Keywords
ankle injuries - joint dislocations - surgical procedures, operative
Introduction
Ankle joint injuries associated with sports are often diagnosed in trauma centers,
especially in the age group ranging from 15 to 35 years-old.[1] The prevalence of trauma-related fractures in this area, such as medial and lateral
malleoli fractures, is higher.[2] As such, the concurrent disjunction of the proximal tibiofibular joint and the distal
syndesmosis in the absence of tibial or fibular fracture is uncommon.[2]
Maisonneuve lesion, first described in 1840 by the surgeon Jules Germain François
Maisonneuve, accounts for 7% of all ankle fractures.[3] The trauma mechanism involves an external rotation associated with ankle pronation,
resulting in an injury of the distal tibiofibular ligament, syndesmotic complex, and
proximal fibular fracture. In one variant, there is concomitant dislocation of the
proximal tibiofibular joint and distal ankle syndesmosis in the absence of a proximal
fibular fracture.[3]
Only four cases of this rare lesion have been reported up to this year.[4] This paper aims to present an original case of a patient with a Maisonneuve variant
lesion, that is, tibiofibular syndesmosis injury, and proximal tibiofibular luxation.
Case report
A 34-year-old patient was admitted to the emergency room after a left lower limb trauma
during a football match. In addition to severe pain in his left ankle and knee, the
patient was unable to walk. Clinical examination revealed edema in the left lateral
malleolus region and the lateral aspect of the left knee. No neurological or vascular
changes were observed.
Radiographs revealed lateral left ankle subluxation and medial clear space enlargement
associated with proximal tibiofibular joint anterolateral luxation ([Fig. 1]), with no evidence of fracture. A computed tomography scan of the knee joint confirmed
the presence of Maisonneuve variant lesion with anterolateral luxation of the proximal
tibiofibular joint ([Fig. 2]).
Fig. 1 Anteroposterior radiographs of the ankle (A) and the leg (B) showing ankle syndesmosis
disjunction and proximal tibiofibular subluxation, respectively.
Fig. 2 Axial computed tomography scan of the proximal tibiofibular joint (A) showing an
anterolateral proximal tibiofibular subluxation. Posterior view of computed tomography
scan with 3D reconstruction of knee (B) showing the proximal tibiofibular anterolateral
subluxation.
The patient underwent surgical anatomical reduction under spinal anesthesia. The curvilinear
lateral access to the knee was used, starting at the lateral femoral condyle, toward
the anterior border of the proximal fibular portion. The common fibular nerve was
identified and carefully retracted. The tibiofibular joint was identified, and, after
hematoma drainage, reduction and fixation were performed. The ankle injury was percutaneously
treated, taking care to maintain the divergence between screws. In this approach,
two 3.5 mm Orthosir (Medtronic®, Dublin, Irlanda) titanium cortical screws were used in the ankle and one Orthosir
titanium cortical screw was placed in the proximal tibiofibular joint after anatomical
reduction under direct visualization ([Fig. 3]). Anatomical reduction and perfect stability were obtained, preserving the ankle
and knee functional arc of motion, as well as their proper alignment and rotation.
Fig. 3 Anteroposterior (A) and lateral (B) radiograph of the leg and anteroposterior (C)
and lateral (D) radiograph of the ankle after surgery.
Active and passive knee and ankle mobilization started immediately after surgery.
In addition, loading was immediately allowed with the use of an axillary crutch for
partial support. Isometric thigh and leg strengthening exercises were started at the
same time. Total load was allowed within a month. The patient returned to work in
two months and resumed sports activities in 3 months. After 6 months of follow-up,
he had total knee flexion, dorsiflexion and plantar flexion, with no limitations ([Fig. 4]).
Fig. 4 Knee and ankle total arcs of motion (A); Total dorsiflexion (B); Total plantar flexion
(C).
Discussion
The stability of the proximal tibiofibular joint depends on the bony and muscle-ligamentous
components. Despite the fragility of this complex, the fibular head displacement is
very rare, and it is little described in the literature. There are four possibilities
for this displacement: anterolateral (more frequent), posteromedial, superior and
atraumatic subluxation.[5]
The distal tibiofibular syndesmosis is an injury frequently seen in the emergency
room due to ankle torsional trauma. However, the isolated lesion of the ligament complex
without fibular fracture is rare.[3]
Thus, Maisonneuve variant lesion with proximal tibiofibular luxation is a rare disorder
that requires a careful diagnostic approach. A search in the BIREME, PUBMED and LILACS
databases in January 2018 retrieved with only 4 cases of Maisonneuve variant lesion.[2]
[4]
[6]
[7] Its incidence varied in high and low-energy traumas, but all patients were surgically
treated with good functional results and complete restoration of the limb's range
of motion.
In this case report, the patient was treated with direct surgical reduction for proximal
tibiofibular luxation and percutaneous ankle reduction and fixation. We also report
the need to immediately allow active and passive movement in addition to partial load
support to obtain good functional results in these patients' rehabilitation.
