title: Cadaveric analysis of capsular attachments of the distal femur related to pin and wire placement.
abstract: OBJECTIVE
  Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices inserted in the lower extremity [1,2]. The authors were unable to find reference to or exact measurements of the capsular attachments relating to the distal femur documented in the current literature. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires or traction devices.
  
  
  METHODS
  The attachments of the capsule to the distal femur were measured in 10 unembalmed cadaveric knees. Capsular attachments were measured anteriorly at the maximal extension of the supra-patella pouch. Medially and laterally measurements were expressed as percentages related to the maximal AP diameter of the distal femur.
  
  
  RESULTS
  Mean distance from the centre of the anterior part of the notch to the superior fold was 79.5mm (Range 48.1-120.7 mm). The medial capsular reflections measured in a plane from the adductor tubercle to the anterior edge of the medial femoral condyle demonstrated the capsular reflection was attached an average of 57% back from the anterior edge (Range 41-74%). Laterally the capsular reflections on a line drawn from the maximal diameter in the sagittal plane were attached an average of 48% from the anterior reference point (Range 33-57%). Measuring the reflections at 45 degrees to the long axis of the femur in the sagittal plane the attachment was an average of 51% from the anterior reference point.
  
  
  CONCLUSIONS
  Capsular reflections varied among specimens. Medially the capsule attachment was up to 74% of diameter of distal femur at the level of the adductor tubercle. Therefore, the insertion of distal femoral traction pins or similar should be placed proximal to the adductor tubercle and no further than 25% of the distance to the anterior cortex. Care is also needed to ensure pins do not travel to exit too anteriorly on the lateral side as capsular attachments were found to be up to a distance 48% of the diameter of the femur from anterior reference point. Distal condylar extra-articular fixation with Schanz screws is feasible if orientated in the oblique plane.
authors.affiliation: Hull Royal Infirmary. Electronic address: Katlowery300@yahoo.com.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Lowery
authors.affiliation: Hull Royal Infirmary. Electronic address: p.dearden@doctors.org.uk.
authors.forename: Paul
authors.initials: P
authors.lastname: Dearden
authors.affiliation: Hull Royal Infirmary. Electronic address: Kevin.Sherman@yh.hee.nhs.uk.
authors.forename: Kevin
authors.initials: K
authors.lastname: Sherman
authors.affiliation: Royal College of Surgeons. Electronic address: vmahadev@rcseng.ac.uk.
authors.forename: Vishy
authors.initials: V
authors.lastname: Mahadevan
authors.affiliation: Hull Royal Infirmary. Electronic address: hksorth@yahoo.co.uk.
authors.forename: Hemant
authors.initials: H
authors.lastname: Sharma
mesh_terms: D001696:Biomechanical Phenomena; D001858:Bone Nails; D001864:Bone Wires; D002102:Cadaver; D016267:External Fixators; D005264:Femoral Fractures / Q000473:pathology / Q000601:surgery*; D005269:Femur / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007719:Knee Joint / Q000033:anatomy & histology / Q000601:surgery*; D010329:Patella / Q000033:anatomy & histology / Q000601:surgery*; D017410:Practice Guidelines as Topic
keywords: Anatomy distal femur; Capsular attachments; Circular frame; External fixation; Femoral fracture; Ilizarov; Septic arthritis; Skeletal traction; TSF