SLR - March 2015 - James R. Foster

Anterior Tibial Artery Injury Following Tibiotalocalcaneal Retrograde Intramedullary Nailing

Reference: Ferrel JR, Davis RL, Witte ZW, Feibel JB. Anterior Tibial Artery Injury Following Tibiotalocalcaneal Retrograde Intramedullary Nailing. JBJS Case Connect. 2014 Nov 12;4(4): e104.

Scientific Literature Review

Reviewed By: James R. Foster, DPM
Residency Program: Grant Medical Center, Columbus, OH

Podiatric Relevance: Tibiotalocalcaneal arthrodesis (TTCA) is performed for multiple indications, most commonly end-stage arthritis of the ankle and subtalar joints with the objective of reducing pain and deformity by creating a stable ankle and hindfoot. There are many options for TTCA including screws, plates, Steinmann pins, external fixation, or intramedullary (IM) nailing. IM nailing has recently increased in popularity due to its minimally invasive nature and biomechanically favorable design, and fusion rates have been reported as high as 80-90 percent. However, as the IM nail is increasing in popularity, complication and reoperation rates have also been high. The authors of the article reported an incident they had with anterior tibial artery injury resulting in an acutely ischemic foot. The goal was to make this possible complication well known, and also to offer proper technique and preoperative planning based on current literature to prevent such an event.

Case Report: The patient was a seventy-one-year-old man who had sustained an ankle fracture and had undergone ORIF at an outside facility. The patient subsequently developed painful traumatic OA of the right ankle joint and underwent an ankle and distal tibiofibular joint fusion with screw and plate fixation also at an outside institution. The patient then presented 40 months after to the author with a nonunion of his right ankle and OA of his subtalar joint on CT. TTC fusion with intramedullary nailing was recommended. A lateral approach was used to remove the hardware from his previous surgeries and standard joint preparation was performed with crushed fibular autograft mixed with demineralized bone matrix. Standard operative technique was used with blunt dissection on the plantar aspect of the foot, and soft-tissue was protected during the reaming process. A 12mm x 15cm VersaNail (Depuy Orthopaedics, Warsaw, Indiana) was inserted, and two calcaneal screws and one talar interlocking screw were inserted using lateral to medial locking technique. A tibial interlocking screw was then inserted proximally in the static hole from medial to lateral using blunt dissection and also taking care to not plunge when drilling. The patient was admitted to the orthopedic unit postoperatively, but approximately 12hrs postoperatively began experiencing parasthesias and greatly increasing pain. Upon exam the foot was dusky, and DP and PT pulses were nonpalpable and absent on Doppler. The patient was taken for an emergent angiogram and an AT injury was demonstrated at the level of the proximal interlocking screw, as well as chronic obstruction of the PT artery. A right popliteal to dorsalis pedis bypass was then performed using greater saphenous vein, and a modified splint was applied to monitor the DP pulse postoperatively. The patient was discharged on POD #5 in stable condition, and no additional vascular complications arose. There were no complications at 14month follow-up with the exception of STJ nonunion, which was treated with an AFO.

Conclusions: The authors also performed an extensive literature review on ATA injury following TTCA retrograde nailing. This included Muckley et al’s cadaveric study of anatomic distance between proximal tibial interlocking screw and ATA, which concluded the curved nail and tibial interlocking screw placement from medial to lateral had the least risk of ATA damage. The authors also noted care needs to be taken in proper drilling technique to avoid plunging, cautious use of the depth gauge, and proper length of screw to avoid prominence into the area of the ATA. Based on the literature review and experience with this case, the authors recommend careful preoperative vascular assessment and acute intraoperative awareness of the ATA in relation to the TTCA nail. The authors also recommend use of fluoroscopy for placement of interlocking screws, and recommend insertion of the proximal tibial interlocking screw from the medial to lateral direction. If there is any concern for acute limb ischemia, vascular surgery needs to be consulted immediately.

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