ORIGINAL ARTICLE
Incidence of Intracapsular Placement When Inserting
Medial Talar Body Schanz Pins: An Anatomic Study
Michael A. Maceroli, MD, Colin D. Canham, MD, and John P. Ketz, MD
Objectives: Medial talar body pins may be inserted to provide
points of xation in the hindfoot when applying external
xators. Because of the proximity to the ankle joint, there is
a risk of intracapsular pin placement. We hypothesized that
intracapsular placement is common when inserting medial talar
body pins.
Methods: Medial talar body pins were inserted in 12 fresh
frozen cadaver ankles. Arthrography of each ankle was then
performed to determine whether the pin was intracapsular. Each
pin was then removed, and uoroscopy was repeated to evaluate
for contrast extravasation from the pin insertion site. The distance
from the apex of the talar head to the anterior extent of the ankle
capsule was measured to determine a safe area for extracapsular
pin placement.
Results: Arthrograms of all 12 ankles demonstrated that the pins
were intracapsular. After pin removal, there was contrast extravasation
from the pin insertion site in all specimens. Contrast was present in the
pin tract in all specimens. Mean distance from the talar head to the
anterior ankle capsule was 20.95 6 4.8 mm (range, 12.227.3 mm) on
the lateral view and 15.5 6 1.8 mm (range, 12.420.0 mm) on the
anteroposterior view of the foot.
Conclusions: There is a high rate of intracapsular pin placement
when inserting medial talar body pins. Pin placement within the joint
capsule risks seeding a sterile joint with bacteria and stula
formation when the pin remains in place for prolonged periods.
For this reason, talar body pins should be avoided in temporizing
external xation frames.
Key Words: external xation, ankle joint, ankle capsule
(J Orthop Trauma 2015;29:e442e445)
INTRODUCTION
Ankle spanning external xators are commonly applied
to manage pilon fractures of the distal tibia before denitive
xation.13 These frame constructs require points of xation in
the hindfoot, which is often achieved by placing a transcalcaneal
Accepted for publication June 9, 2015.
From the Department of Orthopaedics, School of Medicine and Dentistry,
University of Rochester Medical Center, Rochester, NY.
The authors report no conict of interest.
Reprints: Colin D. Canham, MD, Department of Orthopaedics, School of
Medicine and Dentistry, University of Rochester Medical Center, 601
Elmwood Avenue, Box 665, Rochester, NY 14642 (e-mail: colin_canham@
urmc.rochester.edu).
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
e442 | www.jorthotrauma.com
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
pin.4 The talus serves as an alternative site for hindfoot xation
and occasionally must be used when pilon fractures are com-
plicated by concomitant calcaneus fractures. Talar body pins
have also been used for external xation of midfoot and
forefoot fractures,5 tibiotalar arthrodesis,6 and placement of
universal distractors for tibial nail insertion.7 Because the talar
body lies in proximity to the ankle joint capsule, inserting pins
into this area risks iatrogenic ankle arthrotomy. The proximal
extent of the ankle joint capsule and safe zone for extracapsular
pin placement in the distal tibia have been well dened.8,9
However, less is known about the safety of placing pins in
the talar body. Hayeri et al10 demonstrated that the distance
from the articular margin of the talar head to the insertion of
the anterior ankle joint capsule on the medial talus is on average
only 10 mm. This leaves a very small window for extracapsular
pin placement.
Pin sites frequently become infected, and intracapsular
pin placement is therefore undesirable because it increases the
risk of septic arthritis.11,12 Intracapsular pin placement should
also be avoided because it can theoretically lead to synovial
stula formation.13 The safe zone for talar body pin place-
ment has been previously described.4 However, safety was
only dened in terms of distance to neurovascular and tendi-
nous structures. To our knowledge, no one has evaluated the
incidence of intracapsular placement when inserting talar
body pins. The aim of this study was to evaluate the incidence
of intracapsular placement when inserting Schanz pins into
the medial talar body. We hypothesized that placing pins in
the currently accepted safe zone frequently results in intra-
capsular pin placement. A secondary aim was to dene a safe
area for extracapsular pin placement.
MATERIALS AND METHODS
Procedure Technique
Twelve fresh frozen ankle specimens including the foot
to the mid tibia level were obtained through standard institu-
tional protocols. All specimens were procured from patients
older than 18 years. Each ankle was examined, and uoroscopic
images were obtained to rule out preexisting ankle pathology.
Under uoroscopic guidance, a stab incision was made directly
inferior to the anterior colliculus of the medial malleolus. Blunt
dissection was performed down to the talus, and after predril-
ling with a 3.5-mm drill, a 5-mm Schanz pin was inserted into
the medial talar body in the safe zone as dened by Santi and
Botte.4 Each pin was oriented parallel to the talar dome and
placed into the center of the talar body at a point just anterior
and superior to a line drawn from the inferior tip of the medial
J Orthop Trauma  Volume 29, Number 11, November 2015
 J Orthop Trauma  Volume 29, Number 11, November 2015
FIGURE 1. A, Pin placed in medial talar body just
inferior and slightly anterior to the anterior colli-
culus of the medial malleolus. Dotted line repre-
sents the neurovascular bundle. The solid line
represents the posterior border of the safe zone as
described by Santi and Botte. B, Fluoroscopic view
of the lateral ankle showing the Schanz pin tract
with the pin removed. The pin is placed from
medial to lateral, just inferior to the anterior col-
liculus of the medial malleolus, parallel to the talar
dome.
malleolus to the navicular tuberosity (Fig. 1). Appropriate pin
positioning was conrmed uoroscopically.
Radiographic Analysis
Arthrography of each ankle was performed by inserting
an 18-gauge needle into the ankle joint through the standard
anteromedial portal and injecting 30 mL of a 300 mg/mL
solution of iohexol dye. Intra-articular positioning of the
needle and dispersion of dye within the ankle joint were
conrmed with uoroscopy. The volume of dye injected was
selected based on a prior study that demonstrated injection of
30 mL of saline resulted in extravasation in 95% of ankle
arthrotomies.14 Anteroposterior (AP) and lateral views of the
ankle and an AP view of the talus were obtained for each
specimen. Pins were dened as intracapsular if contrast was
observed abutting the pin on all 3 views. The Schanz pin was
then removed from each ankle, and AP views of the talus and
ankle were repeated to evaluate for contrast extravasation
from the pin insertion site. Contrast extravasation was con-
sidered indicative of intracapsular pin placement.
All uoroscopic images were uploaded to a picture
archiving and communication system (IntelliSpace PACS;
Phillips, Andover, MA). The measurement tool for each image
was calibrated to a known standard. The distance from the tip
of the talar head to the anterior ankle capsular reection was
determined on both the AP and lateral views of the talus. This
was performed by drawing a line perpendicular to the talar
neck at the most anterior extent of the ankle joint capsule and
measuring the orthogonal distance from this line to the tip of
the talar head (Fig. 2). The mean distance from the tip of the
talar head to the anterior extent of the ankle capsule was
calculated on both the AP and lateral views.
FIGURE 2. A and B, Pin completely surrounded by
contrast (white line, 2A). Distance from the apex
of talar head to anterior extent measured by line X
on the lateral (A) and line Y on the AP views (B).
Also note the posterior tibial tendon sheath was
violated in this specimen as evidenced by contrast
within the tendon sheath (arrows).
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Intracapsular Talar Pin Incidence
RESULTS
Intracapsular placement of the pin was found in all 12
specimens. Contrast was seen abutting the pin on all views of
every ankle (Fig. 2). After pin removal, contrast extravasation
was observed in all specimens. Contrast was also observed
within the path of the pin in the talus in every specimen
(Fig. 3). Violation of the posterior tibial tendon sheath
occurred in one specimen as evidenced by the presence of
contrast within the sheath (Fig. 2).
The mean distance from the anterior talus to the anterior
ankle capsule was 20.95 6 4.8 mm (range, 12.227.3 mm) on
the lateral view and 15.5 6 1.8 mm (range, 12.420.0 mm)
on the AP view of the foot (Table 1).
DISCUSSION
Periarticular external xation constructs serve important
roles both as temporary and denitive stabilization methods.
However, they have been associated with potentially serious
complications. Pin sites frequently become infected and those
in the periarticular region increase the risk of septic arthri-
tis.11,12 Studies involving tensioned wire xators about the
knee have documented a range of infectious complications
from skin infection requiring intravenous antibiotics to septic
arthritis requiring formal irrigation and debridement.15
Furthermore, intra-articular pin placement can theoretically
lead to synovial stula formation.13 To minimize these
complications, thorough knowledge of capsular origins and
insertions is required before placing transxation wires or
Schanz pins in any periarticular region.
Prior authors have dened the safe zone for percutaneous
medial talar Schanz pin placement relative to neurovascular
www.jorthotrauma.com | e443
 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

e444 | www.jorthotrauma.com Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 J Orthop Trauma  Volume 29, Number 11, November 2015
FIGURE 4. Pin placed in anterior portion of talar neck in
extracapsular position. Note no contrast seen surrounding pin.
observed in all specimens and there was less than 5 mm
standard deviation in distances on both the AP and lateral
views, any anatomic variation is likely minimal and increas-
ing the number of specimens would not likely alter this
studys conclusions. Although anatomic outliers in whom
talar body pin insertion would be safe likely exist, we believe
that our results indicate placing such a pin violates the capsule
in the vast majority.
In summary, placing a Schanz pin in the medial talar
body results in direct communication between the ankle
joint and the cutaneous insertion site. Although no reports of
complications from talar pins have been reported in the
literature, leaving such a pin in place for prolonged periods
of time likely increases the risk of septic arthritis and stula
formation and should therefore be avoided. Placing the pin
in the anterior portion of the talar neck may reduce the
risk of capsulotomy, but it remains unknown whether the
bone in this region can support an external frame. Based on
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Intracapsular Talar Pin Incidence
our ndings, we recommend using these pins only for
intraoperative distraction as long as the pin is removed
before leaving the sterile operating room environment.
Complications associated with temporary intraoperative
pin placementas may be performed for placing a universal
distractorare expected to be unlikely, regardless of the
intracapsular pin placement.
REFERENCES
1. Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue
management in the treatment of complex pilon fractures. J Orthop
Trauma. 1999;13:7884.
2. Thordarson DB. Complications after treatment of tibial pilon fractures:
prevention and management strategies. J Am Acad Orthop Surg. 2000;8:
253265.
3. Liporace FA, Yoon RS. Decisions and staging leading to denitive open
management of pilon fractures: where have we come from and where are
we now? J Orthop Trauma. 2012;26:488498.
4. Santi MD, Botte MJ. External xation of the calcaneus and talus: an
anatomical study for safe pin insertion. J Orthop Trauma. 1996;10:
487491.
5. Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of
the medial column in severe midfoot injuries. J Orthop Trauma. 2003;17:
513520.
6. Bushnell BD, Byram IR, Dahners LE. Compression external xation
with transosseous pins for arthrodesis of the ankle. Tech Foot Ankle
Surgery. 2006;5:7483.
7. Henley MB, Miller AN. Cutaneous landmarks for distractor pin place-
ment in medial talar body. OTA Tip of the Monthfor July, 2011
Web site. Available at: http://ota.org/media/45801/July-_-Dr.-Henley.
pdf. Updated 2011. Accessed March 8, 2014.
8. Lee PT, Clarke MT, Bearcroft PW, et al. The proximal extent of the
ankle capsule and safety for the insertion of percutaneous ne wires.
J Bone Joint Surg Br. 2005;87:668671.
9. Vora AM, Haddad SL, Kadakia A, et al. Extracapsular placement of
distal tibial transxation wires. J Bone Joint Surg Am. 2004;86:988993.
10. Hayeri MR, Trudell DJ, Resnick D. Anterior ankle impingement and
talar bony outgrowths: osteophyte or enthesophyte? Paleopathologic
and cadaveric study with imaging correlation. Am J Roentgenol. 2009;
193:W334W338.
11. Mahan J, Seligson D, Henry SL, et al. Factors in pin tract infections.
Orthopedics. 1991;14:305308.
12. Parameswaran AD, Roberts CS, Seligson D, et al. Pin tract infection with
contemporary external xation: how much of a problem? J Orthop
Trauma. 2003;17:503507.
13. Barber FA, Click J, Britt BT. Complications of ankle arthroscopy. Foot
Ankle. 1990;10:263266.
14. Bariteau JT, Blankenhorn BD, Digiovanni CW. Evaluation of saline load
test for simulated traumatic arthrotomies of the ankle. Injury. 2013;44:
14981501.
15. Hutson JJ Jr, Zych GA. Infections in periarticular fractures of the lower
extremity treated with tensioned wire hybrid xators. J Orthop Trauma.
1998;12:214218.
16. Kelly PJ, Sullivan CR. Blood supply of the talus. Clin Orthop Relat Res.
1963;30:3744.
www.jorthotrauma.com | e445