Irreducible Fracture-Dislocation of the Ankle Associated With Interposition of the Tibialis Posterior Tendon in the Syndesmosis: A Case Report

Ankle fracture-dislocation with the interposition of the tibialis posterior tendon in the ankle syndesmosis and tibiotalar joint - A case report and systematic literature review

INTRODUCTION AND IMPORTANCE

In rare cases of ankle fracture dislocation, PTT can be incarcerated in the ankle syndesmosis. We report a case of a patient who had a fracture-dislocation of the ankle with the interposition of PTT in the ankle syndesmosis and discuss a systematic review of injury mechanics, pathology, diagnosis, management, and outcomes of this injury.

CASE PRESENTATION

I reported a 43-year-old patient presented with an irreducible lateral displacement of the talus after ORIF of the malleolar ankle fractures and fixation of ankle syndesmosis. Subsequent open reduction and surgical management revealed an interposition of PTT in the syndesmosis 1- month post-operative. A systematic review was completed afterward with the following terms: "ankle fracture" OR "ankle dislocation" AND "tibialis posterior tendon interposition" OR "tibialis posterior tendon entrapment" OR "tibialis posterior tendon incarceration" on Medline, ScienceDirect, and Ovid for articles between 1970 and 2022.

CLINICAL DISCUSSION

5 months postoperative, the patient reported no pain and became capable of walking without a steppage gait. The systematic review showed that the entrapment of PTT could be concurrent with FHL, FDL, and tibial neurovascular. It usually occurs in patients with pronation/eversion injury, Weber C ankle fracture with a valgus deformity and a syndesmosis diastasis.

CONCLUSION

The PTT entrapment usually occurs in patients with pronation/eversion injury, Weber C ankle fracture, a valgus deformity, a syndesmosis diastasis. The entrapment of PTT could be concurrent with FHL, FDL, and tibial neurovascular. The tibiofibular syndesmosis and retromalleolar groove should be explored intraoperatively with suspicion of irreducible ankle fracture-dislocations.

Irreducible Ankle Fracture Dislocation Because of Tibialis Posterior and Flexor Digitorum Longus Tendon Entrapment in the Interosseous Membrane: A Case Report

CASE

We describe the case of a 63-year-old man with anterior ankle dislocation and fracture confirmed by x-ray. Postreduction x-ray and computed tomography (CT) revealed Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 44C3 and Lauge-Hansen pronation-external rotation-type ankle fractures.

CONCLUSION

This was a rare case of ankle fracture dislocation because of entrapment of the tibialis posterior and flexor digitorum longus tendons in the interosseous membrane. Tendon entrapment should be suspected in cases of high-energy injuries, Weber type C fractures, Lauge-Hansen pronation-external rotation fractures, syndesmosis widening, and irreducible fractures using manual closed reduction. Fractures and soft tissues should be evaluated by changing the CT settings.

Equinus foot deformity and malunion of the medial malleolus caused by tibialis posterior tendon interposition following irreducible fracture dislocation of the ankle: A case report and literature review

We report a case of equinus foot deformity and malunion of the medial malleolus caused due to tibialis posterior tendon interposition following irreducible fracture-dislocation of the ankle. A 19-year-old female patient was referred to our hospital with the chief complaint of persistent ankle pain and restricted ankle dorsiflexion. Her medical history revealed a fracture-dislocation of the ankle in the left tibia at the age of 18 years. Open reduction and osteosynthesis were performed 3 days after injury. One year after the operation, ankle pain and restricted ankle dorsiflexion persisted. Computed tomography revealed malunion of the medial malleolus and an irregular groove in the interosseous space between the tibia and fibula. Magnetic resonance imaging revealed entrapment of the tibialis posterior tendon within the posterior talocrural joint and syndesmosis, preventing posterior translation of the talus back to its normal position and forcing the fibula to remain anteriorly displaced in the syndesmosis. We performed several procedures, including reduction of the tibialis posterior tendon interposition and dislocation of the talus, augmentation of the tibio-fibular ligament, and recession of the gastrocnemius. Finally, the patient achieved plantigrade stance and improvement in her Japanese Society for Surgery of the foot ankle/hindfoot scale from 42 to 82 points, after a 2-year follow-up. Anterior impingement caused the patient to experience severe osteoarthritis. Early reduction of the tibialis posterior tendon should have been achieved for this case. Age, fracture type, and severely restricted range of motion should raise suspicion of this adverse event.

Level of Clinical Evidence: 4.

Irreducible Ankle Fracture Due to Incarceration of the Long Flexor Tendons Together With the Neurovascular Bundle in the Tibial Fibular Interosseous Space: A Case Report and Short Literature Review

Ankle fracture dislocations with frustrating attempts at closed reduction are a rare traumatic entity. We present a case of an irreducible ankle fracture due to incarceration of all the flexor tendons including the neurovascular bundle in the tibial fibular interosseous space; to date, only one such case has been published in the literature. A computed tomography scan in both bone and soft tissue windows was necessary to clarify the structures that were inhibiting repositioning. The decisive step for surgical treatment was removal of the trapped structures from the tibial fibular interosseous space by a dorsomedial approach. The malleolar joint was then reconstructed anatomically. After 12 weeks, the patient was fully mobile without restrictions in his daily professional activities.

Irreducible Fractures and Dislocations of the Ankle Associated With Entrapment of the Posterior Tibial Tendon Within the Tibiofibular Interosseous Space: A Case Series and Literature Review

Level of Evidence: Level IV, case series.

Fracture dislocation of the ankle with posterior tibial tendon entrapment within the tibiofibular interosseous space: A case report

In rare cases of ankle fracture dislocation, the posterior tibial muscle tendon (TP tendon) is incarcerated between the tibia and fibula, thereby impeding reduction. Here we describe a case that presented with such a condition, in which ankle reduction was achieved and surgical repair of the incarcerated TP was delayed.

The subject was a 30-year-old male who sustained a fracture dislocation of the left ankle (AO:44-C1.3) in a motorbike accident. After repairing the ankle dislocation, external fixation was performed and osteosynthesis was conducted 10 days after the injury. Plate fixation for the fibula fracture and tight rope fixation for the separation between the tibia and fibula were performed; however, internal fixation for the medial malleolus fracture was delayed because the skin on the medial side of the ankle was in poor condition. One month after the injury, osteosynthesis of the medial malleolus was performed, and the TP tendon was identified in the fracture site. After removing the incarcerated tendon, good reduction of the medial malleolus was achieved, and thus, internal fixation and wound closure could be performed. Re-examination revealed that the TP tendon had an abnormal course. After 3 months, upon re-exposing the entire length of the TP tendon, the TP tendon was incarcerated between the tibia and fibula. To date, although several cases have been reported regarding TP tendon incarceration caused by fracture dislocation of the ankle, no study has reported the anatomical repair of the ankle, regardless of tendon incarceration. In our case, rotational displacement of the medial malleolus fracture remained when the second surgery was completed; however, the presence of some type of incarcerated tissue was suspected. Because leaving the incarcerated TP tendon untreated can cause irreversible long-term complications, early anatomical repair is recommended.

Irreducible ankle fracture dislocation due to posterior tibialis tendon interposition: Diagnostic and clues for early management – A case report

Irreducible fracture dislocation of the ankle is a rare condition. Multiple cases have been described throughout the literature. Different known etiologies involve the distal fibula, deltoïd ligament and tendons of the posteromedial malleolar region. More specifically, trapping of the Posterior tibialis tendon has been described at several levels from the inside of the ankle joint, through the syndesmosis and in some cases in the fibula tibial interosseous space depending on the energy of trauma. We hereafter propose a case report and a review of previous cases of posterior tibialis tendon dislocation proximally in the interosseous space of the lower leg. The aim of this review is to point out common features and clues for early management in order to avoid overlooking these rare lesions as they may lead to major functional impairment of the ankle joint.

Characteristics and proposed classification system of posterior pilon fractures

Posterior pilon fractures involve the medial malleolus (MM). Our purpose was to define the characteristics of posterior pilon fractures, and propose a classification system based on fracture morphology and type of management.The records of patients with posterior pilon fractures treated from 2011 to 2015 were retrospectively reviewed. The injury mechanism, fracture morphology, surgical approach, and follow-up results were reviewed and analyzed. This study was approved by the Institutional Review Board of PLA Army General Hospital.Thirty-six patients, 18 males and 18 females (mean age: 48.9 years) were included in the study. Four characteristics were used to define posterior pilon fractures. A simple posterolateral approach or a combined posterolateral and posteromedial approach was used for reduction and fixation in all patients. The mean follow-up time was 28.2 months, and at the end of follow-up, the mean American Orthopedic Foot and Ankle Society Score (AOFAS) was 82.5 points (range: 35-100 points). Based on injury mechanism and fracture morphology, we classified posterior pilon fractures into 3 types that suggest the optimal surgical approach: type I, a single complete fracture fragment; type II, a posterior malleolus fracture with 2 subtypes; type III, a posterior malleolus fracture associated with complete MM fracture with 2 subtypes.The proposed classification system based on injury mechanism and fracture morphology can guide the surgical approach to maximize outcomes.

Open Ankle Dislocation Without Fractures With Tibialis Posterior Tendon Interposition Through the Interosseous Space

Open ankle dislocations without fracture are rare injuries. Dislocation or interposition of adjacent tendons are a rare associated feature of ankle fracture-dislocation. We report an extremely unusual case of open ankle dislocation without fracture with concurrent tibialis posterior tendon interposition through the interosseous space that was detected incidentally on computed tomography. We highlight the clinical, radiologic, and intraoperative features to avoid missing similar diagnoses.

Case Report: Irreducible Ankle Fracture With Posterior Tibialis Tendon and Retinaculum, Deltoid Ligament, and Anteromedial Joint Capsule Entrapment

Irreducible ankle fractures are a relatively rare phenomenon. We present a case of a pronation abduction-type ankle fracture that was irreducible in the emergency room despite sedation. The patient was taken to the operating room, where the posterior tibialis tendon and retinaculum, deltoid ligament, and anteromedial capsule were found to be trapped within the joint. After removal of the tissue, alignment was restored. The patient did well clinically and was advanced to full weightbearing at 6 weeks. This is, to the best of our knowledge, the first report of entrapment of all 4 anatomic structures, preventing closed reduction.

Interposition of Tibialis Posterior and Flexor Digitorum Longus Tendons Resulted in Irreducible Ankle Fracture-Dislocation

Irreducible ankle fracture-dislocations are very rare entities. The present case report demonstrates an unusual finding of tibialis posterior and flexor digitorum longus tendons interposed in the tibiofibular joint impairing successful closed reduction of ankle fracture-dislocation. A 45-year-old patient presented with a bimalleolar pronation-external rotation ankle fracture-dislocation after a motorcycle accident. Attempts to perform closed reduction before surgery were unsuccessful. Subsequent urgent open reduction and internal fixation surgical management revealed interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint. In irreducible fracture-dislocation of the ankle with severe lateral displacement of the talus, one should be aware of the possibility of soft tissue interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint.

Posterior tibial tendon displacement behind the tibia and its interposition in an irreducible isolated ankle dislocation: a case report and literature review

Isolated posteromedial ankle dislocation is a rare condition thanks to the highly congruent anatomical configuration of the ankle mortise, in which the medial and lateral malleoli greatly reduce the rotational movement of the talus, and the strength of the ligaments higher than the malleoli affords protection against fractures. However, other factors, like medial malleolus hypoplasia, laxity of the ligaments, peroneal muscle weakness and previous ankle sprains, could predispose to pure dislocation. In the absence of such factors, only a complex high-energy trauma, with a rotational component, can lead to this event. Irreducibility of an ankle dislocation, which is rarely encountered, can be due to soft tissue interposition. Dislocation of the posterior tibial tendon can be the cause of an irreducible talar dislocation; interposition of this tendon, found to have slid posteriorly to the distal tibia and then passed through the tibioperoneal syndesmosis, is reported in just a few cases of ankle fracture-dislocation.