Repair of the Acute Deltoid Ligament Complex Rupture Associated With Ankle Fractures: A Multicenter Clinical Study

doi:10.1053/j.jfas.2014.12.013

The Journal of Foot and Ankle Surgery

Volume 54, Issue 2, March–April 2015, Pages 198-202

https://doi.org/10.1053/j.jfas.2014.12.013 Get rights and content

Abstract

Controversy exists concerning the need for operative repair of the deltoid ligament during management of acute ankle fractures. The purpose of our report was to identify the indications for surgical intervention for deltoid ligament injury in the setting of ankle fractures. Furthermore, we aimed to elucidate the clinical outcomes after deltoid ligament repair in this setting. This was a multicenter study, involving 4 clinical institutions. From January 2006 to December 2011, 1533 ankle fractures underwent surgical intervention. Of this group, 131 deltoid ligament ruptures (8.55%) were identified and repaired operatively. Of the 131 patients, 74 were male (56.5%) and 57 were female (43.5%), with a mean age of 33.2 (range 16 to 63) years. The outcome measures included the clinical examination findings, radiographic findings, American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, visual analog scale (VAS) scores, and Medical Outcomes Study Short Form 36-item questionnaire scores. All incisions healed primarily. A total of 106 patients were followed up for a minimum of 12 (range 12 to 72) months, with an average follow-up period of 27 months. The mean interval to fracture union was 14.5 (range 9 to 16) weeks. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score at the latest follow-up visit was 91.4 (range 83 to 100) points. The mean visual analog scale score was 1.2 (range 0 to 6) points. The mean Short Form-36 score was 91.2 (range 80 to 96) points. Compared with the preoperative scores, all the 3 outcome measures had improved significantly postoperatively (p < .05). The postoperative stress radiographs did not reveal any ankle instability. None had evidence of post-traumatic arthritis of the ankle from the clinical examination and radiographs. A reasonable clinical evaluation and surgical repair was executed, with an appropriate repair technique chosen according to the site of deltoid ligament rupture. The results of the present multicenter study have shown that deltoid ligament rupture can be repaired in patients with an unstable medial ankle after fracture fixation and prevent ankle stabilization-related complications.

Section snippets

Setting and Location of Data Collection

The institutional review board approved the present multicenter, retrospective, trial involving 4 cities (Shanghai, Dalian, Wuhan, and Hangzhou) in the east, north, and west of China separately. From January 2006 to December 2011, 1533 operatively treated ankle fractures were identified. Of these, a ruptured deltoid ligament was identified in 131. All the authors collected the data from the 4 centers, and 2 of us (Z.M.Z. and Y.G.R.) completed the data analysis.

Inclusion Criteria

The inclusion criteria were

Results

Most of the patients were male and had sustained their ankle injury in falls, traffic accidents, collision sports, or bicycling or motorcycling accidents (Table). No significant differences were found in the demographic features or injury patterns between the 2 groups.

A total of 106 patients (81%) were followed up for an average of 27 (range 12 to 72) months. The mean interval to fracture healing was 14.5 (range 9 to 16) weeks according to the radiographic findings. The initial reduction of the

Biomechanical Characters of Deltoid Ligament

The deltoid ligament is the primary restraint to posterior translation of the talar, with a relative contribution ranging from 50% to 80%. The contribution of the deltoid ligament was significantly greater in plantar flexion than in dorsiflexion (7). The deltoid ligament controls external and internal rotation of the talus, in conjunction with the anterior talofibular ligament. Rupture of the deep deltoid ligament will lead to increased external rotation. The studies by Rasmussen et al (8)

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A clinical guide to the medial ligaments of the ankle: Anatomy, function, diagnosis of injuries and treatment of instability-a narrative review
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The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability.
Literature search on PubMed.
Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse.
There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.
Primary Deltoid Repair for Ankle Fracture Using All-Suture Anchors
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Primary repair of the deltoid ligament is a common surgical option for unstable ankle fracture. However, controversy exists regarding whether such repair is necessary or provides any benefit to patient outcomes. A retrospective study was performed following acute deltoid repairs using all-suture bone anchors. Patients at 2 surgical centers were included when they were over 18 years old at surgery, had a medial clear space (MCS) greater than 4 mm preoperatively, and had at least 6 months of follow-up. Subjective outcomes were measured with PROMIS, FAAM, and numeric rating scale. Preoperative and follow-up scores were compared with t tests (p < .05). For the 47 patients identified, age at time of surgery was 30.6 ± 14.9 years (range 15.4-65.0 years). Follow-up data were captured for 36 (73%) of the patients at 75 ± 37 weeks (range 18-169 weeks) after surgery. Mean time to weightbearing was 4 ± 1 weeks (range 1-7 weeks). Patients returned to sport 14 ± 5 weeks after surgery (range 8-41 weeks). Various complications consisted of wound infection, superficial dehiscence, and complex regional pain syndrome (CRPS). The PROMIS, FAAM, and NRS patient outcome scores improved significantly from preoperative to postoperative follow-up. Significant reduction in the radiographic MCS postoperatively occurred in all patients. These findings suggest primary deltoid repair when associated with ankle fracture to be a safe procedure and has the potential of allowing early weightbearing and return to sports.
Sprain of the Medial Ankle Ligament Complex
2023, Foot and Ankle Clinics
Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures
2022, Foot and Ankle Surgery
Citation Excerpt :
Radiographs were accessed through the Picture Archiving Communication System (PACS). The deep deltoid ligament was assumed to be ruptured if the MCS was ≥ 5 mm [2,4,15,18] on the preoperative mortise view. Patient demographics, mechanism of injury, fracture pattern, syndesmotic fixation, and performance of deltoid ligament repair were recorded.
Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/− deltoid ligament repair.
A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/− deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively.
One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups.
Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits.
Level III, retrospective cohort study.
Deltoid ligament repair versus trans-syndesmotic fixation for bimalleolar equivalent ankle fractures
2022, Injury
The role of deltoid ligament repair is controversial in the treatment of bimalleolar equivalent ankle injuries. Our purpose was to compare midterm functional outcomes and reoperation rates of unstable distal fibula fractures treated with open reduction internal fixation (ORIF) of the fibula and either deltoid ligament repair, trans-syndesmotic fixation, or combined fixation.
Skeletally mature subjects were retrospectively identified after fixation of isolated unstable distal fibula fractures treated at a single academic level 1 hospital from January 2005 to May 2019. The AAOS Foot and Ankle Module outcomes questionnaire (AAOS-FAM) was obtained at a mean time from surgery of 4.6 +/- 3.1 years. Subjects underwent one of three methods of fixation including distal fibula ORIF and one of the following: trans-syndesmotic fixation (N = 66), deltoid ligament repair (N = 16), or combined trans-syndesmotic fixation and deltoid ligament repair (N = 26). Outcomes scores and Charlson Comorbidity Index scores were compared between groups by Kruskal-Wallis testing for non-normally distributed data. Rates of reoperation were compared by Fisher's exact test. Statistical significance was set to P < 0.05 for all comparisons.
There was no significant difference in AAOS-FAM scores between the three groups (P = 0.18). No subjects in the deltoid ligament repair group underwent reoperation compared to 17 (26%) in the trans-syndesmotic fixation group and six (23%) in the combined fixation group. The most common reason for reoperation was removal of hardware, which was performed in 12 (18%) subjects in the trans-syndesmotic fixation group and three (12%) subjects in the combined fixation group.
Direct deltoid ligament repair yields similar functional scores and fewer reoperations compared to trans-syndesmotic fixation at midterm follow up. Deltoid ligament repair may be a favorable treatment strategy when considering trans-syndesmotic fixation in the surgical treatment of unstable distal fibula fractures.
Deltoid ligament arthroscopic repair in ankle fractures: Case series
2021, Injury
Diagnosis and treatment of ankle medial ligament lesions in malleolar fractures has always been a matter of controversy. Even when deltoid involvement is clear, the direct repair of this structure is not a consensus. Recently, deltoid repair through an arthroscopic technique was described aiming to potentialize better clinical results and minimize complications.
Demonstrate safety and functional results on patients with ankle fractures submitted to open reduction and internal fixation and arthroscopic deltoid repair.
This is a retrospective study in patients diagnosed with ankle fractures associated with acute deltoid injuries submitted to open malleolar fixation and deltoid arthroscopic repair between June 2016 and January 2020. All patients were evaluated for pain and functionality according to the Visual Analogue Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) at a minimum of 6 months follow-up.
From January 2016 to January 2020, 20 ankles with fractures or dislocations were operated and the deltoid ligament rupture was repaired arthroscopically. A mean follow-up of 14.45 months (6-48) was observed, and patients presented an average AOFAS of 93.5 (SD 7.25) and a VAS of 0.75 (SD 1.05). Three minor complications were noticed and no signs of medial chronic instability, loss of reduction or osteoarthritis were observed.
The repair of the deltoid complex and the low morbidity of the arthroscopic technique used may improve the clinical outcomes of these patients. Additional studies, with a prospective and comparative methodology are required to sustain this proposal.
Level IV. Retrospective case series.

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: Financial Disclosure: This study was support by funding to M.-z.Z.: NSFC (81401782), Shanghai Natural Science Foundation (13ZR1438200), and Doctoral Fund of Ministry of Education (20120072120074).

: Conflict of Interest: None reported.

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Original ResearchRepair of the Acute Deltoid Ligament Complex Rupture Associated With Ankle Fractures: A Multicenter Clinical Study

Abstract

Section snippets

Setting and Location of Data Collection

Inclusion Criteria

Results

Biomechanical Characters of Deltoid Ligament

J Foot Ankle Surg

Lancet

Clin Biomech (Bristol, Avon)

Injury

Techn Sports Med

Arthroscopic findings in acute fractures of the ankle

J Bone Joint Surg Br

Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes

Foot Ankle Int

The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection

Med Care

A biomechanical evaluation of the tibiofibular and tibiotalar ligaments of the ankle

Foot Ankle Int

Original Research
Repair of the Acute Deltoid Ligament Complex Rupture Associated With Ankle Fractures: A Multicenter Clinical Study