Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures: A Cadaveric Study. David A. Goss, Jr., DO Christopher W. Reb, DO Terrence M. Philbin, DO
David A. Goss, Jr., DO Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures: A Cadaveric Study. Our disclosures are in the Final AOFAS Mobile App. There is a potential conflict with this presentation due to: Consultant, Sonoma Orthopedic Products, Inc. (TMP); Research Grant, DJO Global (TMP)
Statement of Purpose The purpose of this study was to conduct an anatomic analysis with cadaveric specimens in order to determine the structures at risk when performing IM fibular nailing utilizing a modern generation nail design.
Study Methods 10 fresh-frozen cadaveric below knee specimens Specimens were instrumented with a contemporary retrograde locked IM fibular nail (FibuLock Ankle Pin, Sonoma Orthopedic Products, Inc., Buffalo Grove, IL), which provided three distal locking and two syndesmotic fixation screw options using a standardized technique and C-arm. Table 1: Demographic data of the 10 below knee cadaveric specimens. Number of Specimens 10 Average age at time of death (years) 78.6 Female 5 Right Side 5
Study Methods After nail insertion, all cadavers were dissected by a single experienced orthopedic foot and ankle surgeon in a standardized fashion. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (i.e. sural nerve, superficial peroneal nerve and the peroneal tendons) was measured with a digital caliper and recorded. Levels of risk were then assigned based on observed distances as: High (0 to 5 mm) Moderate (5.1 to 10 mm) Low (greater than 10 mm)
Results The peroneal tendons and SPN were at highest risk (less than 5 mm) during the procedure. The distal skin incision was <5 mm from the PB tendon in all 10 specimens. The distal skin incision was <5 mm in 6, <1 cm in 4 specimens, with regards to the PB tendon. The SPN was at greatest risk when inserting the AP screw within the nail. The PL tendon was at greatest risk when insetting the proximal and distal syndesmotic screws. Table 2: Number of Specimens with Structures at Risk High Risk, 0-5 mm Moderate Risk, 5.1-10 mm Low Risk, >10 mm Distal skin incision to PB 10 0 0 Distal skin incision to SPN 1 0 9 Distal skin incision to SN 0 3 7 Fibula aperture to PB 6 4 0 Fibula aperture to SPN 0 1 9 Distal locking incision to PB 0 3 7 Proximal locking incision to PB 1 4 5 AP screw incision to SPN 7 1 2 Proximal syndesmotic screw to PL 1 8 1 Distal syndesmotic screw to PL 0 9 1 Proximal syndesmotic screws to SN 0 0 10 Distal syndesmotic screw to SN 0 0 10
Conclusions The peroneal tendons and superficial peroneal nerve are at greatest risk during this procedure. However, none of these structures were violated or injured during nail and screw placement highlighting the importance of adhering to sound percutaneous surgical technique when utilizing this nailing system for distal fibular fractures.
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