Thomas N. Scioscia, MD, and Bruce H. Ziran, MD

Am J Orthop. 2003;32(1):46-48

Abstract

Transarticular pin fixation has been used successfully to stabilize severe ankle fractures. This technique is most commonly used as provisional fixation until internal fixation is appropriate. In addition, transarticular pin fixation can be a supplement in cases involving persistent tibiotalar instability after internal fixation and can provide sole definitive fixation of arthritic and osteoporotic ankles. In this article, we describe the surgical technique, report results, and review when transarticular pin fixation may be appropriate. We believe that all orthopedic surgeons should know this technique—especially those treating cases of complex orthopedic trauma.

Childress¹ described use of a transarticular pin for unstable ankle fractures and first described use of transarticular fixation as sole fixation on an urgent basis for severe ankle fractures in the critically traumatized patient. He also obtained acceptable results using this technique as sole fixation in geriatric patients.
Advantages of this minimally invasive procedure are that operative time and blood loss are decreased, soft tissues are minimally disrupted, the infection rate is lower than that associated with direct internal fixation, and the fixation device can be removed without further surgery or soft-tissue disruption.¹ The main disadvantage of vertical transarticular fixation is violation of articular cartilage at the subtalar and tibiotalar joints.

Transarticular pin fixation is used most often for temporary fixation of severe ankle and hindfoot injuries when open injury, abrasions, and tense swelling make internal or external fixation difficult. In these situations, internal fixation poses a risk for wound dehiscence and infection, and external fixation of severe open ankle fractures has a significant rate of pin-site infections.² Definitive internal fixation can be performed when the soft tissues permit surgery.

At our institution, transarticular pin fixation also has been used to supplement internal fixation if injury to the capsule and ligaments is severe. In these cases, the transarticular pin is placed after internal fixation if there is persistent tibiotalar instability. Though external fixation is also used in this capacity, placement of the apparatus can significantly impair access to wound care and soft-tissue coverage procedures. Last, we have used the transarticular pin as sole fixation in geriatric patients with osteoporotic bone and poor soft tissues, as Childress¹ described doing in 1976.

The complication rate of this technique has been low, and outcomes have been acceptable. Although not ideal, this technique is a reliable method of stabilization and should be familiar to all orthopedic surgeons.

Surgical Technique

Lines are drawn corresponding to the midtibia in the sagittal plane on both the medial and lateral aspects of the leg (Figure 1). These lines are continued distally around the bottom of the foot, where they meet just anterior to the heel. The insertion site is where the 2 lines meet on the plantar aspect of the foot (Figure 2), which means that the insertion site is posterior and lateral to the lateral plantar neurovascular bundle.

Figure 1	Figure 2
Lines drawn down the tibia intersect at the anterior aspect of the heel.

The foot is then placed in neutral or slight equinus, and a 1/8- to 3/16-in. Steinmann pin is drilled through the calcaneus into the talus (Figure 3). If fluoroscopy shows that the direction of the pin is acceptable, the fracture and the tibiotalar joint are reduced using the pin as an aide (Figure 4). Reduction is then checked by fluoroscopy; if the reduction is acceptable, the pin is advanced up into the tibia (Figure 5). Pin placement and reduction are again checked by fluoroscopy in both anteroposterior and lateral views. This technique, involving only a single reduction, minimizes articular damage to the talus. The pin is then cut and bent 90°, leaving 1/2 to 1 in. outside the skin. A splint or soft dressing can be applied after the space between pin and skin is properly padded.

This technique has the foot in neutral position during fixation. The technique described by Childress¹ angles the foot in plantar flexion to reduce damage to weight-bearing cartilage. We choose to avoid significant plantar flexion to decrease the risk for contracture. If this technique is used to provide provisional fixation, the pin is removed during definitive surgery; if it is used as supplemental or sole definitive fixation, the pin is removed after radiographic evidence of healing has been found.

Figure 3. Steinmann pin is drilled through the calcaneus into the talus.	Figure 4. Fracture and tibiotalar joint are reduced using the Steinmann pin as a reduction aide. Prereduction alignment (Figure 3) is now improved.	Figure 5. After reduction is acceptable, the Steinmann pin is advanced into the tibia.

Results

We reviewed the cases of 12 patients (8 women, 4 men) who had undergone surgery with transarticular pin for 14 severe ankle injuries from 1997 to 1999. Age ranged from 18 to 84 years. The transarticular pin was used either as supplemental fixation to internal fixation or as sole fixation. Eleven of the 12 patients had tibiotalar fracture-dislocations. Two patients had bilateral ankle fracture-dislocations. Seven of the 14 ankle injuries were open fractures. Mechanisms of injury included motor vehicle accident, motorcycle accident, pedestrian-versus-car accident, and fall. All patients experienced polytraumas—except for an elderly women who suffered a
fracture after falling from a standing position.

The 12 patients were followed postoperatively for as long as 2 years. At each postoperative visit, a physical examination was performed, and radiographs were taken. Bony injuries healed in all patients. Displacement of mortise, fracture fragments, or hardware was not seen on postoperative radiographs. All ankles were adequately stable on examination. One of the 14 ankles became infected. This infection, which involved the fibula fixation, not the transarticular pin site, was treated with superficial irrigation and débridement and then with antibiotics, and it resolved without complication. No pins had to be prematurely removed.

Discussion

It is our experience that transarticular stabilization is an effective alternative technique for certain ankle injuries. Transarticular stabilization has been used without complication at our institution. We have expanded its use to supplement internal fixation if the tibiotalar joint remains unstable in severe ankle injury.

Multiple studies have found that persistent reduction (radiographically determined) is the important factor in achieving good outcomes after severe ankle fractures.^3–7 Although internal fixation can be used to make fracture fragments near anatomic, capsular and ligamentous injury may render the talus unstable under the tibia, subsequently displacing the mortise. To achieve and maintain reduction, supplemental fixation is sometimes needed. External fixation, though most often used, has limitations. Incidence of pin-site infections may be as high as 50% in open lower extremity fractures.² Not uncommonly, the zone of injury is located where pins should be placed, increasing the likelihood of deep infection. Obtaining access for soft-tissue procedures may be inhibited by the fixator. In these situations, use of a vertical transarticular pin should be considered.

Conclusion

Transarticular pin fixation can be a valuable technique in treating ankle fractures. Transarticular pin fixation is often useful as a temporary or definitive salvage procedure in open ankle injuries with severe soft-tissue damage. It may also have a role in treating geriatric patients, especially if comorbidities (eg, diabetes, immunodeficiency, preexisting arthritis, osteoporosis, peripheral vascular disease) increase the risk for perioperative complications. In addition, transarticular pin fixation has been used to supplement internal fixation when mortise instability persists and when external fixation cannot be used safely.

This technique has a low complication rate and holds a reliable reduction. After exhausting other options, the orthopedist should not hesitate to use this time-honored technique to stabilize difficult ankle injuries.

References

1.	Childress HM. Vertical transarticular pin fixation for unstable ankle fractures. Clin Orthop. 1976;120:164–171.
2.	Levine A. Orthopaedic Knowledge Update, Trauma. Chicago, IL: American Academy of Orthopaedic Surgeons. 1996;178.
3.	Tunturi T, Kemppainen K, Patiala H, et al. Importance of anatomical reduction for subjective recovery after ankle fracture. Acta Orthop Scand. 1983;54:641–476.
4.	Beris AE, Kabbani KT, Mitsonis G, et al. Surgical treatment of malleolar fractures. Clin Orthop. 1997;341:90 –98.
5.	Mont MA, Sedlin ED, Weiner LS, Miller AR. Postoperative radiographs as predictors of clinical outcome in unstable ankle fractures. J Orthop Trauma. 1992;6:352–357.
6.	Phillips WA, Schwartz HS, Keller CS, et al. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg Am. 1985;67:67 –78.
7.	Olerud C, Molander H. Bi and trimalleolar ankle fractures operated with nonrigid internal fixation. Clin Orthop. 1986;206:253 –260.

Dr. Scioscia is Resident, and Dr. Ziran is Associate Professor, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.