Bosworth Ankle Injuries - Treatment Challenges in Late and Neglected Presentations

Bosworth ankle injuries (BAIs) are rare talocrural dislocations with bi or trimalleolar fractures. Attempted closed reduction fails due to incarcerated fibular fracture behind the distal tibia. The diagnostic delay and failed attempts to restore anatomical reduction result in significant ankle swelling, compromised skin, and imminent compartment syndrome. In neglected cases with unreduced dislocation over months, capsular and tendo-Achilles contracture, additional disuse osteoporosis, adds to the complexity of surgical management. In chronic and neglected cases, literatures have no clear consensus of opinion on the type of surgical intervention and on the extent of optimization. In acute BAI, open reduction is recommended but the soft-tissue swelling may warrant staged internal fixation, after temporary external fixation.

In this retrospective study we present the clinico-radiological outcome of surgically treated delayed presentation of BAI. The primary fixation in delayed cases and the role of reverse talar dome osteotomy for fusion in the chronic neglected case will be discussed. Patients were aged between 25 and 62 years, presented with isolated closed ankle injuries. Initial X-rays were consistent with BAI. The delay in presentation ranges from 2 to 49 days. All had open reduction and stabilization of the ankle. Chronic neglected case with 7 months delay had "Reverse talar dome osteotomy" for reduction of the neglected dislocation and proceeded for the primary fusion. Patients gained back their full weight-bearing mobility at an average of 12 weeks following delayed fixation. Fused ankle gained full weight-bearing mobility at 5 months post-operative period.

Bosworth type of ankle dislocations are difficult injuries for closed reduction. Early diagnosis and recognition of fibular impingement require open reduction of the joint. In cases of delayed presentation, it could be challenging. Even after open reduction, a staged procedure may be warranted based on the soft tissue status. Osteotomy for joint reduction and primary fusion remains a viable option in neglected cases with an ultimate aim to regain plantigrade foot for mobility.