Risk of vascular injury when screw drilling for tibial tuberosity transfer
- 188 Downloads
During tibial tubercle transfer, popliteal vessels are at risk from drills and screws. The risk is around 0.11%, as described in the literature. We reviewed knee injected CT scan for analysis of the location of arteries, identified landmarks allowing minimizing risks, and defined a safe zone.
Material and method
Distances between the posterior cortex and arteries were measured on CT scans from 30 adults (60 knees) at three levels (proximal part of the tibial tuberosity, 20 mm and 40 mm distally). Data were used to create a “risk map” with different angular sectors where the frequency of the presence of arteries was analyzed in each area. We also analyzed the position of 68 screws of 47 patients who underwent a medial tibial tuberosity transfer.
The nearest distance between artery and the posterior tibial cortex was found at the level corresponding to the top of the tuberosity with less than 1 mm, while the largest distance was found at the distal level. We were able to define a safe zone for drilling through the posterior tibial cortex which allows a safe fixation for the screws. This zone corresponds to the medial third of the posterior cortex. When the safe zone is not respected, screws that overtake the posterior cortex may be close to arteries as observed for 37 of the 68 screws analyzed.
We described new landmarks and recommendations to avoid this complication during tibial tuberosity transfer.
KeywordsPopliteal artery injury Landmarks Safe zone Nails External fixation Anterior tibial tuberosity osteotomies
Compliance with ethical standards
Conflict of interest
Jacques Hernigou, Esfandiar Chahidi, Mahine Kashi, Eric Moest, Bassel Dakhil, Georges Hayek, Antoine Callewier, Frederic Schuind, Olivier Bath declare that they have no conflict of interest.
The video presents 3D images of a leg and arteries target and the risk map according to our results (in green areas where arteries were never observed, in red areas were arteries were observed). (MP4 50682 kb)
- 5.Bellemans J, Stockx L, Peerlinck K et al (1999) Arterial occlusion and thrombus aspiration after total knee arthroplasty. Clin Orthop Relat Res 336:164–168Google Scholar
- 10.Kline AJ, Gonzales J, Beach WR, Miller MD (2006) Vascular risk associated with bicortical tibial drilling during anteromedial tibial tubercle transfer. Am J Orthop (Belle Mead NJ) 35:30–32Google Scholar
- 13.Trotter M (1970) Estimation of stature from intact limb bones. In: Stewart TD (ed) Personal identification in mass disasters. National Museum of Natural History, Smithsonian Institution, Washington, pp 71–84Google Scholar
- 14.Eckhoff DG, Johnson KK (1994) Three-dimensional computed tomography reconstruction of tibial torsion. Clin Orthop Relat Res 302:42–6Google Scholar
- 15.Akagi M, Oh M, Nonaka T et al (2004) An anteroposterior axis of the tibia for total knee arthroplasty. Clin Orthop Relat Res 420:213–219Google Scholar
- 16.Tamari K, Tinley P, Briffa K, Breidahl W (2005) Validity and reliability of existing and modified clinical methods of measuring femoral and tibiofibular torsion in healthy subjects: use of different reference axes may improve reliability. Clin Anat 18:46–55. doi: 10.1002/ca.20050 CrossRefPubMedGoogle Scholar
- 17.Tamari K, Tinley P, Briffa K, Aoyagi K (2006) Ethnic, gender, and age related differences in femorotibial angle, femoral antetorsion, and tibiofibular torsion: cross-sectional study among healthy Japanese and Australian Caucasians. Clin Anat 19:59–67. doi: 10.1002/ca.20170 CrossRefPubMedGoogle Scholar
- 25.Wensing PJ, Scholten FG, Buijs PC, et al (1995) Arterial tortuosity in the femoropopliteal region during knee flexion: a magnetic resonance angiographic study. J Anat 187:133–9Google Scholar
- 29.Lane J, Karnatzikos G, Gobbi A (2014) Elmslie-Trillat procedure: a distal-based procedure for patellar stabilization. In: Gobbi A, Espregueira Mendes J, Nakamura N (eds) Patellofemoral Jt. State art Eval. Manag. Springer, New York, pp 155–160Google Scholar
- 30.Hauser E (1938) Total tendon transplant for slipping patella: a new operation for recurrent dislocation of the patella. Surg Gynecol Obs 66:199–214Google Scholar
- 31.Fulkerson JP (1983) Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop Relat Res 177:176–81Google Scholar
- 32.Fulkerson JP, Becker GJ, Meaney JA et al (1990) Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med 18:490–496Google Scholar