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      An unexpected complication of nonoperative treatment for tibial posterior ­malleolus fracture: bony entrapment of tibialis posterior tendon – a case report


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          A 41-year-old patient was referred to our center because of right medial ankle pain increasing for 3 months. He had, 10 years ago, had a displaced lateral malleolus fracture with an associated non-displaced posterior malleolus fracture but without a medial malleolus fracture. A fibular osteosynthesis without medial or posterior exploration was done at another hospital. Postoperatively, the patient remained non-weightbearing for 6 weeks with a cast. The patient recovered completely and returned to work as a fireman 4 months after the initial injury. The fibular osteosynthesis material was removed 1 year after the surgery. 10 years later, when referred to our center, he had increasing medial ankle swelling and pain, preventing him from working as a fireman. Physical examination revealed a medial retromalleolar swelling with local tenderness, but no flat-foot deformity. Testing of the tibialis posterior tendon (TPT) was positive: heel-rise test and strength assessment were painful but with no loss of strength. Radiographs showed a healed lateral malleolus fracture in good alignment with a posterior tibial bony callus (Figure 1). Figure 1. Posterior tibial bony callus (arrow) of the right ankle. A CT scan showed a medial retromalleolar bone tunnel containing the TPT of 15 mm length (Figure 2); the fibular and the posterior malleolus fractures were healed. An MRI scan showed tenosynovitis of the TPT (Figure 3), and thickening of the anterior talo-fibular ligament. Figure 2. Ax CT scan, showing the tibialis posterior tendon (*) in a medial retromalleolar bone tunnel and the healed posterior malleolus fracture (red line). Figure 3. Tibialis posterior tendon tenosynovitis (arrow) on fat-saturation gadolinium injected T1-weighted axial MRI. We performed an open resection of the postero-medial part of the tunnel to release the TPT (Figure 4). The postero-medial part of the bony tunnel was resected and the TPT was released, inspected, and debrided (Figure 5). The TPT moved freely in its groove with no tendency to luxation. Bone wax was pressed into cancellous bone to prevent recurrence of the bony tunnel. Figure 4. Tibialis posterior tendon identification above and below the medial malleolus (arrows), postero-medial part of the bony tunnel (*). (Right ankle, postero-medial approach, patient in supine position.) Figure 5. Tibialis posterior tendon debridement after resection of the retro-malleolar bone tunnel. (Right ankle, postero-medial approach, patient in supine position.) The patient had a walking brace for 3 weeks and functional rehabilitation was started a few days after the surgery. At 6 weeks, the patient could walk with normal shoes and he was able to return to work after 3 months. At last follow-up (12 months), the patient had no pain and had returned to sport without physical limitation. Discussion Tendon entrapment in bony callus is a rare complication of closed-reduction fracture management. Tendon is usually trapped directly in the fracture preventing its anatomical reduction, but it can also be engulfed in the growing osseous callus (Christodoulou et al. 2005, Erra et al. 2013). While displaced medial and lateral malleolus fractures are often operated on, allowing the diagnosis of the tendon entrapment, posterior malleolus fractures are often neglected or fixed with anterior to posterior screws through a percutaneous approach (Solan and Sakellariou 2017). Internal fixation seems recommended for posterior malleolus fractures involving more than 25% of the articular surface to achieve anatomical reduction (Gardner et al. 2011, Mingo-Robinet et al. 2011). Surgery via a postero-lateral or postero-medial approach allows for anatomical reduction and direct control of tendon and soft tissue entrapment, and thus reduces the risk of malunion. Recent research articles showed good results in patients with posterior malleolus synthesis by screw or buttress plate, without increasing the complication rate due to the postero-lateral approach (Verhage et al. 2016, Bali et al. 2017, Gougoulias and Sakellariou 2017). Structure entrapment is better known after upper limb fractures. Tendon entrapment has been reported rate in 1.3% of distal radius fractures involving particularly the extensor tendon and sometimes flexor tendon (Okazaki et al. 2009). Peripheral nerves can also be engulfed in fracture callus (Erra et al. 2013). In our case, the TPT retromalleolar groove was closed by the posterior malleolus fracture’s bony callus, but with no symptoms for almost 10 years. It probably became painful due to a conflict within the inextensible groove, resulting in a painful tenosynovitis. We found 1 similar case in the literature but the entrapment was not circumferential and it concerned a medial malleolus fracture treated nonoperatively (Khamaisy et al. 2012). The treatment and the outcomes were similar in each case, both patients returning fully to their former activities.

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          Most cited references 10

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          Surgeon practices regarding operative treatment of posterior malleolus fractures.

          Operative indications for surgical treatment of posterior malleolar fractures associated with fractures of the distal fibula and tibia are not currently well defined. The purpose of the present study was to determine the current practice among orthopaedic surgeons regarding the management of posterior malleolus fractures.
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            Ankle fractures with posterior malleolar fragment: management and results.

            Trimalleolar ankle fractures can be difficult to manage and convey a high risk of long-term morbidity. The question of whether internal fixation of the posterior malleolar fragment is warranted remains open. We conducted a retrospective cohort study involving 45 patients who underwent surgical repair of a trimalleolar fracture. Our goal was to study the effect of the size of the posterior fragment on outcomes. We defined small posterior malleolar fragments as being ≤ 25% of the distal tibial articular surface as viewed on the lateral radiograph. Outcome measures included the radiographic appearance of the reduction, as well as Olerud and Molander (O&M) scores and AOFAS scores. Overall better outcomes were obtained in patients whose fractures involved ≤ 25% of the articular surface, and the difference in outcomes was statistically significant in regard to the AOFAS scores (P = .05), although not statistically significant in regard to Olerud and Molander scores and the radiographic appearance of the reduction (P = .14 and P = .45, respectively). Anatomic reduction was achieved in 73.3% of patients, but they did not have better clinical results than nonanatomic reduction patients: AOFAS (P = .14), O&M (P = .38), radiographic appearance (P = .74).
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              Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach

              Involvement of the posterior malleolus in fractures of the ankle probably adversely affects the functional outcome and may be associated with the development of post-traumatic osteoarthritis. Anatomical reduction is a predictor of a successful outcome. The purpose of this study was to describe the technique and short-term outcome of patients with trimalleolar fractures, who were treated surgically using a posterolateral approach in our hospital between 2010 and 2014.

                Author and article information

                Acta Orthop
                Acta Orthop
                Acta Orthopaedica
                Taylor & Francis
                December 2019
                12 August 2019
                : 90
                : 6
                : 624-625
                [a ]Université de Lille Nord de France, Service d’orthopédie 1, Hôpital Roger Salengro, Centre Hospitalier Universitaire de Lille , France;
                [b ]Service orthopédie, Centre Hospitalo-Universitaire Amiens Picardie , 80480 Amiens, France
                Author notes
                © 2019 The Author(s). Published by Taylor & Francis on behalf of the Nordic Orthopedic Federation.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 5, Tables: 0, Pages: 3, Words: 1159



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