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Upward tibiotalar dislocation without fracture: A case report
The Foot 20 (2010) 149–150
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Case report
Upward tibiotalar dislocation without fracture: A case report M. Alami ∗ , R. Bassir, M. Mahfoud, M.O. Lamrani, A. Elbardouni, M.S. Berrada, M. El yaacoubi Department of Orthopedic Surgery, Ibn Sina Hospital, Rabat, Morocco
a r t i c l e
i n f o
Article history: Received 5 August 2010 Accepted 14 August 2010 Keywords: Ankle dislocation Medial ligament Syndesmosis
a b s t r a c t Pure tibiotalar dislocations without associated fracture are rare. The authors report a case of an unusual closed tibiotalar dislocation without fracture involving proximal ascension of the talus. Immediate closed reduction was performed. Repair of the disrupted medial ligament was performed and one syndesmosis screw inserted, followed by 6 weeks of immobilization. After 1 year of follow-up, functional results were excellent. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction The dislocation of the ankle without fracture is rare, due to the stability of this joint, which is provided by the capsule and its strong ligamentous complex. These injuries are most often combined with malleolar fractures resulting from high-energy trauma. Most displacements of this kind are posteromedial, posterior or lateral. We report a case of an unusual closed tibiotalar dislocation without fracture, involving proximal ascension of the talus in a 24-year-old man who was involved in a road traffic accident. 2. Case report A 24-year-old man injured his left leg in a road traffic accident. Clinical examination on admission revealed considerable swelling, pain on palpation and the total inability to move the ankle. There was no evidence of neurovascular deficit, nor was there any cutaneous wound. Radiographs showed a tibiotalar dislocation, with considerable diastasis of the syndesmosis linked to the ascending process of the talus, there was no evidence of malleolar fracture (Fig. 1). Immediate closed reduction of the dislocation was performed under general anesthesia. Post-reductional radiographs revealed that slight widening of tibio-talar joint remained (Fig. 2). We decided a surgical repair of the disrupted medial ligament and capsule, and one syndesmosis screw has been inserted at the same time (Fig. 3). The patient then wore an immobilizing plaster cast for 6 weeks. After 6 weeks, the screw was removed under local anaesthetic. The patient had an uneventful follow-up course, 1 year later he was pain-free and there was loss of the last few degrees of plantar flexion and inversion. No instability was detected on clinical
∗ Corresponding author. Tel.: +212 661253530. E-mail address: [email protected] (M. Alami). 0958-2592/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2010.08.002
examination. No calcification or degenerative change was seen on X-ray. 3. Discussion Pure tibiotalar dislocations without associated malleolar fracture are very rare. Up to 1995, only 73 cases were reported in the literature [1]. The ligaments are usually stronger than the malleoli, so that ankle dislocation is usually accompanied by fracture [2]. Predisposing factors in the pathogenesis of tibiotalar dislocation include medial maleollus hypoplasia, lack of coverage of the talus, ligamentous laxity, previous sprains and weakness of the peroneal muscles [3–5]. Most of these dislocations are posteromedial, and also cases of pure posterior, anterior, anterolateral ankle dislocations have been described. However, the upward dislocation is exceptional, indeed Lamraski et al. reviewed four patients reported in the world literature and added one case [6]. The mechanism of upward tibiotalar dislocation appears to be different from that of classic posteromedial dislocation. Fernandes [7], who studied the mechanism of tibiotalar dislocation without fracture on cadaveric ankles, found that forced dorsiflexion of the foot associated with lateral rotation and pronation of the ankle could lead to tibiofibular syndesmotic disruption, allowing upward talar dislocation. Most authors recommend that closed reduction followed by immobilization in a cast for 6–8 weeks should be performed for closed tibiotalar dislocation [1,2,5] but controversy remains with regard to acute ligament repair. Some authors recommend ligament repair in cases of open dislocation [1,8–10]. However, in the case of our patient, a closed reduction did not achieve satisfactory results with persistent slight widening of the tibiotalar joint, Therefore, we had to repair the disrupted medial ligament and capsule, and use screw fixation to restore the tibiofibular joint.
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M. Alami et al. / The Foot 20 (2010) 149–150
Fig. 1. Anteroposterior radiographs showing the upward tibiotalar dislocation.
Fig. 3. Immediate postoperative radiograph showing the reduction and stabilization by one syndesmotic screw.
Functional results of tibiotalar dislocation are usually good with little loss in the range of motion, sometimes a persistent swelling. But some complications have been described, like the chronic instability of the ankle [11] and degenerative arthritis [10]. Conflict of interest There are no conflicts of Interest. References
Fig. 2. Post-reductional radiograph showing the persistence of widening of tibiotalar joint.
[1] Garbuio P, Gérard F, Gagneux E. Pure dislocation of the tibiotalar joint. Report Of 9 cases [French]. Rev Chir Orthop 1995;81:601–8. [2] Wilson MJ, Mlichels AA, Jacobson EW. Ankle dislocation without fracture. J Bone Joint Surg 1939;21:198–204 [cited in, Br J Sports Med 2004; 38:342–343]. [3] Tranovich M. Ankle dislocation without fracture. Physician Sportsmed J 2003;31(5). [4] Marsh JL, Saltzman CL. Ankle fractures. In: Rockwood and Green’s fractures in adults. 5th ed. Lippincot Williams and Wilkins; 2001. pp. 2004–2006. [5] Hammouda A, El Rayes M. Posteromedial dislocation of the ankle without fracture. Foot Ankle Surg 2006;12:169–71. [6] Guyve Lamraski MD, Emilie Clegg MD. Unusual upward closed tibiotalar dislocation without fracture: a case report. Foot Ankle Surg 2010;16:e44–6. [7] Fernandes TJ. Themechanism of talo-tibial dislocation without fracture. J Bone Joint Surg Br 1976;58:364–5. [8] Elisé S, Maynou C, Mestdagh H, Forgeois P, Labourdette P. Simple tibiotalar luxation. Report on 16 cases [in French]. Acta Orthop Belg 1998;64(1):25–34. [9] Finkemeier C, Engebretsen L, Gannon J. Tibiotalar dislocation without fracture: treatment principles and outcome. Knee Surg Sports Traumatol Arthrosc 1995;3:47–9. [10] Moehring H, Tan R, Marder R, Lian G. Ankle dislocation. J Orthop Trauma 1994;8:167–72. [11] Colville MR, Colville JM, Manoli 2nd A. Posteromedial dislocation of the ankle joint without fracture. J Bone Joint Surg Am 1987;69(5):706–11.
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Case report
Upward tibiotalar dislocation without fracture: A case report M. Alami ∗ , R. Bassir, M. Mahfoud, M.O. Lamrani, A. Elbardouni, M.S. Berrada, M. El yaacoubi Department of Orthopedic Surgery, Ibn Sina Hospital, Rabat, Morocco
a r t i c l e
i n f o
Article history: Received 5 August 2010 Accepted 14 August 2010 Keywords: Ankle dislocation Medial ligament Syndesmosis
a b s t r a c t Pure tibiotalar dislocations without associated fracture are rare. The authors report a case of an unusual closed tibiotalar dislocation without fracture involving proximal ascension of the talus. Immediate closed reduction was performed. Repair of the disrupted medial ligament was performed and one syndesmosis screw inserted, followed by 6 weeks of immobilization. After 1 year of follow-up, functional results were excellent. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction The dislocation of the ankle without fracture is rare, due to the stability of this joint, which is provided by the capsule and its strong ligamentous complex. These injuries are most often combined with malleolar fractures resulting from high-energy trauma. Most displacements of this kind are posteromedial, posterior or lateral. We report a case of an unusual closed tibiotalar dislocation without fracture, involving proximal ascension of the talus in a 24-year-old man who was involved in a road traffic accident. 2. Case report A 24-year-old man injured his left leg in a road traffic accident. Clinical examination on admission revealed considerable swelling, pain on palpation and the total inability to move the ankle. There was no evidence of neurovascular deficit, nor was there any cutaneous wound. Radiographs showed a tibiotalar dislocation, with considerable diastasis of the syndesmosis linked to the ascending process of the talus, there was no evidence of malleolar fracture (Fig. 1). Immediate closed reduction of the dislocation was performed under general anesthesia. Post-reductional radiographs revealed that slight widening of tibio-talar joint remained (Fig. 2). We decided a surgical repair of the disrupted medial ligament and capsule, and one syndesmosis screw has been inserted at the same time (Fig. 3). The patient then wore an immobilizing plaster cast for 6 weeks. After 6 weeks, the screw was removed under local anaesthetic. The patient had an uneventful follow-up course, 1 year later he was pain-free and there was loss of the last few degrees of plantar flexion and inversion. No instability was detected on clinical
∗ Corresponding author. Tel.: +212 661253530. E-mail address: [email protected] (M. Alami). 0958-2592/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2010.08.002
examination. No calcification or degenerative change was seen on X-ray. 3. Discussion Pure tibiotalar dislocations without associated malleolar fracture are very rare. Up to 1995, only 73 cases were reported in the literature [1]. The ligaments are usually stronger than the malleoli, so that ankle dislocation is usually accompanied by fracture [2]. Predisposing factors in the pathogenesis of tibiotalar dislocation include medial maleollus hypoplasia, lack of coverage of the talus, ligamentous laxity, previous sprains and weakness of the peroneal muscles [3–5]. Most of these dislocations are posteromedial, and also cases of pure posterior, anterior, anterolateral ankle dislocations have been described. However, the upward dislocation is exceptional, indeed Lamraski et al. reviewed four patients reported in the world literature and added one case [6]. The mechanism of upward tibiotalar dislocation appears to be different from that of classic posteromedial dislocation. Fernandes [7], who studied the mechanism of tibiotalar dislocation without fracture on cadaveric ankles, found that forced dorsiflexion of the foot associated with lateral rotation and pronation of the ankle could lead to tibiofibular syndesmotic disruption, allowing upward talar dislocation. Most authors recommend that closed reduction followed by immobilization in a cast for 6–8 weeks should be performed for closed tibiotalar dislocation [1,2,5] but controversy remains with regard to acute ligament repair. Some authors recommend ligament repair in cases of open dislocation [1,8–10]. However, in the case of our patient, a closed reduction did not achieve satisfactory results with persistent slight widening of the tibiotalar joint, Therefore, we had to repair the disrupted medial ligament and capsule, and use screw fixation to restore the tibiofibular joint.
150
M. Alami et al. / The Foot 20 (2010) 149–150
Fig. 1. Anteroposterior radiographs showing the upward tibiotalar dislocation.
Fig. 3. Immediate postoperative radiograph showing the reduction and stabilization by one syndesmotic screw.
Functional results of tibiotalar dislocation are usually good with little loss in the range of motion, sometimes a persistent swelling. But some complications have been described, like the chronic instability of the ankle [11] and degenerative arthritis [10]. Conflict of interest There are no conflicts of Interest. References
Fig. 2. Post-reductional radiograph showing the persistence of widening of tibiotalar joint.
[1] Garbuio P, Gérard F, Gagneux E. Pure dislocation of the tibiotalar joint. Report Of 9 cases [French]. Rev Chir Orthop 1995;81:601–8. [2] Wilson MJ, Mlichels AA, Jacobson EW. Ankle dislocation without fracture. J Bone Joint Surg 1939;21:198–204 [cited in, Br J Sports Med 2004; 38:342–343]. [3] Tranovich M. Ankle dislocation without fracture. Physician Sportsmed J 2003;31(5). [4] Marsh JL, Saltzman CL. Ankle fractures. In: Rockwood and Green’s fractures in adults. 5th ed. Lippincot Williams and Wilkins; 2001. pp. 2004–2006. [5] Hammouda A, El Rayes M. Posteromedial dislocation of the ankle without fracture. Foot Ankle Surg 2006;12:169–71. [6] Guyve Lamraski MD, Emilie Clegg MD. Unusual upward closed tibiotalar dislocation without fracture: a case report. Foot Ankle Surg 2010;16:e44–6. [7] Fernandes TJ. Themechanism of talo-tibial dislocation without fracture. J Bone Joint Surg Br 1976;58:364–5. [8] Elisé S, Maynou C, Mestdagh H, Forgeois P, Labourdette P. Simple tibiotalar luxation. Report on 16 cases [in French]. Acta Orthop Belg 1998;64(1):25–34. [9] Finkemeier C, Engebretsen L, Gannon J. Tibiotalar dislocation without fracture: treatment principles and outcome. Knee Surg Sports Traumatol Arthrosc 1995;3:47–9. [10] Moehring H, Tan R, Marder R, Lian G. Ankle dislocation. J Orthop Trauma 1994;8:167–72. [11] Colville MR, Colville JM, Manoli 2nd A. Posteromedial dislocation of the ankle joint without fracture. J Bone Joint Surg Am 1987;69(5):706–11.