The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 5

Scientific Articles | May 01, 2004

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

View Disclosures and Other Information

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

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

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.

Figures in this Article

The literature is replete with studies documenting major and minor complications of the management of tibial plafond fractures^1-10. Traditional approaches of open reduction and internal fixation of high-energy fractures have led to a high complication rate and unsatisfactory results in some series^1-4,6-8. An appreciation of the need to respect the compromised soft tissues accompanying these injuries has increased interest in the use of external fixation devices^9,11-14. These devices may involve use of tensioned transfixation wires to secure the periarticular components of the fracture, allowing articular reduction and avoiding the need to span the ankle joint. Vives et al. described safe corridors for the placement of distal tibial transfixation wires in an anatomic study¹⁵. They noted a substantial risk of tendon and nerve impalement as well as a risk of capsular penetration during the placement of transfixation wires.

Intracapsular placement of transfixation wires may lead to joint infection, which has been previously reported in both the knee and the ankle^16-21. In addition, deep infection secondary to tibial transfixation wires has been reported in the distal part of the tibia^9,16, which theoretically may lead to infection of the ankle joint. A review of four studies comprising a total of ninety-three patients treated with external fixation with use of transfixation wires revealed a total of six deep infections^9,11-13,16. Anglen described the complication of septic arthritis of the ankle in his series of patients treated with transfixation wires¹⁶.

The orientation of wires in the distal part of the tibia is limited by both tendinous and neurovascular anatomy, which occasionally makes it necessary for the wires to enter the distal part of the fibula and exit the anterior aspect of the tibia^9,22. The position of such wires invariably results in penetration of the distal tibiofibular joint cavity. The reported 11% rate of communication between the proximal tibiofibular joint and the knee joint has prompted some authors to recommend placement of proximal transfixation wires in positions other than those traversing the fibula, to avoid the risk of knee infection^19,23-25. This concept may be applicable to the ankle.

We are unaware of any report assessing the circumferential proximal reflection of the intra-articular portion of the ankle capsule and thus providing accurate guidelines to ensure extra-articular placement of transfixation wires. We are also unaware of any study examining the relationship and possible communication between the distal tibiofibular joint and the ankle joint. The purposes of this study were to define guidelines to ensure safe, extracapsular placement of distal tibial transfixation wires and to evaluate whether there is communication between the synovial cavities of the distal tibiofibular joint and the ankle joint.

Materials and Methods

Specimens

Fifteen specimens were used for this investigation. Three ankles (two paired) of two living volunteers and twelve cadaver specimens (six paired), all without known pathological changes in the ankle or lower extremity, were examined. The cadaver ankles (mean age of the donors at the time of death, sixty-two years) were fresh-frozen specimens resected at the midtibial level and stored at 4°C until the time of the investigation. The volunteers were a twenty-two-year-old man (two ankles) and a twenty-three-year-old woman (one ankle) who were both healthy and had no history of ankle pain or injury. The capsule of each ankle was distended with a solution containing contrast material before imaging. This was done to maximize the definition of the capsular reflection as well as to mimic the clinical situation of a tense hemarthrosis accompanying a fracture.

Cadaver Ankles

Each ankle was warmed to room temperature, and the solution was injected through a standard anterolateral portal with an 18-gauge needle. Sufficient solution was used to raise the intracapsular pressure to 50 ± 5 mm Hg, as measured with a digital pressure monitor (Stryker Intracompartmental Pressure Monitor System; Stryker Instruments, Kalamazoo, Michigan). The pressure level was chosen to correlate with pressure levels selected in validated studies in which the investigators attempted to simulate a hemarthrosis¹⁹. Normal saline solution with gadolinium contrast medium and a small amount of methylene blue dye was injected. The purpose of the dye was to stain the interior of the ankle capsule for subsequent anatomic sectioning. Each ankle was then placed through a range of dorsiflexion-plantar flexion cyclically to break any intraarticular adhesions. The intracapsular pressure was then measured again, and additional solution was added as necessary to establish the desired pressure of 50 mm Hg. The total amount of solution injected within the ankle joints averaged 25 mL (range, 22 to 30 mL). The ankle was then placed in the ankle coil of a magnetic resonance imaging unit with the second ray directed vertically. After scanning, all ankles were immediately frozen for later dissection and sectioning.

Volunteers

Informed consent and institutional review board approval were obtained for the study of these volunteers. Under the supervision of a senior musculoskeletal radiologist, each ankle was injected superficially and anterolaterally with 5 mL of 1% Xylocaine (lidocaine) for skin anesthesia. Then 25 mL of saline solution containing gadolinium, at a 1:250 volumetric ratio, was slowly injected though the anesthetized skin into the ankle joint. No additional analgesia or supplemental sedation was required, and neither volunteer required abortion of the trial secondary to discomfort, pain, or any other complication. The solution was injected until the volunteer described a feeling of fullness or heaviness of the ankle, at which time pressurization was stopped; the average volume of solution that was injected was 29 mL. Each volunteer was positioned with the ankle in the ankle coil of the magnetic resonance imaging unit, with the second ray directed vertically. Following the scan, arthrocentesis was performed to relieve the capsular distention.

Magnetic Resonance Imaging

The magnetic resonance images were acquired with a research magnetic resonance imaging scanner (General Electric Twin Speed EXCITE 1.5-T Scanner, Milwaukee, Wisconsin) with very-high-resolution images (1-mm cuts) of the distal part of the tibia and the ankle joint. A linear ankle coil was used for all studies. The scan sequence was FSPGR (fast spoiled gradient recalled) with a repetition time of 9.3 msec, an echo time of 3.9 msec, and a flip angle of 60°. The scan sequence was designed to maximize the gadolinium signal. The images included the distal tibiofibular joint for evaluation of its location, proximal extent, and communication (or lack thereof) with the tibiotalar joint. Images were acquired in the coronal and sagittal planes for all ankles. The coronal scans were oriented from axial and sagittal scout images to run parallel to the long axis of the tibial shaft and parallel to a line tangent to the posterior aspect of the tibial plafond at the joint line. The sagittal scans were oriented from axial and coronal scout images to run parallel to the long axis of the tibial shaft and parallel to a line tangent to the second ray. A single acquisition was performed that required a total scan time of approximately twenty minutes.

Anatomic Sectioning

The accuracy of the measurements on the magnetic resonance images was verified by examination of the cadaver specimens. Sectioning was performed with a technique previously described by Reid et al. for the evaluation of the distal extent of the knee capsule, to allow exact correlation of coronal or sagittal magnetic resonance images and the corresponding anatomic sections¹⁹. Prior to imaging, anterior-to-posterior converging 4-mm-diameter carbon fiber rods (Synthes USA, Paoli, Pennsylvania) were inserted in the cadaver ankles, with each placed parallel in the distal part of the tibia approximately 2 to 3 cm proximal to the distal tibial articular surface under fluoroscopic control. The angle of convergence was approximately 45°. After magnetic resonance imaging, the specimens were frozen at —80°C. The ankles were then sectioned at 7.5-mm increments with use of a band saw in a plane parallel to the magnetic resonance images. Half of the cadaver specimens were sectioned in the coronal plane, and the other half were sectioned in the sagittal plane. Each cut face of a section displayed the embedded and sectioned graphite rods. The convergence of the rods was used to create a center-to-center distance that was unique for each plane of sectioning and served to define the anteroposterior or mediolateral location of the section. The magnetic resonance imaging data set for these ankles was then reviewed to locate the scan that contained the identical graphite rod center-to-center distance. The proximal articular capsular measurements of the corresponding magnetic resonance images and anatomic specimens were then compared to verify the measurement accuracy of the magnetic resonance imaging. The locations of the corresponding anteroposterior and mediolateral sections were also confirmed by the thickness of the section as measured from medial to lateral or anterior to posterior for each corresponding magnetic resonance image and anatomic specimen.

Measurement Technique

Cadavera

The proximal intracapsular extent of the dye was measured by drawing a line tangent to the subchondral bone at the most anterior and posterior portions of the ankle joint in the midline sagittal section immediately adjacent to the plafond. This plane of reference was then utilized as the joint line level for all sagittal sections for each respective sagittally sectioned specimen. The perpendicular distance from this line to the proximal intracapsular extent of the dye was then measured with a digital metric caliper device with a range of error of 1 mm and was recorded as the distance "d" in millimeters for each anatomic section. On the coronal sections, any dye extending proximally from the tip of the medial or lateral malleolus was measured and the distance was recorded. All measurements of the cadaveric ankles were performed by a senior orthopaedic resident who was blinded to the measurements of the magnetic resonance images.

Magnetic Resonance Imaging

The coronal and sagittal magnetic resonance images were evaluated on a Sun Microsystems Workstation (Sun Microsystems, Santa Clara, California). A line tangent to the subchondral bone was drawn from the most anterior and posterior portions of the ankle joint at the subchondral level on the anteroposterior images in the midline of the sagittal images. This plane of reference was then utilized as the joint line level for all sagittal images for each specimen. The perpendicular distance from this line to the proximal intracapsular extent of the dye was recorded as the distance "d" in millimeters for each magnetic resonance image. For the coronal section images, any dye extending proximal to the tip of the medial or lateral malleolus was measured and recorded. The most proximal extent of the physeal scar from the referenced joint line was measured on coronal and sagittal images and recorded. The distance between the capsular reflection and the most proximal extent of the physeal scar was then calculated for each measurement. On the lateral side of the ankle, sequential 1-mm-interval cuts were evaluated to identify communication of dye between the ankle joint and the distal tibiofibular joint on sagittal and coronal images. Communication between these two synovial cavities, represented by extrusion of dye from the ankle joint into the distal tibiofibular joint, was recorded if present. The most proximal extent of the dye within the distal tibiofibular joint was measured from the referenced tibiotalar joint line and the most proximal physeal extent on coronal and sagittal images. All evaluations and measurements were made with use of software at 3× magnification. Resolution with use of this technique in the knee has been described as ±1 mm¹⁹. All measurements of the magnetic resonance images were performed by a senior musculoskeletal radiologist who was blinded to the anatomic measurements.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2: Coronal magnetic resonance imaging scan of a volunteer subject, demonstrating communication of the ankle and distal tibiofibular joints.

Statistical Analysis

The specific data points available for corresponding sagittal magnetic resonance images of the cadaveric specimens and sagittal anatomic sections of the cadaveric specimens were compared to identify any significant difference, defined as >2 mm of absolute difference between the imaging and section measurements. The value of 2 mm was arbitrarily chosen on the basis of the error of ±1 mm for measurements of magnetic resonance images with the Sun Microsystems Workstation¹⁹ and the error of ±1 mm for measurements of the anatomic sections with the digital caliper. Each measurement was performed independently, with the investigator blinded to the other measurements, and then the measurements were compared with use of confidence interval for equivalence testing with a 95% confidence interval criterion. This was performed for the measurements performed on anatomic sections and on all corresponding sagittal magnetic resonance images. Thirty-one corresponding data points were available for comparison.

Results

The relationships among the tibiotalar joint, proximal capsular synovial reflection, distal tibiofibular joint, and physeal scar are illustrated in Figure 1. Representative sagittal magnetic resonance images and respective anatomic sections of a cadaveric specimen, representative coronal magnetic resonance images and coronal anatomic sections of a cadaveric specimen, and representative sagittal magnetic resonance images of the ankle of a human volunteer are shown in the Appendix. The maximum capsular synovial reflection anteriorly, posteriorly, medially, laterally, and within each quadrant are shown in Table I (anterior reflections) and Table II (posterior reflections). Posteriorly, the proximal capsular synovial reflection was minimal (=2 mm in all specimens). No specimen demonstrated a proximal capsular synovial reflection over the medial or lateral malleolus on the coronal images. The majority of the capsular reflection of the ankle joint was noted anteriorly, with the distance "d" consistently showing the largest reflection within the anterolateral quadrant (Fig. 1). In the anterolateral quadrant, there was a maximum capsular synovial reflection of 12.2 mm and an average capsular synovial reflection of 9.3 mm (range, 5.4 to 12.2 mm). In the anteromedial quadrant, the maximum capsular synovial reflection was 5.5 mm and the average capsular synovial reflection was 3.3 mm (range, 0.5 to 5.5 mm). Anatomically, the area of greatest capsular synovial reflection anterolaterally was in the region of the tibiofibular recess. The maximum proximal capsular synovial reflection was 3.8 mm above the most proximal portion of the physeal scar, and the average distance was 0.7 mm distal to the physeal scar (range, 5.8 mm distal to it to 3.8 mm proximal to it).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1: Depiction of the maximum capsular synovial reflections of the ankle capsule demonstrated in relationship to the average level of the distal tibial physeal scar and the tibiotalar joint line. (The tibiotalar joint is light blue, and the distal tibiofibular joint is dark blue. The anterolateral capsule demonstrates a maximum synovial reflection of 12.2 mm from the tibiotalar joint line and 3.8 mm from the physeal scar. The distal tibiofibular joint demonstrated a maximum reflection of 20.6 mm from the tibiotalar joint line and 11.2 mm from the physeal scar.

View Larger

TABLE I Maximum Anterior Capsular Reflection on Magnetic Resonance Images of Each Cadaveric Specimen and Each Ankle of a Living Volunteer

	Maximum Capsular Reflection (mm)
	Anteromedial	Anterior	Anterolateral
Cadaver 1	5	5.2	9.6
Cadaver 2	4.1	7.5	8.9
Cadaver 3	1.1	5	6.7
Cadaver 4	0.5	3.7	5.4
Cadaver 5	4	4.2	7.6
Cadaver 6	3.6	5.9	12.2
Cadaver 7	2	5.9	7.8
Cadaver 8	3.4	4.5	11.1
Cadaver 9	1	2	6.5
Cadaver 10	3.5	5.2	8.5
Cadaver 11	3.5	7.5	12
Cadaver 12	5.5	8.2	10.4
Living volunteer 1	5	9.6	12.1
Living volunteer 2	2	5	10
Living volunteer 3	4.7	5.9	10.8
Average	3.3	5.7	9.3
Range	(0.5-5.5)	(2-9.6)	(5.4-12.2)

Add to My JBJS

TABLE I Maximum Anterior Capsular Reflection on Magnetic Resonance Images of Each Cadaveric Specimen and Each Ankle of a Living Volunteer

	Maximum Capsular Reflection (mm)
	Anteromedial	Anterior	Anterolateral
Cadaver 1	5	5.2	9.6
Cadaver 2	4.1	7.5	8.9
Cadaver 3	1.1	5	6.7
Cadaver 4	0.5	3.7	5.4
Cadaver 5	4	4.2	7.6
Cadaver 6	3.6	5.9	12.2
Cadaver 7	2	5.9	7.8
Cadaver 8	3.4	4.5	11.1
Cadaver 9	1	2	6.5
Cadaver 10	3.5	5.2	8.5
Cadaver 11	3.5	7.5	12
Cadaver 12	5.5	8.2	10.4
Living volunteer 1	5	9.6	12.1
Living volunteer 2	2	5	10
Living volunteer 3	4.7	5.9	10.8
Average	3.3	5.7	9.3
Range	(0.5-5.5)	(2-9.6)	(5.4-12.2)

View Larger

TABLE II Maximum Posterior Capsular Reflection on Magnetic Resonance Images of Each Cadaveric Specimen and Each Ankle of a Living Volunteer

	Maximum Capsular Reflection (mm)
	Posteromedial	Posterior	Posterolateral
Cadaver 1	0	0	0
Cadaver 2	0	0	0
Cadaver 3	1.8	1.5	2
Cadaver 4	0	1.9	1
Cadaver 5	0	1	0
Cadaver 6	0	1	0
Cadaver 7	1.1	1.9	1.5
Cadaver 8	0	1	0
Cadaver 9	0	0	0
Cadaver 10	0	1	0
Cadaver 11	0	1	0
Cadaver 12	0	0	0
Living volunteer 1	1	0	0
Living volunteer 2	0	0	0
Living volunteer 3	1	1	1.5
Average	0.3	0.8	0.4
Range	(0-1.8)	(0-1.9)	(0-2.0)

Add to My JBJS

TABLE II Maximum Posterior Capsular Reflection on Magnetic Resonance Images of Each Cadaveric Specimen and Each Ankle of a Living Volunteer

	Maximum Capsular Reflection (mm)
	Posteromedial	Posterior	Posterolateral
Cadaver 1	0	0	0
Cadaver 2	0	0	0
Cadaver 3	1.8	1.5	2
Cadaver 4	0	1.9	1
Cadaver 5	0	1	0
Cadaver 6	0	1	0
Cadaver 7	1.1	1.9	1.5
Cadaver 8	0	1	0
Cadaver 9	0	0	0
Cadaver 10	0	1	0
Cadaver 11	0	1	0
Cadaver 12	0	0	0
Living volunteer 1	1	0	0
Living volunteer 2	0	0	0
Living volunteer 3	1	1	1.5
Average	0.3	0.8	0.4
Range	(0-1.8)	(0-1.9)	(0-2.0)

The distal tibiofibular joint appeared to communicate with the ankle joint on the magnetic resonance images of all of the ankles of the cadavera and living volunteers as well as in the anatomic sections as demonstrated by the extravasation of dye between these two synovial cavities. The maximum proximal dye extension within the distal tibiofibular joint as measured from the referenced tibiotalar joint line was 20.6 mm, and the average extension was 15.4 mm (range, 10.8 to 20.6 mm). The maximum proximal dye extension within the distal tibiofibular joint as measured from the most proximal portion of the tibial physeal scar was 11.2 mm, and the average extension was 5.4 mm (range, 3.4 to 11.2 mm).

Statistical Analysis

The average difference between the capsular measurements on the cadaveric sections and those on the magnetic resonance images was 0.56 mm (range, 0.1 to 1.9 mm) for the anterior reflections and 0.22 mm (range, 0.0 to 0.5 mm) for the posterior reflections. Confidence interval for equivalence testing showed 99% confidence intervals of 0.27 to 0.85 (anterior measurements) and 0.02 to 0.42 (posterior measurements) for the finding that all absolute differences between the measurements on corresponding magnetic resonance images and cadaveric sections were no more than 2 mm.

Discussion

Several authors have reported on the complications associated with periarticular transfixation wires at the level of the knee^17-21. In a review by Hutson and Zych¹⁷, pin track infection was found to occur after 10% of such procedures and septic arthritis in the knee was a sequela after 1%. Investigators have performed anatomic studies to evaluate the distal reflection of the knee capsule so that they could propose safe guidelines for extracapsular placement of transfixation wires^19,23,24. These investigators utilized the tibiofemoral joint line as the reference for measurement of capsular reflection. For consistency, we used the tibiotalar joint line as a reference for our measurements. We followed the experimental design of Reid et al.¹⁹, as we thought it to be the most accurate method for evaluation of periarticular capsular synovial reflection. Clinically, the tibiotalar joint line may be difficult to access accurately. Thus, we also calculated the distance of the capsular reflection from the most proximal extent of the distal tibial physeal scar, an easily identified landmark.

We are not aware of any study in which the investigators attempted to delineate the circumferential reflection of the ankle joint capsule. Boardman and Liu evaluated the contribution of the anterolateral joint capsule to the mechanical stability of the ankle, but they did not specifically define the capsular reflection²⁶. Vives et al. recently described soft-tissue injuries that can occur during placement of transfixation wires during external fixation of the tibia¹⁵. They noted that, during placement of wires in a standard pattern in cadavers, one of five surgeons placed a wire within the superior capsular synovial reflection. They described the superior capsular synovial reflection as being an average of 32 ± 1.58 mm from the tip of the medial malleolus and 21 ± 1.63 mm from the anterior joint line according to gross anatomic measurements (no sectioning was performed). With use of arthrography, they noted the mean distance of the superior capsular reflection to be 30 mm from the tip of the medial malleolus and 20 mm from the anterior joint line. We believe that our measurements differ from those of Vives et al. because of differences in measurement techniques. Vives et al. performed their arthrography with plain radiography and examined only two specimens. We made our measurements on magnetic resonance imaging arthrograms, and we used specifically defined measurement criteria. We also specifically designated the level of the joint in order to minimize variations in measurements due to the dome shape of the distal part of the tibia. Capsular distention may have been minimal in the study by Vives et al., as only 10 mL of contrast medium was used for each ankle. We injected enough contrast medium and dye to elevate the intra-articular pressures to approximately 50 mm Hg, thereby maximizing the definition of the intra-articular synovial portion of the capsular reflection while simulating the clinical situation of a tense hemarthrosis. The anatomic measurements by Vives et al. were performed on only five cadaver specimens, and they did not provide a specific description of how the proximal extent of the capsular synovial reflection was determined. We believe that it may have been difficult to determine the termination of the proximal extent of the capsular synovial reflection by gross dissection and without enhancement with methylene blue (or an alternate staining technique).

In addition to our description of safe extracapsular placement of distal transfixation wires from the level of the ankle joint, we attempted to analyze the prevalence of communication between the distal tibiofibular joint and the ankle joint. The magnetic resonance images of all fifteen ankles (of cadavera and living volunteers) demonstrated extrusion of dye from the ankle joint extending proximally into the distal tibiofibular joint and farther into the syndesmosis. This 100% rate of communication supports the recommendation that fibulotibial wires not be inserted at the level of the ankle joint whenever possible. If transfixation of the fibula is necessary, the wires should not be placed in the distal tibiofibular joint.

The data obtained in this study are subject to the inherent limitations of experiments on cadavera. However, we also assessed magnetic resonance imaging arthrograms of three ankles of living human volunteers, and the findings were similar to those in the cadaveric specimens. We utilized cadavers with healthy-appearing tissue and without any known history of lower-extremity injury. To our knowledge, our sample size of fifteen is larger than that in any other study performed to evaluate the capsular reflection of the ankle or the knee.

In order to verify the accuracy of our data derived from the magnetic resonance images of our cadaveric specimens, we utilized the method described by Reid et al.¹⁹ to correlate specific anatomic sections with appropriate magnetic resonance images. Each technique was performed by investigators who were blinded to the results of the other technique, and all corresponding measurements were within 2 mm of one another. In order to avoid measurement error attributable to the dome shape of the distal part of the tibia, we clearly defined the level of the joint as a reference for subsequent measurement of the capsular synovial reflection.

In conclusion, penetration of the ankle joint capsule can be avoided by placing distal tibial transfixation wires >12.2 mm proximal to the subchondral surface of the tibial plafond, and, since the distal tibiofibular joint communicates with the tibiotalar joint, it should not be penetrated to ensure extracapsular placement of the wires.

Appendix

Figures showing representative magnetic resonance images and anatomic sections are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Acknowledgements

Note: The authors thank Valerie Harder, BS, for assistance with the statistical analysis.

References

Bone LB. Fractures of the tibial plafond. The pilon fracture. Orthop Clin North Am.1987;18: 95-104.1895 1987 [PubMed]

Bourne RB, Rorabeck CH, Macnab J. Intra-articular fractures of the distal tibia: the pilon fracture. J Trauma.1983;23: 591-6.23591 1983 [PubMed][CrossRef]

Brumback RJ, McGarvey WC. Fractures of the tibial plafond. Evolving treatment concepts for the pilon fracture. Orthop Clin North Am.1995;26: 273-85.26273 1995 [PubMed]

Dillin L, Slabaugh P. Delayed wound healing, infection, and nonunion following open reduction and internal fixation of tibial plafond fractures. J Trauma.1986;26: 1116-9.261116 1986 [PubMed][CrossRef]

Helfet DL, Koval K, Pappas J, Sanders RW, DiPasquale T. Intraarticular "pilon" fracture of the tibia. Clin Orthop.1994;298: 221-8.298221 1994 [PubMed]

McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma.1992;6: 195-200.6195 1992 [PubMed][CrossRef]

Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg Am.1986;68: 543-51.68543 1986 [PubMed]

Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop.1993;292: 108-17.292108 1993 [PubMed]

Tornetta P 3rd, Weiner L, Bergman M, Watnik N, Steuer J, Kelley M, Yang E. Pilon fractures: treatment with combined internal and external fixation. J Orthop Trauma.1993;7: 489-96.7489 1993 [CrossRef]

Watson JT, Moed BR, Karges DE, Cramer KE. Pilon fractures. Treatment protocol based on severity of soft tissue injury. Clin Orthop.2000;375: 78-90.37578 2000 [PubMed][CrossRef]

Barbieri R, Schenk R, Koval K, Aurori K, Aurori B. Hybrid external fixation in the treatment of tibial plafond fractures. Clin Orthop.1996;332: 16-22.33216 1996 [PubMed][CrossRef]

Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixation in tibial plafond fractures. Clin Orthop.1996;329: 223-32.329223 1996 [CrossRef]

Griffiths GP, Thordarson DB. Tibial plafond fractures: limited internal fixation and a hybrid external fixator. Foot Ankle Int.1996;17: 444-8.17444 1996 [PubMed]

McDonald MG, Burgess RC, Bolano LE, Nicholls PJ. Ilizarov treatment of pilon fractures. Clin Orthop.1996;325: 232-8.325232 1996 [CrossRef]

Vives MJ, Abidi NA, Ishikawa SN, Taliwal RV, Sharkey PF. Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomic study. J Orthop Trauma.2001;15: 555-9.15555 2001 [PubMed][CrossRef]

Anglen JO. Early outcome of hybrid external fixation for fracture of the distal tibia. J Orthop Trauma.1999;13: 92-7.1392 1999 [CrossRef]

Hutson JJ Jr, Zych GA. Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators. J Orthop Trauma.1998;12: 214-8.12214 1998 [PubMed][CrossRef]

Murphy CP, D'Ambrosia R, Dabezies EJ. The small pin circular fixator for proximal tibial fractures with soft tissue compromise. Orthopedics.1991; 14: 273-80.14273 1991 [PubMed]

Reid JS, Van Slyke MA, Moulton MJ, Mann TA. Safe placement of proximal tibial transfixation wires with respect to intracapsular penetration. J Orthop Trauma.2001;15: 10-7.1510 2001 [PubMed][CrossRef]

Weiner LS, Kelley M, Yang E, Steuer J, Watnick N, Evans M, Bergman M. The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures. J Orthop Trauma.1995;9: 244-50.9244 1995 [CrossRef]

Yang EC, Weiner L, Strauss E, Sedlin E, Kelley M, Raphael J. Metaphyseal dissociation fractures of the proximal tibia. An analysis of treatment and complications. Am J Orthop.1995;24: 695-704.24695 1995

Watson JT. Tibial pilon fractures. Tech Orthop.1996;11: 150-9.11150 1996 [CrossRef]

DeCoster TA, Crawford MK, Kraut MA. Safe extracapsular placement of proximal tibia transfixation pins. J Orthop Trauma.1999;13: 236-40.13236 1999 [PubMed][CrossRef]

Hyman J, Moore T. Anatomy of the distal knee joint and pyarthrosis following external fixation. J Orthop Trauma.1999;13: 241-6.13241 1999 [CrossRef]

Resnick D, Newell JD, Guerra J Jr, Danzig LA, Niwayama G, Goergen TG. Proximal tibiofibular joint: anatomic-pathologic-radiographic correlation. AJR Am J Roentgenol.1978;131: 133-8.131133 1978

Boardman DL, Liu SH. Contribution of the anterolateral joint capsule to the mechanical stability of the ankle. Clin Orthop.1997;341: 224-32.341224 1997 [PubMed]

Topics

ankle ; ankle joint ; bone wires ; cadaver ; tibia ; vibration ; reflection ; distal tibiofibular joint

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

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.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Extracapsular Placement of Distal Tibial Transfixation Wires'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Extracapsular Placement of Distal Tibial Transfixation Wires'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Anand M. Vora, Steven L. Haddad, Anish Kadakia, Martin L. Lazarus, Bradley R. Merk; Extracapsular Placement of Distal Tibial Transfixation Wires. The Journal of Bone & Joint Surgery. 2004 May;86(5):988-993.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment
Data Supplements