Original Article Efficacy of Deltoid Ligament Reconstruction on the Curative Effect, Complication and Long-Term Prognosis in A

Int J Clin Exp Med 2017;10(9):13778-13783 www.ijcem.com /ISSN:1940-5901/IJCEM0060421

Original Article Efficacy of deltoid ligament reconstruction on the curative effect, complication and long-term prognosis in ankle fracture-dislocation with deltoid ligament injury

Guangxue Gu, Jiwen Yu, Yongfeng Huo, Gang Xu, Zhaoyang Yin, Jian Yu, Luxin Sheng, Leiming Li

Department of Traumatic Orthopedics, The First People’s Hospital of Lianyungang, Lianyungang, Jiangsu Province, China Received June 28, 2017; Accepted August 2, 2017; Epub September 15, 2017; Published September 30, 2017

Abstract: Objective: To investigate the clinical efficacy, complications and long-term prognosis of deltoid ligament reconstruction in the treatment of ankle fracture-dislocation with deltoid ligament injury. Methods: Forty enrolled patients with ankle fracture and deltoid ligament injury were diagnosed and treated in our hospital from May 2010 to June 2014. They were divided into control group and treatment group with 20 cases in each according to the random number table method. The patients in the control group were only treated with fracture open reduction and internal fixation, while the patients in the treatment group were treated with deltoid ligament reconstruction as well as fracture open reduction and internal fixation. After the surgery, all the patients were regularly followed up for 12 to 18 months. Meanwhile, the degree of pain (VAS score) and the incidences of complications were evaluated and recorded 3 months after the operation. At the final follow-up, the Ankle Hindfoot Scale of American Orthopaedic Foot and Ankle Society (AOFAS) was applied to evaluate the ankle recovery of patients. Results: There was no significant differences in the general information between the two groups (P>0.05). All the patients who underwent the surgery under the combined spinal-epidural anesthesia, were followed up for 12-18 months and healed with similarly duration (P>0.05). However, even though the operation time and bleeding loss of the treatment group were longer and greater than those of the control group (P=0.026, P=0.032), its hospital stay was significantly shorter than that of the control group (P=0.041). Moreover, the VAS scores after treatment were evidently decreased in both groups compared with that before the surgery (P=0.012, P=0.020), which was also apparently lower in the treatment group than that in the control group (P=0.025). Additionally, the medial clear space (MCS) of the two groups 1-year after the surgery was significantly lower than that before the surgery (P=0.010, P=0.020), which in the treatment group was obviously smaller than that in the control group (P=0.011). At the final follow-up, the AOFAS Ankle Hindfoot Scale showed that the excellent and good rate (90%) in the treatment group was considerably higher than that in the control group (60%) with significant difference (P=0.001), while the difference in the incidences of complications three months after the operation showed no statistical significance (P>0.05). Conclusion: The deltoid ligament reconstruction can promote the recovery of ankle function and alleviate pain with remarkable curative effect in the treatment of ankle fracture-dislocation with deltoid ligament injury.

Keywords: ankle fracture, deltoid ligament injury, ligament reconstruction, internal fixation, therapeutic effect

Introduction anterior tibiotalar ligament and posterior tibiotalar ligament [1, 2]. The main function of the Ankle fracture-dislocation is one of the com- deltoid ligament is to control the internal and mon injuries in orthopedics. The deltoid liga- external rotation of ankle with anterior talofibu- ment, which is located on the medial side of the lar ligament, especially, compared with the ankle joint, is often associated with ligament shallow layer, the deep layer is more significant rupture in the ankle fracture. In addition, it can in maintaining the stability of the ankle joint [3, divide into shallow and deep layers, while the 4]. In the current study, if the fracture displace- former includes the tibiocalcanean ligament, ment is over 4 mm, it should consider examin- tibionavicular ligament and the shallow layer of ing the condition of deltoid ligament. Additional- posterior tibiotalar ligament; the latter includes ly, MRI can be applied as an auxiliary diagnosis Efficacy of deltoid ligament reconstruction in ankle fracture-dislocation to determine the location and degree of injury of limb functional rehabilitation; the patients [5]. In patients with acute injury, deltoid liga- might not be scheduled to review or could not ment injury is usually accompanied by ankle take rehabilitation training on request. fracture ortibiofibular syndesmosis injury, while deltoid ligament injury alone is very rare. Grouping and surgical method Furthermore, Halai et al. found that more than 40% of patients suffered ankle fractures were According to the random number table method, diagnosed deltoid ligament injury via arthros- the patients were divided into two groups: treat- copic examination and the injury would cause ment group and control group with 20 patients permanent pain or deformity of pronator mus- in each. The patients in the control group were cle, if the lesion was failed to treat [6]. routinely taken ankle lateral incision and the restoration of fracture and other injuries, but In the currently published study, there is still a the deltoid ligament was not repaired, mean- great controversy over the need for repair of while, the injured ankle was fixed in plaster in ligaments in the treatment of ankle joint with the position of mild varus-internal rotation-dor- deltoid ligament injury [7, 8]. In our previous sal extension after the surgery. In the treatment clinical treatment, we found that some patients, group, besides the operations in the control whose deltoid ligament was not repaired, tend- group, patients also received deltoid ligament ed to appear pain in the shallow area of medial reconstruction. Briefly, a lateral incision was malleolus which affected the ankle function. performed on fibular. The lateral malleolus frac- Therefore, this article discusses the clinical ture was repaired and fixed, then, an arc inci- effects, complications and long-term prognosis sion was made on the medial malleolus to of deltoid ligament reconstruction in ankle frac- expose the deltoid ligament and its broken ture-dislocation with deltoid ligament injury. ends. Subsequently, MCS was cleaned and anchors were penetrated into the broken ends Methods followed by suturing and knotting tightly to ensure the stability of the ankle. Patients Follow-up This study was approved by the Ethics Com- mittee of our hospital and all patients had All the patients were followed up for at least 12 already provided the signed informed consent. months, once per month. The changes of pain, Forty patients with ipsilateral ankle fracture incision healing condition and the occurrence complicated with deltoid ligament rupture and of complications including tissue infection, ner- treated in our hospital from May 2010 to June ve injury, motor dysfunction and fixation failure 2014 were recruited. were observed and recorded 3 months after operation. In addition, according to the visual Inclusion criteria: The patients who met the analogue scale (VAS) score, the degree of pain diagnostic criteria of deltoid ligament rupture of patients was expressed with numbers from 0 complicated with ipsilateral ankle fracture, to 10: 0 represents painless while 10 means especially for acute injury; the patients whose the most pain. The patients would select a age was between 20 and 60 years old without number from the 11 figures on behalf of their gender limitation; patients whose preoperative pain degree based on their own condition. The stress X-ray of ankle joint showed a medial MCS was reviewed and recorded via anteropos- clear space (MCS) over 5 mm and their MRI terior stress X-ray 1 year postoperatively. At the examination confirmed that the rupture of deep final follow-up, Ankle Hindfoot Scale of American and shallow deltoid ligaments was complete. Orthopaedic Foot and Ankle Society (AOFAS) was adopted for the assessment of the postop- Exclusion criteria: The patients accompanied erative recovery of ankle: excellent, 90-100 with fracture or injuries in other parts of body, points; good, 75-89 points; fair, 50-74 points; or combined with the posterior malleolar frac- poor, less than 50 points. ture involving over 25% of the articular surface; the patients had comorbidities such as severe Observe indicators cardiovascular diseases that could not tolerate surgery; the patients who complicated with vas- The main outcome indicators: The change of cular injury, nerve injury, or unnormal progress AOFAS Ankle Hindfoot Scale score before the

13779 Int J Clin Exp Med 2017;10(9):13778-13783 Efficacy of deltoid ligament reconstruction in ankle fracture-dislocation

Table 1. Comparison of the General information between two groups Secondary outcome indi- _ ( x±s/n) cators: fracture healing Control Treatment P time, other surgical relat- Groups χ2/t group group value ed indicators and the Cases 20 20 incidences of complications. Gender 1 0.752 Male 11 10 Statistical analysis Female 9 10 Age (years) 37.53±5.41 40.57±8.72 0.234 0.524 SPSS13.0 statistical soft- Follow-up duration (months) 13.28±5.96 12.83±5.94 0.265 0.753 ware was adopted for Complicating diseases 3 4 0 1 the data analysis. All the Injured region 1.145 0.227 quantitative data were expressed as mean ± Left feet 12 11 standard deviation, and Right feet 8 9 the differences between Open injury 2 3 0.000 1 two independent sam- Time from injury to treatment (days) 16.2±5.6 15.8±4.9 0.265 0.753 ples were compared with t test. Categorical data were expressed as per- Table 2. Comparison of the operation parameters between two groups _ centage and compared ( x±s) by using chi-square test. Groups Control group Treatment group P value P<0.05 indicated that the Operation time (min) 88.5±6.8 158.5±18.7 0.026 difference was statisti- Blood loss (ml) 276.7±58.7 385.5±95.3 0.032 cally significant. Length of stay (day) 17.6±6.2 10.4±4.1 0.041 Results Fracture concrescence time (week) 8.13±0.42 7.64±0.28 0.075 General information of Table 3. Comparison of VAS score before and after the surgery be- patients tween the two groups The differences between Groups Control group Treatment group t P value the two groups in terms Cases 20 20 of gender, age, injured Pre-operation 7.19±0.44 7.22±0.67 0.069 0.12 region, the time of injury, Three months after operation 2.98±0.45 1.14±0.34 6.873 0.025 and whether combining t 35.312 25.478 with open injury or oth- P value 0.003 0.001 ers diseases that would affect the recovery or not showed insignificance (P Table 4. Comparison of medial clear space before and after the surgery >0.05). In addition, all between two groups the patients were follow- Groups Control group Treatment group t P value ed up for 12 to 18 months Cases 20 20 of which the duration was also not statistically sig- Medial clear space (mm) nificant (P>0.05). See Pre-operation 5.6±0.6 5.7±0.8 1.16 0.21 Table 1. Post-operation 2.8±0.8 2.1±1.4 5.41 0.011 t 11.48 4.731 Comparison of surgical P value 0.01 0.02 related indicators between two groups treatment and at the final follow-up; the change All the patients were received combined spinal of VAS score before the surgery and 3 months and epidural anesthesia and their fractures all postoperatively. recovered with similar duration (P<0.05). The

13780 Int J Clin Exp Med 2017;10(9):13778-13783 Efficacy of deltoid ligament reconstruction in ankle fracture-dislocation

Table 5. Comparison of AOFAS score between two groups than that in the control group (65%) Cases Excellent and with statistical significance (P= Groups Excellent Good Fair Poor (n) good rate 0.001). See Table 5. Control group 20 10 8 1 1 90% Comparison of postoperative com- Treatment group 20 8 4 5 3 60% plications between two groups P value 0.001 Three months after the surgery, the incidences of complications in the Table 6. Comparison of postoperative complications between two were similar without statistical two groups significance (All P>0.05). See Table Pulmonary Incision Incision Groups Cases Swelling 6. infection infection bleeding Control group 20 5 3 2 1 Discussion Treatment group 20 1 1 0 1 χ2 1.765 0.278 0.526 0 Deltoid ligament located in the P value 0.184 0.598 0.468 1 medial ankle and its main function is to limit the anteroposterior trans- lation of the talus which plays a key operation time and bleeding loss of the treat- role in the maintenance of stability of the ankle ment group were longer and greater than those and its medial structure. Meanwhile, the del- of the control group (P=0.026, P=0.032), how- toid ligament had greater effects on the plantar ever its hospital stay was significantly shorter flexion than dorsiflexion as both the lateral and than the control group (P=0.041). See Table 2. medial ligaments work on keeping the inside and outside balance of joints in the glenoid Comparison of postoperative pain before and fossa [9]. The main stress loaded by the ankle three months after the surgery between two joint is weight-bearing and twist, so the stability groups of ankle joint is crucial for the maintenance of its weight-bearing and motor function. Tian et The VAS score in the control group and the al. have confirmed that separating the shallow treatment group before and after the surgery layer of the deltoid ligament would change the were (7.19±0.44 vs 2.98±0.45 for control position of the tibiotalar ligament [10]. More- group) and (7.22±0.67 vs 1.14±0.34 for treat- over, deltoid ligament injury could result in ment group) respectively, which were signifi- oblique displacement of joints, thus lead to the cantly lower than those before operation (P= change of joint mechanics, causing joint stabil- 0.003, P=0.001). Meanwhile, the improvement ity decreased. in the treatment group was greater (P=0.025). See Table 3. In clinic, on the one hand, there are many patients who suffered deltoid ligament injury Comparison of MCS between two groups did not received ligament reconstruction, however, their ankle function is no obvious obsta- There was no difference in preoperative MCS cles. Therefore, some scholars argue that there between the two groups (P=0.21), however, is no need to repair the damaged deltoid liga- compared with pre-operation, the MCS at one ment [11]. On the other hand, McCollum et al. year after the operation was evidently decrea- also found that the patients without deltoid lig- sed in both control group (P=0.01) and treat- aments reconstruction in the surgery would ment group (P=0.02), which was much lower in suffer ligament laxity and chronic pain. Besides, the treatment group. See Table 4. result of some long-term follow-up studies also indicated that deltoid ligaments injured patients Comparison of AOFAS score between two without ligament reconstruction had a symp- groups tom of chronic pain [12-17]. Therefore, we sug- gest performing reconstruction of damaged At the final follow-up, results of AOFAS score deltoid ligament to patients. In addition, Van et showed that the rate of excellent and good in al. proposed several specific indications for del- treatment group (90%) was obviously higher toid ligament repair, including: 1) X-ray film of

13781 Int J Clin Exp Med 2017;10(9):13778-13783 Efficacy of deltoid ligament reconstruction in ankle fracture-dislocation ankle mortise showed the MCS was bigger The results of this study also proved that even than the contralateral clear space over 5 mm, though the deltoid ligaments reconstruction and the talus was lateral dislocation or sublux- would significantly increase the operation time ation; 2) after ankle fracture reduction and fixa- and the intraoperative blood loss, the hospital- tion, Valgus stress test showed that the medial ization time was reduced in a certain degree, ankle was instable; 3) after joint reduction and manifesting that deltoid ligaments reconstruc- fixation, MCS is still widened more than 1 mm, tion might be beneficial to the healing and prog- which may be caused by an embedded tissue nosis of ankle fracture-dislocation. such as fractured deltoid ligaments or other tis- sues [18]. However, as the sample size is relatively small, the follow-up time is short, and patient phy- The research of Henari et al. showed that it was sique and other factors may lead to biased easy to be missed diagnosis or misdiagnose for results, more studies with large sample volume most of the ankle fractures which combined are needed to validate the conclusions in this with deltoid ligament injury, thus leading to study in the future. ankle instability, ankle chronic pain and traumatic arthritis [19]. In this study, no patient In conclusion, this controlled study confirmed appears complications that affected the stabil- that deltoid ligaments reconstruction plays a ity of the ankle joint, possibly because the time positive role in the restoring of MCS, healing from the patients were injured to they received fracture, restoring impaired ankle function and treatment was short and they were treated in reducing chronic pain, so it is worth a popular- a timely manner. Similarly, Schuberth et al. ization and application in clinic. believe that the lateral malleolus fracture com- Disclosure of conflict of interest bined with deltoid ligament rupture should be considered as bimalleolar fracture, which None. should be surgical repaired [20]. In addition, Stufkens et al. and another study evaluated the Address correspondence to: Leiming Li, Department clinical therapeutic efficacy of suture anchor in of Traumatic Orthopedics, The First People’s Hos- ankle fractures combined with deltoid ligament pital of Lianyungang, No.182 Tongguan North Road, injury, and their results confirmed that the use Haizhou District, Lianyungang 222002, Jiangsu Pro- of suture anchor in the repair of deltoid liga- vince, China. Tel: +86-18961326321; E-mail: leim- ment injury can achieve better recovery of the [email protected] stability of the ankle [21, 22]. The results of our study are similar to those of the above studies. References Compared with the control group, the MCS in the treatment group at 1-year post-surgery was [1] Kelikian and Armen S. Sarrafian’s anatomy of the foot and ankle. Wolters Kluwer Health/Lip- significantly reduced (P<0.05) while the AOFAS pincott Williams and Wilkins 2011. Ankle Hindfoot Scale in the treatment group [2] Ventura A and Legnani C. Chronic Ankle Insta- was obviously increased (P<0.05), suggesting bility. Springer International Publishing; 2016. that performing deltoid ligaments reconstruc- [3] Watanabe K, Kitaoka HB, Berglund LJ, Zhao tion could improve the stability of ankle joint in KD, Kaufman KR and An KN. The role of ankle the treatment of ankle fracture combined with ligaments and articular geometry in stabilizing deltoid ligament injury. the ankle. Clin Biomech (Bristol, Avon) 2012; 27: 189-195. Three months after the surgery, the pain scores [4] Heim D, Schmidlin V and Ziviello O. Do type B of both the control group and the treatment malleolar fractures need a positioning screw? group were dramatically lower than that before Injury 2002; 33: 729-734. the surgery (all P<0.05), and the improvement [5] Crim J and Longenecker LG. MRI and surgical findings in deltoid ligament tears. AJR Am J of the pain condition was more evident in the Roentgenol 2015; 204: 63-69. treatment group, which indicated that the del- [6] Halai M, Jamal B, Rea P, Qureshi M and Pillai A. toid ligaments reconstruction could significant- Acute fractures of the pediatric foot and ankle. ly inhibit the postoperative chronic pain (P< World J Pediatr 2015; 11: 14-20. 0.05), thus improve the life quality of the [7] Kitaoka HB, Alexander IJ, Adelaar RS, Nunley patients. JA, Myerson MS and Sanders M. Clinical rating

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