1
|
Yang T, Zhu F, Wang H, Wu B, Jia D, Meng C, Zhao Y. Kirschner Wire Internal Fixation of the Medial Tibiotalar Joint for Indirect Repair of Deltoid Ligament Injury: A Retrospective Comparative Study. Orthop Surg 2024; 16:140-148. [PMID: 38086605 PMCID: PMC10782261 DOI: 10.1111/os.13968] [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] [Received: 05/05/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE Ankle joint fractures are often accompanied by medial deltoid ligament rupture. There is controversy over whether or how to treat deltoid ligament rupture. This study was aimed to explore the feasibility of repairing the medial deltoid ligament using Kirschner wire internal fixation of the medial tibiotalar joint combined with external fixation. METHODS Forty-six patients with ankle fractures involving deltoid ligament rupture, treated between October 2012 and February 2021, were retrospectively evaluated. Twenty-five patients were treated with a Kirschner wire to fix the tibiotalar joint and indirectly repair the deltoid ligament as the repaired group. Twenty-one patients underwent reduction and fixation of internal and external malleolus fractures, and the deltoid ligament was not repaired in the unrepaired group. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS), Medical Outcomes Short Form 36-item questionnaire score (SF-36), and Medial clear space perpendicular (preoperative, postoperative, final follow-up) were used for functional evaluations and reduction assessments. Mann-Whitney test were used to compare the differences between the groups. RESULTS The follow-up time was 13-112 months with a mean of 59.32 months for the repaired group and 11-94 months with a mean of 53.43 months for the unrepaired group. There was no significant difference in the operative time or intraoperative blood loss between the two groups (p > 0.05). At the last follow-up, the AOFAS ankle-hindfoot and SF-36 scores of the repaired group were significantly higher than those of the non-repaired group (p < 0.05). Moreover, the VAS pain score was significantly lower and the Medial clear space perpendicular was significantly narrower in the repaired group than that in the unrepaired group. CONCLUSION Tibiotalar joint fixation using Kirschner wires is a simple and effective technique that can indirectly reduce and repair the deltoid ligament and stabilize the ankle.
Collapse
Affiliation(s)
- Tao Yang
- Jining Medical UniversityJiningChina
| | - Fenghua Zhu
- Department of OncologyAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Haibin Wang
- Department of Traumatic OrthopedicsAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Bin Wu
- Department of Traumatic OrthopedicsAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Dailiang Jia
- Department of Emergency SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Chunyang Meng
- Department of Spine SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Yifeng Zhao
- Department of Traumatic OrthopedicsAffiliated Hospital of Jining Medical UniversityJiningChina
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| | | |
Collapse
|
4
|
Li CCH, Lui TH. Arthroscopic Deltoid Ligament Reconstruction in Rotational Ankle Instability. Arthrosc Tech 2023; 12:e1179-e1184. [PMID: 37533912 PMCID: PMC10391247 DOI: 10.1016/j.eats.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/26/2023] [Accepted: 03/16/2023] [Indexed: 08/04/2023] Open
Abstract
Chronic lateral ankle instability is a common orthopaedic problem. The continuous stress applied by the lateral instability may affect the superficial deltoid ligament. The combination of lateral ankle instability and injury to the most anterior fascicles of the deltoid ligament contributes to rotational ankle instability. The purpose of this Technical Note is to describe the details of arthroscopic deltoid ligament reconstruction in rotational ankle instability. This minimally invasive approach allows other associated lesions to be detected and managed arthroscopically.
Collapse
Affiliation(s)
| | - Tun Hing Lui
- Department of Orthopaedics and Traumatology, Sheung Shui, NT, Hong Kong SAR, China
| |
Collapse
|
5
|
de Cesar Netto C, Valderrabano V, Mansur NSB. Multidirectional Chronic Ankle Instability: What Is It? Foot Ankle Clin 2023; 28:405-426. [PMID: 37137631 DOI: 10.1016/j.fcl.2023.01.012] [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: 05/05/2023]
Abstract
Not all ankle sprains are the same and not all ankles behave the same way after an injury. Although we do not know the mechanisms behind an injury producing an unstable joint, we do know ankle sprains are highly underestimated. While some of the presumed lateral ligament lesions might eventually heal and produce minor symptoms, a substantial number of patients will not have the same outcome. The presence of associated injuries, such as additional medial chronic ankle instability, chronic syndesmotic instability, has been long discussed as a possible reason behind this. To explain multidirectional chronic ankle instability, this article aims to present the literature surrounding the condition and its importance nowadays.
Collapse
Affiliation(s)
- Cesar de Cesar Netto
- University of Iowa, Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA; Duke University Medical Center, USA.
| | - Victor Valderrabano
- Swiss Ortho Center & University of Basel, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 15, 4010 Basel, Switzerland
| | - Nacime Salomão Barbachan Mansur
- University of Iowa, Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA; Escola Paulista de Medicina - Universidade Federal de São Paulo, 740 Botucatu Street, Sao Paulo, SP, Brazil 04023-062
| |
Collapse
|
6
|
Li CCH, Lui TH. Arthroscopically Assisted Reduction and Fixation of Deltoid Ligament Avulsion Fracture From Medial Malleolus. Arthrosc Tech 2022; 11:e1681-e1687. [PMID: 36311332 PMCID: PMC9596391 DOI: 10.1016/j.eats.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/01/2022] [Indexed: 02/03/2023] Open
Abstract
Ankle fractures are one of the most common orthopaedic injuries. The surgical principle is to restore anatomy and stability of the ankle mortise. Repositioning of the talus under the tibia with normalization of the medial clear space is mandatory for a good outcome. Deltoid ligament injuries can present as an avulsion fracture of the medial malleolus. The purpose of this Technical Note is to describe the details of arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus. This can restore the medial stability of the ankle.
Collapse
Affiliation(s)
| | - Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong SAR, China
- Address correspondence to Dr. Tun Hing Lui, M.B.B.S. (H.K.), F.R.C.S. (Edin.), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Rd., Sheung Shui, NT, Hong Kong SAR, China.
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|