed according to a standard protocol. The insertion point of the tibial nail was just above the level of the tibial tuberosity. The direction of the proximal locking screw was oblique from caudal to cranial and from lateral to medial. For imaging, both the nail and screws were removed and titanium screws were inserted, thereby allowing good visualization.
Results: MRI sections combined with CT and 3D-CT have been used to illustrate the findings, as they clearly demonstrate the relationships between the locking screws and adjacent vascular structures. Analysis of these findings highlighted the surgical risks associated with this type of proximal locking and its direction.
Conclusions: Proximal anterior-posterior locking in intramedullary tibial nailing is a hazardous procedure because of the small distance between tibia and vascular structures. The use of a new direction for proximal anterior-posterior locking is recommended.

Key words

Tibia - intramedullary nailing - proximal locking - vascular complications

References

• 1 Alho A, Benterud J G, Høgevold H E, Ekeland A, Strøms øe K. Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures.  Clin Orthop. 1992;  277 243-250
• 2 Bone L B, Johnson K D. Treatment of tibial fractures by reaming and intramedullary nailing.  J Bone Joint Surg [Am]. 1986;  68 877-887
• 3 Bone L B, Sucato D, Stegemann P M, Rohrbacher B J. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients.  J Bone Joint Surg [Am]. 1997;  79 1336-1341
• 4 Browner B D. Pitfalls, errors and complications in the use of locking Küntscher nails.  Clin Orthop. 1986;  212 192-208
• 5 Court- Brown C M, Christie J, McQueen M M. Closed intramedullary tibial nailing. Its use in closed and type I open fractures.  J Bone Joint Surg [Br]. 1990;  72 605-611
• 6 Court-Brown C M. An atlas of closed nailing of the tibia and the femur. Springer, New York, Berlin 1991
• 7 Court- Brown M C, McBirnie J. The epidemiology of tibial fracture.  J Bone Joint Surg [Br]. 1995;  77 417-421
• 8 Goessens M LMJ, Sijbers R, Harbers J S, Stapert J WJL. Application of a proximal entry point for intramedullary nailing of the tibia.  Osteosynthese International. 2001;  9 101-104
• 9 Gregory P, Sanders R. The treatment of closed, unstable tibial shaft fractures with unreamed interlocking nails.  Clin Orthop. 1995;  315 48-55
• 10 Houston J, Zych G A, Cole J D, Johnson K D, Ostermann P, Milne E L, Latta L. Mechanical failures of intramedullary tibial nails applied without reaming.  Clin Orthop. 1995;  315 129-137
• 11 Kempf I, Leung K S. Practice of Intramedullary locked nails. Springer, Berlin 2002
• 12 Kessler S B, Kaiser E, Eibl-Eibesfeldt B. Prevention of vascular injuries in tibial interlocking nailing.  Unfallchirurg. 1987;  90 148
• 13 Koval K, Clapper M F, Brumback R J, Ellison P S, Poka A, Bathon G H, Burgess A. Complications of reamed intramedullary nailing of the tibia.  J Orthop Trauma. 1991;  5 184-189
• 14 Müller M E, Allgöwer M, Schneider R, Willeneger H. Manual of internal fixation. Springer, Berlin, Heidelberg, New York 1991
• 15 Paige Whittle A, Wester W, Russel T A. Fatigue failure in small diameter tibial nails.  Clin Orthop. 1995;  315 119-128
• 16 Roberts C, Ruktanonchai D, King D, Seligson D. Vascular compromise and amputation after intramedullary nailing of a tibia fracture.  J Orthop Trauma. 1998;  12 136-141
• 17 Smith P N, Gelinas J, Kennedy K, Thain L, Rorabeck C H, Bourne R B. Popliteal vessels in knee surgery. A magnetic resonance imaging study.  Clin Orthop. 1999;  367 158-164
• 18 Stindel E, Colin D, Le Guillou E, Lefevre C. The use of MR images to evaluate the risks associated with proximal locking of intramedullary tibial nails.  Surg Radiol Anat. 2001;  23 173-177
• 19 Toivanen J AK, Vaisto O, Kannus P, Latvala K, Honkonen S, Jarvinen M. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft.  J Bone Joint Surg [Am]. 2002;  84 580-585
• 20 Urban W P, Tornetta P. Vascular compromise after intramedullary nailing of the tibia: a case report.  J Trauma. 1995;  38 804-807
• 21 Williamson D M, Kershaw C J. Serious vascular complications of locked tibial nailing.  Injury. 1989;  20 310-312