SLR - August 2021 - Garrett D. Nelson

Gustillo IIIA Open Bimalleolar Fracture Dislocation of Ankle with Ipsilateral Achilles Tendon Rupture: A Case Report and Review of Literature

Reference: Sarrel K, Girard P. Gustilo IIIA Open Bimalleolar Fracture Dislocation of Ankle with Ipsilateral Achilles Tendon Rupture: A Case Report and Review of Literature. JBJS Case Connect. 2021 May 21;11(2).

Level of Evidence: Case Report

Scientific Literature Review 

Reviewed By: Garrett D. Nelson, DPM
Residency Program: Regions Hospital/HealthPartners Institute – St. Paul, MN

Podiatric Relevance: Achilles tendon ruptures can be easy to miss in the context of an ankle fracture. Prior case reports have described an Achilles tendon rupture in the setting of an ipsilateral medial malleolus fracture. This study describes a case of an open bimalleolar ankle fracture with a concomitant ipsilateral Achilles tendon rupture. These can often be missed on initial presentation, which can then lead to delayed management and possible harm to the patient. It is important to note that Achilles tendon ruptures are missed up to 25 percent of the time. 

Methods: This study reported on a case involving a 20 year old active male patient who endured a motorcycle accident. The patient lost control of his motorcycle and put his foot on the ground in a reflex attempt to help himself slow down. This caused his foot to undergo violent dorsiflexion, causing the trauma of the open bimalleolar ankle fracture with Achilles tendon rupture. The patient was seen for surgical treatment at their institution after having been placed in an external fixator. 

Results: 
• Patient presents to Emergency Department with open bi-malleolar ankle fracture and Achilles tendon rupture after motorcycle accident. Underwent irrigation, reduction, and application of external fixator.
• Patient presented to institution 24 days following injury due to difficulty finding a treating surgeon
o Ultrasound demonstrated a 4-centimeter gap between proximal and distal Achilles tendon fibers
o CT scan showed an articular fragment at the medial shoulder, appearing anatomic in alignment
o Underwent external fixator removal, open reduction internal fixation, excisional debridement of traumatic wounds, and incisional wound vacuum application
• After hospital discharge, was seen weekly for wound checks. 
• After posterior soft tissue healed, patient underwent Achilles tendon reconstruction
o Underwent proximal Vulpuis gastroc lengthening, distal V-Y lengthening, with FHL tendon transfer
• Postop course consisted of 2 weeks non-weightbearing (NWB) in a splint followed by partial WB in a cam boot with heel wedge and physical therapy. Full WB after 6 weeks with no complications.
• Patient was highly satisfied and was seen at 2 years, at which time he denied any subjective limitations, pain, and had fully returned to activity and running as well as his duty for the USARNG

Conclusions: There have been 15 prior studies to report on Achilles tendon rupture with medial malleolar fractures as shown, but this was the first known case study to report on an Achilles tendon rupture with an open bimalleolar ankle fracture. Surgeons should always carry suspicion of Achilles tendon rupture when encountering an oblique or vertical medial malleolus fracture, which this patient did have. The association between an Achilles tendon injury and medial malleolus fractures can be high as they have been reported in many studies. These unfortunately are missed at a rate of up to 46.7 percent. The most common mechanism of injury is a fall from a height and likely occur after a forceful load on the forefoot with forced ankle dorsiflexion. Overall, this was a novel and interesting case study, furthering the insight into the body of literature of concomitant Achilles tendon ruptures and ankle fractures. 

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