Zusammenfassung
Hintergrund
Die Rate an klinisch relevanten neurovaskulären Schäden nach proximaler Tibiamarknagelung ist schwer abschätzbar. Aus diesem Grund sollte in einer prospektiven MRT-Untersuchung das anatomisch begründbare Risiko für Verletzungen in dieser Region eingeschätzt werden.
Material und Methoden
In die Untersuchung eingeschlossen wurden 99 konsekutive Patienten, die zum Ausschluss einer intraartikulären Kniegelenkpathologie eine MRT-Untersuchung (Philips Intera 1,0 Tesla, Philips Medizingeräte, Böblingen, Deutschland) im Institut für Radiologie des Klinikums Worms erhielten. Zunächst wurde die Distanz des Gefäß-Nerven-Bündels (GNB) zur dorsalen Tibiakortikalis (dTK) bestimmt, um abschätzen zu können, wie hoch das Risiko einer Verletzung der vulnerablen Strukturen beim bikortikalen Bohren ist. Die Position des GNB (pGNB) in medialer (+pGNB) und lateraler (−pGNB) Richtung wurde in Bezug zu einer Mittellinie durch das Tibiakopfplateau bestimmt, um damit den Vorteil einer leicht rotierten Nagelinsertion beurteilen zu können.
Ergebnisse
Unter den bestimmten Distanzen wurde der Abstand der dorsalen Tibiakortikalis zum Gefäß-Nerven-Bündel als der wichtigste bzgl. einer möglichen Läsion der vulnerablen Strukturen definiert. Im Mittel betrug dieser Abstand 11,54 (4–21 mm, Standardabweichung [SD] 3,42 mm). In Bezug zur Tibiakopfmittelline wurde die mediale und laterale Position des GNB bestimmt. Die maximale laterale Position betrug 23 mm von der Tibiakopfmittellinie und die maximale mediale Position 6 mm von der Tibiakopfmittellinie. In 9 Fällen lag das GNB medial, in 12 Fällen genau mittig und in den übrigen 69 Fällen lag das GNB lateral der Tibiakopfmittellinie. Im Mittel befand sich das GNB 6,03 mm lateral der Tibiakopfmittelline.
Schlussfolgerung
Die vorliegende Arbeit zeigt, dass die proximale dreidimensionale Verriegelung von Tibiamarknägeln bei Beachtung der korrekten Insertionstechnik unter konsequenter intraoperativer Bildwandlerkontrolle als ausreichend sicher gegenüber iatrogenen Gefäß-Nerven-Schäden anzusehen ist. Eine rotierte Insertion des Nagels zur Vermeidung einer strikten a.p.-Ausrichtung von Schraube nist nicht zu empfehlen.
Abstract
Background
The rate of clinically relevant neurovascular injuries after proximal intramedullary nailing of the tibia remains unclear. The anatomical risk of iatrogenic damage to these structures should be estimated in a prospective MRI examination.
Material and methods
A total of 99 consecutive patients were included in the study cohort. All patients underwent an MRI examination due to suspected intra-articular lesions of the knee joint.
Examinations were performed at the Institute for Radiology at the Clinic of Worms. The MRI system used was a Philips Intera 1.0 Tesla (Philips, Böblingen, Deutschland). The distance of the neurovascular bundle (GNB) to the posterior tibial cortex was measured (dTK) to estimate the risk of bicortical drilling. The position of the GNB (pGNB) in the medial (+pGNB) and lateral (−pGNB) directions was determined relative to the tibial head midline to estimate potential advantages of oblique or rotated insertion of the nail.
Results
The mean distance between the posterior tibial cortex and the GNB was 11.54 mm (range 4–21 mm standard deviation 3.42 mm). In relation to the tibia head midline, the maximal lateral position was determined as 23 mm and maximal medial position was 6 mm. In 9 cases the GNB was found medially, in 12 cases in the midline and in 69 cases laterally. The mean lateral position of the GNB was 6.03 mm.
Conclusions
Triple proximal interlocking in tibial nailing procedures can be considered a safe procedure if care is taken with the correct operation technique and careful image intensification control of drilling procedures. A rotated nail insertion to avoid a strict anterior-posterior positioning of proximal interlocking screw is not to be recommended.
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Hansen, M., Roux, P., Adolph, J. et al. Risiko iatrogener neurovaskulärer Verletzung bei proximal dreidimensionaler Verriegelung von Tibiamarknägeln. Unfallchirurg 113, 476–480 (2010). https://doi.org/10.1007/s00113-010-1769-9
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DOI: https://doi.org/10.1007/s00113-010-1769-9