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

Abstract

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.

Keywords: ankle dislocation; displacement; irreducible; open reduction; posterior tibial tendon.

Fig. 1

Standard AP views showing an isolated anterolateral talar dislocation, no fractures, and enlargement of the tibioperoneal syndesmosis.

Fig. 2

Post-reduction X-rays showed a persistent lateral talar subluxation with an asymmetrical joint rim and enlargement of the tibioperoneal syndesmosis.

Fig. 3

A: Illustration showing the pattern of the posterior tibialis tendon dislocation. B: The tendon, sliding posteriorly to the distal tibia and passing through the tibioperoneal syndesmosis, reached the anterior part of the ankle joint causing lateral traction on the talus and making it impossible to perform closed reduction of the ankle joint.

Fig. 4

The dislocated posterior tibialis tendon was gently relocated in the retromalleolar groove.

Fig. 5

Soft tissue reconstruction: the capsular joint, flexor retinaculum and ligaments were sutured with absorbable stitches.

Fig. 6

The syndesmosis was stabilized with a syndesmotic screw and the tibiotalar joint with a Kirschner wire; a below-knee cast was applied.

Fig. 7

X-ray taken at 3-month follow-up. A: anteroposterior view. B: lateral view.