Injury to the deep femoral artery during proximal locking of a distal femoral nail--a report of 2 cases

Relationship Between Femur and Femoral Arteries for Identifying Risk Factors for Vascular Injury

Background

This study aimed to identify risk factors for vascular injury in proximal femoral fracture through identifying frequency and distances between femur and femoral arteries with computed tomography angiography and 3-dimensional reconstruction.

Material/Methods

In a series of 400 participants, based on measurement results regarding the distribution of femoral arteries in the medial femur, the femoral portion covering that part was divided into levels A–E. The center region, margin region, and risky area in the medial femur were defined. The frequency of femoral arteries and interested shortest distance between the outer femur and superficial, deep, and perforating femoral arteries (SFAs, DFAs, and PFAs) in the center region, margin region, and risky area at each level were recorded.

Results

There were 173 males and 227 females (average age: 63.61±19.18 years) in this study. The starting point and end point for femoral arteries in the medial femur were from 22.55±4.23% to 54.56±8.39% of the whole femur. The femoral arteries in the medial femur mainly were distributed at levels B (88.2%), C (65.9%), and D (40.6%). The femoral arteries in center regions in the risky area, most of which were DFAs and PFAs, were mainly concentrated at levels B (26.93%) and C (11.81%).

Conclusions

The mid-shaft level was the most risky level, and the DFAs and PFAs were easier to injure than the SFAs when performing internal fixation of proximal femoral fracture. We recommended that great attention be paid to drill and screw insertion around the mid-shaft level for prevention of iatrogenic vascular injury.

Safe zone for the superficial femoral artery demonstrated on computed tomography angiography

INTRODUCTION

Internal or external fixation of the femur is common following trauma. Neurovascular structures around the shaft of the femur are at risk, particularly the superficial femoral artery (SFA). Damage to this structure, when it is medial to the femur, can occur during the lateral approach, when drills, pins or screws are inserted. This anatomical study aims to delineate a safe zone for operative intervention to the shaft of the femur with respect to the SFA, and describe the relationship between this zone and the width and length of the femur.

MATERIALS AND METHODS

41 limbs from 22 patients were examined using Computed Tomography Angiography to determine the relationship between the SFA and the medial shaft of the femur. The danger zone where the SFA lies medial to the shaft of the femur in the sagittal plane was identified and measured, and the width and length of the femur were measured for reference points.

RESULTS

The SFA begins anterior to the shaft of the femur proximally and passes posteriorly, crossing the shaft of the femur in the sagittal plane at points 239.6±39.8mm and 172.5±40.9mm proximal to the adductor tubercle (AT). The width of the femur correlates to the inferior crossing point of the SFA on the femur with a mean ratio of 1:2.05, p=0.000, the length of the femur correlates to the mid crossing point of the SFA on the femur with a ratio of 2.00:1, p=0.000.

CONCLUSIONS

There is a safe zone along the medial shaft of the femur, which can be estimated intraoperatively using anatomical reference points.

Is There an Optimal Proximal Locking Screw Length in Retrograde Intramedullary Femoral Nailing? Can We Stop Measuring for These Screws?

Insertion of locking screws through the proximal thigh while locking retrograde femoral nails is arguably more difficult and traumatic to local tissues than locking at other intramedullary nail sites. The purpose of this study was to evaluate whether a "standard" screw length for proximal interlocking of retrograde nails is possible, therefore assessing whether the act of measuring for these screws can be omitted. This article retrospective evaluates screw position and estimated proximal locking screw length in patients undergoing retrograde nailing using a large radiographically measured computed tomography cohort, with validation through a smaller clinical cohort. According to these data, it seems reasonable to skip depth gauge measurement during anteroposterior interlocking of retrograde femoral nails and insert a standard length screw based on location relative to the lesser trochanter. This should decrease the amount of local trauma to the patient at the locking screw site while increasing operating room efficiency by avoiding what can often become a difficult step during the procedure.

Lower extremity bypass graft occlusion after intramedullary fixation of intertrochanteric hip fracture on a fracture table

This article presents a case of a 90-year-old woman who previously underwent a common femoral to anterior tibial artery bypass grafting with a Gore-Tex graft (Gore Medical, Flagstaff, Arizona). She subsequently sustained an ipsilateral intertrochanteric hip fracture after a mechanical fall and underwent internal fixation with an intramedullary nail using a fracture table. In the immediate postoperative period, she developed limb-threatening ischemia in her leg due to graft thrombosis. The patient underwent a successful thrombectomy and embolectomy. However, she subsequently developed nonhealing ulcers to this extremity over the course of weeks, requiring surgical debridement. Gangrene ensued and she underwent a below-the-knee amputation.Complications from the use of fracture tables have been described for perineal soft tissue injury, leg malrotation or malalignment, neurologic injury, and iatrogenic compartment syndrome of the healthy leg. Arterial complications after intramedullary fixation of femur fractures are rare and may be caused by direct arterial trauma during placement of the locking screws through the intramedullary nail. This article is the first, to our knowledge, to describe an occlusion of a lower extremity bypass graft after intramedullary fixation on a fracture table. Surgeons should be aware of potential limb threatening ischemia in patients with peripheral vascular disease, especially in those with prior lower extremity bypass grafts. Proper preoperative counseling should be given to these patients when using fracture tables during hip fracture surgery.

An alternative direction for proximal locking in retrograde femoral nails

Lateral-to-medial proximal interlocking screw insertion for retrograde femoral nails avoids potential neurovascular injury while maintaining stable interlocking mechanics.

Treatment of acute distal femur fractures

An emphasis on indirect reduction techniques to restore limb alignment has improved the rate of fracture healing and decreased infection rates, fixation failure, and the need for bone grafting.

Delayed pseudoaneurysm caused by distal locking screw of a femoral intramedullary nail: a case report

Interlocked intramedullary nailing is an accepted technique in the management of closed femoral shaft fractures. If this technique is used in patients who are skeletally immature, the position of locking screws relative to soft tissues can alter with time. We present a case of an 11-year-old male who developed a delayed pseudoaneurysm 4 years after intramedullary nailing that was most likely produced by movement of the distal locking screws of his femoral nail in relation to the surrounding vascular structures.

Retrograde intramedullary nailing in distal femoral fractures--results in a series of 46 consecutive operations

We present a series of 44 consecutive patients with 46 distal femoral fractures, who were treated with a retrograde intramedullary nail (Distal Femoral Nail (DFN)). Operational data, per- and post-operative complications and the outcome were studied retrospectively after a mean follow-up of 9 months. The final union rate was 95%, with a mean union time of 17.5 (8-68) weeks. Restoration of the limb axial alignment and length was inadequate in two cases, whereas three losses of reduction and one non-union were observed. Two cases of distal locking screw breakage were also observed. Moreover, one patient suffered from an iatrogenic lesion of the branch of the deep femoral artery. No deep, but three superficial infections were observed. In conclusion, our results suggest that DFN is a reliable alternative in distal femoral fracture treatment with a low complication rate.