Acute Deltoid Ligament Repair in Ankle Fractures: Five-year Follow-up

Repair of deep deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture by using suture anchors into the talus combined with the transosseous suture in the medial malleolar

Purpose

For deep deltoid ligament ruptures near the medial malleolar attachment, anchors were usually placed at the posterior colliculus and intercollicular groove. However, this procedure usually requires a prolonged surgical incision to fully expose the deep deltoid ligament, causing more trauma. In order to reduce surgical trauma, we explored the treatment outcomes of suture anchor into the talus combined with transosseous suture in the medial malleolar for the treatment of deep deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture.

Patients and methods

This is a retrospective study of patients who received suture anchor into the talus combined with transosseous suture in the medial malleolar for repairing deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture. The outcome measures include the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and the active range of motion (ROM) of the ankle at the final follow-up visit after surgery. Medial malleolus gap was evaluated by radiographic examination.

Results

This study included 64 patients. The mean follow-up time was 36.3 ± 15.2 months. There were 43 patients with injuries on the medial malleolar side, and 21 cases on the midsubstance. The average AOFAS and VAS were 87.5 ± 4.9 and 0.7 ± 0.5, respectively. No significance in medial malleolus gap between the contralateral side and affected side was observed.

Conclusion

For deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture, suture anchor into the talus combined with transosseous suture in the medial malleolar yields good clinical effect and outcome, is an optimal management of ankle syndesmosis injuries.

Kirschner Wire Internal Fixation of the Medial Tibiotalar Joint for Indirect Repair of Deltoid Ligament Injury: A Retrospective Comparative Study

OBJECTIVE

Ankle joint fractures are often accompanied by medial deltoid ligament rupture. There is controversy over whether or how to treat deltoid ligament rupture. This study was aimed to explore the feasibility of repairing the medial deltoid ligament using Kirschner wire internal fixation of the medial tibiotalar joint combined with external fixation.

METHODS

Forty-six patients with ankle fractures involving deltoid ligament rupture, treated between October 2012 and February 2021, were retrospectively evaluated. Twenty-five patients were treated with a Kirschner wire to fix the tibiotalar joint and indirectly repair the deltoid ligament as the repaired group. Twenty-one patients underwent reduction and fixation of internal and external malleolus fractures, and the deltoid ligament was not repaired in the unrepaired group. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS), Medical Outcomes Short Form 36-item questionnaire score (SF-36), and Medial clear space perpendicular (preoperative, postoperative, final follow-up) were used for functional evaluations and reduction assessments. Mann-Whitney test were used to compare the differences between the groups.

RESULTS

The follow-up time was 13-112 months with a mean of 59.32 months for the repaired group and 11-94 months with a mean of 53.43 months for the unrepaired group. There was no significant difference in the operative time or intraoperative blood loss between the two groups (p > 0.05). At the last follow-up, the AOFAS ankle-hindfoot and SF-36 scores of the repaired group were significantly higher than those of the non-repaired group (p < 0.05). Moreover, the VAS pain score was significantly lower and the Medial clear space perpendicular was significantly narrower in the repaired group than that in the unrepaired group.

CONCLUSION

Tibiotalar joint fixation using Kirschner wires is a simple and effective technique that can indirectly reduce and repair the deltoid ligament and stabilize the ankle.

Primary Deltoid Repair for Ankle Fracture Using All-Suture Anchors

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.

Prediction of anterior tibiotalar ligament injury: measurement of the angle between the deep posterior tibiotalar ligament and talus on MRI

Background

Identification of anterior tibiotalar ligament (aTTL) injury is essential because it influences the surgeon's treatment option and patient prognosis.

Purpose

To assess the diagnostic accuracy of the angle measurement between the talus and posterior tibiotalar ligament (talus-pTTL) on magnetic resonance imaging (MRI) in patients with arthroscopically proven aTTL injuries.

Material and Methods

Ankle MRI scans of 67 patients who underwent arthroscopic examination were retrospectively reviewed. The talus-pTTL angle on axial T2-weighted MRI and the medial clear space (MCS) on mortise ankle radiograph were measured. Inter-observer agreement of the measurements was calculated. Also, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) were the metrics of diagnostic accuracy.

Results

AUC was 0.90 for observer 1 with 78.6% sensitivity, 97.4% specificity, 88% accuracy, and 54.7° cutoff value for the talus-pTTL angle. AUC was 0.87 for observer 2 with 85.7% sensitivity, 84.6% specificity, 85.2% accuracy, and 53.7° cutoff value for the talus-pTTL angle. AUC was 0.86 with 82.1% sensitivity, 79.5% specificity, and 80.8% accuracy for observer 1 and 0.79 with 57.1% sensitivity, 92.3% specificity, and 74.7% accuracy for observer 2 for the MCS. Different MCS values and additional capabilities when complemented with the angle measurement showed an increase in diagnostic performances. Intra-observer reliability of MCS and talus-pTTL angle of the two radiologists was excellent. Inter-observer reliability of the two radiologists was excellent for both the talus-pTTL angle (0.95) and the MCS (0.85).

Conclusion

Measurement of the talus-pTTL angle showed good sensitivity, specificity, and accuracy for the evaluation of aTTL injury with excellent inter-observer reliability.

Deltoid Rupture in Ankle Fractures: To Repair or Not to Repair?

The most common injury mechanism for ankle fractures with concomitant deltoid ligament injury is a supination external rotation type 4 trauma. In the acute setting, malalignment, ecchymosis, and profound edema of the affected ankle can be found. Clinical examination is a poor indicator for deltoid ligament injury. There is a lack of high-quality studies with suturing the deltoid as the primary question. The authors found 4 comparative studies that found it unnecessary to explore and to reconstruct the deltoid ligament and 4 comparative studies that find it unnecessary to explore and to reconstruct the deltoid ligament.

Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures

BACKGROUND

The deep deltoid ligament (DDL) is a key stabilizer to the medial ankle and ankle mortise and can be disrupted in ligamentous supination external rotation type IV (LSER4) ankle fractures. The purpose of this study was to define the medial clear space (MCS) measurement on injury mortise radiographs that corresponds with complete DDL injury.

METHODS

A retrospective record review at a level 1 hospital was performed identifying patients with LSER4 ankle fractures who underwent arthroscopy and open reduction internal fixation. Chart reviews provided arthroscopic images and operative reports. Complete DDL injury was defined as arthroscopic visualization of the posterior tibial tendon (PTT). Inability to completely visualize the PTT was defined as a partial DDL injury. MCS was measured on injury mortise radiographs. Eighteen subjects met inclusion criteria.

RESULTS

Twelve subjects had complete and 6 subjects had partial DDL injury based on arthroscopic findings. Patients with complete DDL injury and those with partial DDL injury had injury radiograph MCS ranging from 5.5 to 29.9 mm and 4.0 to 5.0 mm, respectively. All patients with MCS ≥5.5 mm on injury radiographs had complete DDL injury and all patients with MCS ≤5.0 mm on injury radiographs had partial DDL injury.

CONCLUSION

Complete DDL injury was found on injury ankle mortise radiographs as MCS widening of ≥5.5 mm, which correlated with arthroscopic visualization of the PTT. Using this cutoff, surgeons can surmise the presence of a complete deltoid ligament injury, allowing for improved preoperative planning.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

[Unstable injuries of the deltoid ligament complex in ankle fractures : How to diagnose, how to treat?]

Unstable injuries of the deltoid ligament complex can have a substantial negative effect on the prognosis and treatment of ankle injuries. Lesions of the deltoid ligament are often overlooked at the initial presentation, both as isolated ruptures and in combination with more complex injuries of the ankle. Neglected unstable injuries of medial ankle ligaments may result in chronic instability, especially following correct treatment of fractures and lateral ligament injuries. These are accompanied by reduced ankle mobility, persisting pain, reduced load bearing and osteoarthritis. Despite the possible subsequent damage, the need for surgical repair of the deltoid ligament in patients with ankle fractures is controversially discussed. Although in most cases of ligament injuries of the upper ankle joint conservative treatment leads to very good results, there is increased interest in acute surgical treatment particularly for unstable injuries in order to avoid secondary instability and the associated sequelae. When surgical treatment should be given priority over conservative treatment has not yet been sufficiently clarified. This article gives an overview of the diagnosis and treatment of injuries of the deltoid ligament complex in patients with ankle fractures based on the current literature.

Recent advances in 3D bioprinting of musculoskeletal tissues

The musculoskeletal system is essential for maintaining posture, protecting organs, facilitating locomotion, and regulating various cellular and metabolic functions. Injury to this system due to trauma or wear is common, and severe damage may require surgery to restore function and prevent further harm. Autografts are the current gold standard for the replacement of lost or damaged tissues. However, these grafts are constrained by limited supply and donor site morbidity. Allografts, xenografts, and alloplastic materials represent viable alternatives, but each of these methods also has its own problems and limitations. Technological advances in three-dimensional (3D) printing and its biomedical adaptation, 3D bioprinting, have the potential to provide viable, autologous tissue-like constructs that can be used to repair musculoskeletal defects. Though bioprinting is currently unable to develop mature, implantable tissues, it can pattern cells in 3D constructs with features facilitating maturation and vascularization. Further advances in the field may enable the manufacture of constructs that can mimic native tissues in complexity, spatial heterogeneity, and ultimately, clinical utility. This review studies the use of 3D bioprinting for engineering bone, cartilage, muscle, tendon, ligament, and their interface tissues. Additionally, the current limitations and challenges in the field are discussed and the prospects for future progress are highlighted.