Ankle stiffness and osteoarthritis in fracture-dislocation: an avoidable complication or natural history

Abstract

Dear Editor, We read the article “Ankle stiVness after Bosworth fracture dislocation of the ankle” by Lui et al. [1] with great interest. They presented four cases who had ankle stiVness after Bosworth fracture dislocation. In their study, three of the four cases were transferred to hospital late, and the authors suggest that delayed treatment in these patients was the cause of stiVness or ankle osteoarthritis or both. One early case that was treated immediately did not have such problems. Hockenbury and Friermood [2] reported a patient with dislocation of the intact Wbula, small avulsion fracture of the medial malleolus, rupture of the deltoid ligament and tarsal injury. Although the patient was treated by open reduction and internal Wxation without delay, he subsequently developed talar avascular necrosis and degenerative arthritis. In fracture-dislocation cases, there may also be some additional intra-articular pathology like osteochondral injuries. Hoblitzell et al. [3] described a large osteochondral fragment from posterior malleolus after such injury. The authors also found osteochondral lesions in three out of their four patients. Therefore, they commented that “this may have some bearing on the prognosis, as ankle degeneration developed in all three patients.” Bosworth fracture dislocation is characterized with the Wxed displacement of the Wbula behind the tibia; however, anatomic conWguration may change. For instance, in our series of ankle osteoarthritis patients that were treated with total ankle arthroplasty, a patient had a fracture dislocation without Wbular entrapment who was operated immediately after the injury (Fig. 1). The ankle anatomy was restored (Fig. 2). However, in the follow-up, degenerative arthritis was seen (Fig. 3). We have been performing ankle replacement for advanced osteoarthritis, and during our observations regarding the natural history and etiology of our series, we observed that despite the early motion that can be obtained after early reduction and stable internal Wxation some