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Extracapsular Placement of Distal Tibial Transfixation Wires
Anand M. Vora, MD1; Steven L. Haddad, MD2; Anish Kadakia, MD3; Martin L. Lazarus, MD4; Bradley R. Merk, MD3
1 Lake Forest Orthopaedic Associates, Illinois Bone and Joint Institute, 1200 North Westmoreland Drive, Suite 100, Lake Forest, IL 60045
2 Illinois Bone and Joint Institute, Glenview Medical Arts Building, 2401 Ravine Way, 2nd Floor, Glenview, IL 60025. E-mail address: slhaddad@earthlink.net
3 Department of Orthopaedic Surgery, Northwestern University Medical School, 645 North Michigan Avenue, Suite 910, Chicago, IL 60611
4 Department of Radiology, Evanston Hospital, 2650 Ridge Avenue, Evanston, IL 60201
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Magnetic Resonance Imaging Research Laboratory, Evanston Hospital, Evanston, Illinois

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 May 01;86(5):988-993
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Background: Treatment of tibial plafond fractures with external fixation may involve use of transfixation wires within the periarticular region. Pin track infections that develop along wires placed intracapsularly may lead to joint infection. To our knowledge, there have been no previous investigations assessing the circumferential reflection of the ankle capsule or the potential for communication between the distal tibiofibular joint and the tibiotalar joint. The purpose of this study was to define these anatomic entities to provide guidelines for safe extracapsular placement of distal tibial wires.

Methods: Twelve fresh-frozen cadaveric ankles and three ankles of living human volunteers were utilized for this study. High-resolution magnetic resonance imaging was performed on each ankle after pressurized distention of the joint capsule with gadolinium solution. The perpendicular distance from the subchondral bone at the joint line to the capsular synovial reflection was measured with use of a verified technique. The cadaveric ankles were sectioned, the capsular synovial reflections were measured by investigators who were blinded to the imaging results, and the corresponding measurements were compared.

Results: The anterolateral capsular synovial region displayed the most proximal reflection in all specimens (mean, 9.3 mm; maximum, 12.2 mm). The anteromedial region displayed less reflection (mean, 3.3 mm; maximum, 5.5 mm). All posteromedial and posterolateral synovial reflections were =2 mm. Capsular synovial reflections proximal to the medial and lateral malleoli were negligible. In all ankles, the distal tibiofibular joint communicated with the tibiotalar joint and had a maximum proximal extension of 20.6 mm.

Conclusions: Placement of distal tibial transfixation wires >12.2 mm from the subchondral surface of the plafond avoids penetration of the capsule. The distal tibiofibular joint communicates with the tibiotalar joint and thus should not be penetrated, to ensure extracapsular placement of the wires.

Clinical Relevance: Stabilization with distal tibial transfixation wires should be proximal to the reflected joint capsule and should avoid penetration of the distal tibiofibular joint to minimize the risk of penetration of the capsule and the potential for joint infection as a sequela of superficial pin track infection.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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