title: Proximity and Risks of the Anterior Neurovascular and Tendinous Anatomy of the Distal Leg Relative to Anteriorly Applied Distal Locking Screws for Tibia Nailing: A Plea for Open Insertion.
abstract: OBJECTIVE
  To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing.
  
  
  METHODS
  Retrospective.
  
  
  METHODS
  ACS level I trauma center.
  
  
  METHODS
  Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs.
  
  
  METHODS
  Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy.
  
  
  RESULTS
  All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line.
  
  
  CONCLUSIONS
  The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.
authors.affiliation: *Department of Orthopedic Surgery, Vanderbilt University, Nashville, TN; and †Campbell Clinic/University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Mitchell
authors.forename: Cory A
authors.initials: CA
authors.lastname: Collinge
authors.forename: Eric
authors.initials: E
authors.lastname: Barcak
authors.forename: Edward
authors.initials: E
authors.lastname: Perez
authors.forename: Kostas
authors.initials: K
authors.lastname: Triantafillou
mesh_terms: D000328:Adult; D001863:Bone Screws / Q000009:adverse effects*; D005260:Female; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects* / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D007866:Leg / Q000098:blood supply* / Q000000981:diagnostic imaging / Q000294:innervation*; D008297:Male; D059348:Peripheral Nerve Injuries / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D057772:Vascular System Injuries / Q000209:etiology