The Journal of Foot & Ankle Surgery xxx (2017) 15

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Case Reports and Series

Open Ankle Dislocation Without Fractures With Tibialis Posterior

Tendon Interposition Through the Interosseous Space
Bryan J.Y. Bae, MBChB 1, Joseph F. Baker, MCh, FRCSI 2, Robert J. Orec, MBChB, FRACS Orth 3,
Alastair T. Hadlow, MBChB, FRACS Orth 4
1
Junior Registrar, Department of Orthopaedics, Auckland City Hospital, Auckland, New Zealand
2
Orthopaedic Surgeon, Department of Orthopaedics, Waikato Hospital, Hamilton, New Zealand
3
Orthopaedic Surgeon, Department of Orthopaedics, Middlemore Hospital, Auckland, New Zealand
4
Orthopaedic Surgeon, Department of Orthopaedics, Auckland City Hospital, Auckland, New Zealand

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 4 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
Keywords:
bula
dislocation without fracture with concurrent tibialis posterior tendon interposition through the interosseous
pure tibiotalar dislocation space that was detected incidentally on computed tomography. We highlight the clinical, radiologic, and
syndesmosis intraoperative features to avoid missing similar diagnoses.
talus 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
tendon dislocation
tibia

Ankle dislocations are usually seen with an accompanying fracture
of the tibia or bula, or both, as described in many well-known
classications. Ankle dislocation without an associated fracture,
however, is less common, and only a few series have been reported
(1). Understanding the potential pitfalls in the management of these
serious injuries is important for all involved in the care pathway to
avoid complications and unnecessary returns to the operating theater.
We describe an unusual case of an open ankle dislocation without
fracture in a healthy young female and report the incidental nding of
tibialis posterior (TP) tendon interposition in the interosseous space.
To the best of our knowledge, ours is the rst case of TP tendon
interposition in an open ankle dislocation without an associated
fracture. The management of this case highlights important clinical,
radiologic, and intraoperative features that could help avoid missing
similar diagnoses.
Case Report
A 17-year-old female, with no pertinent medical history, presented
to the emergency department (ED) after having sustained an isolated
injury to her right ankle. She had been involved in a rugby tackle that
Financial Disclosure: None reported.
Conict of Interest: None reported.
Address correspondence to: Bryan J.Y. Bae, MBChB, Department of Orthopaedics,
Middlemore Hospital, 100 Hospital Road, Otahuhu, Auckland 2104, New Zealand.
E-mail address: bryanjybae@hotmail.com (B.J.Y. Bae).
resulted in twisting of her right ankle and the opponent then falling
onto her ankle from behind, forcing it into extreme plantarexion. She
was immediately removed from the eld of play with a painful
deformed ankle.
On examination in the ED, she had grossly deformed right ankle
with a 12-cm transverse wound medially through which the medial
malleolus was exposed (Fig. 1). She had intact sensation in the distri-
bution of the supercial peroneal, deep peroneal, and tibial nerves, and
both dorsalis pedis and tibialis posterior pulses were detectable using a
Doppler probe. Antibiotic coverage (amoxicillin and clavulanic acid
1.2 g intravenously) and an intramuscular tetanus booster were
administered, and the wound was irrigated with 2 L of normal saline. A
series of portable plain radiographs were obtained before reduction,
given their immediate availability, to assess the extent of injury (Fig. 2).
Reduction was rst attempted with the patient under conscious
sedation in the ED. Reduction was difcult, and the tibiotalar joint had
to be swept clear with a nger through the open wound to ensure no
structures were within the joint space and mechanically blocking the
reduction. Syndesmosis disruption and the resultant splaying contrib-
uted to a lack of a rm endpoint to conrm reduction. Once the joint
space had been cleared, reduction was facilitated, and a plaster-of-Paris
splint was applied. A computed tomography (CT) scan (Fig. 3) was then
taken, which showed persistent subluxation of the tibiotalar joint with
a widened syndesmosis and talar shift but without overt fracture.
The patient underwent surgery 4 hours after the injury with
wound washout and stabilization of the syndesmosis with 2 fully

1067-2516/$ - see front matter 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2017.04.018
2 B.J.Y. Bae et al. / The Journal of Foot & Ankle Surgery xxx (2017) 15

threaded 3.5-mm cancellous screws, which were applied percutane-

ously. Examination with the patient under anesthesia at that point
conrmed a stable ankle joint (Fig. 4). The syndesmosis had not been
reduced using an open approach because of concerns of a second
incision over the lateral malleolus, given the swelling around the
ankle.
A subsequent review of the case, including a formal report of the
initial CT scan by a senior radiologist, revealed an abnormal path of
the tibialis posterior tendon, which passed between the distal tibia
and bular 5 cm above the tibial plafond and anteromedially to the
distal tibia and down to its normal insertion (Fig. 5). A second CT scan
was performed on both ankles to assess the syndesmosis reduction
and xation and to compare the right ankle joint to the left. The
second CT scan revealed an imperfect syndesmosis reduction and
slightly wider medial clear space in the right ankle compared with the
left, despite satisfactory positioning of the screws (Fig. 6).
The patient returned to the operating theater for a second surgery,
at which time, exploration of the medial wound showed an intact
exor hallucis longus tendon; however, the TP tendon was missing
from the tendon sheath. The TP tendon was found anterior to the
medial gutter. A second incision was made over the lateral malleolus
to further explore the ankle, which revealed the anterior compart-
ment stripped subperiosteally from the tibia and the TP tendon
appearing between the tibia and bula, approximately 5 cm above the
distal tibiobular joint, and draped over the front of the distal tibia.
Once the original 2 syndesmosis screws had been removed and the
ankle dislocated, the TP tendon could be relocated to its original po-
sition and remained stable. The syndesmosis was then secured with
three 4.0-mm cortical screws. The ankle joint was still shown to be
unstable by an anterior draw test; therefore, lateral talobular liga-
ment avulsions and medial ligament avulsions were repaired with
Fig. 1. Right open ankle dislocation with exposed medial malleolus.

Fig. 2. Initial anteroposterior and lateral plain radiographs of right ankle showing dislocated talus anterolaterally to the tibia and bula and a small foreign body anterior to the lateral
malleolus. No obvious fractures can be seen.
 B.J.Y. Bae et al. / The Journal of Foot & Ankle Surgery xxx (2017) 15 3

Fig. 3. Three-dimensional reformatting of initial computed tomography scan of right ankle after attempted reduction and application of plaster-of-Paris backslab in the emergency
department. Persisting talar shift shown with a few small avulsion fragments (not seen on 3-dimensional reproduction).

Mitek GII anchors (DePuy Synthes, West Chester, PA). The nal ra-
diographs of the right ankle (Fig. 7) showed complete reduction of the
ankle with a medial clear space comparable to that of the left side.
A plaster-of-Paris backslab was applied with non-weightbearing
status for 6 weeks postoperatively. At the 2-month postoperative
follow-up examination, the patient had completely healed surgical
scars and had gained full range of motion of the ankle. The ankle had
mild soft tissue swelling. The patient was only partially weightbearing
owing to persisting pain. Continued physiotherapy with a gradual
increase in weightbearing status as tolerated and additional follow-up
examinations were recommended. At the 6-month follow-up exam-
ination, the patient was ambulating well with only mild discomfort
over the peroneal tendons. The patient had return to work as an usher.
Further follow-up was recommended for review of the mild
discomfort.
Discussion
Irreducible ankle fracture dislocation due to TP tendon dislocation
is a rare injury with only a few cases reported. However, unlike these
cases, to the best of our knowledge, our case is the rst described with
open ankle dislocation and TP tendon interposition through the
interosseous space without associated fractures. The intent of
reporting this case is to describe clinical and radiological ndings of
such injury.
Lacasse et al (2) described the difculty and delay in diagnosing TP
tendon interposition in the syndesmosis in the case of a 17-year-old
male with a closed Weber C fracture of the right ankle. TP tendon
interposition was only suspected 2 months after the initial trauma
because of clinical features of loss of dorsiexion, hallux interpha-
langeal joint contracture, and residual anterior translation of the talus,
despite 2 procedures to correct the ankle deformity. Subsequently,
magnetic resonance imaging was used to determine the TP tendon
location, which was within the posterior ankle joint and syndesmosis.
This was corrected with a third surgical procedure. At the 9-month
follow-up examination, the patient had regained most dorsiexion
and the hallux interphalangeal joint contracture had fully resolved
(2). Magnetic resonance imaging can be useful in diagnosing soft
tissue injuries but might not be readily available in most acute set-
tings and could delay the patients surgery. It could also be costly to
routinely recommend magnetic resonance imaging for all open ankle
dislocations.
Al Khudairy et al (3) described a case in a 17-year-old female who
was involved in a motor vehicle accident that in a swollen left ankle
with medial malleolar fracture. In their case, a possible TP dislocation
was suspected preoperatively by a senior clinician who noted on

Fig. 4. Intraoperative images of right ankle (anteroposterior and lateral views).

4 B.J.Y. Bae et al. / The Journal of Foot & Ankle Surgery xxx (2017) 15

Fig. 5. A series of axial images of initial computed tomography scan showing tibialis posterior tendon (white arrows) running between tibia and bula (1 and 2), sitting anterior to the
distal tibia (3 and 4), and then sitting just anterior to the medial gutter, with pockets of air (5) before resuming its normal course (6).

inspection a localized swelling with a palpable cord-like structure
anterior to the medial malleolus. Although thorough inspection and
palpation of the injured ankle should be routine practice, in the acute
trauma setting, in which gross deformity can cause diffuse swelling,
detecting a palpable mass could be difcult and hence inaccurate.
Connors et al (4) described the case of a 13-year-old female with a
Weber C fracture of a right ankle after a trip and fall on an uneven
sidewalk. They proposed that a large medial clear space, seen both
before and after attempts at closed reduction, noted to be extremely
out of proportion to the mechanism of injury could be an observable
indicator of TP tendon interposition. In our case, the talar shift also
persisted even after attempted reduction in ED; however, in the
setting of an inherently unstable ankle dislocation, the degree of talar
shift could be due to multiple reasons, such as interposition of deltoid
ligaments or a malreduced syndesmosis with an intact lateral liga-
ment complex.
Connors et al (4) also described the intraoperative difculty of
open reduction that led to their nding TP tendon interposition in the
medial gutter. However, in our case, syndesmosis reduction was
largely successful even at the rst surgery, because the TP tendon

Fig. 6. Axial image of second computed tomography scan of bilateral distal tibiobular joint. Note that right (R) distal tibiobular joint is wider anteriorly than the left (L) at the same level.
 B.J.Y. Bae et al. / The Journal of Foot & Ankle Surgery xxx (2017) 15
Fig. 7. Final radiographs (anteroposterior and lateral views) of right ankle after the second surgery.
interposition was 5 cm above the level of syndesmosis, allowing for a
near anatomic mortise that was conrmed by intraoperative imaging.
Only on a secondary review of the imaging studies by a radiologist
after the initial surgery did the diagnosis become apparent in our
patient.
Ballard et al (5) conducted a retrospective study to assess the
incidence of tendon entrapment and dislocation associated with
ankle and hindfoot fractures in patients undergoing CT. Of 398 pa-
tients with ankle fractures and dislocations, 64 (16.1%) had tendon
entrapment and/or dislocation. Of these 64 patients, 60 had associ-
ated ankle and/or hindfoot fractures and only 4 (6.25%) had tendon
dislocations with no associated fractures. Of the 4 patients without
fractures, only 1 demonstrated a single TP tendon dislocation in a
setting of concurrent subtalar and tibiotalar dislocation. The other 3
patients included 2 patients with TP tendon with exor digitorum
longus tendon dislocation with concurrent subtalar and tibiotalar
dislocation and 1 patient with peroneal brevis and longus tendon
dislocation with tibiotalar dislocation (5). No patient was described,
similar to our patient, with TP tendon dislocation with pure tibiotalar
dislocation only. Although Ballard et al (5) did not provide a clear
indication for CT other than its inclusion in a trauma protocol at the
study center and also did not include postoperative CT scans. These
ndings demonstrated that tendon entrapments and dislocations are
commonly seen in complex injuries of the ankle and hindfoot, with a
small percentage of these (4 of 398; 1%) showing tendon dislocation
without associated fractures.
We propose that any unusual ankle injuries, for which the initial
reduction attempts remain difcult despite all necessary maneuvers,
including appropriate positioning, conscious sedation, and adminis-
tration of muscle relaxants, should raise suspicion for tendon dislo-
cation. In such cases, preoperative CT or intraoperative open
exploration, as appropriate, should be used to conrm or rule out the
diagnosis of tendon dislocations.
A thorough exploration and methodically accounting of all struc-
tures in any open injuries should be mandatory in all cases. In our
5
patient, it was evident once the medial wound was explored during
the second surgery that the TP tendon was missing and only 2 tendons
were visible within the posterior tendon sheath. The second lateral
incision also helped in understanding the exact location of the tendon
interposition and the extent of the injury.
A CT scan, if readily available, will provide benet because the
exact fracture type and pattern can be determined for appropriate
preoperative planning. We propose that in reviewing the CT scans, it
should become routine that not only the bony windows, but also the
soft tissue windows, are scrutinized by the operating surgeon for
abnormalities preoperatively.
In conclusion, TP tendon displacements can be a difcult diagnosis
in the setting of ankle dislocation with or without fracture if a CT scan
is not performed routinely as a part of the initial trauma assessment.
From the ndings from our case and others reported, in the setting of
an unusual ankle dislocation without fracture or an irreducible ankle
fracture-dislocation, a preoperative CT scan with examination of both
bony and soft tissue windows and, where appropriate, a systematic
surgical exploration to identify all structures will prove useful in
diagnosing possible tendon dislocations.
References
1. Lazarettos I, Brilakis E, Efstathopoulos N. Open ankle dislocation without associated
malleolar fracture. J Foot Ankle Surg 52:508512, 2013.
2. Lacasse JS, Laamme M, Penner MJ. Irreducible fracture-dislocation of the ankle
associated with interposition of the tibialis posterior tendon in the syndesmosis: a
case report. J Foot Ankle Surg 54:962966, 2015.
3. Al Khudairy A, Zafar M, Padinjarathala B. The unexpected with ankle fracture:
traumatic tibialis posterior tendon dislocation: a case report and literature review.
Foot Ankle Spec 6:482489, 2013.
4. Connors JC, Coyer MA, Hardy MA. Irreducible ankle fracture dislocation due to
tibialis posterior tendon interposition: a case report. J Foot Ankle Surg 55:1276
1281, 2016.
5. Ballard DH, Campbell KJ, Blanton LE, Williams JT, Sangster G, Hollister AM,
Simoncini AA. Tendon entrapments and dislocations in ankle and hindfoot frac-
tures: evaluation with multidetector computed tomography. Emerg Radiol 23:357
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