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e442 | www.jorthotrauma.com J Orthop Trauma Volume 29, Number 11, November 2015
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J Orthop Trauma Volume 29, Number 11, November 2015 Intracapsular Talar Pin Incidence
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Maceroli et al J Orthop Trauma Volume 29, Number 11, November 2015
the ankle joint extends into the safe zone described by Santi
and Botte, and placing pins in this area risks violation of the
capsule. Our results support this notion.
The ndings in this study demonstrate that inserting
Schanz pins in the medial talar body in the previously
described safe zone frequently results in intracapsular pin
placement. Arthrography demonstrated contrast abutting the
pin in all 12 specimens in this study. More convincingly,
contrast was seen extravasating from the pin insertion site and
within the path of the pin in the talus in every specimen. One
would expect this could only occur if the pin were in direct
communication with the ankle joint.
In this study, orthogonal radiographs were used to
dene the anterior extent of the ankle joint capsular insertion
on the talar neck. The average distance from the apex of the
talar head to the anterior ankle capsule on the lateral and AP
views of the talus were 20.95 6 4.8 mm and 15.5 6 1.8 mm,
respectively. The 5 mm difference between the lateral and AP
views is due to the fact that the anterior ankle joint capsule
extends farther distally on the dorsum of the talus than it does
on either the medial or lateral surfaces. Hayeri et al measured
FIGURE 3. After pin removal, contrast within the pin tract in the distance from the anterior talus to the anterior ankle joint
the talus (arrow) and extravasating from the pin insertion site capsule in the sagittal plane with MR arthrography. They
(arrow head). reported an average distance of 10.63 and 12.04 mm on the
medial and lateral aspects of the talus, respectively. The average
structures.4,7 They concluded that by placing pins just anterior distance in this study of 20.95 mm is considerably higher.
and inferior to the anterior colliculus of the medial malleolus, However, this is likely due to differences in measuring
injury to neurovascular structures could be avoided. However, techniques. Hayeri et al measured along the superior portion
safety in terms of avoiding intracapsular pin placement has not of the talar neck on the medial and lateral sagittal cuts on
been evaluated. Because the majority of the talar body surface magnetic resonance imaging. In this study, the measurement
is covered with articular cartilage,16 a high likelihood of was performed from the apex of the talar head along the axis of
capsular violation is expected when inserting pins in this area. the talar neck using uoroscopy, which would be expected to
Using magnetic resonance (MR) arthrography, Hayeri et al10 yield a larger distance.
found that the average distance from the talar head to the Placement of talar pins in the anterior portion of the
anterior capsular insertion on the medial talar neck was only neck may facilitate extracapsular pin placement. Our results
10.63 mm. This suggests that the anterior capsular reection of suggest that pins would have to be placed no more than
15 mm from the apex of the talar head. Pin placement in this
location is between the apex of the angle of Gissane and the
TABLE 1. Distance From the Talar Head Apex to the Ankle anterior process of the calcaneus. As an example, we were
Capsule Anterior Reflection able to place a pin in this location in one additional specimen,
Distance Lateral, Distance AP, and arthrography conrmed the pin was extracapsular
Specimen mm mm Intracapsular (Fig. 4). However, placing pins in this location may increase
1 27.3 16.1 Yes the risk of iatrogenic talar neck fracture and injury to talar
2 25.2 15.5 Yes blood supply. Furthermore, the bone in the talar neck may not
3 24 14.8 Yes be adequate for satisfactory pin xation. Additional studies
4 26.2 20 Yes examining the biomechanics of talar neck pin placement are
5 24.3 15.2 Yes warranted before it can be recommended.
6 14.1 12.4 Yes This study has several limitations. Prior anatomic
7 12.2 15.4 Yes studies of the ankle joint used MR arthrography to dene
8 21.2 15.1 Yes the capsular origins and insertions. Although this technique
9 20.2 15 Yes would more accurately dene the capsular margins, artifact
10 18.1 16 Yes from the metal Schanz pins used in this study would likely
11 22 16.8 Yes limit the utility of MRI. The average distance of the ankle
12 16.6 13.4 Yes capsule from the talar head as measured on uoroscopy is
Mean 20.95 15.5 All intracapsular also likely to provide more practical information to surgeons
SD 4.8 1.8 who commonly use uoroscopy for intraoperative localiza-
tion. This study is also limited by its small sample size,
The table lists the AP and lateral measurements for all 12 specimens. Note that
medial talar body pin was noted to be intracapsular in all ankles. limiting the ability to extrapolate the results to the general
population. However, because intracapsular placement was
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Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 11, November 2015 Intracapsular Talar Pin Incidence
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