Deltoid Ligament Injuries Associated with Ankle Fractures— Argument for Repair of the Deltoid Ligament Vinod K Panchbhavi

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DEBATE Deltoid Ligament Injuries Associated with Ankle Fractures— Argument for Repair of the Deltoid Ligament Vinod K Panchbhavi

Abstract Deltoid ligament ruptures are frequently associated with ankle fractures. Poor outcomes are associated with inadequate healing of the deltoid ligament. Repair of the deltoid ligament has potential to improve outcomes in a subset of patients with ankle fractures where medial ankle instability persists and medial ankle space remains wide even after the ankle fracture is stabilized. Keywords: Ankle fractures, Ankle injury, Deltoid ligament, Fibula fracture. Journal of Foot and Ankle Surgery (Asia Pacific) (2020): 10.5005/jp-journals-10040-1120

The deltoid ligament complex provides stability to the ankle joint. It resists translation of the talus within the ankle mortise especially Department of Orthopaedic Surgery and Rehabilitation, University of in the posterior and in the lateral directions. In addition, it controls Texas Medical Branch, Galveston, Texas, USA external and internal rotation.1 The superficial fibers of the deltoid Corresponding Author: Vinod K Panchbhavi, Department of Orthopaedic resist eversion of the hind foot, while the deep fibers of the deltoid Surgery and Rehabilitation, University of Texas Medical Branch, serve as the primary restraint to external rotation of the talus.2 Galveston, Texas, USA, Phone: +2147483647, e-mail: vkpanchb@utmb. It has been noted that the deltoid ligament ruptures are edu associated with ankle fractures in about 40% of ankle fractures How to cite this article: Panchbhavi VK. Deltoid Ligament Injuries on intraoperative arthroscopic examination. Such injuries have Associated with Ankle Fractures—Argument for Repair of the Deltoid been documented to be a source of persistent pain or a pronation Ligament. J Foot Ankle Surg (Asia Pacific) 2020;7(1):5–7. deformity.3 Source of support: Nil There are several previous studies that have reported Conflict of interest: None satisfactory results when the deltoid ligament rupture was not repaired along with open reduction and internal fixation of ankle On the other hand, operative reconstruction of the deltoid fractures. These studies however lacked objective measures and ligament complex using suture anchors resulted in good to additionally the outcomes reported were suboptimal in about 29% excellent results in most of the cases in a prospective study by 9 (10–29%). Further more details on severity of the residual pain and Hintermann et al. In the National Football League (NFL), players deformity were not provided.4–7 Another study documented that with high-energy unstable ankle fractures, the deltoid complex was over 60% patients showed tenderness over the deltoid ligament, found to be impinged in the medial gutter or retracted distally in and 38% patients showed medial instability.8 a study by Hsu et al. They reviewed their results in 14 NFL players

Figs 1A to C: (A) A Weber B ankle fracture; (B) Stabilized with a locking plate; (C) A loss of medial clear space on follow-up radiographs

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons. org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Deltoid Repair who underwent ankle fracture fixation with open deltoid complex repair. Operative intervention for all patients consisted of ankle arthroscopy and debridement, followed by fixation of the fibula with plate and screws, fixation of the syndesmosis with suture- endobutton devices, and repair of the deltoid complex with suture anchors. All NFL players were able to return to running and cutting maneuvers by 6 months after surgery. There were no significant differences in playing experience compared to before surgery and after surgery. About 86% of these elite class players successfully returned to play and participated in at least one full regular- season NFL game after surgery. There were no intraoperative or postoperative complications, and none of the players had clinical evidence of medial pain or instability at final follow-up. On final follow-up radiographs, the ankle mortise alignment was maintained.10 Woo et al. noted that when the deltoid ligament was not repaired, some patients complained of persistent pain and swelling around the medial malleolus over the deltoid ligament. These findings continued even after an anatomic healing of the ankle fracture. Additionally, there were symptoms of medial ankle instability, associated with feelings of the ankle giving way and findings of medial clear space widening on follow-up radiographs. These authors therefore changed their practice and started direct repair of the deltoid ligament complex after fixation of the ankle fracture. Then they subsequently compared their results in patients with and without deltoid ligament repair. The outcome measures included radiographic findings, the American Orthopedic Foot and Ankle Society ankle hind foot scores, visual analog scale scores, and the Foot Function Index. At an average of 17 months, the medial clear space (MCS) was significantly smaller when the deltoid ligament was repaired (p < 0.01). Clinical outcomes were similar between the two groups (p > 0.05). But in the subset who underwent syndesmotic fixation there was a significantly smaller final follow-up MCS, and all clinical outcomes were better in when deltoid ligament was repair (p < 0.05). The linear regression analysis showed that the final follow-up MCS had a significant influence on 11 clinical outcomes (p < 0.05). Zhao et al.12 reviewed 74 patients with Weber B and C ankle fractures and deltoid ligament injury (MCS > 6 mm). Twenty patients were treated with open reduction and internal fixation (ORIF) of lateral malleolus and deltoid repair was accomplished with suture anchors and bone sutures. Fifty-four patients were treated with ORIF only. The mean follow-up was 53.7 months (range, 14–97). Outcomes measured were preoperative, postoperative, and final follow-up MCS, and the AOFAS and VAS scores. The results did not show a difference between the two groups; however, when patients with Weber C fractures were considered, the deltoid ligament repair group showed better reduction in the MCS when compared to the nonrepair group (p = 0.03). More significantly, complications of malreduction (11/54) and failure and reoperation due to symptomatic malreduction were limited to the nonrepair group. No complications were reported in the deltoid repair group. The authors concluded that surgical repair of the DL is helpful in decreasing the postoperative MCS and the rate of malreduction, especially for the Weber C ankle fractures. A recent meta-analysis13 concluded that there is no clear indication for deltoid repair in setting of acute ankle fractures, but recent studies show that there are advantages of adding deltoid ligament repair in certain subset of patients, especially those with high fibular fractures (Weber C) or those with concomitant syndesmotic injury. With wall of the talus; on medial (C) B ankle anchor placement fracture for suture with a locking (B) A wide MCS after of the fibular fracture; fixation and a drill plate Weber A D: (A) to 2A Figs radiographs follow-up reduction of MCS on 6 months’ of anatomic Maintenance image; (D) reduction of the MCS on fluoroscopic

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Nonanatomic or suboptimal healing in the deltoid ligament is 6. Stromsoe K, Hoqevold HE, Skjeldal S, et al. The repair of a ruptured associated with poor outcomes, residual pain and tenderness over deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg medial malleolus (Fig. 1). With the current evidence, therefore, it is Br 1995;77(6):920–921. DOI: 10.1302/0301-620X.77B6.7593106. clear that deltoid repair (Fig. 2) should be in consideration by the 7. Zeegers AV, van der Werken C. Rupture of the deltoid ligament in ankle fractures: should it be repaired? Injury 1989;20(1):39–41. DOI: operating surgeon and is necessary in a subset of patients with 10.1016/0020-1383(89)90043-0. ankle fractures. 8. Johnson DP, Hill J. Fracture-dislocation of the ankle with rupture of the deltoid ligament. Injury 1988;19(2):59–61. DOI: 10.1016/0020- References 1383(88)90071-X. 1. Watanabe K, Kitaoka HB, Berglund LJ, et al. The role of ankle ligaments 9. Hintermann B, Valderrabano V, Boss A, et al. Medial ankle instability: and articular geometry in stabilizing the ankle. Clin Biomech (Bristol, an exploratory, prospective study of fifty-two cases. Am J Sports Med Avon) 2012;27(2):189–195. DOI: 10.1016/j.clinbiomech.2011.08.015. 2004;32(1):183–190. DOI: 10.1177/0095399703258789. 2. Campbell KJ, Michalski MP, Wilson KJ, et al. The ligament anatomy 10. Hsu AR, Lareau CR, Anderson RB. Repair of acute superficial of the deltoid complex of the ankle: a qualitative and quantitative deltoid complex avulsion during ankle fracture fixation in national anatomical study. J Bone Joint Surg Am 2014;96(8):e62. DOI: 10.2106/ football league players. Foot Ankle Int 2015;36(11):1272–1278. DOI: JBJS.M.00870. 10.1177/1071100715593374. 3. Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic findings in 11. Woo SH, Bae SY, Chung HJ. Short-term results of a ruptured deltoid acute fractures of the ankle. J Bone Joint Surg Br 2000;82(3):345–351. ligament repair during an acute ankle fracture fixation. Foot Ankle DOI: 10.1302/0301-620X.82B3.0820345. Int 2018;39(1):35–45. DOI: 10.1177/1071100717732383. 4. de Souza LJ, Gustilo RB, Meyer TJ. Results of operative treatment 12. Zhao HM, Lu J, Zhang F, et al. Surgical treatment of ankle fracture of displaced external rotation-abduction fractures of the ankle. J with or without deltoid ligament repair: a comparative study. BMC Bone Joint Surg Am 1985;67(7):1066–1074. DOI: 10.2106/00004623- Musculoskelet Disord 2017;18(1):543. DOI: 10.1186/s12891-017- 198567070-00010. 1907-4. 5. Harper MC. The deltoid ligament: an evaluation of need for 13. Dabash S, Elabd A, Potter E, et al. Adding deltoid ligament repair in surgical repair. Clin Orthop Relat Res 1988;226:156–168. DOI: ankle fracture treatment: is it necessary? A systematic review. Foot 10.1097/00003086-198801000-00022. Ankle Surg 2019;25(6):714–720. DOI: 10.1016/j.fas.2018.11.001.

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