Injury 51 (2020) 384–388

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Injury
journal homepage: www.elsevier.com/locate/injury

Evaluation of the positional relationship between femoral arteries and

distal screws in the proximal femoral intramedullary nail for
preventing iatrogenic vascular injury
Yohei Asano∗, Daisuke Yamauchi, Yukio Gonoji
Department of Orthopaedic Surgery, Fukui-ken Saiseikai Hospital, 7-1, Wadanaka-machi funabashi, Fukui-shi, Fukui, 918-8503, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Background and Aims: Iatrogenic vascular injury associated with distal screw in the intramedullary nail
Accepted 2 October 2019 for femoral trochanteric fracture is a rare but serious complication. This study aimed to investigate the
positional relationship between distal screws and superficial (SFA), deep (DFA), and perforating femoral
Keywords: artery (PFA) using computed tomography (CT) angiography and to identify the risk factors of vascular
Iatrogenic vascular injury injury.
Femoral artery Patients and Methods: Thirty-eight patients (11 patients who underwent osteosynthesis with proximal
Femoral trochanteric fracture femoral intramedullary nail and 27 healthy people) who underwent CT angiography were included. The
Distal screw distance from the great trochanter tip and insertion angle from posterior condylar axis (reference line)
Intramedullary nail
of the distal screws were measured, and the presence rates and distances from the femur of each artery
within the insertion angle were investigated.
Results: The distance from the great trochanter tip to the distal screw was 142.5 ± 8.8 mm. The inser-
tion angle from the reference line was 27.3°±15° The measurement points were set at 130, 140, and
150 mm distal from the great trochanter tip, and the assumed insertion angle as 27°±15° Within this an-
gle, the presence rates and distances were 50.8%/34.2 ± 7.0 mm (130 mm), 38.5%/34.3 ± 6.0 mm (140 mm),
30.8%/33.4 ± 6.0 mm (150 mm) in SFA; 12.3%/14.2 ± 3.3 mm (130 mm), 3.1%/13.1 ± 5.9 mm (140 mm), and
0% (150 mm) in DFA; and 0% (130−150 mm) in PFA. The presence rate of DFA increased at the postero-
medial area in the thigh, and the distance from the femur became closer.
Conclusion: Within the angle that distal screws were likely to be inserted, the risk of DFA injury was the
highest. Therefore, anatomical reduction of the femoral neck anteversion should be performed so that the
distal screw will be inserted towards the anteromedial area in the thigh, and great attention should be
paid not to over-drill the medial femoral cortex.
© 2019 Elsevier Ltd. All rights reserved.

Introduction
Internal fixation with intramedullary nail (IM nail) for femoral
trochanteric fractures is the standard surgical method [1]. Sev-
eral reports revealed the complications of IM nail, such as cut-
out and reduction loss due to over telescoping and nail breakage
[2–6]. Conversely, the iatrogenic vascular injury is a rare but se-
rious complication [7–10]. Its causes were improperly positioned
retractor, reduction by internal rotation and adduction, direct in-
juries by fracture fragments [8,11–13], and mostly distal screw of
the IM nail [8–10,13–15]. Especially, deep femoral artery (DFA) runs
along with the medial of the femur; thus, the risk of DFA injury is
high [10,12,16]. However, only three studies were found on the po-
sitional relationship between femoral arteries and the distal screw
of IM nail at the medial thigh using computed tomography (CT)
[17–19].
Therefore, this study aimed (1) to investigate the positional re-
lationship between femoral arteries and the distal screw in the
proximal femoral IM nail for femoral trochanteric fracture at the
medial thigh using CT angiography, making a graph to facilitate in
positioning them, and (2) to identify the risk factors of vascular
injury.
Patients and methods

Eleven patients (1 male and 10 females, with the mean age

∗
Corresponding author. of 86.4 [72−96] years) who underwent internal fixation with
E-mail addresses: you.you.mounin@gmail.com (Y. Asano), proximal femoral IM nail for femoral trochanteric fracture and CT
yamadai947@yahoo.co.jp (D. Yamauchi), gonoyuki857@yahoo.co.jp (Y. Gonoji). angiography of the lower extremity postoperatively from January

https://doi.org/10.1016/j.injury.2019.10.003
0020-1383/© 2019 Elsevier Ltd. All rights reserved.
 Y. Asano, D. Yamauchi and Y. Gonoji / Injury 51 (2020) 384–388
Fig. 1. (A) The line connecting the posterior condyles in the femur was used as
the reference line (0°). (B) The angle between the reference line (0°) and the distal
screw was measured as the insertion angle (θ ).
2014 to November 2017, and 27 patients (21 males and 6 females,
with the mean age of 70.4 [49−90] years) who underwent CT
angiography of the lower extremity in other departments were
included in this study. Among them, eleven limbs, which were the
surgical side of eleven patients were selected and defined as the
fracture group, whereas 65 limbs (eleven from the non-surgical
side of eleven patients and 54 of 27 patients) were defined as the
non-fracture group. Exclusion criteria were fracture history and/or
femoral deformity and femoral artery diseases.
The implants used in this study were as follows: Prox-
imal Femoral Nail Antirotation-II (PFNA-II; DePuy Synthes,
Solothurn, Switzerland), 2 cases; Gamma3 nail (STRYKER Trauma
GmbH, Schönkirchen, Germany), 8 cases; Zimmer Natural Nail
Cephalomedullary Long Nail (Zimmer Biomet, Warsaw, IN USA), 1
case. The nail length/distance from the nail top to the distal screw
were 200/136, 170/140, and 180/135 mm, respectively.
CT angiography was performed using Aquilion64CXL (Toshiba
Medical Systems, Otawara, Japan), set to 120 kVp, automatic ex-
posure control (mAs), and images were reconstructed with a slice
thickness of 1 mm.
The insertion angle and distance from the great trochanter tip
of the distal screw and the postoperative femoral neck anteversion
were measured in the fracture group. The line connecting the pos-
terior condyles in the femur was used as the reference line (0°),
and the angle between the reference line and distal screw was
measured and used as the insertion angle (Fig. 1A, B). From these
results, measurement points were set and the insertion angle of
385
Fig. 2. The angle from the reference line (θ ’) and the distance from the far femoral
cortex (D) of each artery were measured. The distances from the center of the
medullary canal to the far cortex (d1) and to each artery (d2) were measured, re-
spectively. The difference between the two distances was defined as D.
the distal screw was estimated to investigate the positional rela-
tionship between femoral arteries and the distal screw.
At the outset, the superficial femoral artery (SFA), DFA, and per-
forating femoral artery (PFA) were identified on the axial view of
CT angiography at each measurement point in the non-fracture
group. PFA branches were identified as first PFA (1st PFA) and sec-
ond PFA (2nd PFA) from the proximal side, and each branch was
measured.
Then, the angle from the reference line and the distance from
the femur of each artery were measured (Fig. 2). The angle of ar-
teries located anterior to the reference line was defined positive,
and those located posterior was defined negative. In order to mea-
sure the distance from the femur, a straight line was drawn from
center of the femoral medullary canal to each artery. Based on this
straight line, the distance from the center of the medullary canal
to the far cortex of the femur was measured. The difference be-
tween the two distances was calculated, and its result was defined
as the distance from the femur (Fig. 2). All data are summarized as
mean ± standard deviations along with the range values.
Finally, a graph was made with the reference line as X axis
(mm) and vertical line as the reference line as Y axis (mm), and
the results in each artery were plotted. The origin was the center
of the medullary femoral canal, and the circle had the following
mean femoral radius at each measurement point; 130 mm: r, 140
mm: r’, 150 mm: r’’. These circles were considered as the femur,
and the positional relationship with the femoral arteries was visu-
alized. The mean insertion angle and assumed insertion angle of
the distal screw were also added. Based on these graphs, the posi-
tional relationship between the femur, femoral arteries, and distal
screw in the proximal femoral IM nail was investigated.
Results
In the fracture group, the insertion angle in the distal screw
was 27.3°±15.0° (−2.2°−46.1°), and the distance from the great
trochanter tip to the distal screw was 142.5 ± 8.8 (124.0 − 152.1)
mm. The postoperative femoral neck anteversion from the refer-
ence line was 19.9°±16.0° (−9.6°−45.8°). From these results, mea-
surement points were set as 130 mm, 140 mm, and 150 mm distal
from the great trochanter tip (Fig. 3) and the assumed insertion
angle of the distal screw as 27°±15°.
386 Y. Asano, D. Yamauchi and Y. Gonoji / Injury 51 (2020) 384–388

Table 1
The distance between the far femoral cortex and superficial femoral artery (SFA), deep femoral artery (DFA), and perforating femoral artery (PFA).

Measurement point SFA DFA 1st PFA 2nd PFA

130 mm 30.7 ± 7.5 (12.9 − 47.4) mm 13.7 ± 4.6 (2.4 − 30.2) mm 7.0 ± 4.5 (−0.10−17.7) mm 6.7 ± 6.7 (−1.01−22.2) mm
140 mm 30.1 ± 7.1 (13.5 − 44.6) mm 13.0 ± 4.1 (4.8 − 23.0) mm 11.7 ± 4.7 (3.3 − 21.0) mm 5.9 ± 7.5 (0.0 − 25.9) mm
150 mm 29.4 ± 6.6 (14.8 − 45.2) mm 11.6 ± 4.1 (1.9 − 23.1) mm 17.6 ± 4.6 (9.9 − 24.3) mm 6.9 ± 7.5 (0.90−26.8) mm

PFA branches were identified as first PFA (1st PFA) and second PFA (2nd PFA) from the proximal side.

Table 2
The presence rate and distance from the far femoral cortex within the assumed insertion angle of the distal screw (27°±15°).

Measurement point SFA DFA PFA

Presence rate (%) Distance (mm) Presence rate (%) Distance (mm) Presence rate (%) Distance (mm)

130 mm 50.8 34.2 ± 7.0 (22.3 − 47.4) 12.3 14.2 ± 3.3 (6.8 − 18.0) 0 −
140 mm 38.5 34.3 ± 6.0 (20.7 − 41.5) 3.1 13.1 ± 5.9 (7.2 − 19.0) 0 −
150 mm 30.8 33.4 ± 6.0 (22.9 − 42.2) 0 − 0 −

SFA superficial femoral artery, DFA deep femoral artery, and PFA perforating femoral artery.

vestigated using CT angiography, and risk factors of vascular in-

Fig. 3. The measurement points were set as 130 mm, 140 mm, and 150 mm distal
from the great trochanter tip.
In the non-fracture group, distances from the far femoral cor-
tex to each artery were 30.7 ± 7.5 mm (130 mm), 30.1 ± 7.1 mm
(140 mm), and 29.4 ± 6.6 mm (150 mm) in SFA; 13.7 ± 4.6 mm
(130 mm), 13.0 ± 4.1 mm (140 mm), and 11.6 ± 4.1 mm (150 mm)
in DFA; 7.0 ± 4.5 mm (130 mm), 11.7 ± 4.7 mm (140 mm), and
17.6 ± 4.6 mm (150 mm) in the 1st PFA; and 6.7 ± 6.7 mm (130 mm),
5.9 ± 7.5 mm (140 mm), and 6.9 ± 7.5 mm (150 mm) in the 2nd PFA
(Table 1).
A graph was made based on these results, and the posi-
tion of each artery was plotted (Fig. 4A-C). The mean femoral
radius was 130 mm (r): 15.3 mm, 140 mm (r’): 14.9 mm, and
150 mm (r’’): 14.8 mm, respectively. Within the assumed insertion
angle, the presence rates and distances from the femur were
50.8%/34.2 ± 7.0 mm (130 mm), 38.5%/34.3 ± 6.0 mm (140 mm),
and 30.8%/33.4 ± 6.0 mm (150 mm) in SFA; 12.3%/14.2 ± 3.3 mm
(130 mm), 3.1%/13.1 ± 5.9 mm (140 mm), and 0% (150 mm) in DFA;
and 0% (130−150 mm) in PFA (Table 2).
Discussion
The positional relationship between femoral arteries and distal
screw in the proximal femoral IM nail at the medial thigh was in-
jury were identified. Based on the insertion angle results of the
distal screw, it was likely to be inserted at an angle of 27°±15°
Ramanoudjame et al. [20] investigated patients with postoperative
femoral neck anteversion who underwent osteosynthesis with dy-
namic hip screw or IM nail for femoral trochanteric fracture using
CT, which is similar with our methods, and reported as 23°±16.8°
(−33°−47°). From these results and the result in this study
(19.9°±16.0° (−9.6°−45.8°)), we thought that the assumed inser-
tion angle of the distal screw used in this study was reasonable.
Within the assumed insertion angle of the distal screw at each
measurement point, approximately half of SFA existed were found,
but the distance from the femur was >33 (33.4 − 34.3) mm and
was relatively far (Table 2). Therefore, the risk of SFA injury will
increase if the drilling medial femoral cortex exceeds 33 mm but
the possibility was considered not so high.
The presence rate of DFA within this angle was approximately
10% (3.1%−12.3%), and the mean distance from the femur was
13.1 − 14.2 mm (Table 2). The presence rate was not so high but
DFA was very close to the femur, and the risk of DFA injury will
increase if the drilling medial femoral cortex exceeds 13 mm. In
addition, the presence rate of DFA further increased at the pos-
teromedial area in the thigh, and the distance from the femur be-
came closer (Fig. 4). The risk of DFA injury will further increase
if the distal screw is inserted towards the posteromedial area in
the thigh. The insertion angle of the distal screw is the same
as that of the proximal screw (lag screw or blade) in most in-
tramedullary nails, and is determined by the femoral neck antev-
ersion. Therefore, anatomical reduction of the femoral neck antev-
ersion should be performed so that the proximal screw and the
distal screw will be inserted towards the anteromedial area in the
thigh.
Most PFA located at approximately 10 mm from the femur and
ran along the posterior area of the femur at measurement points
(Table 1). The distance from the femur was the closest in the
femoral arteries, but the presence rate within the assumed inser-
tion angle of the distal screw was 0% (Table 2). The risk of PFA
injury associated with the distal screw in the proximal femoral IM
nail was thought to be low.
Iatrogenic vascular injury due to internal fixation with IM nail
for femoral trochanteric fracture is rare [7,8], and most reports are
DFA injury associated with the distal screw [15]. Only two reports
were found on SFA injury associated with internal fixation with
IM nail for the femoral trochanteric fracture [8,14], but no report
regarding PFA injury. The results in this study showed that the risk
of DFA injury due to distal screw of IM nail was highest in the
femoral arteries, which is consistent with previous reports.
 Y. Asano, D. Yamauchi and Y. Gonoji / Injury 51 (2020) 384–388 387

Fig. 4. (A) The graphs were made with the reference line as X axis (mm) and vertical line as the reference line as Y axis (mm), and the results in each artery in the non-
fracture group were plotted. The origin was the center of the medullary femoral canal, and the circle had the following mean femoral radius at each measurement point.
The mean insertion angle (27.3°) and assumed insertion angle (27°±15°) of the distal screw were added. 130 mm distal from the great trochanter tip, r: 15.3 mm (B) 140 mm
distal from the great trochanter tip, r’: 14.9 mm . (C) 150 mm distal from the great trochanter tip, r”: 14.8 mm.

There is a limitation in the design of this study. The angle from
the reference line and distance from the femur of femoral arteries
were measured using CT angiography. However, the IM nail surgery
for femoral trochanteric fracture is performed on the traction table,
and is usually reduced by traction, internal rotation, and adduction.
Thus, the position of the femoral arteries may possibly be different
between CT angiography and surgery. Therefore, in the future, we
plan to investigate the intraoperative position of femoral arteries
using an ultrasonography.
Conclusions
Within the angle that distal screw in the proximal femoral IM
nail was likely to be inserted, DFA was closest to the femur but
the presence rate was low. Therefore, the vascular injury is unlikely
unless there is significant malreduction of the fracture or malposi-
tioning of the implant.
Declaration of Competing Interest
The authors declare that they have no conflict of interest.
Acknowledgements
We thank to Department of General Affairs in Fukui-ken Sai-
seikai Hospital for data organization and graphic help.
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