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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 111-114

Relationship between distal tibial transosseous wires and ankle joint synovium: A cadaveric analysis


Department of Orthopaedics, Assam Medical College and Hospital, Dibrugarh, Assam, India

Date of Submission08-Apr-2019
Date of Decision28-Oct-2019
Date of Acceptance12-Nov-2019
Date of Web Publication19-Dec-2019

Correspondence Address:
Dr. S Shyam Sunder
Department of Orthopaedics, Assam Medical College and Hospital, Dibrugarh - 786 002, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_7_19

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  Abstract 


Background: Distal tibial fractures are managed with external fixation techniques such as Ilizarov to prevent soft-tissue-related complications. In spite of adequate care in wire placement techniques, some cases experience synovitis of ankle joint, stiffness of joint due to pin-tract infections, and deep-seated infection. The accurate description of the ankle joint capsular and synovial recess anatomy is still not clear. The purpose of our study was to study the accuracy of the available guidelines for wire insertion by identifying the relationship between the ankle capsular attachments and the wires in an Indian population. Materials and Methods: 1.8-mm Ilizarov transosseous wires were inserted percutaneously through the distal fibula to tibia from posterolateral to anteromedial direction 2 cm above the joint line in 20 embalmed cadaveric limbs. Dissection of the ankle joint was performed after a dye was introduced into the joint capsule to look for the extent of synovium from the joint line, medial malleolus, and lateral malleolus by the visible bulging and color change of the membrane. Distance from the wire to the synovial extensions distally was measured with a vernier caliper. Results: The mean distance of synovial extension from the joint line, medial malleolus, and lateral malleolus were 20.2 mm, 30.8 mm, and 41.4 mm, respectively. Distal wire-to-synovial extension distance anteriorly was ± 0.2 mm. Wire-to-joint line distance after dissection was 20 mm. The proximal synovial extension was found to be in the 101% from the joint line to the wire. Conclusion: The synovial extensions were found to be close to the distal tibial transosseous wires. A minimum distance of 2.5–3 cm from the joint line proximally should be the safe extent for passing the wires to prevent the risk of synovitis.

Keywords: Ilizarov fixation, infection, pilon fractures, synovial extent


How to cite this article:
Baruah RK, Baruah JP, Sunder S S. Relationship between distal tibial transosseous wires and ankle joint synovium: A cadaveric analysis. J Limb Lengthen Reconstr 2019;5:111-4

How to cite this URL:
Baruah RK, Baruah JP, Sunder S S. Relationship between distal tibial transosseous wires and ankle joint synovium: A cadaveric analysis. J Limb Lengthen Reconstr [serial online] 2019 [cited 2020 Apr 5];5:111-4. Available from: http://www.jlimblengthrecon.org/text.asp?2019/5/2/111/273576




  Introduction Top


Tibial pilon fractures, fractures of distal tibial shaft with high-grade soft-tissue injuries and compound tibial fractures are treated with Ilizarov or hybrid external fixators to avoid soft-tissue-related complications [Figure 1] and [Figure 2].[1] This option gives stable fixation, preserves soft tissues, allows early weight-bearing and better functional outcomes.[2] The surgeon needs expertise in wire insertion techniques to avoid neurovascular complications. Many authors have proposed safe corridors for wire placements.[3],[4] In spite of adequate care, some experience synovitis, stiffness of ankle joint due to pin-tract infections, and also deep-seated infections.[5]
Figure 1: Comminuted Distal tibia fracture with poor soft tissue cover

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Figure 2: Fixation witth a fine-wire Ilizarov fixator

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The accurate description of the ankle joint capsular and synovial recess anatomy is still not clear. Studies to show synovial recess using magnetic resonance imaging (MRI) has been published in Western literature.[1] To date, there is only a single cadaveric dissection study that shows the synovial extent in relation to distal tibial pins.[6]

The purpose of our study was to identify the relationship of the ankle joint synovium and the transosseous wires inserted percutaneously from the available literature guidelines in an Indian population. We also tried to find out the relationship of the ankle joint synovial extension with the palpable anatomical landmarks such as joint line and malleoli.


  Materials and Methods Top


Twenty embalmed and uninjured cadaveric limbs of both sexes were selected for the study after obtaining institutional ethical committee clearance. Anatomical landmarks such as medial malleolus, lateral malleolus, and ankle joint line were palpated and marked with a skin marker. A 1.8-mm Ilizarov transosseous wire was inserted 2 cm above the palpable joint line from the distal fibula to tibia from posterolateral to anteromedial direction by the senior author in all specimens. 10–15 ml of colored ink was injected into the ankle joint anteromedially after exposing the joint capsule. Passive movements of ankle joint were performed few times to allow even distribution of the ink. Dissection of the ankle joint was performed to look for extent of synovium from the joint line, medial malleolus, and lateral malleolus by the visible bulging and color change of the membrane. Distance from the wire to the synovium extension proximal to the joint line was measured with a vernier caliper. The ratio of the distance between synovial extension to ankle joint line and the wire to joint line was calculated.


  Results and Observation Top


The mean distance of proximal synovial extension from the anterior joint line was 20.2 mm (range, 16.7 mm to 23.4 mm). The synovial extension from the tip of the medial malleolus was at a mean distance of 30.8 mm (range, 28.8 mm to 34.2 mm) and from the tip of the lateral malleolus was 41.4 mm (range, 38.6 cm to 44.6 cm) [Table 1] and [Figure 3], [Figure 4], [Figure 5].
Table 1: Observations made

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Figure 3: Synovial expansion from tip of lateral malleolus ,joint line and tip of medial malleolus

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Figure 4: Relationship of the wire to the synovial expansions in lateral view

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Figure 5: Relationship of the wire to the synovial expansions in AP view

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The mean distance of the wire to synovial extension was 0.2 mm (range, −3.4 mm to 3.3 mm). The ratio of distance from joint line to the 2cm proximal wire and distance of synovial extension from joint line was calculated be 101% [Table 2].
Table 2: Observations made

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  Discussion Top


Distal tibial fractures with high-grade soft-tissue injuries which cannot be treated by internal fixation are managed by hybrid external fixation or Ilizarov ring fixators.[7],[8] Even though the union rate is good with method of ankle spanning external fixation, poor functional outcome due to ankle stiffness is still a problem.

This can be avoided by using tensioned wires in Ilizarov fixators, which allows early movements of ankle joint, thereby keeps the articular cartilage viable.[2],[5]

Safe corridors for wire placements have been established by various authors to prevent neurovascular and tendon impalement.[3] However, the risk of penetration into ankle joint capsule was only highlighted by Vives et al. in 2001, where they first described capsular impalement by pins placed according to the safe zones published in literature. They identified the anteromedial superior capsular extension 32 mm (by dissection) and 30 mm (by arthrogram) from the medial malleolus and 21 mm (by dissection) and 20 mm (by arthrogram) from the anterior joint line, respectively.[6] Boardman and Liu described an anterolateral extension of the ankle joint capsule.[9]

Lee et al. noted that the proximal capsular extension is continuous spanning anterior to the distal tibia from the anteromedial to the anterolateral aspects of the distal tibia in contrary to the earlier impression that there were two separate anteromedial and anterolateral proximal capsular extensions anterior to the distal tibia.[1] Lee et al. used MRI arthrogram for evaluation and found that the distance was 1 cm [Table 3].
Table 3: Comparison with other studies

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Whereas, the previous studies used either X-ray arthrogram and dissection or only dissection and they found it to be 2 cm. We used only dissection to study the accuracy of the above values in the Indian population.

Complications of Ilizarov ring fixators such as tendon and neurovascular injuries are inevitable even after following the safe corridors.[6] Several measures such as tapping the wire in near soft-tissue and drilling only when wire hits the bone as advised by many authors like Tornetta et al. are employed to minimize the injury to these structures.[5]

Though septic arthritis is rare in the ankle compared to knee as stated by Hutson and Zych in their meta-analysis of 17 studies with periarticular tibial fractures, its prognosis is worse.[10] Tornetta et al. noted pin-tract infections (11.5%) and deep infections (3.8%) are and can cause septic arthritis.[5]

In our study, the proximal capsular extension was very close to the wires inserted 2 cm from the joint line. The capsule could possibly be penetrated if the wires are placed distally to achieve better reduction or fixation in very distal fractures.

Our results show that the synovial extent was more proximal in the Indian population compared to the Western population. There are variations in knee anatomy, but there is no literature mentioning the difference in ankle joint anatomy among different races,[11] which needs further evaluation.


  Conclusion Top


We conclude that the safe limit of 2 cm from the joint line for wire insertion as proposed by Vives et al. in the Western population should be increased to at least 2.5–3 cm for Indian population. Furthermore, clinically, lateral malleolus is a better bony landmark as it is easier to locate than the anterior joint line and wires can be safely passed 4 cm above the lateral malleolus without penetrating the synovium.

A pilon fracture may increase the zone of communication beyond 2 cm. Hence, in articular fractures, if the wires are needed to be passed distally to achieve better reduction, the possibility of infection should be kept in mind and the patient followed up frequently. Prompt treatment of early pin-tract infections is necessary in such cases to prevent devastating complications such as septic arthritis.

The limitations of our study are the cadaveric measurements may not correlate exactly with live patients. Furthermore, a fracture model was not used in our study. Hence, the exact capsular extensions may vary a little in patients. This study gives a rough idea regarding the distal safe extent for wire placement. We could not assess the differences between male and female because of limited availability of cadavers. Furthermore, we did not study the relationship of synovium with half pins. Further studies are needed to overcome these limitations.

Acknowledgments

We would like to thank Professor Anuradha and her team from the Department of Anatomy for their valuable help in providing cadavers for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee PT, Clarke MT, Bearcroft PW, Robinson AH. The proximal extent of the ankle capsule and safety for the insertion of percutaneous fine wires. J Bone Joint Surg Br 2005;87:668-71.  Back to cited text no. 1
    
2.
Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D, Clements ND. The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in the rabbit. J Bone Joint Surg Am 1980;62:1232-51.  Back to cited text no. 2
    
3.
Tracy Watson J. Tibial pilon fractures. Tech Orthop 1996;11:150-9.  Back to cited text no. 3
    
4.
Behrens F, Searls K. External fixation of the tibia. Basic concepts and prospective evaluation. J Bone Joint Surg Br 1986;68:246-54.  Back to cited text no. 4
    
5.
TornettaP 3rd, Weiner L, Bergman M, Watnik N, Steuer J, Kelley M, et al. Pilon fractures: Treatment with combined internal and external fixation. J Orthop Trauma 1993;7:489-96.  Back to cited text no. 5
    
6.
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.  Back to cited text no. 6
    
7.
Bone LB. Fractures of the tibial plafond. The pilon fracture. Orthop Clin North Am 1987;18:95-104.  Back to cited text no. 7
    
8.
Bourne RB, Rorabeck CH, Macnab J. Intra-articular fractures of the distal tibia: The pilon fracture. J Trauma 1983;23:591-6.  Back to cited text no. 8
    
9.
Boardman DL, Liu SH. Contribution of the anterolateral joint capsule to the mechanical stability of the ankle. Clin Orthop Relat Res 1997;(341):224-32.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Hovinga KR, Lerner AL. Anatomic variations between japanese and caucasian populations in the healthy young adult knee joint. J Orthop Res 2009;27:1191-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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