Review Article Deltoid Rupture in Fracture: Diagnosis and Management

Abstract Simon Lee, MD The last stage of a supination-external rotation ankle fracture involves Johnny Lin, MD either transverse fracture of the medial or rupture of the deltoid ligament. When the deltoid ligament ruptures, a “bimalleolar Kamran S. Hamid, MD, MPH equivalent” ankle fracture occurs, and the surgeon is presented with Daniel D. Bohl, MD, MPH several diagnostic and therapeutic challenges. In the native ankle, the deltoid ligament provides restraint to eversion and external rotation of the talus on the . In bimalleolar equivalent ankle fractures, there is often gross medial instability even after fibular reduction. Retraction of the deltoid with subsequent healing in a nonanatomic position theoretically may cause instability, persistent medial gutter pain, and loss of function with risk of early arthritis. In mild cases, deltoid injury may not be obvious, and potential diagnostic techniques include preoperative and intraoperative stress radiography, MRI, and ultrasonography. The most common injury pattern is avulsion from the medial malleolus, and most current repair techniques involve direct repair of the capsular and deltoid injuries involving suture anchors in the medial malleolus and imbrication of the superficial and deep deltoid fibers. To date, there is limited From the Department of Orthopaedic Surgery, Rush University Medical evidence of superior clinical outcomes with the addition of deltoid Center, Chicago, IL. repair compared with open reduction and internal fixation of the Dr. Lee or an immediate family alone. member serves as a board member, owner, officer, or committee member of the American Orthopaedic and Ankle Society. Dr. Lin or an immediate ost rotational injuries about reduction and internal fixation (ORIF) family member has received research Mthe ankle fit the supination- of both malleoli is indicated to restore or institutional support from Arthrex external rotation (SER) model of the stability to the mortise. However, and has received nonincome support landmark 1950 study by Lauge-Han- when the deltoid ruptures and the (such as equipment or services), sen.1,2 According to this model, with medial malleolus remains intact, the commercially derived honoraria, or other non–research-related funding the foot supinated, external rotation of injury is termed a bimalleolar equiv- (such as paid travel) from Medwest. the talus on the tibia produces (1) alent ankle fracture, indicating that Neither of the following authors nor rupture of the anterior-inferior tibio- although the medial malleolus re- any immediate family member has received anything of value from or has fibular ligament, (2) oblique fracture mains intact, the ruptured deltoid stock or stock options held in a com- of the lateral malleolus, (3) rupture of ligament renders the ankle function- mercial company or institution related the posterior-inferior tibiofibular lig- ally unstable. ORIF of the fibula is directly or indirectly to the subject of ament (or posterior malleolar frac- recommended in these cases, and the this article: Dr. Hamid and Dr. Bohl. ture), and (4) either transverse fracture syndesmosis is typically repaired with J Am Acad Orthop Surg 2018;00:1-11 of the medial malleolus or rupture of syndesmotic fixation if unstable. DOI: 10.5435/JAAOS-D-18-00198 the deltoid ligament. When the medial However, controversy remains re- malleolus fractures before the deltoid garding the assessment of deltoid Copyright 2018 by the American Academy of Orthopaedic Surgeons. ligament ruptures, the injury is called a integrity and long-term consequences bimalleolar ankle fracture, and open of deltoid repair.

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Figure 1 ondary to external rotation force. Either the superficial or the deep deltoid ligament can rupture as an avulsion from the medial malleolus (majority), as an avulsion from the distal insertion (minority), or as a midsubstance tear (least common).10-12 Ruptures are most commonly of both the superficial and deep portions but canalsobeisolatedtoeitherportion alone. Michelson et al13 conducted a cadaver study of different stages of SER ankle injuries in which they transected and/or made Schematics showing the anatomy of the deltoid ligament. A, The superficial bony osteotomies to simulate frac- deltoid ligament consists of the superficial posterior tibiotalar ligament, tures and then subjected the cadaver tibiocalcaneal ligament, the tibiospring ligament, and the tibionavicular ligament. specimens to axial loading through B, The deep deltoid ligament consists of the deep posterior tibiotalar ligament and the deep anterior tibiotalar ligament. physiologic motions. These authors demonstrated that the talus continues to move in a physiologic manner calcaneal, tibiospring, and tibiona- following SER stages I-III, presum- Anatomy and vicular ligaments (Figure 1, A). Second, ably because the deltoid functions as Biomechanics the deep ligament is confluent with an effective medial tether, stabilizing the tibiotalar capsule and inserts The tibiotalar joint has been described the talus sufficiently to guide its onto the medial aspect of the talus as as a mortise and tenon joint because of motion. It is only when the deltoid the deep anterior tibiotalar ligament its similarity to the woodworking joint ligament is rendered incompetent (originating from the anterior malleo- of the same name. The medial, lateral, (SER stage IV) that talar motion be- lus just deep to the tibionavicular and and posterior malleoli, together with comes abnormal. tibiospring ligaments) and deep pos- their supporting ligaments and the In another important cadaver study, terior tibiotalar ligament (originating contours of the tibial plafond and talar Ramsey and Hamilton14 demonstrated from the posterior malleolus and in- dome, stabilize the talus under the the implications of small changes in tercollicular groove) (Figure 1, B). tibia.3,4 The syndesmotic ligaments tibiotalar alignment. These authors The deltoid ligament is critical in the stabilize the fibula within the incisura. showed that even a 1-mm lateral normal biomechanics of the ankle, On the lateral side, the anterior and deviation of the talus on the tibia re- serving as the tether of the talus to the posterior talofibular ligaments and sults in a 42% reduction in the tibio- medial malleolus to guide the talus the pro- talar contact area. This phenomenon through normal physiologic motion.6-8 vide restraint to talar inversion and represents a dramatic alteration in The superficial deltoid is understood to anterior/posterior talar translation. joint kinematics that has the potential be the primary restraint to hindfoot On the medial side, the deltoid com- to lead to abnormal cartilage wear and eversion, whereas the deep deltoid is plex stabilizes the talus against the degenerative change. understood to be the primary restraint medial malleolus. to talar external rotation.7 Valgus tilt- The deltoid complex is a large, fan- ing of the talus within an intact mortise like structure that originates from the requires complete ruptures of both the Diagnostic Techniques medial malleolus and inserts broadly deep and superficial ligaments.6,9 onto the talus, , and navic- Distinguishing bimalleolar equivalent ular5 (Figure1).Thedeltoidcanbe ankle fractures from isolated lateral dividedintotwoligamentsbasedonits malleolar fractures is critical because insertion sites. First, the superficial Pathoanatomy and isolated lateral malleolar fractures can ligament originates primarily from the Pathomechanics generally be managed nonsurgically, anterior malleolus of the medial mal- whereas lateral malleolar fractures leolus, fanning out to include the In the Lauge-Hansen1,2 model of SER associated with deltoid incompetence superficial posterior tibiotalar, tibio- injury, the deltoid is ruptured sec- constitute unstable injuries requiring

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ORIF in most patients.15 The avail- become the external rotation stress Magnetic Resonance able methods of testing for rupture test.21,22 Park et al21 took radiographs Imaging of the deltoid ligament are reviewed of six fresh cadaver with sim- Nortunen et al23 identified 61 patients here. ulated SER ankle fractures and found with isolated lateral malleolar frac- that a medial clear space of $5mm tures resulting from SER mechanisms. with manual dorsiflexion and external Physical Examination Patients were evaluated with a manual rotation was a reliable predictor of external rotation stress test, and the Swelling, ecchymosis, and medial ten- deep deltoid ligament status. Michel- anterior and posterior portions of the derness are physical examination find- son et al22 conducted a similar study deep deltoid ligament were investi- ings that have been advocated for use with respect to gravity stress views gated using MRI. The authors found in determining whether there is injury (where the patient lies in the lateral that all 61 patients had injuries to the to the deltoid ligament in the setting position and gravity is allowed to deltoid ligament on MRI. These were of a lateral malleolar fracture with a induce an external rotation and lateral 16 typically just partial tears or edema; normal medial clear space. Using translation stress) and demonstrated complete tears were rare, even among stress radiography (discussed later) similar results. patients who had positive stress tests. as the benchmark, McConnell et Of note, some have speculated that 17 There was a high degree of variability al determined that each of these if the mortise is stable to weight bear- of medial clear space in patients with physical exam modalities had little ing, there is adequate stability to the similar MRI findings, and the inter- utility in detecting deltoid injury. mortise and that stress or gravity stress 18 rater reliability of MRI findings was DeAngelis et al reported similar images are not necessary. However, much lower than the interrater reli- results. congruent weight bearing does not ability of stress test findings. On the maximally stress the syndesmosis basis of these results, the authors rec- Plain Radiography because the vast majority of weight ommended against use of MRI in passes directly from the talar dome to Examination of the medial clear space choosing between surgical and non- the tibial plafond regardless of the on a static (unstressed) mortise radio- surgical management of SER fractures. presence of the fibular lateral buttress. graph view is another method that has Of note, one group used MRI to On the basis of the current literature, been advocated for identifying deltoid evaluate the ability of the Lauge- stress or gravity stress films appear to ligament ruptures. On neutral or dor- Hansen classification system to be superior to simple weight-bearing siflexion mortise views, a wide medial predict ligament injuries in ankle . films for evaluation of syndesmotic clear space is defined as 4mmandat fractures.24 They found that the Lauge- integrity. least 1 mm more than the superior Hansen system correctly predicted lig- 18,19 One algorithm is to perform either tibiotalar clear space. Ankles amentous injuries in 94% of cases. with a fibula fracture and a wide gravity or manual external rotation medial clear space are generally con- stress testing on all patients with a Weber B fibula fracture and a normal sidered to have deltoid disruption Surgical Management requiring surgical treatment. Notably, medial clear space. Manual external rotation testing consists of a patient a normal medial clear space is likely Surgical Sequence not sufficient to exclude deltoid liga- lying supine with the ankle internally ° ment injury because a subset of ankles rotated by 10 to obtain a mortise Surgical management of bimalleolar with a normal static medial clear space view of the ankle in neutral dorsi- equivalent ankle fractures typically will have widening with external flexion. The tibia is stabilized and begins with ORIF of the fibula rotation stress (discussed later). Of an external rotation force is applied through a lateral or posterolateral note,inaninteresting study, Nwosu to the foot. Gravity stress testing is approach. The deltoid ligament or et al20 described the “medial malleolus achieved by having the patient lie posterior tibial tendon can become fleck sign,” thought to represent a in the lateral decubitus position with impinged between the talus and small avulsion of bone from the the injured extremity down such that medial malleolus, preventing closure medial malleolus in bimalleolar equiv- the weight of the foot induces an of the medial clear space and/or alent ankle fractures. external rotation and lateral trans- reduction of the fibula. In these ca- lation stress. For both manual and ses, clearance of the medial gutter gravity tests, the medial clear space is through a separate medial incision is Stress Radiography considered to have widened if it recommended. After the fibula has The benchmark for preoperative eval- is .4 and .1 mm greater than the been fixed, the syndesmosis should be uation of deltoid ligament integrity has superior tibiotalar joint space. evaluated using the Cotton test, in

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Figure 2 matics. Other surgeons repair the deltoid only if medial-sided exposure is already required to clear soft tissue from the medial gutter. One group advocates deltoid ligament repair among high-level athletes and only after arthroscopic confirmation of complete deltoid ligament rupture.27 Others have used intraoperative stress radiography to evaluate for persistent medial-sided instability at the end of the case, indicating repair only among those who are intra- operatively unstable after ORIF.12 Intraoperative stress testing can be in the form of external rotation and talar tilt stress12 or syndesmotic distraction using a transfibular tap.28 One algorithm is to perform intra- operative stress radiography after the fibular (and, if indicated by the Cotton test, syndesmotic) ORIF.12 An external rotation stress is applied on the mor- tise view, and the medial clear space is evaluated for widening of .4 and .1 mm greater than the superior tibiotalar clear space. Patients who meet both of these parameters are considered to have a positive intra- operative external rotation stress test. Intraoperative fluoroscopic images showing the eversion stress test. A, Importantly, this is supplemented Unstressed ankle after fibular and syndesmotic open reduction and internal with an eversion stress test in which fixation (ORIF). B, Eversion-stressed ankle after fibular and syndesmotic ORIF an eversion stress is applied and the showing 9° of talar eversion. C, Unstressed ankle after fibular ORIF. D, Eversion- stressed ankle after fibular ORIF showing 7° of talar eversion. A–D, Along with talus is evaluated for tilt (which evi- talar eversion, one observes corresponding increases in the distances between dence suggests indicates a complete the tip of the medial malleolus and the distal-medial radiographic projections of rupture of both the deep and super- the talus. ficial deltoid ligaments6,9)(Figure2). This eversion stress test functions similarly to the lateral talar tilt test which a lateral distracting force is Indication for Deltoid used in patients with potential lateral applied to the fibula and the syndes- Ligament Repair ligament instability. Corresponding mosis is evaluated for dynamic wid- Even among those advocating deltoid to talar tilt with eversion stress, one ening on the mortise view.25,26 If ligament repair, it remains contro- also observes increases in the dis- the syndesmosis widens on Cotton versial in which patients deltoid tances between the tip of the medial test, the syndesmosis should be re- repair should be performed. One malleolus and the distal-medial radio- duced and transsyndesmotic fixation argument is that deltoid repair should graphic features of the talus. $7° should be placed. For many sur- be performed in all patients with bi- of talar tilt is used as the cutoff to geons, the operation is considered malleolar equivalent ankle fractures. declare a positive intraoperative ever- complete at this point; however, for The rationale is that if the deltoid was sion stress test. This value was arrived others, the final step in the procedure incompetent enough to consider the at as follows: All patients were stressed consists of evaluation for deltoid fracture unstable, the deltoid should intraoperatively; the deltoid was re- incompetence and/or potential per- be repaired to restore the medial paired only on patients for whom it formance of deltoid ligament repair. tether and optimize tibiotalar kine- was felt that “meaningful” tilt had

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Table 1 Published Techniques for Deltoid Repair in the Setting of Ankle Fracturea Authors Year of Publication Technique Summary

Lack et al11 2012 A suture anchor is placed in the talus to secure suture running up within the intercollicular groove to a screw in the distal-medial tibial metaphysis, creating an anchor-to-post reinforcement of the subsequent repair. The sutures are then continued from the tibial screw down to the superficial and deep deltoid fibers in a fan-like fashion. Alternatively, if the deep ligament is avulsed from its insertion on the talus, two sutures from the talar suture anchor are used to repair the deep ligament to the talus; all four sutures (including the two from the knot on the deep ligament) are then brought up within the intercollicular groove to a distal-medial tibia screw to create a similar anchor-to-post reinforcement. Yu et al29 2015 One or two suture anchors in the medial malleolus are used to reattach the superficial deltoid fibers to their anatomic origin. If the deep ligament is avulsed from its insertion on the talus, two anchors are placed in the medial aspect of the talus and attached to the deep deltoid ligament. Luckino and Hardy30 2015 One suture anchor is placed in the medial talus, and the associated suture is run up within the medial gutter and from deep to superficial through an oblique drill hole in the medial malleolus. The sutures are secured to a suture button on the superficial aspect of the medial malleolus, creating an anchor-to-button reinforcement against talar tilt. No specific suture repair of the deltoid ligament itself was described. Hsu et al27 2015 One or two suture anchors are placed in the medial malleolus and used to reattach the superficial deltoid fibers to their anatomic origin. Woo et al12 2017 One or two suture anchors are placed on the medial malleolus nearest to the rupture site. If the superficial and deep ligaments are both avulsed from the medial malleolus, an anterior suture anchor is placed for the superficial deltoid and a posterior suture anchor is placed for the deep deltoid. If the deep deltoid is avulsed from the talus, one or two suture anchors are placed into the medial aspect of the talus and used to reattach the deep deltoid.

a The studies by Stromsoe et al31 and Baird and Jackson19 are not included in this table because the authors did not describe their technique for deltoid repair. occurred. The handful of cases for lation does not occur. Fibular and All recent descriptions have in com- which intraoperative stress films were syndesmotic fixation appear not to mon the anchoring of suture to the available postoperatively were retro- allow for widening medially unless the distal-medial tibia with anatomic spectively reviewed. It was found that syndesmosis or fibula was malreduced repair of the deltoid fibers to the the cutoff for fixing the deltoid had or fixation was inadequate. However, medial malleolus. The authors vary in generally been about 7°; hence, this meaningful talar tilt, nevertheless, oc- the location of their skin incision, was adopted as the threshold. Little curs in about half of these patients. In whether they incorporate the superfi- work has been done in the literature patients with positive intraoperative cial versus deep deltoid fibers, how to establish a threshold value for stress radiographs, deltoid repair is they address avulsion from the cal- such a measurement; establishing indicated and performed. caneus, the number and position of this threshold should be an area for suture anchors, and the inclusion of future research. Widespread adop- anchor-to-post or anchor-to-button tion of any specific threshold should Technique for Deltoid Repair reinforcement. not be encouraged until studies Techniques for deltoid ligament repair Deltoidrepairisperformedas have born such a threshold out. in ankle fracture have been described follows. A 5-cm curvilinear incision Of note, after anatomic reduction of by several different groups (Table 1), is made midline over the medial the fibula and syndesmosis (if neces- although the techniques have not been malleolus, and the corresponding sary), meaningful lateral talar trans- compared with each other.11,12,27,29,30 skin flaps are mobilized to facilitate

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Figure 3 and a scalpel is used to elevate 1 cm of tissue proximally. A drill hole of appropriate size is created in the medial malleolus for placement of the desired suture anchor(s) (Figure 3, A). One or two suture anchors are placed for fixation of two or four sets of braided nonabsorbable suture (Figure 3, B). Once the anchor(s) is secured within bone, the capsule, deep deltoid, and superficial deltoid are imbricated and reduced to the medial malleolus in a “vest-over-pants” technique (Figure 3, C and D). Suture is used to directly repair the capsular disruption as well. Theankleisthengentlystressedin external rotation and eversion to confirm adequate stability. Although much less common, it is also worth discussing distal avulsion of the deep deltoid from the talus. In these circumstances, it is recommended to use the technique described by Yu et al29 for repair. In this technique, the exposure is extended distally using the same interval, but taking increased care not to injure the posterior tibial tendon, posterior tibial artery, and tibial nerve. Two anchors are placed on the medial aspect of the talus at the Photographs showing the deltoid ligament repair technique. A, The distal tip of sites of insertion of the deep anterior the medial malleolus is identified (arrow), and a scalpel is used to elevate 1 cm of and deep posterior tibiotalar ligaments tissue proximally. A drill hole of appropriate size is created in the medial (Figure 1, B). These anchors are malleolus for placement of the desired suture anchor(s). B, One or two suture anchors are placed for fixation of two or four sets of braided nonabsorbable sutured to the deep anterior and deep suture. C, Once the anchor is secured within bone, the capsule, deep deltoid, posterior tibiotalar ligaments, respec- and superficial deltoid (arrow head) are imbricated and reduced to the medial tively. Depending on the location of “ ” malleolus in a vest-over-pants technique. D, The defect in the deltoid ligament rupture of the superficial deltoid, that is obliterated, and the deltoid tissue is in mild tension with the ankle in neutral after repair. structure is repaired by either direct suture repair (if midsubstance) or a single suture anchor into the fibula visualization. At this point, hori- wire may be used (traditional Pridie (if a fibular avulsion). zontal rents in the superficial deltoid drilling), a dedicated microfracture ligament, joint capsule, and/or deep awl is an alternative (more current Outcomes deltoid ligament can often be visu- technique). The advantage is of the alized. The posterior tibial tendon is awl technique is that the small diam- Studies Suggesting identified and retracted posteriorly eter wire may heat the bone, which and inferiorly. The talus and medial will not occur with the microfracture Adequate Results Without tibia are often visible through the awl. Deltoid Repair rent and are inspected for traumatic In cases of deltoid avulsion from A number of retrospective studies osteochondral lesions. If sizable le- the medial malleolus (most common), (published mostly during the 1980s) sions are identified, they are treated attention is turned to preparing the introduced the idea that ORIF of bi- with microfracture using a Kirschner medial malleolus for repair. The distal malleolar equivalent ankle fractures wire. Of note, although a Kirschner tip of the medial malleolus is identified, without deltoid repair has acceptable

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Table 2 Studies Directly Comparing Deltoid Repair to No Deltoid Repair Number Repaired/ Mean Level of Not Follow-up Authors Year Evidence Repaired (mo) Main Result Conclusion Limitations

Baird and 1987 IV (case series, 3/21 36 90% of patients in Exploration of the Only three Jackson19 included the no repair group medial side of the patients in patients with had good or ankle and repair of deltoid repair and without excellent results. the deltoid group; no deltoid repair Patients in the ligament are not statistical but did not repair group necessary unless comparison; statistically reportedly did lateral malleolar no compare not do as well, but reduction fails to postoperative groups) the sample size close the medial stress testing. reportedly was clear space. not sufficient to statistically compare the nonrepaired and repaired groups. Stromsoe 1995 II (lesser quality 25/25 17 No difference Deltoid repair is No power et al31 randomized between the two unnecessary analysis; no controlled trial) groups in terms of assuming that the postoperative working ability, talus is reduced to stress testing; sports activities, the medial no subjective pain, swelling, malleolus and the assessment and overall anatomy of the of medial movement. fibula is restored. instability. Longer surgical time was reported for the deltoid repair cohort. Maynou 1997 III (retrospective 18/17 56 Subjective and Repair of the deltoid No power et al36 comparative objective ligament is analysis. study) assessments did unnecessary if not differ between fibular reduction the groups. Medial reconstitutes the instability (defined mortise. using a system of Exploration of the static and stress medial side is radiographs at indicated only final follow-up) when fibular was observed in reduction fails to four patients (ie, close the medial two in the repair clear space. group and two in the nonrepair group). Radiographically, one posttraumatic osteoarthritis developed in the nonrepair group and none in the repair group. (continued)

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Table 2 (continued) Studies Directly Comparing Deltoid Repair to No Deltoid Repair Number Repaired/ Mean Level of Not Follow-up Authors Year Evidence Repaired (mo) Main Result Conclusion Limitations

Woo et al12 2018 III (retrospective 41/37 17 Final follow-up Radiographic Clinical comparative medial clear space medial stability is significance study) on gravity stress improved with of medial examination was deltoid ligament clear space smaller in patients repair. No clinical widening on managed with benefit is realized postoperative deltoid repair, for those patients stress view is although clinical without uncertain. outcomes were syndesmotic similar. However, injury; however, when restricted for patients only to patients who requiring also underwent syndesmotic syndesmotic repair, repair, medial clear supplementing space was smaller, with deltoid repair and clinical results in outcomes were improvements in superior in the patient-reported deltoid repair outcomes. Hence, group. deltoid repair may be beneficial in patients with concurrent syndesmotic injury. long-term results.32-35 The theory ration of the mortise at the time of observed in two patients in each behind these studies is that by re- surgical treatment. Because all but group. Radiographically, one patient approximating the deltoid tissue one of the osteoarthritic patients was developed posttraumatic osteo- through anatomic reconstitution of asymptomatic at final follow-up, the arthritis—this was in the nonrepair the mortise (through fibular and authors concluded that there is no group. On the basis of these findings, syndesmotic ORIF), the deltoid need to explore or repair a ruptured the authors concluded that they could should have the opportunity to scar deltoid in an ankle that has been not support deltoid ligament repair in in and heal into a functional liga- anatomically reduced. cases in which fibular reduction and ment without direct repair. In a good Later studies suggesting adequate fixation achieves an anatomic recon- example of one of these early studies, results without deltoid repair were stitution of the mortise. Zeegers and van der Werken retro- improved in design in that they were The first and only randomized study spectively studied 28 lateral malleo- more commonly comparative stud- that analyzed the utility of deltoid lar fractures that were associated ies19,31,36 (Table 2). For example, repair in ankle fractures was conducted with ruptures of the deltoid ligament Maynou et al36 retrospectively in 1995 by Stromsoe et al.31 These that all received lateral malleolar studied 35 patients with bimalleolar authors randomized 50 patients with ORIF without exploration or repair equivalent ankle fractures whose Weber B and C fractures and a rup- of the deltoid ligament. After an surgical treatment did include (n = tured deltoid ligament to receive ORIF average of 18 months, no patient had 18) or did not include (n = 17) del- either with (n = 25) or without (n = 25) medial laxity either clinically or on toid repair. Subjective and objective repair of the deltoid. At mean 17- eversion stress testing. However, assessments did not differ between month follow-up, the authors found early signs of osteoarthritis were seen the groups. Medial instability (defined no difference in terms of working in seven patients, five of whom were using a system of static and stress ability, sports activities, pain, swelling, noted to have had anatomic resto- radiographs at final follow-up) was and movement. The only difference

8 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Simon Lee, MD, et al they reported was longer surgical time firmed deltoid rupture underwent bimalleolar equivalent ankle frac- for the deltoid repair cohort. The au- fibular ORIF, syndesmotic fixation, tures, they found that repairing the thors concluded that deltoid repair and open deltoid repair. Eighty-six deltoid ligament at the time of lateral was unnecessary assuming that the percent of players returned to play, malleolus fixation has outcomes that talus was reduced to the medial mal- and no players reported of medial are comparable to lateral malleolus leolus and the anatomy of the fibula pain or instability at final follow-up. fixation plus syndesmotic fixation. was restored. However, the reader Finally, Woo et al12 retrospec- They state that the former avoids the should note that no power analysis tively evaluated 78 consecutive ca- costs and risks of any subsequent was reported and no assessment of ses of ORIF of bimalleolar equivalent operation for removal of a syn- medial instability (either subjective or anklefractureovera15-yearperiod. desmotic implant, as well as the risk objective) was performed. The authors changed their clinical of syndesmotic malreduction. Pro- practice half way through this period; spective studies are needed to con- patients in the early group (2001– firm these results. Studies Suggesting Superior 2008, n = 37) were managed without Outcomes With Deltoid deltoid repair, whereas patients in the Repair late group (2009–2016, n = 41) were Future Work Although most patients in the studies managed with deltoid repair. Inter- The field of orthopaedic foot and ankle mentioned earlier did well without estingly, the authors found that the surgery is lacking a well-powered, rig- deltoid repair, there have been pub- gravity stress view medial clear space orous, randomized, controlled trial lished and anecdotal reports of sub- at final follow-up was significantly evaluating the utility of deltoid repair populations of patients that had less smaller in patients managed with in bimalleolar equivalent ankle frac- than optimal outcomes.19,31-37 These deltoid repair (3.2 6 0.5 versus 3.7 6 tures. This review uncovered only included reports of medial instabil- 0.6 mm; P , 0.001). Clinical out- one randomized study attempting ity, persistent medial gutter pain, and comes were similar between the to address this subject. That study loss of function with early develop- groups. The authors conducted a included only 25 patients in each ment of posttraumatic arthritis. The post hoc subgroup analysis in which group, lacked a description of statis- concern is that these outcomes were they included only patients who also tical power, had minimum follow-up related to failure of the deltoid liga- had syndesmotic injury detected in- of only 5 months, and lacked any ment to heal in an anatomic position. traoperatively and consequently had form of assessment of medial insta- It is in this setting that a number of undergone syndesmotic fixation (27 bility. The ideal study would be orthopaedic foot and ankle surgeons in the deltoid repair group and 17 in powered to detect a difference both in have been performing primary del- the no deltoid repair group). In this patient-reported outcomes and in toid repair in subsets of patients with subgroup analysis, clinical outcomes medial clear space widening on stress bimalleolar equivalent ankle fractures. including the AOFAS score, VAS views, would have follow-up of at Several published studies support pain score, and medial-sided pain least 2 years (to evaluate for early deltoid repair. Yu et al29 studied 106 were all superior in the deltoid re- development of posttraumatic arthri- patients with distal fibular fractures pair group. These results suggest that tis), and would carefully exclude or associated with deltoid ligament rup- deltoid repair may be clinically stratify on the basis of syndesmotic tures that underwent deltoid repair beneficial in patients who not only injury to minimize the impact of con- as part of the primary ORIF. At an have deltoid rupture but also have founding. Such a study would enable a average of 27 months, clinical out- syndesmotic injury for which they more conclusive answer to this set of comes scores were acceptable, post- are undergoing syndesmotic repair. controversial questions. operative stress radiographs were all That is, the two repairs may work in negative, and no cases of posttrau- concert to reinforce each other and matic arthritis were seen. facilitate healing in these patients. Summary Hsu et al27 report their experience repairing the deltoid in 14 National Manual or gravity external rotation Football League players with bi- A Note on the Syndesmosis stress radiography is the benchmark malleolar equivalent ankle fractures. In one recent study, a group of au- to differentiate isolated lateral mal- All patients underwent ankle arthros- thors argued that if the deltoid liga- leolar fractures from bimalleolar copy and débridement as a first step to ment is repaired, syndesmotic repair equivalent fractures of the ankle. If confirm deltoid ligament rupture. may not be necessary.38 In their ret- the medial clear space widens on After arthroscopy, patients with con- rospective study of 27 patients with stress radiography, the patient is

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Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Deltoid Ligament Rupture in Ankle Fracture diagnosed with rupture of the deltoid 6. Earll M, Wayne J, Brodrick C, Vokshoor A, 20. Nwosu K, Schneiderman BA, Shymon SJ, Adelaar R: Contribution of the deltoid Harris T: A medial malleolar “fleck sign” ligament, and surgical intervention is ligament to ankle joint contact may predict ankle instability in ligamentous recommended. Surgical treatment characteristics: A cadaver study. Foot Ankle supination external rotation ankle consists of fibular ORIF (with syn- Int 1996;17:317-324. fractures. Foot Ankle Spec 2017;11: 246-251. desmotic fixation if the syndesmosis 7. Rasmussen O, Kromann-Andersen C, Boe widens on the Cotton test after fibu- S: Deltoid ligament: Functional analysis of 21. Park SS, Kubiak EN, Egol KA, Kummer F, the medial collateral ligamentous apparatus Koval KJ: Stress radiographs after ankle lar ORIF) with or without deltoid of the ankle joint. Acta Orthop Scand 1983; fracture: The effect of ankle position and repair depending on surgeon prefer- 54:36-44. deltoid ligament status on medial clear space measurements. J Orthop Trauma ence and intraoperative findings. 8. Clarke HJ, Michelson JD, Cox QG, Jinnah 2006;20:11-18. When performed, deltoid repair is RH: Tibio-talar stability in bimalleolar ankle fractures: A dynamic in vitro contact 22. Michelson JD, Varner KE, Checcone M: undertaken after fibular ORIF (and area study. Foot Ankle 1991;11:222-227. Diagnosing deltoid injury in ankle after syndesmotic repair, if per- fractures: The gravity stress view. Clin 9. Harper MC: An anatomic study of the short Orthop Relat Res 2001;178-182. formed). Deltoid repair most com- oblique fracture of the distal fibula and monly involves placement of a suture ankle stability. Foot Ankle 1983;4:23-29. 23. Nortunen S, Lepojarvi S, Savola O, et al: anchor (or anchors) in the medial Stability assessment of the ankle mortise in 10. Hintermann B, Knupp M, Pagenstert GI: supination-external rotation-type ankle malleolus and imbrication of the deep Deltoid ligament injuries: Diagnosis and fractures: Lack of additional diagnostic and superficial ligaments to the mal- management. Foot Ankle Clin 2006;11: value of MRI. J Bone Joint Surg Am 2014; 625-637. 96:1855-1862. leolar anchor. The only randomized study to evaluate the utility of deltoid 11. Lack W, Phisitkul P, Femino JE: Anatomic 24. Warner SJ, Garner MR, Hinds RM, Helfet deltoid ligament repair with anchor-to-post DL, Lorich DG: Correlation between the ligament repair in ankle fracture suture reinforcement: Technique tip. Iowa lauge-hansen classification and ligament could not support the procedure, but Orthop J 2012;32:227-230. injuries in ankle fractures. J Orthop Trauma 2015;29:574-578. this study was severely limited. The 12. Woo SH, Bae SY, Chung HJ: Short-term field would benefit from an appro- results of a ruptured deltoid ligament repair 25. Cotton FJ: Fractures and Joint during an acute ankle fracture fixation. priately powered, rigorous, ran- Dislocations. Philadelphia, PA, WB Foot Ankle Int 2018;39:35-45. Saunders, 1910, pp 549. domized, controlled trial of deltoid 13. Michelsen JD, Ahn UM, Helgemo SL: 26. Mizel MS: Technique tip: A revised method ligament repair with both patient- Motion of the ankle in a simulated of the Cotton test for intra-operative reported outcome and stress radio- supination-external rotation fracture evaluation of syndesmotic injuries. Foot model. J Bone Joint Surg Am 1996;78: Ankle Int 2003;24:86-87. graphic outcome evaluation. 1024-1031. 27. Hsu AR, Lareau CR, Anderson RB: Repair 14. Ramsey PL, Hamilton W: Changes in of acute superficial deltoid complex References tibiotalar area of contact caused by lateral avulsion during ankle fracture fixation in talar shift. J Bone Joint Surg Am 1976;58: national Football League players. Foot 356-357. Ankle Int 2015;36:1272-1278. References printed in bold type are 15. Sanders DW, Tieszer C, Corbett B: 28. Wu K, Lin J, Huang J, Wang Q: Evaluation those published within the past 5 years. Operative versus nonoperative treatment of of transsyndesmotic fixation and primary unstable lateral malleolar fractures: A deltoid ligament repair in ankle fractures 1. Lauge-Hansen N: Fractures of the ankle: II. randomized multicenter trial. J Orthop with suspected combined deltoid ligament Combined experimental-surgical and Trauma 2012;26:129-134. injury. J Foot Ankle Surg 2018;57:694-700. experimental-roentgenologic investigations. Arch Surg 1950;60: 16. van den Bekerom MP, Mutsaerts EL, van 29. Yu GR, Zhang MZ, Aiyer A, et al: Repair 957-985. Dijk CN: Evaluation of the integrity of the of the acute deltoid ligament complex deltoid ligament in supination external rupture associated with ankle fractures: A 2. Lauge-Hansen N: Ligamentous ankle rotation ankle fractures: A systematic multicenter clinical study. J Foot Ankle Surg fractures; diagnosis and treatment. Acta review of the literature. Arch Orthop 2015;54:198-202. Chir Scand 1949;97:544-550. Trauma Surg 2009;129:227-235. 30. Luckino FA III, Hardy MA: Use of a 3. Sarrafian SK, Kelikian AS: Osteology, in 17. McConnell T, Creevy W, Tornetta P III: flexible implant and bioabsorbable anchor ’ Sarrafian SK, ed: Sarrafian sAnatomyof Stress examination of supination external for deltoid rupture repair in bimalleolar the Foot and Ankle. Philadelphia, PA, rotation-type fibular fractures. J Bone Joint equivalent Weber B ankle fractures. J Foot Wolters Kluwer/Lippincott Williams & Surg Am 2004;86-A:2171-2178. Ankle Surg 2015;54:513-516. Wilkins, 2011, pp 40-119. 18. DeAngelis NA, Eskander MS, French BG: 31. Stromsoe K, Hoqevold HE, Skjeldal S, Alho 4. Sarrafian SK, Kelikian AS: Syndesmology, Does medial tenderness predict deep deltoid A: The repair of a ruptured deltoid ligament ’ in Sarrafian SK, ed: Sarrafian sAnatomy ligament incompetence in supination- is not necessary in ankle fractures. J Bone of the Foot and Ankle. Philadelphia, PA, external rotation type ankle fractures? J Joint Surg Br 1995;77:920-921. Wolters Kluwer/Lippincott Williams & Orthop Trauma 2007;21:244-247. Wilkins, 2011, pp 163-222. 32. Harper MC: The deltoid ligament: An 19. Baird RA, Jackson ST: Fractures of the evaluation of need for surgical repair. Clin 5. Campbell KJ, Michalski MP, Wilson KJ, distal part of the fibula with associated Orthop Relat Res 1988;156-168. et al: The ligament anatomy of the deltoid disruption of the deltoid ligament: complex of the ankle: A qualitative and Treatment without repair of the deltoid 33. de Souza LJ, Gustilo RB, Meyer TJ: quantitative anatomical study. J Bone Joint ligament. J Bone Joint Surg Am 1987;69: Resultsofoperativetreatmentofdisplaced Surg Am 2014;96:e62. 1346-1352. external rotation-abduction fractures of

10 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Simon Lee, MD, et al

the ankle. J Bone Joint Surg Am 1985;67: fractures: Should the medial collateral 37. Bluman EM: Deltoid ligament injuries 1066-1074. ligament be sutured or not? J Foot Ankle in ankle fractures: Should I leave it Surg 1999;38:24-29. or fix it? Foot Ankle Int 2012;33: 34. Zeegers AV, van der Werken C: Rupture 236-238. of the deltoid ligament in ankle fractures: 36. Maynou C, Lesage P, Mestdagh H, Should it be repaired? Injury 1989;20:39-41. Butruille Y: Is surgical treatment of 38. Jones CR, Nunley JA II: Deltoid deltoid ligament rupture necessary in ligament repair versus syndesmotic 35. Tourne Y, Charbel A, Picard F, ankle fractures? [in French]. Rev Chir fixation in bimalleolar equivalent ankle Montbarbon E, Saragaglia D: Surgical Orthop Reparatrice Appar Mot 1997;83: fractures. J Orthop Trauma 2015;29: treatment of bi- and trimalleolar ankle 652-657. 245-249.

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