The risk of iatrogenic injury to anterior tibial artery variations during tibial nail distal interlocking

Abstract

Introduction: 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. Materials and Methods: 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. Results: 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. Conclusions: 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.