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Schrempf J, Baumbach S, Abdelatif NMN, Polzer H, Böcker W. A systematic review on how to diagnose deltoid ligament injuries-are we missing a uniform standard? BMC Musculoskelet Disord 2024; 25:782. [PMID: 39363254 PMCID: PMC11450994 DOI: 10.1186/s12891-024-07869-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 09/11/2024] [Indexed: 10/05/2024] Open
Abstract
BACKGROUND Up to now, there is no convincing evidence, that surgical treatment of deltoid ligament injuries, especially in the setting of ankle fractures, does result in improved outcome. One reason could be a missing diagnostic standard. The aim of the current systematic review was to analyze the applied diagnostic strategies for acute deltoid ligament injuries in outcome studies. METHODS MEDLINE, Scopus, Central, and EMBASE were searched through February 2022 for any original studies addressing diagnostics of acute deltoid injuries. The study was conducted per the PRISMA guidelines. The inclusion criteria were formed according to the PICOS criteria. The data assessed were study type, level of evidence, included fractures, time point and method of diagnosing deltoid ligament layers, differentiation between layers and syndesmotic injuries. RESULTS 31 studies were included in the final analysis. Most studies (n = 28) based their decision to treat the deltoid ligament injury on radiologic findings only, with stressed radiographs (n = 18) being the most common. The radiographs were applied at one or more time points (preoperative, before ORIF, after ORIF, after ORIF and syndesmotic repair). The most frequently assessed parameter was the Medial Clear Space (MCS, n = 27) with cut-off-values considered pathological ranging between MCS > 1 mm and MCS > 6 mm. CONCLUSION Comparing the 31 studies shows that a standardized method to diagnose deltoid ligament injuries is missing. Further research is needed to establish evidence-based guidelines on how to diagnose acute deltoid ligament injuries. TRIAL REGISTRATION Prospero ID: CRD42022307112. CLINICAL TRIAL NUMBER not applicable.
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Affiliation(s)
- Judith Schrempf
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Munich, Germany.
| | - Sebastian Baumbach
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Munich, Germany.
| | | | - Hans Polzer
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Munich, Germany
| | - Wolfgang Böcker
- Musculoskeletal University Centre Munich (MUM), University Hospital, Ludwig-Maximilians-University Munich (LMU), Munich, Germany
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Sogard O, McDonald J, Waters ME, Lee W. The clinical outcome comparison between trans-syndesmotic fixation and anatomic deltoid ligament repair in unstable ankle fractures with medial clear space widening: A systematic review and meta-analysis. Foot Ankle Surg 2024:S1268-7731(24)00187-5. [PMID: 39256063 DOI: 10.1016/j.fas.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 08/04/2024] [Accepted: 08/23/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Due to the variability in evidence supporting either trans-syndesmosis fixation or deltoid ligament repair in unstable ankle fractures with medical clear space (MCS) widening makes it unclear which surgical technique leads to the best patient outcomes. The goal of our systematic review and meta-analysis was to compare clinical outcomes of trans-syndesmotic fixation versus anatomic deltoid ligament repair in the management of unstable ankle fractures with MCS widening. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized in this study. A comprehensive and systematic search was conducted using the PubMed, Embase, Web of Science and Cochrane Library databases. Outcomes investigated in this review included the rates of syndesmotic malreduction, removal of hardware, postoperative complications including wound issues, and functional/pain scores. RESULTS A total of five level-3 studies were selected in this review, with 280 unstable ankle fractures with MCS widening: 165 for the trans-syndesmotic fixation group and 115 for the anatomic deltoid ligament repair group. Three out of five studies evaluated syndesmotic malreduction using CT. Compared to the trans-syndesmosis fixation group, the deltoid repair group showed significant lower rates of syndesmotic malreduction rates and removal of hardware: 6.5 % (4/61) Vs. 27 % (16/59) (RR=0.26, 95 % CI=[0.10, 0.68]), and 2.6 % (3/115) Vs.54.5 % (90/165) (RR=0.06, CI=[0.02, 0.14]), respectively. No significant differences were found between the two groups in postoperative wound complications, reoperations, and functional scores including AOFAS and VAS pain score. CONCLUSIONS Based on our findings, anatomic deltoid ligament repair was associated with a lower rate of syndesmotic malreduction and the need for hardware removal while there was no significant difference in terms of postoperative wound complications, reoperation, AOFAS score, or VAS pain score. These results should be interpreted with caution due to limitations related to heterogeneity among the studies. Further high-level RCTs with larger sample sizes are necessary to establish a robust consensus.
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Affiliation(s)
| | - John McDonald
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA.
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Patel S, Dionisopoulos SB. Current Concepts in Ankle Fracture Management. Clin Podiatr Med Surg 2024; 41:519-534. [PMID: 38789168 DOI: 10.1016/j.cpm.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Ankle fractures are one of the more common musculoskeletal injuries that are treated by foot and ankle specialists. A thorough understanding of managing these injuries requires the ability to differentiate between stable and unstable fractures. The current literature supports the nonoperative management of stable Weber B ankle fractures, whereas unstable fractures have much better outcomes with surgical intervention. Specifically, we review the fixation strategies for the lateral, medial, and posterior malleolar fractures respectively. Finally, we discuss the current trends in postoperative management of some of the more common fracture patterns, and the safety in early weight-bearing protocols.
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Affiliation(s)
- Sandeep Patel
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA.
| | - Shontal Behan Dionisopoulos
- The Permanente Medical Group Diablo Service Area, Department of Orthopedics and Podiatry, San Francisco Bay Area Foot and Ankle Residency, 1425 S. Main Street, Walnut Creek, CA 94596, USA
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Koris J, Calder JDF, Dalmau-Pastor M, Fernandez MA, Ramasamy A. Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38796726 DOI: 10.1002/ksa.12274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. METHODS A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods. RESULTS A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available. CONCLUSION There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jacob Koris
- Trauma & Orthopaedic Specialty Registrar, John Radcliffe Hospital, Oxford, UK
| | - James D F Calder
- Department of Bioengineering, Imperial College London, London, UK
- Fortius Clinic, London, UK
| | - Mikel Dalmau-Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
| | - Miguel A Fernandez
- Fortius Clinic, London, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Arul Ramasamy
- Department of Bioengineering, Imperial College London, London, UK
- Academic Department of Military Trauma and Orthopaedics, Royal Centre for Defence Medicine, Edgbaston, Birmingham, UK
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Liang W, Zhou M, Jiang Z, Mao X, Zhou X, Wang F. 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. Front Surg 2024; 10:1287427. [PMID: 38249313 PMCID: PMC10796676 DOI: 10.3389/fsurg.2023.1287427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
- Wei Liang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Mingping Zhou
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Zhongting Jiang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Xuanyu Mao
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Xiang Zhou
- Department of Orthopaedics, Longquan People’s Hospital, Longquan, Zhejiang, China
| | - Fei Wang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
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Tansey PJ, Chen J, Panchbhavi VK. Current concepts in ankle fractures. J Clin Orthop Trauma 2023; 45:102260. [PMID: 37872976 PMCID: PMC10589378 DOI: 10.1016/j.jcot.2023.102260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.
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Affiliation(s)
- Patrick J. Tansey
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Jie Chen
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Vinod K. Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
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Wagner E, Wagner P, Escudero MI, Pacheco F, Salinas D, Godoy-Santos AL, Palma F, Guzmán-Venegas R, Berral-De la Rosa FJ. Acute Deltoid Injury in Ankle Fractures: A Biomechanical Analysis of Different Repair Constructs. Foot Ankle Int 2023; 44:905-912. [PMID: 37489020 DOI: 10.1177/10711007231184844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND The importance of the deltoid ligament in the congruency and coupling of the tibiotalar joint is well known. The current trend is to repair it in cases of acute injuries in the context of ankle fractures; however, there is limited information on how it should be reconstructed. The objective of this study was to compare different deltoid ligament repair types in an ankle fracture cadaveric model. METHODS Sixteen cadaveric foot-ankle-distal tibia specimens were used. All samples were prepared as a supination external rotation ankle fracture model. Axial load and cyclic axial rotations were applied on every specimen using a specifically designed frame. This test was performed without deltoid injury, with deltoid injury, and after repair. The reconstruction was performed in 4 different ways (anterior, posterior, middle, and combined). Medial clear space (MCS) was measured for each condition on simulated weightbearing (WB) and gravity stress (GS) radiographs. Reflective markers were used in tibia and talus, registering the kinematics through a motion analysis system to record the tibiotalar uncoupling. RESULTS After deltoid damage, in all cases the MCS increased significantly on GS radiographs, but there was no increase in the MCS on WB radiographs. After repair, in all cases, the MCS was normalized. Kinematically, after deltoid damage, the tibiotalar uncoupling increased significantly. All isolated repairs achieved a similar tibiotalar uncoupling value as its baseline condition. The combined repair resulted in a significant decrease in tibiotalar uncoupling. CONCLUSION Our results show that deltoid repair recovers the tibiotalar coupling mechanism in an ankle fracture model. Isolated deltoid repairs recovered baseline MCS and tibiotalar uncoupling values. Combined repairs may lead to overconstraint, which could lead to postoperative stiffness. Clinical studies are needed to prove these results and show clinically improved outcomes. CLINICAL RELEVANCE This study helps in finding the optimum deltoid repair to use in an acute trauma setting.
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Affiliation(s)
- Emilio Wagner
- Orthopaedic Department, Clinica Alemana de Santiago-Universidad del Desarrollo, Santiago, Chile
| | - Pablo Wagner
- Orthopaedic Department, Clinica Alemana de Santiago-Universidad del Desarrollo, Santiago, Chile
- Orthopaedic Department, Hospital Militar de Santiago-Universidad de los Andes, Santiago, Chile
| | - Mario I Escudero
- Orthopaedic Department, Clinica Alemana de Santiago-Universidad del Desarrollo, Santiago, Chile
- Department of Orthopaedics, University of Chile, Santiago, Chile
| | - Florencia Pacheco
- Hospital Clinico IST, Viña del Mar, Chile
- SPORTS Medicina deportiva, Viña del Mar, Chile
| | - David Salinas
- Orthopaedic Department, Clinica Alemana de Santiago-Universidad del Desarrollo, Santiago, Chile
| | - Alexandre Leme Godoy-Santos
- Lab. Prof. Manlio Mario Marco Napoli, Departamento de Ortopedia e Traumatologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Felipe Palma
- Laboratorio LIBFE, Escuela de kinesiología, Facultad de Medicina, Universidad de los Andes, Santiago, Chile
| | - Rodrigo Guzmán-Venegas
- Laboratorio LIBFE, Escuela de kinesiología, Facultad de Medicina, Universidad de los Andes, Santiago, Chile
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Brady AW, Bryniarski A, Brown JR, Waltz R, Stake IK, Kreulen CD, Haytmanek CT, Clanton TO. The Biomechanical Role of the Deltoid Ligament on Ankle Stability: Injury, Repair, and Augmentation. Am J Sports Med 2023; 51:2617-2624. [PMID: 37449714 DOI: 10.1177/03635465231181082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Deltoid ligament injuries occur in isolation as well as with ankle fractures and other ligament injuries. Both operative treatment and nonoperative treatment are used, but debate on optimal treatment continues. Likewise, the best method of surgical repair of the deltoid ligament remains unclear. PURPOSE To determine the biomechanical role of native anterior and posterior components of the deltoid ligament in ankle stability and to determine the efficacy of simple suture versus augmented repair. STUDY DESIGN Controlled laboratory study. METHODS Ten cadaveric ankles (mean age, 51 years; age range, 34-64 years; all male specimens) were mounted on a 6 degrees of freedom robotic arm. Each specimen underwent biomechanical testing in 8 states: (1) intact, (2) anterior deltoid cut, (3) anterior repair, (4) tibiocalcaneal augmentation, (5) deep anterior tibiotalar augmentation, (6) posterior deltoid cut, (7) posterior repair, and (8) complete deltoid cut. Testing consisted of anterior drawer, eversion, and external rotation (ER), each performed at neutral and 25° of plantarflexion. A 1-factor, random-intercepts, linear mixed-effect model was created, and all pairwise comparisons were made between testing states. RESULTS Cutting the anterior deltoid introduced ER (+2.1°; P = .009) and eversion laxity (+6.2° of eversion; P < .001) at 25 degrees of plantarflexion. Anterior deltoid repair restored native ER but not eversion. Tibiocalcaneal augmentation reduced eversion laxity, but tibiotalar augmentation provided no additional benefit. The posterior deltoid tear showed no increase in laxity. Complete tear introduced significant anterior translation, ER, and eversion laxity (+7.6 mm of anterior translation, +13.8° ER and +33.6° of eversion; P < .001). CONCLUSION A complete deltoid tear caused severe instability of the ankle joint. Augmented anterior repair was sufficient to stabilize the complete tear, and no additional benefit was provided by posterior repair. For isolated anterior tear, repair with tibiocalcaneal augmentation was the optimal treatment. CLINICAL RELEVANCE Deltoid repair with augmentation may reduce or avoid the need for prolonged postoperative immobilization and encourage accelerated rehabilitation, preventing stiffness and promoting earlier return to preinjury activity.
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Affiliation(s)
- Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Justin R Brown
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Ingrid K Stake
- Steadman Philippon Research Institute, Vail, Colorado, USA
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Abstract
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
- Rajeev Vohra
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Avtar Singh
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Babaji Thorat
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Dharmesh Patel
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
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10
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Yang X, Zeng J, Yang W, Dela Rosa RD, Jiang Z. A meta-analysis of deltoid ligament on ankle joint fracture combining deltoid ligament injury. Front Surg 2023; 10:976181. [PMID: 37051572 PMCID: PMC10083234 DOI: 10.3389/fsurg.2023.976181] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
PurposeAnkle fracture combined with deltoid ligament (DL) injury results in decreased stability of ankle mortise, reduced contact surface between tibial and talus, increased local stress, and increased postoperative complications. The purpose of this meta-analysis was to evaluate the postoperative effects of repairing ligaments in ankle fractures with DL rupture.MethodsAccording to the steps of the Cochrane systematic review, the related literatures from PubMed, Embase and the Cochrane Library Databases were retrieved as of September 1, 2021, and all relevant randomized controlled trials and retrospective studies were collected. The evaluation indicators include medial clear space (MCS), visual analogue scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), complications rate. Meta-analysis was conducted by RevMan® 5.3 provided by the Cochrane collaboration.ResultsA total of 388 patients (195 patients in the ligament repair group and 193 patients in the non-repair group) were included in 7 clinical trials. Meta-analysis data showed there were no statistically significant differences between the ligament repair group and non-repair group in final follow-up VAS, final AOFAS and postoperative MCS (P = 0.50, P = 0.04, P = 0.14, P = 0.14, respectively). Final follow-up MCS and complications rate in ligament repair group were smaller than those in the non-repair group and were statistically significant (P < 0.00001, P = 0.006, respectively).ConclusionAlthough there was no difference in in final follow-up VAS, final follow-up AOFAS and postoperative MCS between experimental group and control group, It's statistically significant in final follow-up MCS and complications rate. Ligament repair could reduce the width of MCS, restore ankle stability, reduce the incidence of complications and lead to a better prognosis.
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Affiliation(s)
- XiaoLing Yang
- Department of Nursing, Guizhou Nursing Vocational College, Guiyang, People's republic of China
- School of Nursing, Philippine Women's University, Manila, Philippines
| | - Jianshuang Zeng
- Department of Dermatology, Guizhou Provincal People's Hospital, Guiyang, People's republic of China
| | - Wei Yang
- Department of Neurosurgery, People's Hospital of Dechang County, Dechang, People's republic of China
| | - Ronnell D Dela Rosa
- School of Nursing, Philippine Women's University, Manila, Philippines
- College of Nursing and Midwifery, Bataan Peninsula State University, Balanga, Philippines
- Correspondence: Zhixia Jiang Ronnell D. Dela Rosa
| | - Zhixia Jiang
- Department of Nursing, Guizhou Nursing Vocational College, Guiyang, People's republic of China
- Correspondence: Zhixia Jiang Ronnell D. Dela Rosa
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11
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Rigby RB, Fleisig GS, Waldrop NE. Primary Deltoid Repair for Ankle Fracture Using All-Suture Anchors. J Foot Ankle Surg 2023:S1067-2516(23)00063-7. [PMID: 37037736 DOI: 10.1053/j.jfas.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 04/12/2023]
Abstract
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.
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12
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Li H, Xue X, Tong J, Li H, Hua Y. Deltoid ligament (DL) repair produced better results than DL nonrepair for the treatment for rotational ankle instability. Knee Surg Sports Traumatol Arthrosc 2022; 31:2015-2022. [PMID: 36175528 DOI: 10.1007/s00167-022-07169-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the clinical and magnetic resonance imaging (MRI) results after arthroscopic deltoid ligament (DL) repair versus DL nonrepair in patients with rotational ankle instability. METHODS All patients with rotational ankle instability were enrolled in this retrospective cohort study. Clinical evaluation was performed by the American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score preoperatively and at a minimum follow-up of 2 years. MRI at follow-up was performed to evaluate the DL morphology. RESULTS A total of 50 patients were enrolled in this study. Among them, 24 patients received DL repair (the repair group), whereas 26 patients did not (the nonrepair group). No significant difference was found in the AOFAS score (98 ± 4 vs. 97 ± 4; n.s.), KAFS (94 ± 7 vs. 93 ± 9; n.s.), or Tegner activity score (5 ± 2 vs. 5 ± 1; n.s.) between the repair group and the nonrepair group at the final follow-up. However, the repair group had a significantly shorter return-to-sport time than the nonrepair group (4.6 ± 1.6 mo vs. 6.0 ± 2.5 mo; p = 0.03). Comparison of the postoperative deltoid ligament showed that the repair group had a lower signal intensity than the nonrepair group. CONCLUSION Arthroscopic treatment of rotational ankle instability revealed good to excellent clinical results. However, patients who underwent DL repair had a significantly earlier return to sports as well as a lower signal intensity of DL than those who did not undergo DL repair. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hong Li
- Department of Sports Medicine, Huashan Hospital, No 12, Wulumuqi Zhong Road, 200040, Shanghai, People's Republic of China
| | - XiaoAo Xue
- Department of Sports Medicine, Huashan Hospital, No 12, Wulumuqi Zhong Road, 200040, Shanghai, People's Republic of China
| | - Jiahui Tong
- Department of Sports Medicine, Huashan Hospital, No 12, Wulumuqi Zhong Road, 200040, Shanghai, People's Republic of China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, No 12, Wulumuqi Zhong Road, 200040, Shanghai, People's Republic of China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, No 12, Wulumuqi Zhong Road, 200040, Shanghai, People's Republic of China.
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13
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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Correspondence: Yun-Feng Rui
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14
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Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures. Foot Ankle Surg 2022; 28:720-725. [PMID: 34493449 DOI: 10.1016/j.fas.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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 OF CLINICAL EVIDENCE Level III, retrospective cohort study.
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15
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Shazadeh Safavi K, Rezvani A, Janney CF, Chen J, Cassis W, Darayan N, Panchbhavi VK, Jupiter DC. Assessing the Utility of Deltoid Ligament Repair in Ankle Fracture: A Systematic Review. Cureus 2022; 14:e27040. [PMID: 35989770 PMCID: PMC9388398 DOI: 10.7759/cureus.27040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/05/2022] Open
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16
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Whitlock KG, LaRose M, Barber H, Fletcher A, Cunningham D, Menken L, Yoon RS, Gage MJ. Deltoid ligament repair versus trans-syndesmotic fixation for bimalleolar equivalent ankle fractures. Injury 2022; 53:2292-2296. [PMID: 35437167 DOI: 10.1016/j.injury.2022.03.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Keith G Whitlock
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA.
| | - Micaela LaRose
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Helena Barber
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Amanda Fletcher
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Daniel Cunningham
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Luke Menken
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Richard S Yoon
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Mark J Gage
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
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Yüce A, Mısır A, Yerli M, Bayraktar TO, Tekin AÇ, Dedeoğlu SS, İmren Y, Gürbüz H. The Effect of Syndesmotic Screw Level on Postoperative Syndesmosis Malreduction. J Foot Ankle Surg 2022; 61:482-485. [PMID: 34656414 DOI: 10.1053/j.jfas.2021.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 09/09/2021] [Accepted: 09/15/2021] [Indexed: 02/03/2023]
Abstract
Tibiofibular injury repair of ankle fractures may result in over-compression when performed via a partially threaded screw depending on its placed level. We aimed to examine the relationship between the screw level relative to the tibiotalar joint and syndesmosis malreduction in postoperative radiographs of ankle fractures treated with partially threaded screws. We retrospectively analyzed 129 patients who underwent surgery due to lateral malleolar fractures between 2011 and 2019. We measured the distance between the screw and the tibiotalar joint and stratified the patients per their screw level as either trans-syndesmotic or suprasyndesmotic. According to Lauge-Hansen, 83 cases were supination-external rotation type (64.3%), and the remaining were pronation-external rotation type (35.7%) injuries. We found postoperative syndesmosis malreduction in 20 cases (15.5%). Eight (6.2%) cases had medial clear space mismatch. As the distance of the screw to the joint increased, postoperative medial clear space values increased (rho: 0.190, p = .031). The relationship between postoperative syndesmosis mismatch and the level of the syndesmotic screw was statistically significant (p = .044). In syndesmosis repair with a partially threaded screw, as the distance of the screw from the joint increases, the over-compression caused by the screw may cause an increase in postoperative syndesmotic malreduction rates.
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Affiliation(s)
- Ali Yüce
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Abdulhamit Mısır
- Department of Orthopedic and Traumatology, Başakşehir Çam and Sakura City Hospital, İstanbul, Turkey
| | - Mustafa Yerli
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey.
| | - Tahsin Olgun Bayraktar
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Ali Çağrı Tekin
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Süleyman Semih Dedeoğlu
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Yunus İmren
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
| | - Hakan Gürbüz
- Department of Orthopedic and Traumatology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Istanbul, Turkey
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18
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Does repair of deltoid ligament contribute to restoring a mortise in SER type IV ankle fracture with syndesmotic diastasis? Arch Orthop Trauma Surg 2022; 142:535-541. [PMID: 33119800 DOI: 10.1007/s00402-020-03645-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To analyze the radiographic and clinical outcomes of deltoid ligament repair, we studied 34 supination external rotation type IV ankle fracture patients with deltoid ruptures who required syndesmosis fixation. METHODS We retrospectively evaluated 34 cases of ruptured deltoid ligaments with associated supination external rotation type IV ankle fractures with a widening of the syndesmosis between 2011 and 2017. All of the ankle fractures were treated with a similar surgical protocol (plate and screw fixation). Syndesmotic fixations were performed on all patients. The deltoid ligaments were surgically repaired in 19 patients and in 15 patients, they were not. The preoperative, immediate postoperative, and final follow-up radiographic outcomes (medial clear space, overlap space, and clear space) and clinical scores (Foot and Ankle Outcome Scores and the Foot Function Index) were compared. Patients were followed for an average of 13.6 months. RESULTS There was no significant difference in radiographic and clinical outcomes between the deltoid repair group and the unrepair group (P > 0.05). In both groups, the mean immediate postoperative radiographic outcomes were satisfactory, showing reduced MCS, reduced CS, and increased OS to within-normal ranges that were maintained at the final follow-up. Clinical outcomes were similar between the two groups (P > 0.05). The rate of complications, such as intra-articular lesions, malunions, nonunions, and arthrosis was comparable between the two groups. CONCLUSION In both groups, the postoperative and final follow-up radiographic measures were within normal ranges and the radiographic and clinical outcomes were not significantly different between the two groups. Syndesmotic reduction could be much more important than deltoid repair in regard to mortise restoration and medial stability.
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19
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Chiang CC, Lin CFJ, Tzeng YH, Teng MH, Yang TC. Arthroscopic Quantitative Measurement of Medial Clear Space for Deltoid Injury of the Ankle: A Cadaveric Comparative Study With Stress Radiography. Am J Sports Med 2022; 50:778-787. [PMID: 35289224 DOI: 10.1177/03635465211067806] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The deltoid ligament (DL) is an important stabilizer of the ankle. DL injury of varying severity can occur alone or with syndesmotic injury and fibular fracture. Limited diagnostic tools are available to assess DL injury quantitatively. PURPOSE To establish an arthroscopic quantitative assessment of DL injury and to compare its performance with that of external rotation stress (ERS) and gravity stress (GS) radiography. STUDY DESIGN Controlled laboratory study. METHODS In total, 24 cadaveric lower extremities were divided into 4 groups: group 1 consisted of intact DL, group 2 of superficial DL disruption, group 3 of deep DL disruption, and group 4 of complete DL (superficial and deep) disruption. All specimens underwent sequential sectioning of syndesmotic ligaments, and medial clear space (MCS) was measured with ankle arthroscopy, ERS radiography, and GS radiography at different stages of syndesmotic sectioning. RESULTS For noninjured deltoid (group 1) and injured deltoid (groups 2-4), area under the receiver operating characteristic curve (AUC) of measurement of MCS was 0.939 for arthroscopy, 0.932 for ERS radiography, and 0.874 for GS radiography, with a significant difference between arthroscopy and GS radiography (P = .014). For incomplete deltoid injury (groups 1-3) and complete deltoid injury (group 4), the AUC of MCS was 0.811 for arthroscopy, 0.656 for ERS radiography, and 0.721 for GS radiography, with a significant difference between arthroscopy and ERS radiography (P < .001) and between arthroscopy and GS radiography (P = .035). For all stages of syndesmotic sectioning, cutoff values of arthroscopic MCS with intact fibula were ≤2.5 mm for intact DL, between 2.5 and 3.5 mm for partial DL injury (superficial or deep), and ≥3.5 mm for complete DL injury. Arthroscopy was unable to detect a difference between superficial deltoid injury (group 2) and deep deltoid injury (group 3) in partial DL injury, with a measured MCS between 2.5 and 3.5 mm. The intraclass correlation coefficient of interrater reliability was 0.975 for arthroscopy, 0.917 for ERS radiography, and 0.811 for GS radiography. CONCLUSION Arthroscopic MCS measurement can differentiate intact DL, partial DL injury, and complete DL injury. Compared with ERS and GS radiography, arthroscopic MCS measurement has greater accuracy with excellent interrater reliability. CLINICAL RELEVANCE For patients with suspected DL injury, arthroscopic MCS is useful for determining deltoid lesion severity based on defined cutoff values for consideration in preoperative planning to improve surgical outcomes.
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Affiliation(s)
- Chao-Ching Chiang
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Fu Jeff Lin
- Department of Statistics, National Taipei University, Taipei, Taiwan.,Department of Orthopedic Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yun-Hsuan Tzeng
- Division of Medical Imaging for Health Management, Cheng-Hsin General Hospital, Taipei, Taiwan.,Department of Radiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Hung Teng
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopedics, Taipei Veterans General Hospital, Yuli Branch, Hualien, Taiwan
| | - Tzu-Cheng Yang
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopaedics, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
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20
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Bartoníček J, Rammelt S, Tuček M. Maisonneuve Fractures of the Ankle: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202202000-00009. [PMID: 35180143 DOI: 10.2106/jbjs.rvw.21.00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures. » The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT). » The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN. » Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome. » Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.
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Affiliation(s)
- Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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21
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Dodd A, Halai M, Buckley R. Unstable weber B Ankle fracture with a deltoid ligament rupture - ORIF of the fibula with no repair of the deltoid ligament versus ORIF of the fibula but operative repair of the deltoid ligament. Injury 2022; 53:221-223. [PMID: 34991864 DOI: 10.1016/j.injury.2021.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew Dodd
- Section of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Mansur Halai
- Assistant Professor, University of Toronto, Orthopedic Surgeon, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Richard Buckley
- University of Calgary, Dept. of Surgery, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW Calgary, Alberta, T2N 5A1, Canada.
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22
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James M, Dodd A. Management of deltoid ligament injuries in acute ankle fracture: a systematic review. Can J Surg 2022; 65:E9-E15. [PMID: 35017184 PMCID: PMC8759295 DOI: 10.1503/cjs.020320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Deltoid ligament repair (DLR) was historically a common adjunct to ankle fracture fixation; however, prevailing clinical practice is to explore the medial side of the ankle only if reduction is blocked. We performed a systematic review to determine the breadth and quality of the literature evaluating DLR in the context of ankle fractures. METHODS We searched the MEDLINE and Embase databases in May 2020 for English-language articles evaluating DLR versus no repair or syndesmotic fixation in patients with acute ankle fractures. We used descriptive statistics to compare studies and draw conclusions. RESULTS Of 362 articles identified, 8 (3 randomized controlled trials [RCTs] and 5 retrospective cohort studies) were included in our final analysis. Five studies compared DLR to conservative management, and 3 compared DLR to transsyndesmotic fixation. Functional outcomes were equivalent between groups. Five of the 6 studies that included radiographic outcomes showed a statistically significant decrease in the medial clear space and decreased malreduction rates postoperatively in the DLR groups. CONCLUSION High-quality evidence guiding treatment of deltoid ligament injury in acute ankle fractures is lacking; currently available evidence appears to support DLR. Given recent increased interest in DLR and syndesmotic fixation, a comprehensive multicentre RCT is warranted. Although radiographic evidence indicates the potential benefit of DLR, further research is required to establish the superiority of DLR versus clinical equipoise.
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Affiliation(s)
- Michael James
- From the Department of Surgery, University of Calgary, Calgary, Alta. (James); and the Foothills Medical Centre, Calgary, Alta. (Dodd).
| | - Andrew Dodd
- From the Department of Surgery, University of Calgary, Calgary, Alta. (James); and the Foothills Medical Centre, Calgary, Alta. (Dodd)
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23
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Pisanu F, Ortu S, Corda M, Andreozzi M, Caggiari G, Manunta AF, Doria C. Deltoid ligament reconstruction with autologous gracilis tendon in chronic medial ankle instability after ankle fracture surgery: A case report. Foot (Edinb) 2021; 49:101714. [PMID: 33036835 DOI: 10.1016/j.foot.2020.101714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/03/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The repair of a deltoid ligament injury, following an ankle fracture with involvement of the syndesmosis, has no univocal consensus. Also the surgical strategies in case of a subsequent chronic instability are still under debate. In this work the result of a double bundle anatomic reconstruction of deltoid ligament with ipsilateral autologous gracilis muscle tendon is presented. CASE REPORT A 50 year old active male patient came to our attention with a catastrophic medial ankle instability, a severe pronation of the hindfoot and disabling ankle pain. He reported a Weber type B fracture of the left ankle with a lesion of the syndesmosis treated with anatomic plate and screws and a transyndesmotic screw 8 months before. The imaging showed a complete deltoid ligament lesion. Due to the impossibility of a direct repair of the ligament, we performed the reconstruction of the medial ligamentous complex with an autologous gracilis tendon graft. 10 months after the medial ligamentous complex reconstruction, the patient showed an excellent recovery of walking ability, disappearance of pain under load and resumed an active lifestyle. DISCUSSION The deltoid ligament has a key role in ankle joint stability and its integrity promotes the recovery after ankle fractures. However, its lesion is often left untreated in the acute setting. The result of a chronic untreated deltoid ligament injury could be extremely disabling and the ligament reconstruction, when an optimal native deltoid ligament repair is not achievable, is the choice to restore ankle function and stability. CONCLUSION In the delayed treatment of a deltoid ligament rupture the described double bundle anatomic reconstruction with autologous tendon graft can be an effective and suitable option.
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Affiliation(s)
- Francesco Pisanu
- Orthopaedic Department, University of Sassari, Sassari, Viale San Pietro 43, Italy
| | - Sebastiano Ortu
- Orthopaedic Department, University of Sassari, Sassari, Viale San Pietro 43, Italy.
| | - Marco Corda
- Orthopaedic Department, University of Sassari, Sassari, Viale San Pietro 43, Italy
| | - Matteo Andreozzi
- Orthopaedic Department, University of Sassari, Sassari, Viale San Pietro 43, Italy
| | - Gianfilippo Caggiari
- Orthopaedic Department, University of Sassari, Sassari, Viale San Pietro 43, Italy
| | - Andrea Fabio Manunta
- Orthopaedic Department, University of Sassari, Sassari, Viale San Pietro 43, Italy
| | - Carlo Doria
- Orthopaedic Department, University of Sassari, Sassari, Viale San Pietro 43, Italy
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Comparison of deltoid ligament repair and non-repair in acute ankle fracture: A meta-analysis of comparative studies. PLoS One 2021; 16:e0258785. [PMID: 34767584 PMCID: PMC8589189 DOI: 10.1371/journal.pone.0258785] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Background Rupture of the deltoid ligament (DL) in acute ankle fracture is very common. However, there is still insufficient evidence on whether to repair the DL in acute ankle fracture. Therefore, a systematic review and meta-analysis of comparative studies was performed to report the outcome of DL repair in acute ankle fracture. Methods The PubMed, Cochrane Library, EMBASE and Web of Science databases were searched from the inception dates to October 31, 2020, for comparative studies. The methodological quality was evaluated based on the risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials (RCTs) or the Risk-of-Bias Assessment Tool for Non-randomized Studies (RoBANS). The post-operative medial clear space (MCS), final MCS, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) score and incidence of complications were analysed. Results A total of 8 comparative studies involving 388 participants who suffered Weber type B or C ankle fractures were included in this meta-analysis. The results showed that the post-operative MCS, final MCS, AOFAS score and rate of complications were statistically superior in the DL repair group. For the VAS score, there was no significant difference between the DL repair group and the DL non-repair group. Conclusions In this meta-analysis of comparative studies, DL repair offered great advantages in terms of the post-operative MCS, final MCS, AOFAS score and rate of complications compared with non-repair. The repair of the DL in patients with acute ankle fractures might be beneficial to ankle joint stability and assist in improving the quality of ankle reduction. More high-quality and prospective studies with long follow-up durations are needed to further demonstrate the superiority of DL repair over non-repair.
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Barbachan Mansur NS, Raduan FC, Lemos AVKC, Baumfeld DS, Sanchez GT, do Prado MP, de Souza Nery CA. Deltoid ligament arthroscopic repair in ankle fractures: Case series. Injury 2021; 52:3156-3160. [PMID: 34247766 DOI: 10.1016/j.injury.2021.06.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION 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. OBJECTIVE Demonstrate safety and functional results on patients with ankle fractures submitted to open reduction and internal fixation and arthroscopic deltoid repair. METHODS 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. RESULTS 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. DISCUSSION 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. DESIGN Level IV. Retrospective case series.
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Nott E, Matheny LM, Clanton TO, Lockard C, Douglass BW, Tanghe KK, Matta N, Brady AW. Accessibility and Thickness of Medial and Lateral Talar Body Cartilage for Treatment of Ankle and Foot Osteochondral Lesions. Foot Ankle Int 2021; 42:1330-1339. [PMID: 34049457 DOI: 10.1177/10711007211015189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purposes of this study were to determine (1) if cartilage thicknesses on the talar dome and medial/lateral surfaces of the talus were similar, (2) whether there was sufficient donor cartilage surface area on the medial and lateral talar surfaces to repair talar dome cartilage injuries of the talus, and (3) whether the cartilage surface could be increased following anterior talofibular ligament (ATFL) and sectioning of the tibionavicular and tibiospring portion of the anterior deltoid. METHODS Medial and lateral approaches were utilized in 8 cadaveric ankles to identify the accessible medial, lateral, and talar dome cartilage surfaces in 3 conditions: (1) intact, (2) ATFL release, and (3) superficial anterior deltoid ligament release. The talus was explanted, and the cartilage areas were digitized with a coordinate measuring machine. Cartilage thickness was quantified using a laser scanner. RESULTS The mean cartilage thickness was 1.0 ± 0.1 mm in all areas tested. In intact ankles, the medial side of the talus showed a larger total area of available cartilage than the lateral side (152 mm2 vs 133 mm2). ATFL release increased the available cartilage area on the medial and lateral sides to 167 mm2 and 194 mm2, respectively. However, only the lateral talar surface had sufficient circular graft donor cartilage available for autologous osteochondral transplantation (AOT) procedures of the talus. After ATFL and deltoid sectioning, there was an increase in available graft donor cartilage available for AOT procedures. CONCLUSION The thickness of the medial and lateral talar cartilage surfaces is very similar to that of the talar dome cartilage surface, which provides evidence that the medial and lateral surfaces may serve as acceptable AOT donor cartilage. The surface area available for AOT donor site grafting was sufficient in the intact state; however, sectioning the ATFL and superficial anterior deltoid ligament increased the overall lateral talar surface area available for circular grafting for an AOT procedure that requires a larger graft. These results support the idea that lateral surfaces of the talus may be used as donor cartilage for an AOT procedure since donor and recipient sites are similar in cartilage thickness, and there is sufficient cartilage surface area available for common lesion sizes in the foot and ankle. CLINICAL RELEVANCE This anatomical study investigates the feasibility of talar osteochondral autografts from the medial or lateral talar surfaces exposed with standard approaches. It confirms the similar cartilage thickness of the talar dome and the ability to access up to an 8- to 10-mm donor graft from the lateral side of the talus after ligament release. This knowledge may allow better operative planning for use of these surfaces for osteochondral lesions within the foot and ankle, particularly in certain circumstances of a revision microfracture.
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Affiliation(s)
- Erik Nott
- The Steadman Clinic, Vail, CO, USA.,The Steadman Philippon Research Institute, Vail, CO, USA
| | | | | | - Carly Lockard
- The Steadman Philippon Research Institute, Vail, CO, USA
| | | | - Kira K Tanghe
- The Steadman Philippon Research Institute, Vail, CO, USA
| | - Nicholas Matta
- The Steadman Philippon Research Institute, Vail, CO, USA
| | - Alex W Brady
- The Steadman Philippon Research Institute, Vail, CO, USA
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27
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Wang J, Stride D, Horner NS, Petrisor B, Johal H, Khan M, Alolabi B. The Role of Deltoid Ligament Repair in Ankle Fractures With Syndesmotic Instability: A Systematic Review. J Foot Ankle Surg 2021; 60:132-139. [PMID: 33218869 DOI: 10.1053/j.jfas.2020.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/24/2020] [Accepted: 02/13/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is a primary ankle stabilizer against valgus forces. It is frequently ruptured in ankle fractures; however, there is currently no consensus regarding repair. A systematic database search was conducted with Medline, PubMed, and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. Screening, quality assessment, and data extraction were performed independently and in duplicate. Data extracted included pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction, and complications. After screening, 9 eligible studies from 1990 to 2018 were included (N = 508). Compared to nonrepair groups, deltoid ligament repair patients had lower syndesmotic malreduction rates (0%-9% vs 20%-35%, p ≤ .05), fewer implant removals (5.8% vs 41% p ≤ .05), and longer operating time by 16-20 minutes (p ≤ .05). There was no significant difference for pain, function, ROM, MCS, and complication rate (p ≤ .05). In conclusion, deltoid ligament repair offers lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal in comparison to trans-syndesmotic screws. Repair groups demonstrated equivalent or better outcomes for pain, function, ROM, MCS, and complication rates. Other newer syndesmotic fixation methods such as suture-button fixation require further evaluation when compared to the outcomes of deltoid ligament repair. A randomized control trial is required to further examine the outcomes of ankle fracture patients who undergo deltoid ligament repair versus trans-syndesmotic screw fixation.
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Affiliation(s)
- Julian Wang
- Resident, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canda
| | - Devon Stride
- Resident, Department of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nolan S Horner
- Resident, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Bradley Petrisor
- Professor, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Herman Johal
- Assistant Professor, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Moin Khan
- Assistant Professor, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Bashar Alolabi
- Assistant Professor, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Abstract
Chronic deltoid instability (CDI), or medial ankle instability, can happen following traumas of the foot and ankle, predominantly rotational injuries. CDI is frequently underdiagnosed or misdiagnosed. Long-term residual instability can lead to ankle posttraumatic arthritis. Adequate assessment of patients with suspected CDI is paramount. Conservative treatment can be tried for stable or mildly unstable cases, but surgical treatment is usually needed for the more severely unstable patients, or when conservative measures fail. Few reconstruction techniques have been proposed in the setting of posttraumatic CDI. This article describes our preferred technique for reconstruction of the deep components of the deltoid ligament.
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Affiliation(s)
- Cesar de Cesar Netto
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - John E Femino
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA
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29
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Abstract
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.
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Affiliation(s)
| | - Sjoerd A Stufkens
- Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
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30
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Deltoid Ligament Injuries Associated With Ankle Fractures: Arguments For and Against Direct Repair. J Am Acad Orthop Surg 2021; 29:e388-e395. [PMID: 33417379 DOI: 10.5435/jaaos-d-20-00323] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 12/06/2020] [Indexed: 02/01/2023] Open
Abstract
Ankle fractures are an extremely common orthopaedic injury treated by surgeons on a routine basis. The deltoid ligament is torn in a large number of these fractures and is commonly seen with associated radiographic changes of medial clear space widening. The clinical relevance of addressing the injured deltoid ligament with acute surgical repair has been debated for decades. The early literature documenting repair or reconstruction of the deltoid ligament dates back to the 1950s. Most commonly, orthopaedic surgeons restore the lateral column directly with fibula fracture fixation. The injury may then be further evaluated intraoperatively by stress testing to ensure syndesmosis integrity and mortise stability with indirect medial column reduction, which allows for secondary healing of the medial deltoid ligamentous complex. This popular treatment paradigm is based primarily on literature from the 1980s and has not been thoroughly evaluated with modern surgical implants, techniques, and research methods. A review and background of the supportive literature for and against deltoid ligament repair in the setting of acute ankle fractures is presented. Undeniably, the deltoid ligament complex has been proven to confer some element of stability to maintaining a congruent ankle mortise. The commonly cited data in favor of not repairing the deltoid ligament warrants careful consideration to allow accuracy in obtaining the best patient outcomes with the most predictable surgical methods available.
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Thevendran G, Kadakia AR, Giza E, Haverkamp D, D'Hooghe JP, Veljkovic A, Abdelatif NMN. Acute foot and ankle injuries and time return to sport. SICOT J 2021; 7:27. [PMID: 33861196 PMCID: PMC8051311 DOI: 10.1051/sicotj/2021024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/20/2021] [Indexed: 01/18/2023] Open
Abstract
Foot and ankle sports injuries encompass a wide spectrum of conditions from simple contusions or sprains that resolve within days to more severe injuries that change the trajectory of an athlete’s sporting career. If missed, severe injuries could lead to prolonged absence from the sport and therefore a catastrophic impact on future performance. In this article, we discuss the presentation of the commonest foot and ankle sports injuries and share recent evidence to support an accurate diagnosis and best management practice.
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Affiliation(s)
- Gowreeson Thevendran
- Consultant Orthopaedic Surgeon, Mount Elizabeth Novena Hospital, 38 Irrawaddy Road, 329563, Singapore
| | - Anish R Kadakia
- Professor of Orthopedic Surgery, Northwestern Memorial Hospital, Chicago, 60611 IL, USA
| | | | - Daniel Haverkamp
- Xpert Clinics Orthopedics, Laarderhoogtweg 12, 1101 EA Amsterdam, The Netherlands
| | - Jonkheer Pieter D'Hooghe
- Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, 29222 Doha, Qatar
| | - Andrea Veljkovic
- Department of Orthopaedic Surgery, St. Paul's Hospital, Footbridge Clinic, University of British Columbia, Vancouver, V6T 1Z4 BC, Canada
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Nasrallah K, Haim S, Einal B. Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review. Orthop Rev (Pavia) 2021; 13:8987. [PMID: 33936572 PMCID: PMC8082171 DOI: 10.4081/or.2021.8987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/29/2020] [Indexed: 11/23/2022] Open
Abstract
Ankle fractures are among the most common injuries treated by orthopaedic traumatologists. These fractures range from stable, simple injuries to complex, multi-planar unstable ones. Osseo-ligamentous structures play a paramount role in maintaining the stability of the ankle joint. The deltoid ligament is among the most important ankle static stabilizers. Rupture of this ligament along with a lateral malleolar fracture is considered by many as an unstable type of injury and usually requires surgical treatment (bi-malleolar equivalent). Left untreated, it may lead to chronic pain, loss of function and secondary arthritis. Due to lack of high-quality evidence, there are no welldefined, well-accepted criteria for the diagnosis and treatment for treating this type of injury.
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Affiliation(s)
- Khalil Nasrallah
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
| | - Shtarker Haim
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
| | - Bathish Einal
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
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Arthur D, Pyle C, Shymon SJ, Lee D, Harris T. Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures. Foot Ankle Int 2021; 42:251-256. [PMID: 33106030 DOI: 10.1177/1071100720962796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Schlickewei C, Krähenbühl N, Dekeyser GJ, Mills M, Priemel M, Rammelt S, Frosch KH, Barg A. [Unstable injuries of the deltoid ligament complex in ankle fractures : How to diagnose, how to treat?]. Unfallchirurg 2021; 124:190-199. [PMID: 33616680 DOI: 10.1007/s00113-021-00970-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Carsten Schlickewei
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | | | | | - Megan Mills
- Radiologische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA
| | - Matthias Priemel
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Alexej Barg
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland. .,Orthopädische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA.
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35
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Park YH, Jang KS, Yeo ED, Choi GW, Kim HJ. Comparison of Outcome of Deltoid Ligament Repair According to Location of Suture Anchors in Rotational Ankle Fracture. Foot Ankle Int 2021; 42:62-68. [PMID: 32951566 DOI: 10.1177/1071100720952053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The suture anchors for the repair of deltoid ligament in rotational ankle fracture are inserted mostly into the medial malleolus, but sometimes are placed into the talus depending on the rupture site. This study sought to compare the radiological and clinical outcomes of deltoid ligament repair according to using these 2 locations for suture anchor placement. METHODS The cases of 131 patients (114 patients with suture anchors on the medial malleolus and 17 patients with suture anchors on the talus) who underwent deltoid ligament repair along with ankle fracture fixation were retrospectively reviewed. Medial clear space oblique (MCSo), medial clear space perpendicular (MCSp), tibiofibular clear space (TFCS), and tibiofibular overlap (TFO) were measured as radiological outcomes, while the Olerud-Molander Ankle Score (OMAS) and visual analog scale (VAS) score for pain were calculated as clinical outcomes. The follow-up period did not differ between the 2 groups (16.8 ± 10.9 months in the medial malleolus group vs 17.9 ± 14.3 months in the talus group; P = .670). RESULTS There were no differences in MCSo, MCSp, TFCS, and TFO at 3 months after surgery and final follow-up. The OMAS and VAS for pain did not show intergroup differences at final follow-up. CONCLUSION The surgical outcome of deltoid ligament repair in rotational ankle fracture did not differ whether the suture anchors were inserted into the medial malleolus or into the talus. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Young Hwan Park
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Guro-gu, Seoul, Korea
| | - Kyu Sun Jang
- Department of Orthopaedic Surgery, Barunsesang Hospital, Gyeonggi-Do, Seoul, Korea
| | - Eui Dong Yeo
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Gi Won Choi
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, Danwon-gu, Ansan, Korea
| | - Hak Jun Kim
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Guro-gu, Seoul, Korea
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Mansur NSB, Lemos AVKC, Baumfeld DS, Baumfeld TS, Prado MPD, Raduan FC, Nery CAS. Medial and Lateral Combined Ligament Arthroscopic Repair for Multidirectional Ankle Instability. FOOT & ANKLE ORTHOPAEDICS 2021; 6:2473011420986150. [PMID: 35097429 PMCID: PMC8702971 DOI: 10.1177/2473011420986150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: The high prevalence of ankle sprains in the population produces a significant number of patients with lateral instability. Persistence of this condition may lead to the progressive involvement of medial structures, causing a multidirectional rotational instability. Methods: This is a retrospective study with patients diagnosed with multidirectional instability who underwent ankle arthroscopy with medial (arthroscopic tensioning) and lateral repair (arthroscopic Bröstrom) between January 2018 and January 2020. All patients were evaluated for pain and function according to the visual analog scale (VAS) score and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score at a mean of 14.8 months (5-27 months) in follow-up. A total of 30 ankles (29 patients) were included in the study. Results: The AOFAS score increase from a 49.7 (CI 5.8) to a 91.9 (CI 2.4) mean (P = .001) and was followed by significant improvement in the mean VAS score (6.8, CI 0.37-0.95, CI 0.31). The majority of patients had associated procedures (53.3%), and a low complication rate was found (16.6%). Conclusion: Combined medial and lateral arthroscopic repair might be an effective and safe alternative in the treatment of multidirectional instability. Inclusion of the deltoid ligament complex and the low invasiveness of the arthroscopic technique may improve the clinical outcomes of these patients. Level of Evidence: Level IV, retrospective case series.
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Abstract
There is no consensus on whether the deltoid ligament must be repaired in ankle fractures. Recent studies have shown better early radiologic results when the deltoid ligament is repaired, but no differences in long term functional outcomes. However, there is evidence suggesting that patients with high fibular fractures or injuries with concomitant syndesmotic instability may benefit from repair. The authors recommend repairing the deltoid ligament complex in bimalleolar equivalent fractures associated with syndesmotic or gross multiligamentous instability as well as in heavier patients with greater mechanical requirements.
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Affiliation(s)
- Gonzalo F Bastias
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes, Estoril 450, Las Condes, Santiago 7591047, Chile; Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Ramon Carnicer 185, Providencia, Santiago 7501239, Chile; Department of Orthopedic Surgery, Universidad de Chile, Complejo Hospitalario San Jose, 1027 Independencia, Santiago 8380453, Chile
| | - Jorge Filippi
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes, Estoril 450, Las Condes, Santiago 7591047, Chile; Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Ramon Carnicer 185, Providencia, Santiago 7501239, Chile.
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38
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The Importance of the Deep Deltoid Ligament Repair in Treating Supination-External Rotation Stage IV Ankle Fracture: A Comparative Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2043015. [PMID: 33313312 PMCID: PMC7719498 DOI: 10.1155/2020/2043015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/26/2020] [Accepted: 11/21/2020] [Indexed: 11/26/2022]
Abstract
Background The necessity of the deep deltoid ligament repair in the treatment of supination-external rotation (SER) ankle stage IV fracture with deltoid ligament rupture is highly debated. We conducted this retrospective research aimed at exploring the curative effect of the deep deltoid ligament repair in treating SER fracture. Methods Sixty-three patients with closed SER stage IV fractures received open reduction and internal fixation (ORIF), using either deep deltoid ligament repair (the DDLR group, 31 patients) or nondeep deltoid ligament repair (the NDDLR group, 32 patients). The radiographic parameters examined include the talocrural angle (TA), fibular length (FL), tibiomedial malleolar angle (TMMA), medial clear space (MCS), and tibiofibular clear space (TFCS). The functional performance parameters examined in the study were visual analog scale (VAS) pain score, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scales, and range of motion of bilateral ankles (RMBA). Complications, including bone nonunion, infection, and fragment displacement, were also recorded and compared. Results Similar basic characteristics were found in both cohorts. All patients completed follow-up ranging from 12 to 22 months (mean time: 12.41 ± 4.21 months). The DDLR group had significantly reduced VAS score (p < 0.05), with markedly increased RMBA (p < 0.05) compared to the NDDLR group. The two cohorts showed similar follow-up performance at 3 months (p > 0.05), 6 months (p > 0.05), and 12 months (p > 0.05), in terms of parameters including TA, FL, TMMA, MCS, TCS, and AOFAS ankle-hindfoot scales. Conclusion Although similar radiographic performances were achieved in both cohorts, the DDLR group displayed enhanced functional outcome postsurgery, indicating that DDLR may be a better potential for the treatment of SER stage IV fracture with deltoid ligament rupture.
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Luo G, Ni W, Guo S, Guo S. [Effectiveness of repairing the deep layer of deltoid ligament by suture anchor repair method in treatment of mixed medial injury associated with ankle fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1387-1391. [PMID: 33191695 DOI: 10.7507/1002-1892.202004148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore the necessity of repairing the deep layer of deltoid ligament in the treatment of mixed medial injury associated with ankle fractures. Methods Between January 2016 and December 2018, 12 patients with mixed medial injury associated with ankle fractures were treated with the fixation of the lateral malleolus by bone plates, the fixation of the anterior colliculus of medial malleolus by cannulated screws, and the repair of the deltoid ligament by suture anchors. There were 8 males and 4 females, with an average age of 42 years (range, 18-56 years). According to the Lauge-Hansen classification criteria, there were 11 cases of supination-external rotation type and 1 case of pronation-external rotation type. According to the Weber classification criteria, all cases were type B. The time from injury to operation was 3-6 days, with an average of 4.7 days. In each patient, X-ray films of anteroposterior and lateral views and mortise view of ankle were taken postoperatively. The motion range of ankle joints was observed. The function of the ankle and the outcome of the treatment were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Olerud-Molander scoring system, and the visual analogue scale (VAS) score. Results All cases were followed up 12-42 months (mean, 28 months). The 12 patients returned to their pre-injury jobs. Five patients with sports injury completely recovered to their pre-injury motor function. No patient experienced persistent medial ankle pain or ankle instability. At last follow-up, the ankle range of motion in dorsiflexion was 9°-25° (mean, 17.96°), which was 0°-11° (mean, 4.02°) less than that in normal side; the range of motion in plantar flexion was 38°-50° (mean, 43.90°), which was 0°-7° (mean, 2.53°) less than that in normal side. The AOFAS score was 88-100 (mean, 96.7); the Olerud-Molander score was 90-100 (mean, 96.5); the VAS score was 0-3 (mean, 1.1). Conclusion It is necessary to repair the deep layer of deltoid ligament in the mixed medial injuries associated with ankle fracture, which include anterior colliculus fracture and deep deltoid ligament injury. A better outcome can be achieved by employing the suture anchor repair method.
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Affiliation(s)
- Gang Luo
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - Weidong Ni
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - Shihang Guo
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - Shuquan Guo
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
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Mococain P, Bejarano-Pineda L, Glisson R, Kadakia RJ, Akoh CC, Chen J, Nunley JA, Easley ME. Biomechanical Effect on Joint Stability of Including Deltoid Ligament Repair in an Ankle Fracture Soft Tissue Injury Model With Deltoid and Syndesmotic Disruption. Foot Ankle Int 2020; 41:1158-1164. [PMID: 32545997 DOI: 10.1177/1071100720929007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The current operative standard of treatment for bimalleolar equivalent ankle fracture is open reduction and internal fixation (ORIF) of the lateral malleolus followed by syndesmotic stabilization if indicated. There is controversy surrounding the indication and need for deltoid ligament repair in this setting. The purpose of this study was to quantify the biomechanical effect of deltoid ligament repair in an ankle fracture soft tissue injury model. METHODS Nine fresh-frozen cadaveric specimens were included in this study. Each leg was tested under 5 conditions: intact, syndesmosis and deltoid ligament sectioned, syndesmosis fixed, deltoid repaired, and both the syndesmosis and deltoid ligament repaired. Anterior, posterior, lateral, and medial drawer and rotational stresses were applied to the foot, and the resulting talus displacement was documented. RESULTS Isolated deltoid repair significantly reduced anterior displacement to normal levels. Displacement with lateral drawer testing was not significantly corrected until both structures were repaired. Deltoid repair and syndesmosis fixation each reduced internal rotation significantly with further reduction to normal levels when both were repaired. External rotation remained elevated relative to the intact condition regardless of which structures were repaired. CONCLUSION There is existing controversy regarding the importance of deltoid ligament repair in the setting of ankle fractures. The findings of this biomechanical study indicate that deltoid ligament repair enhances ankle stability in ankle fractures with both syndesmotic and deltoid disruption. CLINICAL RELEVANCE Concomitant deltoid ligament repair in addition to stabilization of fracture and syndesmosis may improve long-term functioning of the ankle joint and clinical outcomes.
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Affiliation(s)
- Pablo Mococain
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | | | - Richard Glisson
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Rishin J Kadakia
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Craig C Akoh
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Jie Chen
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - James A Nunley
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Mark E Easley
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
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Abstract
Despite the fact that ankle fractures are common injuries, not all patients obtain satisfactory results. Historically, the deltoid ligament injury and intra-articular pathology have not often been treated at the time of fracture stabilization. Recent literature has suggested that repair of the deltoid ligament may lead to better stability of the ankle mortise. Additionally, the use of arthroscopy in conjunction with fracture fixation may allow for better identification and treatment of intra-articular lesions and improve detection and reduction of subtle instability.
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Affiliation(s)
- Minton Truitt Cooper
- Department of Orthopaedic Surgery, University of Virginia, Box 800159, Charlottesvlle, VA 22908, USA.
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Acevedo JI, Kreulen C, Cedeno AA, Baumfeld D, Nery C, Mangone PG. Technique for Arthroscopic Deltoid Ligament Repair With Description of Safe Zones. Foot Ankle Int 2020; 41:605-611. [PMID: 32100553 DOI: 10.1177/1071100720909138] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level V, expert opinion.
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Affiliation(s)
- Jorge I Acevedo
- Department of Orthopedics, Southeast Orthopedic Specialists, Jacksonville, FL, USA
| | - Christopher Kreulen
- Department of Orthopaedics, University of California, Davis, Sacramento, CA, USA
| | | | | | - Caio Nery
- Federal University of São Paulo, SP, Brazil
| | - Peter G Mangone
- Department of Orthopedics, Blue Ridge Division of EmergeOrtho, Foot and Ankle Center, Arden, NC, USA
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Yin Z, Wang Z, Ge D, Yan J, Jiang C, Liang B. Treatment of a high-energy transsyndesmotic ankle fracture: A case report of "logsplitter injury". Medicine (Baltimore) 2020; 99:e19380. [PMID: 32118785 PMCID: PMC7478461 DOI: 10.1097/md.0000000000019380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 12/15/2019] [Accepted: 01/29/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The "logsplitter injury" is a special type of ankle fractures that results from high energy violence with combined rotational forces and axial loads. So far, the diagnose and treatment of "logsplitter injury" remain largely unsettled and related literature is rare. PATIENT CONCERNS An 18-year-old male fell from a fence and got his left ankle injured with severe malformation and swollen condition. No open wound was observed. DIAGNOSIS Logsplitter injury, ankle fracture (AO/OTA classification 44C1.1, Lauge-Hansen classification: pronation-external rotation). INTERVENTIONS AND OUTCOMES The patient was initially treated by internal fixation of fibular, repair of deltoid ligaments, and 1 syndesmotic screw fixation. When the X-ray applied after surgery, another 2 syndesmotic screws were performed to enhance stability. The syndesmotic screws were removed at 12-week and 16-week respectively. The patient was allowed for full weight-bearing immediately. However, the syndesmotic space was slightly increased compared to the contralateral side in CT views at 1-year follow-up, the function outcome was satisfied. CONCLUSION The logsplitter injury is a high-energy ankle fracture that requires both axial and rotational load. It is categorized as 44B or 44C by the AO/OTA classification. In the classification scheme of Lauge-Hansen, our case is in line with the pronation-external rotation classification. Anatomic reduction and fixation of ankle syndesmotic injuries are required to restore the biomechanics of the ankle joint so that long-term complications can be prevented. How to fixation the syndesmosis, whether to reconstruct the deltoid ligament remains in debate in the treatment of logsplitter injury, whether and when to remove the syndesmotic screws were still debated. Correct surgical intervention is successful in the treatment of "logsplitter injury", however, the optimal fixation of syndesmosis and repair of deltoid ligaments need further investigate.
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Lubberts B, Massri-Pugin J, Guss D, Wolf JC, Bhimani R, Waryasz GR, DiGiovanni CW. Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model. Foot Ankle Int 2020; 41:237-243. [PMID: 31592680 DOI: 10.1177/1071100719879673] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane. METHODS Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured. RESULTS Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state (P values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%). CONCLUSION Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation. CLINICAL RELEVANCE These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.
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Affiliation(s)
- Bart Lubberts
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jafet Massri-Pugin
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Daniel Guss
- Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rohan Bhimani
- Foot and Ankle Research and Innovation Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory R Waryasz
- Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher W DiGiovanni
- Massachusetts General Hospital, Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
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Salameh M, Alhammoud A, Alkhatib N, Attia AK, Mekhaimar MM, D'Hooghe P, Mahmoud K. Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies. INTERNATIONAL ORTHOPAEDICS 2020; 44:341-347. [PMID: 31776609 PMCID: PMC6968990 DOI: 10.1007/s00264-019-04416-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/13/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others stated that persistent medial clear space widening and malreduction are higher when deltoid ligaments went without repair. This meta-analysis aims to report the current published evidence about the outcomes of deltoid ligament repair in ankle fractures. METHODS Several databases were searched through May 2018 for comparative studies. The primary outcome was the medial clear space correction, while secondary outcomes included maintenance of medial clear space reduction, pain scores, functional outcome, and total complications if any. Three comparative studies met the inclusion criteria for the meta-analysis. The analysis included a total of 192 patients, 81 in the deltoid ligament repair group and 111 in the non-repair group. RESULTS The medial clear space correction and maintenance of the said correction on final follow-up radiographs were superior in the deltoid ligament repair group. Although the pain scores were better in the repair group at the final follow-up, this did not result in a better functional outcome, with similar total complication rates. CONCLUSION In conclusion, those who had their deltoid ligament repaired had superior early and late radiological correction of the medial clear space, an indicator of the quality of ankle reduction with better pain scores. However, no differences in the functional outcome and complications rate were reported.
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Affiliation(s)
- Motasem Salameh
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar.
| | | | - Nedal Alkhatib
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Ahmed K Attia
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Mohamed M Mekhaimar
- Orthopedic Surgery Department, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Pieter D'Hooghe
- Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar
| | - Karim Mahmoud
- University of Pennsylvania Foot and Ankle Program, Philadelphia, PA, USA
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Bae KJ, Kang SB, Kim J, Lee J, Go TW. Reduction and fixation of anterior inferior tibiofibular ligament avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. J Int Med Res 2019; 48:300060519882550. [PMID: 31885342 PMCID: PMC7607056 DOI: 10.1177/0300060519882550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. Methods We retrospectively reviewed 66 consecutive patients with displaced malleolar fracture combined with AITFL avulsion fracture. We performed reduction and fixation for the AITFL avulsion fracture when syndesmotic instability was present after malleolar fracture fixation. A syndesmotic screw was inserted only when residual syndesmotic instability was present even after AITFL avulsion fracture fixation. The radiographic parameters were compared with those of the contralateral uninjured ankles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were assessed 1 year postoperatively. Results Fifty-four patients showed syndesmotic instability after malleolar fracture fixation and underwent reduction and fixation for AITFL avulsion fracture. Among them, 45 (83.3%) patients achieved syndesmotic stability, while 9 (16.7%) patients with residual syndesmotic instability needed additional syndesmotic screw fixation. The postoperative radiographic parameters were not significantly different from those of the uninjured ankles. The mean AOFAS score was 94. Conclusion Reduction and fixation of AITFL avulsion fracture obviated the need for syndesmotic screw fixation in more than 80% of patients with AITFL avulsion fracture and syndesmotic instability.
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Affiliation(s)
- Kee Jeong Bae
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung-Baik Kang
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jihyeung Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jaewoo Lee
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Tae Won Go
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
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Dabash S, Elabd A, Potter E, Fernandez I, Gerzina C, Thabet AM, McGarvey W, Abdelgawad A. Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review. Foot Ankle Surg 2019; 25:714-720. [PMID: 30482440 DOI: 10.1016/j.fas.2018.11.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/18/2018] [Accepted: 11/02/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Deltoid ligament injuries are typically caused by supination-external rotation or pronation injury. Numerous ligament reconstruction techniques have been proposed; however, clear indications for operative repair have not yet been well established in the literature. METHODS We reviewed primary research articles comparing ORIF treatment for ankle fracture with versus without deltoid ligament repair. RESULTS Five studies were identified with a total of 281 patients. 137 patients underwent ORIF with deltoid repair, while 144 patients underwent ORIF without deltoid ligament repair. Clinical, radiographic, and functional outcomes, as well as complications were considered. The average follow-up was 31 months (range, 5-120). CONCLUSIONS Current literature does not provide clear indication for repair of the deltoid ligament at the time of ankle fracture repair. There may be some advantages of adding deltoid ligament repair for patients with high fibular fractures or in patients with concomitant syndesmotic fixation. LEVEL OF CLINICAL EVIDENCE III.
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Affiliation(s)
- Sherif Dabash
- Department of Orthopaedic Surgery, The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX, 77030, United States.
| | - Ahmed Elabd
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center - El Paso, 4801 Alberta Avenue, El Paso, TX, 79905 United States
| | - Eric Potter
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center - El Paso, Medical Education Building 2200, 5001 El Paso Drive, El Paso, TX, 79905, United States
| | - Isaac Fernandez
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center - El Paso, 4801 Alberta Avenue, El Paso, TX, 79905 United States
| | - Chris Gerzina
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center - El Paso, Medical Education Building 2200, 5001 El Paso Drive, El Paso, TX, 79905, United States
| | - Ahmed M Thabet
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center - El Paso, 4801 Alberta Avenue, El Paso, TX, 79905 United States
| | - William McGarvey
- Department of Orthopaedic Surgery, The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX, 77030, United States
| | - Amr Abdelgawad
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center - El Paso, 4801 Alberta Avenue, El Paso, TX, 79905 United States
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Abstract
The last stage of a supination-external rotation ankle fracture involves either transverse fracture of the medial malleolus or rupture of the deltoid ligament. When the deltoid ligament ruptures, a "bimalleolar equivalent" ankle fracture occurs, and the surgeon is presented with several diagnostic and therapeutic challenges. In the native ankle, the deltoid ligament provides restraint to eversion and external rotation of the talus on the tibia. 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 evidence of superior clinical outcomes with the addition of deltoid repair compared with open reduction and internal fixation of the fibula alone.
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Butler BA, Hempen EC, Barbosa M, Muriuki M, Havey RM, Nicolay RW, Kadakia AR. Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures. J Orthop 2019; 17:87-90. [PMID: 31879481 DOI: 10.1016/j.jor.2019.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/03/2019] [Accepted: 06/02/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Treatment of supination external rotation type IV (SER-IV) ankle injuries has focused on reduction and fixation of the fibula and syndesmosis (ORIF), not repair of the deltoid ligament. Methods Twenty-one ankles were analyzed with a motion capture system. Uninjured ankles were stressed and compared to ankles with SER-IV injuries, then with ORIF, and finally ORIF and deltoid repair. Results After deltoid ligament repair, talar coronal and axial rotation normalized to the uninjured state and were significantly reduced compared to ORIF alone. Discussion Deltoid ligament repair after an SER-IV ankle injury can help directly reduce and stabilize the tibiotalar joint.
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Affiliation(s)
- Bennet A Butler
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Eric C Hempen
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Mauricio Barbosa
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Muturi Muriuki
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr VA Hospital, 5000 5th Ave, Hines, IL, 60141, USA
| | - Robert M Havey
- Musculoskeletal Biomechanics Laboratory, Edward Hines, Jr VA Hospital, 5000 5th Ave, Hines, IL, 60141, USA
| | - Richard W Nicolay
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
| | - Anish R Kadakia
- Northwestern Memorial Hospital Department of Orthopaedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
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Affiliation(s)
- Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Mansur Halai
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Jacob Matz
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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