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    1382 THE JOURNAL OF BONE AND JOINT SURGERY

      CASE REPORT

    Open medial dislocation of the ankle withoutfracture

    U. Tarantino,G. Cannata,E. Gasbarra,L. Bondi,M. Celi,R. Iundusi

    From the University

    of Rome, Rome, Italy

    U. Tarantino, MD, Professor

    G. Cannata, MD, Assistant

    Professor

    E. Gasbarra, MD, Assistant

    Professor

    L. Bondi, PhD, Orthopaedic

    Surgeon

    M. Celi, MD

    R. Iundusi, MD, Orthopaedic

    Surgeon

    Department of Orthopaedic

    Surgery

    University of Rome “Tor

    Vergata”, Oxford Street 81,00133 Rome, Italy.

    Correspondence should be sent

    to Professor U. Tarantino;

    e-mail:

    [email protected]

    ©2008 British Editorial Society

    of Bone and Joint Surgery

    doi:10.1302/0301-620X.90B10.

    21015 $2.00

    J Bone Joint Surg [Br]

    2008;90-B:1382-4.

    Received 10 March 2008;

    Accepted 11 June 2008 

    A 20-year-old man sustained an open medial dislocation of the ankle without an associated

    fracture after a low-energy inversion injury. Prompt debridement and reduction with primary

    wound closure of the skin were performed without suture of the capsule. Immobilisation in

    a non-weight-bearing cast for 30 days followed by ankle bracing for two weeks and

    subsequent physiotherapy, produced full functional recovery by three months. At follow-up

    at one year there was a full range of pain-free movement, although the radiographs and MR

    scan showed early post-traumatic degenerative change at the medial aspect of the tibiotalar

    and the calcaneocuboid joints.

    Dislocation of the ankle without fracture is

    uncommon.1  Previous ankle sprains, medial

    malleolar hypoplasia, weakness of the per-

    oneal muscles and ligamentous laxity are pre-

    disposing factors for dislocation. Although

    there are few reports in the literature, Toohey

    and Worsing2 and Elisé et al3 have described

    the largest series, comprising 19 and 16

    patients, respectively. Because of the intrinsic

    stability of the ankle mortise and its ligaments

    and tendons, dislocation is usually caused by

    high-energy trauma which causes combined

    plantar flexion and inversion or eversion of thefoot, accompanied by fractures of the malleoli.

    We describe a case of an open dislocation of 

    the ankle without malleolar fracture which

    followed a low-energy trauma.

    Case report

    A 20-year-old man presented after sustaining

    an inversion injury to his right ankle while

    running after his cat. On examination there

    was a large lacerated wound over the dorso-

    lateral aspect of the right ankle approxi-

    mately 10 cm in length (Fig. 1). The foot was

    displaced medially. The distal articular sur-faces of the fibula and the tibia were exposed.

    The posterior tibial pulse was absent and

    there were paraesthesiae involving the dorsal

    aspect of the foot. Anteroposterior (AP)

    radiographs indicated a medial dislocation of 

    the talus without concomitant fracture or

    disruption of the ankle mortise (Fig. 2). There

    was medial malleolar hypoplasia according to

    the criteria described by Elise et al3  with a

    medial-to-lateral ratio of 0.31.

    After administration of antibiotics and local

    irrigation, under general anaesthesia, the dislo-

    cation was reduced, and the wound was closed

    without repair of the capsule (Fig. 3). Spiral

    CT angiography of the right leg, performed

    immediately after reduction, showed no arte-

    rial injury. The paraesthesiae over the dorsal

    aspect of the foot resolved after three days. A

    below-knee non-weight-bearing cast was

    applied with the ankle in the neutral position

    Fig. 1

    Photograph showing the open dislocation of the ankle at presentation.

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    OPEN MEDIAL DISLOCATION OF THE ANKLE WITHOUT FRACTURE 1383

    VOL. 90-B, No. 10, OCTOBER 2008

    and retained for 30 days. An ankle brace was used for

    another two weeks with progressive weight-bearing. Non-

    steroidal anti-inflammatory treatment was given as

    prophylaxis against heterotopic bone formation for four

    weeks.4

    The patient started physiotherapy after removal of the

    cast. Examination three months after injury revealed a

    pain-free stable joint with a full range of movement. Plain

    radiographs and MRI at follow-up showed a normal joint

    without evidence of heterotopic bone formation. At one

    year, clinical examination confirmed a full pain-free rangeof movement and he reported no limitation in sport and

    activities of daily living. Radiological and MR examination

    showed minor post-traumatic medial tibiotalar and

    calcaneocuboid degenerative changes (Figs 4 and 5).

    Discussion

    Pure talotibial dislocations are rare.5,6 Generally because of 

    the intrinsic stability of the ankle they are associated with

    malleolar fractures, mostly resulting from high-energy

    trauma such as motor-vehicle accidents, sports injuries and

    Fig. 2

    Anteroposterior radiograph showing the medial dislocation of the rightankle at presentation.

    Fig. 3

    Anteroposterior radiograph immedi-ately after reduction.

    Fig. 4

    Anteroposterior and lateral radiographs at follow-up at one year.

    Fig. 5

    MR scan at follow-up at one year.

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    1384 U. TARANTINO, G. CANNATA, E. GASBARRA, L. BONDI, M. CELI, R. IUNDUSI

    THE JOURNAL OF BONE AND JOINT SURGERY

    falls from a height. Only a few cases caused by low-energy

    trauma have been reported.5,7-9

    The talus, according to the studies of Fernandes,10 may

    dislocate medially or laterally, without associated fractures

    after application of an inversion or eversion force on a

    maximally plantar flexed foot. Fahey and Murphy11

    described five types of ankle displacement according to the

    direction of the dislocation: anterior, posterior, medial,

    lateral or superior combined. The posteromedial direction

    is the most common. In our patient the dislocation was

    medial. There was no history of recurrent sprains and on

    examination there were no signs of ligamentous laxity.

    However, there was hypoplasia of the medial malleolus

    with a medial to lateral ratio of 0.31;8 the reported normal

    ratio ranges from 0.58 to 0.62.3

    On the lateral radiograph the cover of the talus by the

    tibia measured 0.64, while the normal range is 0.58 to 0.60.

    This ratio is determined by two angles (b/a) of which angle

    is measured between two lines projected from the centre of 

    the talus through its anterior and posterior articular ridge,and angle a is measured between two lines projected from

    the centre of the talus through the anterior and posterior

    articular ridge of the tibia.3,5

    Other authors agree that immediate reduction decreases

    the risk of vascular or neurological complications and that

    reduction, debridement and capsular suture should be fol-

    lowed by immobilisation in a short-leg cast for six weeks.12,13

    The repair of disrupted ligaments is controversial. Sev-

    eral authors have recommended repair of the lateral liga-

    ments at the time of debridement.3,14  Others state that

    repair does not improve ankle function.11,15 It is interesting

    that despite massive ligamentous disruption, instability is

    rare2,5 and such types of dislocation, have a good outcome.Our patient did not undergo repair of the ligaments.

    No benefits in any form have been received or will be received from a commer-

    cial party related directly or indirectly to the subject of this article.

    References1. Kiefer EA, Wikstrom EA, Douglas McDonald J. Ankle dislocation without frac-

    ture: an on-field perspective. Clin J Sport Med 2006;16:269-70.

    2. Toohey JS, Worsing RA Jr. A long-tem follow-up study of tibiotalar dislocations

    without associated fractures. Clin Orthop 1989;239:207-10.

    3. Elisé S, Maynou C, Mestdagh H, Forgeois P, Labourdette P. Simple tibiotalar

    luxation: apropos of 16 cases. Acta Orthop Belg  1998;64:25-34 (in French).

    4. Radi ZA, Khan NK. Effects of cyclooxygenase inhibition on bone, tendon, and liga-

    ment healing. Inflamm Res 2005;54:358-66.

    5. Rivera F, Bertone C, De Martino M, Pietrobono D, Ghisellini F. Pure dislocation

    of the ankle: three case reports and literature review. Clin Orthop 2001;382:179-84.

    6. Hatori M, Kotajima S, Smith RA, Kokubun S. Ankle dislocation without accompa-

    nying malleolar fracture: a case report. Ups J Med Sci 2006;111:263-8.

    7. Uyar M, Tan A, Isler M, Cetinus E.Closed posteromedial dislocation of the tibiota-

    lar joint without fracture in a basketball player. Br J Sports Med 2004;38:342-3.

    8. D’Anca AF. Lateral rotary dislocation of the ankle without fracture: a case report. J 

    Bone Joint Surg [Am]  1970;52-A:1643-6.

    9. Shaik MM, Tandon T, Agrawal Y, Jadhav A, Taylor LJ. Medial and lateral rota-tory dislocations of the ankle after trivial trauma-pathomechanics and management

    of two cases. J Foot Ankle Surg  2006;45:346-50.

    10. Fernandes TJ. The mechanism of talo-tibial dislocation without fracture. J Bone 

    Joint Surg [Br] 1976;58-B:364-5.

    11. Fahey JJ, Murphy JL. Dislocations and fractures of the talus. Surg Clin North Am 

    1965;45:79-102.

    12. Soyer AD, Nestor BJ, Friedman SJ. Closed posteromedial dislocation of the tibi-

    otalar joint without fracture or diastasis: a case report. Foot Ankle Int 1994;15:622-4.

    13. Kaneko K, Mogami A, Maruyama Y, Shimamura Y, Yamaguchi T. Posterolateral

    dislocation of the ankle without fracture. Injury 2000;31:740-3.

    14. Colville MR, Colville JM, Manoli A 2nd. Posteromedial dislocation of the ankle

    without fracture. J Bone Joint Surg [Am]  1987;69-A:706-11.

    15. Kelly PJ, Peterson LF. Compound dislocation of the ankle without fracture. Am J 

    Surg  1962:103:170-2.