A simple method to protect the great saphenous vein and saphenous nerve in percutaneous plate fixation of distal tibial fractures

Abstract

Open reduction and internal fixation for distal tibial fractures can achieve anatomical reduction, but may result in delayed union, nonunion or soft-tissue complications. Minimally invasive plate osteosynthesis (MIPO), which involves insertion of the plate through a limited incision, placement of screws through stab incisions and using the principles of biologic fixation with indirect reduction techniques to reduce the fracture, is believed to decrease the rates of nonunion and lower soft-tissue complications because of the undisrupted local fracture environment and limited skin incisions. Locking plates (LPs) have the biomechanical properties of internal and external fixators, with superior holding power because of fixed angular stability through the heads of locking screws. As a result, percutaneous plate fixation of distal tibial fractures is becoming more and more popular as a minimally invasive technique. However, because the great saphenous vein (GSV) and saphenous nerve (SN) lie in the medial facet of the distal tibia, and cross the tibia from anterior to posterior, percutaneous plates must be inserted underneath these structures. These structures are difficult to dissect and identify through the stab incisions used to place screws. Therefore, percutaneous insertion of the drill sleeves and screws can increase the risk of injury to the GSV and SN more than does open reduction and internal fixation. Despite this risk, the incidence of numbness resulting from iatrogenic injury to the SN has not been reported in the literature. Although minimal attention has been paid to this complication, having little overall clinical importance, it can be a source of patient dissatisfaction and impaired quality of life as a result of the sensory disturbance, and furthermore, may be readily preventable. On the other hand, injury to the GSV is thought to have little clinical importance other than increased bleeding from the incision, because drainage can be achieved through the communicating veins. However, haematoma, foot oedema and possible decrease in venous return from the already injured local soft-tissue