1
|
Harrasser N, Toepfer A. [Injuries of the ankle ligaments]. Orthopadie (Heidelb) 2024; 53:223-233. [PMID: 38324018 DOI: 10.1007/s00132-023-04462-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/08/2024]
Abstract
Lateral ligament injuries are the most common injuries of the ankle joint and are usually treated with early weight bearing after a short period of immobilization. If the clinical presentation is suspicious, additional injuries to the deltoid ligament complex and the syndesmosis should be considered. The indications for additional diagnostics should be generously applied. Injuries to the deltoid ligament usually occur as part of a complex ankle injury and should also be addressed in the surgical treatment of accompanying injuries. Chronic instability in this area necessitates complex bony and soft tissue procedures. Syndesmotic injuries with insufficiency of the capsule-ligament apparatus are frequent in ankle fractures and are stabilized during fracture treatment. Isolated syndesmotic instability should also be surgically treated as chronic injuries are usually associated with poor clinical results and early osteoarthritis.
Collapse
Affiliation(s)
- N Harrasser
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland.
- ECOM Excellent Center of Medicine, München, Deutschland.
| | - A Toepfer
- Klinik für Orthopädische Chirurgie und Traumatologie des Bewegungsapparates, Kantonsspital St. Gallen, St. Gallen, Schweiz
| |
Collapse
|
2
|
Luo Y, Tian X, Jiang T, Ge L. The "Hand as Foot" teaching method in anatomy of deltoid ligament. Asian J Surg 2023; 46:5198-5199. [PMID: 37481360 DOI: 10.1016/j.asjsur.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/07/2023] [Indexed: 07/24/2023] Open
Affiliation(s)
- Yitong Luo
- Graduate School of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia Autonomous Region, China; Department of Radiology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia Autonomous Region, China.
| | - Xinyue Tian
- Graduate School of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia Autonomous Region, China
| | - Tianqi Jiang
- Graduate School of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia Autonomous Region, China
| | - Lihong Ge
- Department of Radiology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, 010050, Inner Mongolia Autonomous Region, China.
| |
Collapse
|
3
|
Mansur H, Ramos LS, Lucas PPA, Battaglion LR, Freitas A. Syndesmosis dislocation and ankle ligament stress in the posterior malleolus fracture fixated - "in vitro analysis". Injury 2023; 54 Suppl 6:110782. [PMID: 38143124 DOI: 10.1016/j.injury.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 12/26/2023]
Abstract
PURPOSE The objectives of this study were to compare syndesmosis dislocation and ankle ligament stress after the fixation of the posterior malleolus fracture (PMF) with four different techniques by Finite Element Analysis (FEM). METHODS Four internal fixation techniques used for fixation of PMF were assessed by FEM: posterior one-third tubular 3.5 mm buttress plate (PP) with one screw (PP 1 screw), PP with two screws (PP 2 screws), two cannulated 3.5 mm lag screws in the anteroposterior (AP) direction (AP lag screws), and two posteroanterior (PA) cannulated 3.5 mm lag screws (PA lag screws). PMF with 30% fragment size was simulated through computational processing reconstructed from computed tomography (CT). The simulated loads of 700 N and 1200 N were applied to the proximal tibial end. The FEM evaluated the syndesmosis dislocation (mm) and stress values of the posterior tibiofibular ligament (PTFL) (in Kpa) and deltoid ligament (in Kpa) in the four mentioned subgroups. RESULTS We found that with a load of 700 N, syndesmosis dislocation varied from 6.5 to 7.9 mm, being the lowest and greatest for PA lag screw and PP 1 screw, respectively. In all groups was observed a greater dislocation in the syndesmosis at 1200 N of load. We observed that the stress values on the PTFL were lower for AP lag screws and PP 2 screws with 700 N and 1200 N, respectively. For both loads, PP 1 screw presented the greatest stress. Regarding the stress in the deltoid ligament, the AP lag screws presented the lowest stress for 700 N and PP 1 screw for 1200 N. For all fixation techniques, the syndesmosis displacement and ligament stresses were higher when 1200 N were imposed. CONCLUSION This study demonstrated that PMF fixed with lag screws presents greater stability in the distal tibiofibular syndesmosis and higher joint loadings promoted greater displacement and ligaments stress, regardless of the fixation technique. Besides, lower stress in the syndesmosis is accompanied by a greater load on the deltoid ligament.
Collapse
Affiliation(s)
- Henrique Mansur
- Hospital Regional do Gama and Hospital Santa HelenaHospital Regional do Gama, Gama, Distrito Federal, Brazil.
| | | | | | - Leonardo Rigobello Battaglion
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, Brazil
| | - Anderson Freitas
- Instituto de Pesquisa e Ensino do Hospital Ortopédico e Medicina Especializada (IPE - H O M E), Brasília, Distrito Federal, Brazil
| |
Collapse
|
4
|
Ajoy SM, Bhatia A, Galagali DA, Vohra R. Foot length - A reliable predictor of posterior tibial tendon thickness: A cadaveric study. J Clin Orthop Trauma 2023; 44:102252. [PMID: 37817760 PMCID: PMC10561053 DOI: 10.1016/j.jcot.2023.102252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/16/2023] [Accepted: 09/21/2023] [Indexed: 10/12/2023] Open
Abstract
Background Tibialis posterior tendon, deltoid ligament and spring ligament are the three most important structures on the medial aspect of the foot. They contribute to the stability of the foot and ankle and also to the maintenance of the arches of the foot. These structures get affected and dimensions get disrupted in various traumatic and degenerative conditions. Normal range of dimensions of these structures has not been studied in an Indian population. Our objective is to define the normal thicknesses of these structures using a cadaveric model. We also hypothesize that longer the foot, higher stresses on these structures and hence thicker they will be. We aim to assess this hypothesis as well. Methods Dissection of the medial aspect of the foot was done on twenty cadaveric below knee specimens. Tibialis posterior tendon was identified and its thickness was measured. Deltoid and plantar calcaneonavicular ligaments were identified. Their lengths and thicknesses were measured. Length of the feet was also measured prior to dissection. Statistical analysis was done using the data obtained. Results Mean tibialis posterior thickness was 7.0165 ± 0.387 mm. Mean deltoid thickness was 5.124 ± 0.28 mm. Its mean length was 21.328 ± 2.22 mm. Mean plantarcalcaneonavicular ligament thickness was 2.491 ± 1.120 mm. Thicknesses of the tibialis posterior tendon and plantarcalcaneonavicular ligament correlated significantly with the length of the foot. Conclusion The thicknesses of the tibialis posterior tendon and plantar calcaneonavicular ligament are shown to be a function of and significantly proportional to the length of the foot. This helps the surgeon to estimate the thicknesses which the structures had prior to the pathology, in order to recreate the non-pathological anatomy after a tendon transfer or a reconstruction procedure. The normal thicknesses of tibialis posterior, deltoid and plantar calcaneonavicular ligaments are described for an Indian setting and deviations can be used to assess various pathologies of the foot and ankle affecting these structures.
Collapse
Affiliation(s)
- Shiv Manik Ajoy
- Department of Orthopaedics, Ramaiah Medical College and Hospital, Matthikere, Bangalore, 560054, Karnataka, India
| | - Aanchal Bhatia
- Department of Orthopaedics, Ramaiah Medical College and Hospital, Matthikere, Bangalore, 560054, Karnataka, India
| | - Dev Anand Galagali
- Department of Orthopaedics, Ramaiah Medical College and Hospital, Matthikere, Bangalore, 560054, Karnataka, India
| | - Rajeev Vohra
- Department of Orthopaedics, Amandeep Hospital, Grand Trunk Rd, Model Town, Rani Ka Bagh, Mohindra Colony, Amritsar, Punjab, 143001, India
| |
Collapse
|
5
|
Pflüger P, Valderrabano V. Sprain of the Medial Ankle Ligament Complex. Foot Ankle Clin 2023; 28:355-367. [PMID: 37137629 DOI: 10.1016/j.fcl.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.
Collapse
Affiliation(s)
- Patrick Pflüger
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Victor Valderrabano
- SWISS ORTHO CENTER, Swiss Medical Network, Schmerzklinik Basel, University of Basel, Hirschgässlein 15, Basel 4010, Switzerland.
| |
Collapse
|
6
|
Abstract
The deltoid ligament is the primary stabilizer of the medial side of the ankle joint. It is a complex structure with an origin at the medial malleolus from where it spreads fan shaped distally with an insertion into the medial side of the talus, calcaneus and navicular bone. This chapter gives an overview of the anatomy, function, and pathology of the deltoid ligament.The deltoid ligament can become insufficient as a result of an ankle injury or prolonged strain. In the acute setting, deltoid insufficiency often coincides with multi ligament injury the ankle joint; syndesmosis injury, or ankle fractures. Management in the acute phase remains a subject of debate. Some orthopedic surgeons have a tendency towards repair, whereas most trauma surgeons often treat the deltoid nonoperatively. In the chronic setting the ligament complex is often elongated as a result of prolonged strain. It often coexists with a hindfoot valgus, as is the case in planovalgus feet. In such a case a realignment procedure should be combined with the deltoid repair.
Collapse
Affiliation(s)
- Loek Loozen
- Footbridge Center for Integrated Foot and Ankle Care, Department of Orthopaedics, University of British Columbia, Vancouver, CA
| | - Andrea Veljkovic
- Footbridge Center for Integrated Foot and Ankle Care, Department of Orthopaedics, University of British Columbia, Vancouver, CA
| | - Alastair Younger
- Footbridge Center for Integrated Foot and Ankle Care, Department of Orthopaedics, University of British Columbia, Vancouver, CA
| |
Collapse
|
7
|
Mateen S, Van JC. Ligament Insufficiency with Flatfoot: Spring Ligament and Deltoid Ligament. Clin Podiatr Med Surg 2023; 40:307-314. [PMID: 36841581 DOI: 10.1016/j.cpm.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The objective of this article was to review the deltoid ligament and spring ligament specifically as they pertain to ligament insufficiency and adult-acquired flatfoot deformity. Discussion includes the normal and abnormal biomechanical forces that extend through these ligaments in normal and flatfoot deformity. Current literature related to spring ligament repair as part of the flatfoot deformity reconstruction is also reviewed.
Collapse
Affiliation(s)
- Sara Mateen
- Foot and Ankle Deformity and Orthoplastics, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jennifer C Van
- Department of Podiatric Surgery, Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA.
| |
Collapse
|
8
|
Iyengar KP, Gregory K, Beale D, Prem H, Gavvala S, Botchu R. Isolated, periosteal stripping injuries of the Flexor Retinaculum: Case series of 3 patients with clinico-radiological review. J Clin Orthop Trauma 2023; 36:102082. [PMID: 36465495 PMCID: PMC9712989 DOI: 10.1016/j.jcot.2022.102082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/03/2022] [Accepted: 11/23/2022] [Indexed: 11/25/2022] Open
Abstract
Isolated periosteal avulsion injuries of the flexor retinaculum on the medial side of the ankle are rare and may mimic osseous injuries or deltoid ligament tears. We describe a case series of 3 individuals with isolated, stripping injuries of the tibial attachment of the flexor retinaculum without underlying fracture or deltoid ligament disruption. A new classification system of flexor retinaculum periosteal stripping injuries of the ankle is proposed with clinico-radiological features.
Collapse
Affiliation(s)
| | - K.M. Gregory
- Department of Sport and Exercise Medicine, University Hospitals of Birmingham, Birmingham and University Hospitals of Leicester, UK
| | | | - H. Prem
- Department of Foot and Ankle Surgery, Royal Orthopedic Hospital, Birmingham, UK
| | - S.N. Gavvala
- Department of Radiology, Kurnool Medical College, Kurnool, India
| | - R. Botchu
- Heath Lodge Clinic, Knowle, UK
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
| |
Collapse
|
9
|
Cao S, Wang C, Zhang C, Huang J, Wang X, Ma X. The effect of partial deltoid ligament injuries on the external rotation stability: A cadaveric study. Foot Ankle Surg 2022; 28:1215-9. [PMID: 35431116 DOI: 10.1016/j.fas.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/18/2022] [Accepted: 03/31/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The anterior and posterior part of the deltoid ligament have different functions during ankle flexion motion. Partial ligament injuries have been demonstrated in previous clinical reports. However, the efficacy of external rotation stress test in partial injured cases is unavailable till now. METHODS Thirty-two fresh cadaveric specimens were included and allocated into two destabilization groups. In the first group, the anterior portion of deltoid ligament (DL) and syndesmotic ligament were sequentially severed, while in the second group, the posterior portion of DL and syndesmotic ligament were sequentially severed. Mortise view radiographs were taken after each destabilization stage when the ankles were placed at plantarflexion and dorsiflexion positions and stressed in standard external rotation force. The medial clear space (MCS) and talar tilt (TT) angle were measured and compared among different destabilization stages. RESULTS When the ankles were placed at neutral position, the TT significantly increased in all destabilization stages. The MCS significantly increased after the partial deltoid ligament ruptures only with presence of syndesmotic ligament injuries. There was no significant difference of MCS at plantarflexion for all stages of destabilization if the anterior portion of DL is preserved. Similarly, no significant increase of MCS was detected at dorsiflexion if the posterior portion of DL and posterior inferior tibiofibular ligament are intact. CONCLUSION Partial DL rupture causes ankle rotational instability at different ankle joint positions, especially when combined with syndesmotic injuries. The neutral position is recommended for diagnosis of partial DL ruptures under external rotation stress.
Collapse
|
10
|
Cao S, Wang C, Zhang C, Huang J, Wang X, Ma X. Length change pattern of the ankle deltoid ligament during physiological ankle motion. Foot Ankle Surg 2022; 28:950-955. [PMID: 35074287 DOI: 10.1016/j.fas.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/29/2021] [Accepted: 01/12/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Length change pattern of the ankle deltoid ligament during physiological ankle motion is still confused currently and had not been studied in vivo. METHODS The deltoid ligaments from 7 cadaveric specimens were dissected. Lengths of each band during 30° plantarflexion to 20° dorsiflexion were measured. A dual fluoroscopy imaging system was utilized to capture the images of hindfoot joint of 7 healthy subjects during the stance phase of walking. 3D bone models were reconstructed from CT images. Lengths of each band were calculated after model-image registration utilizing a solid modeling software. Percentage of length variation and poses when the bands were in maximum extension were documented among each band. RESULTS The anterior border of tibiocalcaneal ligament (TCL) had only 1.7% length variation in vitro and 5.7% length variation in vivo. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension at 30° plantarflexion, however, superficial posterior tibiotalar ligament, deep posterior tibiotalar ligament, and the posterior border of TCL were in maximum extension at 20° dorsiflexion. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension during foot flat. The TCL was in maximum extension during midstance. The superficial posterior tibiotalar ligament and deep posterior tibiotalar ligament were in maximum extension during heel off and toe off. CONCLUSION The length of TCL did not change during ankle dorsiflexion and plantarflexion. The bands anterior to and posterior to the TCL showed different length change pattern during physiological ankle dorsiflexion and plantarflexion.
Collapse
Affiliation(s)
- Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China.
| | - Chao Zhang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiazhang Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
11
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|
12
|
Sogbein OA, Yi J, Sanders DW, Lawendy AR, MacLeod M, Del Balso C. Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures. Foot Ankle Surg 2022; 28:720-5. [PMID: 34493449 DOI: 10.1016/j.fas.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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.
Collapse
|
13
|
Omodani T, Takahashi K. Ultrasound findings of the deltoid ligament in patients with acute ankle sprains: A retrospective review. J Orthop Sci 2022:S0949-2658(22)00130-0. [PMID: 35691876 DOI: 10.1016/j.jos.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/31/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The deltoid ligament is a complex structure composed of multiple ligaments located on the medial side of the ankle joint that can be injured by ankle sprains. Although there have been previous reports on ultrasound imaging of the injured deltoid ligament, a systematic method for depicting each ligament component has not been established. This study aimed to clarify the ultrasound findings of the deltoid ligament in ankle sprains using a systematic scanning protocol. METHODS We examined the tenderness of the medial ankle and evaluated the ultrasound findings of the deltoid ligament in 169 sprained ankles with no fracture, within 3 days after injury. Observation and evaluation of the six components of the deltoid ligament were performed using a systematic scanning protocol with four probe positions. RESULTS Of the 169 ankles, 48 ankles had tenderness in the deltoid ligament. Ultrasonography confirmed deltoid ligament damage in 13 of these 48 ankles. Of the 13 ankles, 3 ankles had damages only in the superficial layer, 3 ankles only in the deep layer, and 7 ankles in both the superficial and deep layers. CONCLUSIONS We clarified the details of the damage pattern of the deltoid ligament in acute ankle sprains. It was possible to identify the superficial and deep layers of the ligament and to observe the damage pattern of each ligament component in detail, and it appeared that ultrasonography could be used as a tool to evaluate the damage pattern of the deltoid ligament in acute ankle sprains.
Collapse
Affiliation(s)
- Toru Omodani
- Sports Medicine & Joint Center, Funabashi Orthopaedic Hospital, 1-833, Hasama-cho, Funabashi, Chiba Prefecture 2740822, Japan; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
| | - Kenji Takahashi
- Sports Medicine & Joint Center, Funabashi Orthopaedic Hospital, 1-833, Hasama-cho, Funabashi, Chiba Prefecture 2740822, Japan
| |
Collapse
|
14
|
Black JDJ, Dhillon G, Tadros BJ, Malik-Tabassum K, Southgate C, Dhinsa B. Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review. Foot (Edinb) 2022; 51:101897. [PMID: 35255405 DOI: 10.1016/j.foot.2021.101897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/19/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Lauge-Hansen supination external rotation (SER)-type ankle fractures are very common and account for up to 75% of all ankle fractures. Assessing deltoid integrity is key for surgical decision making. Ultrasound has been used recently to assess the integrity of the deltoid ligament and differentiate between SER II and SER IV fractures. The aim of this article is to review the literature for studies assessing the diagnostic accuracy of ultrasound in this group of patients. METHODS After registering the protocol with PROSPERO, Embase, Ovid MEDLINE, Web of Science Core Collection, and Google Scholar were systematically searched. Studies that satisfied the following inclusion criteria were assessed: (1) Adult patients (>16 years), (2) Acute SER-type ankle fractures assessed within 2 weeks of the injury, (3) Diagnostic accuracy studies. Risk of bias assessment was conducted and a narrative synthesis of the results presented. RESULTS A total of five studies satisfied our inclusion criteria and were included for review. These had a total of 175 patients studied. All studies showed a sensitivity of 100% and specificity of 90-100% for detecting a complete tear of the deltoid. All papers had a significant risk of bias inherent to the design. Only patients undergoing surgery were exposed to the gold standard of operative intervention. CONCLUSION Ultrasound scan has shown excellent diagnostic accuracy for detecting complete deltoid ruptures in SER ankle fractures. These results however should be interpreted with caution. Perhaps a different approach is needed to assess the efficacy of ultrasound scans in patient with SER type fractures.
Collapse
Affiliation(s)
| | - Govind Dhillon
- Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage, Hertfordshire, SG1 4AB, UK.
| | - Baha John Tadros
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
| | - Khalid Malik-Tabassum
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Crispin Southgate
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
| | - Baljinder Dhinsa
- William Harvey Hospital, East Kent Hospitals NHS Trust, Kennington Rd, Willesborough, Ashford, TN24 0LZ, UK.
| |
Collapse
|
15
|
Choi S, Choi Y, Baek E, Jo S. Does repair of deltoid ligament contribute to restoring a mortise in SER type IV ankle fracture with syndesmotic diastasis? Arch Orthop Trauma Surg 2022; 142:535-41. [PMID: 33119800 DOI: 10.1007/s00402-020-03645-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [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.
Collapse
|
16
|
de Krom MA, Kalmet PH, Jagtenberg EM, Hermus JP, van Vugt R, Seelen HA, Poeze M. Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis. Injury 2022; 53:724-731. [PMID: 34602247 DOI: 10.1016/j.injury.2021.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/08/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
AIM Supination-external rotation (SER) ankle fractures account for the majority of ankle fractures and can be divided into stable or unstable fractures, based on the state of the deltoid ligament. The objective of this review was to appraise the available literature concerning diagnostic tools to evaluate deltoid ligament integrity in patients with SER-type ankle fractures. METHODS A comprehensive literature search of Pubmed and Embase was performed up to December 2020. The outcome measures were sensitivity, specificity and positive and negative predictive value of the diagnostic tools. A meta-analysis was performed to obtain an overview of sensitivity, specificity and area under the curve (AUC). The methodological quality of the articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies. RESULTS A total of 12 studies investigating tools for deltoid ligament rupture in patients with SER-type ankle fractures were included. The present study found sensitivity (and specificity) ranges of 0.20-0.90 (and 0.38-0.97) for clinical features, Magnetic Resonance Imaging (MRI) 0.57-0.85 (and 0.81-1.00), ultrasonography 1.00 (and 0.89-1.00), Malleolar Medial Fleck Sign (MMFS) 0.25 (and 0.99), conventional ankle mortise radiography 0.33-0.57 (and 0.60-0.94), gravity stress radiography 0.71-1.00 (and 0.72-0.88) and manual stress ankle radiography 0.65-1.00 (and 0.00-0.77). The largest AUC was found for ultrasonography, followed by MMFS, gravity stress radiography and MRI. CONCLUSION Ultrasonography and gravity stress radiography seem the most accurate diagnostic tools to evaluate deltoid ligament integrity. To strengthen this conclusion, future research should use an identical reference test to ensure comparability of results. Nevertheless, present study is of high value to close the knowledge gap about which presently available diagnostic tool is to be preferred to evaluate deltoid ligament integrity in patients with SER-type ankle fractures.
Collapse
Affiliation(s)
- Maartje Ap de Krom
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands.
| | - Pishtiwan Hs Kalmet
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands
| | - Eline M Jagtenberg
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands
| | - Joris Ps Hermus
- Maastricht University Medical Centre+, Dept. of Orthopedic Surgery, Maastricht, The Netherlands
| | - Raoul van Vugt
- Zuyderland Medical Centre, Dept. of Surgery, Heerlen, The Netherlands
| | - Henk Am Seelen
- Adelante Center of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands; Research School CAPHRI, Dept. of Rehabilitation Medicine, Maastricht University, Maastricht, The Netherlands
| | - Martijn Poeze
- Maastricht University Medical Centre+, Dept. of Trauma Surgery, Maastricht, The Netherlands; Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
17
|
Babacan S, Kafa İM. Morphology of the ligaments located on the medial side of the ankle and on the plantar surface of the foot. Surg Radiol Anat 2022. [PMID: 35075567 DOI: 10.1007/s00276-021-02872-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
To have biodynamic features, the feet have bones located in a special posture, the joints that keep together those bones, the ligaments that provide linkage to those joints, and tendons of muscles particularly which end the foot. This study aimed to research the morphology of the medial side and plantar ligaments. The study was conducted on a total of 30 feet belonging to 2 women and 13 men cadavers that exist at the Anatomy Department of the Medical Faculty of Uludag University. After the dissections, 61 parameters that belonging to the ligaments and general features of the foot, were evaluated. The statistical analysis of the collected data was evaluated by SPSS 20.0. According to the findings, while the descriptive statistics of the foot and the ligaments related to the foot, the statistically significant difference of any of the parameters wasn't observed when they were compared between the right and left sides of the foot. In terms of the correlative relations, the parameters that showed high correlation were chosen and 28 formulas were developed using regression analysis. We foresee that our findings of the features belonging to normal anatomic structures will deepen our knowledge besides providing important benefits before or during orthopedic and plastic surgery operations related to the region. Also, our findings were discussed by comparing the findings of similar studies belonging to many other researchers in literature, and our study's contribution to the literature was evaluated.
Collapse
|
18
|
Abstract
The spring ligament is the main static supporter of the medial longitudinal arch. Identifying every detail of the pathophysiology of each condition in which these structures are involved is the key to an appropriate approach and treatment. Isolated reconstruction of the posterior tibial tendon present long-term results with a high failure rate. It is important to diagnose spring ligament injuries because of the probable consequences if not treated, such as acquired flatfoot deformity and loss of correction of treated flatfoot. The option of surgical treatment is discussed in this article.
Collapse
Affiliation(s)
- Caio Nery
- Orthopedic & Traumatology Department, Federal University of São Paulo, Av. Albert Einstein, 627 - Morumbi, São Paulo, SP CEP 05652.000, Brazil; Foot and Ankle Clinic.
| | - Daniel Baumfeld
- Department of Locomotor Apparatus, Federal University of Minas Gerais, Av. Prof. Alfredo Balena, 190 - Belo Horizonte, MG CEP 30130-100, Brazil
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Abstract
Flatfoot deformity consists of a loss of medial arch, hindfoot valgus, and forefoot abduction. Historically considered a posterior tendon insufficiency, multiple ligament damage and subsequent incompetence explain the different clinical presentations with varying degrees of deformity. When surgery is deemed necessary, depending on the apex of the deformity, skeletal and soft tissue procedures are considered to keep motion and restore function. Osteotomies are considered at every level where an apex of deformity is found. The recently designated tibiocalcaneonavicular ligament comprises the older superficial and deep deltoid and spring ligaments; its repair or reconstruction should be considered in most flatfoot cases.
Collapse
Affiliation(s)
- Emilio Wagner
- Universidad del Desarrollo, Clinica Alemana de Santiago, Vitacura 5951, Santiago, Chile.
| | - Pablo Wagner
- Universidad del Desarrollo, Clinica Alemana de Santiago, Vitacura 5951, Santiago, Chile
| |
Collapse
|
21
|
Abstract
Although far less common than lateral ankle injuries, medial ankle sprains have been reported to result in significantly greater time lost and long-term disability when not diagnosed and treated accurately. Adequate diagnosis is paramount and the most important aspect is to determine whether the lesion is stable or unstable. Evidence confronting surgical versus conservative treatment in acute deltoid ligament lesions is largely anchored in the setting of ankle fractures. Ultimately treatment decisions rely on the clinical and imaging appraisal of each individual patient. This article discusses the isolated acute deltoid ligament impairment.
Collapse
Affiliation(s)
- Gastón Slullitel
- Foot and Ankle Surgery Department, J Slullitel Institute of Orthopaedics, San Luis 2534, Rosario, Santa Fe 2000, Argentina.
| | - Juan Pablo Calvi
- Foot and Ankle Surgery Department, J Slullitel Institute of Orthopaedics, San Luis 2534, Rosario, Santa Fe 2000, Argentina. https://twitter.com/pieijs
| |
Collapse
|
22
|
Abstract
A thorough knowledge of the anatomy of the deltoid and spring ligament complex is important for treatment of deformities that impact the foot and ankle. Both ligaments are interconnected, and the study of their anatomic characteristics is better performed together than in isolation. The deltoid ligament is a group of ligaments that derives its origin from the medial malleolus, and the spring ligament complex consist of a group of ligaments that connects the navicular and the sustentaculum tali of the calcaneus. They both play an important role in stabilization of the medial ankle and medial column of the foot.
Collapse
Affiliation(s)
- Jarrett D Cain
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - Miki Dalmau-Pastor
- Human Anatomy 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.
| |
Collapse
|
23
|
Jona James J, Al-Dadah O. Ankle injuries in athletes: A review of the literature. World J Meta-Anal 2021; 9:128-138. [DOI: 10.13105/wjma.v9.i2.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/26/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
Ankle injuries are commonplace in the athletic population, with lateral ligament sprains accounting for the majority of them. The medial ligament complex, the distal tibiofibular syndesmosis as well as any of the bones that constitute the ankle joint can also be injured. Typical mechanisms of injury include inversion-plantarflexion and external rotation on a supinated, dorsiflexed or pronated foot. Lesions of the ankle present with similar symptoms of pain, swelling and tenderness. Therefore, a thorough history and physical examination must be obtained to make the correct diagnosis. This is especially critical for athletes as certain injuries can lead to termination of their career if not treated accurately on time. Imaging may be useful in some cases to confirm or rule out differential diagnoses. Most injuries can be managed conservatively using the Protection, Rest, Ice, Compression and Elevation protocol followed by a comprehensive rehabilitation programme. Surgery is reserved for grade III ligament tears that are refractory to initial non-operative treatment and displaced fractures that are unlikely to unite without surgical intervention. The objective of this review is to discuss the common ankle injuries encountered in the athletic population and the approaches to their diagnosis and management.
Collapse
Affiliation(s)
- Jenita Jona James
- The Medical School, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
| | - Oday Al-Dadah
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
| |
Collapse
|
24
|
Pasapula C, Ali AMS, Kiliyanpilakkil B, Hardcastle A, Koundu M, Gharooni AA, Kabwama S, Cutts S. High incidence of spring ligament laxity in ankle fractures with complete deltoid ruptures and secondary first ray instability. Foot (Edinb) 2021; 46:101720. [PMID: 33531204 DOI: 10.1016/j.foot.2020.101720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/31/2020] [Accepted: 07/03/2020] [Indexed: 02/04/2023]
Abstract
AIMS To assess the incidence of spring ligament failure in patients who have complete deltoid ruptures. PATIENTS AND METHODS The authors retrospectively analysed ankle fractures in our trauma database from January 2015 to January 2019. 61 patients who sustained ankle fractures with complete deltoid ligament ruptures based on an AP ankle radiographs with increased medial joint space were identified. 25 patients attended clinic for assessment. Of these, 5 were found to have gross planovalgus with pre-existing spring ligament laxity in the uninjured control foot and these were excluded from the analysis. 20 patients were assessed for spring ligament failure /laxity. For each patient, the uninjured foot was used as the control. RESULTS The TMT instability score and the lateral translation score showed statistically significant increases in the injured compared to the uninjured foot. The ratio of increase in both TMT instability and lateral translation scores (strain) in the injured versus the uninjured foot was assessed. A strong correlation (+0.62 pearson correlation coefficient) was found between the two ratios. CONCLUSION All 20 patients showed increased spring ligament laxity and 19 patients showed increased TMT instability. Our results show that with complete deltoid rupture, there is likely greater disruption of the medial ligamentous structures of the foot than previously recognised. The degree of increase in the spring ligament strain also correlates with the degree of strain at the plantar TMT joint ligaments, and thus first ray instability. This finding has significant implications for the long-term assessment and management of ankle fractures involving complete deltoid disruption. Early intervention with orthotics in this cohort may prevent progressive destabilisation of the midfoot and the first ray. This evolving understanding may lead to the prospect of earlier surgical intervention to reconstitute the integrity of the spring ligament and protect the foot progressing to stage 2 AAFD.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Steven Cutts
- James Paget University Hospital, Great Yarmouth, UK
| |
Collapse
|
25
|
Plaass C, Louwerens JW, Claassen L, Ettinger S, Yao D, Lerch M, Stukenborg-Colsman C, Donken C. Treatment concepts for pes valgoplanus with concomitant changes of the ankle joint : Tibiotalocalcaneal arthrodesis, total ankle replacement and joint-preserving surgery. Orthopade 2020; 49:991-999. [PMID: 33104862 DOI: 10.1007/s00132-020-03996-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Concomitant valgus deformities of the ankle joint are found in approximately 3% of patients with symptomatic flat foot deformities. Conservative treatment is mostly successful only in the short term or in low-demand patients. The operative treatment of flat foot deformities follows the standard algorithm for flat foot treatment. The ankle joint can be treated while retaining mobility or by arthrodesis depending on the degree and rigidity of the deformity, degenerative changes, patient factors and expectations. Achieving an orthograde hindfoot and midfoot is obligatory for successful treatment as well as in ankle reconstructive or arthrodesis procedures.
Collapse
Affiliation(s)
- Christian Plaass
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany.
| | - Jan Willem Louwerens
- Foot and Ankle Reconstruction Unit of the Orthopaedic Department, St. Maartenskliniek, Hengstdal 3, 6574, Ubbergen, NA, The Netherlands
| | - Leif Claassen
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Sarah Ettinger
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Daiwei Yao
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Matthias Lerch
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Christina Stukenborg-Colsman
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Christian Donken
- Foot and Ankle Reconstruction Unit of the Orthopaedic Department, St. Maartenskliniek, Hengstdal 3, 6574, Ubbergen, NA, The Netherlands
| |
Collapse
|
26
|
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.
Collapse
Affiliation(s)
- Minton Truitt Cooper
- Department of Orthopaedic Surgery, University of Virginia, Box 800159, Charlottesvlle, VA 22908, USA.
| |
Collapse
|
27
|
Dalmau-Pastor M, Malagelada F, Kerkhoffs GM, Karlsson J, Guelfi M, Vega J. Redefining anterior ankle arthroscopic anatomy: medial and lateral ankle collateral ligaments are visible through dorsiflexion and non-distraction anterior ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2020; 28:18-23. [PMID: 31292688 DOI: 10.1007/s00167-019-05603-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/24/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE A thorough understanding of the arthroscopic anatomy is important to recognise pathological conditions. Although some ankle ligaments have been described as intra-articular structures, no studies have assessed the full visibility of these structures. The purpose of this study was to assess arthroscopic visibility of medial and lateral ankle collateral ligaments. METHODS Arthroscopy was performed in 20 fresh frozen ankles. The arthroscope was introduced through the anteromedial portal and the anterior compartment was explored in ankle dorsiflexion without distraction. Intra-articular structures were tagged using a suture-passer introduced percutaneously and they were listed in a table according to the surgeon's identification. After the arthroscopic procedure, the ankles were dissected to identify the suture-tagged structures. RESULTS According to the suture-tagged structures, 100% correlation was found between arthroscopy and dissection. In the anterior compartment, the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament on the medial side were observed. The deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament were tagged at the posterior compartment. CONCLUSION Ankle dorsiflexion and non-distraction arthroscopic technique allows full visualisation of the medial and lateral ankle collateral ligaments: the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament. When using distraction, posterior structures as the deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament can be observed with anterior arthroscopy.
Collapse
Affiliation(s)
- Miki Dalmau-Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain. .,GRECMIP-MIFAS (Groupe de Recherche et d'Étude en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), Merignac, France. .,Vilamèdic Medical Center, Santa Coloma de Gramanet, Barcelona, Spain.
| | - F Malagelada
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain.,Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - G M Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Amsterdam, The Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Academic Medical Center, Amsterdam, The Netherlands.,Amsterdam Collaboration on Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
| | - J Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden
| | - M Guelfi
- Foot and Ankle Unit, Clinica Montallegro, Genoa, Italy.,Human Anatomy and Embryology Unit, Department of Morphological Sciences, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Vega
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain.,GRECMIP-MIFAS (Groupe de Recherche et d'Étude en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), Merignac, France.,Foot and Ankle Unit, iMove Tres Torres, Barcelona, Spain
| |
Collapse
|
28
|
Vega J, Malagelada F, Karlsson J, Kerkhoffs GM, Guelfi M, Dalmau-Pastor M. A step-by-step arthroscopic examination of the anterior ankle compartment. Knee Surg Sports Traumatol Arthrosc 2020; 28:24-33. [PMID: 31667570 DOI: 10.1007/s00167-019-05756-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/07/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Despite the increased use of ankle dorsiflexion without distraction, no reports have specifically addressed the arthroscopic anatomy of the ankle in this position. The purpose of this study was to describe the normal arthroscopic anatomy of the ankle joint, when using the ankle dorsiflexion and the dynamic distraction technique, and to propose an arthroscopic examination system for the anterior ankle compartment. METHODS Ankle arthroscopy was performed in 20 fresh frozen specimens. Arthroscopic examination was performed with the arthroscope introduced through the anteromedial portal. The anterior compartment was examined in ankle dorsiflexion without distraction. The compartment was examined in four steps: (1) lateral area including the lateral gutter; (2) the central area of the anterior tibial rim; (3) the medial area including the medial gutter; (4) the talar neck. Next, distraction was applied to visualise the anterior compartment again and to examine the central and posterior ankle compartments. RESULTS Anatomic intra-articular structures were visualised in all specimens. Four intra-articular fat pads, one anteromedial, two syndesmotic and another posteromedial, were constantly observed. A description of the normal arthroscopic anatomy of the ankle using the ankle dorsiflexion and the dynamic distraction technique is detailed for the anterior, central and posterior compartments. CONCLUSION The ankle arthroscopic procedure without distraction allows constant visualisation of the ATFL's superior fascicle on the floor of the lateral gutter, the ATiFL's distal fascicle laterally and the most anterior margin of the deltoid ligament in the medial gutter (anterior tibiotalar ligament). However, ankle distraction is required to observe the central and posterior compartments, but it does not provide optimal visualisation of the anterior ankle compartment structures. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- J Vega
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain. .,Foot and Ankle Unit, Orthopedic Department, iMove Tres Torres Barcelona 76, Dr Roux st, Barcelona, Spain. .,GRECMIP-MIFAS (Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), Merignac, France.
| | - F Malagelada
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain.,Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - J Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - G M Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Academic Center for Evidence-Based Sports Medicine (ACES), Academic Medical Center, Amsterdam, The Netherlands.,Amsterdam Collaboration On Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
| | - M Guelfi
- Foot and Ankle Unit, Clinica Montallegro, Genoa, Italy.,Human Anatomy and Embryology Unit, Department of Morphological Sciences, Universitad Autònoma de Barcelona, Barcelona, Spain
| | - M Dalmau-Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain.,GRECMIP-MIFAS (Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), Merignac, France
| |
Collapse
|
29
|
Vega J, Allmendinger J, Malagelada F, Guelfi M, Dalmau-Pastor M. Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability. Knee Surg Sports Traumatol Arthrosc 2020; 28:132-140. [PMID: 28983653 DOI: 10.1007/s00167-017-4736-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/28/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. METHODS Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique. RESULTS During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up. CONCLUSION Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Jordi Vega
- Foot and Ankle Unit, Hospital Quirón Barcelona, Plaza Alfonso Comín 5, 08023, Barcelona, Spain.
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain.
| | | | - Francesc Malagelada
- Foot and Ankle Unit, Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matteo Guelfi
- Orthopaedic and Traumatology Unit, Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Chieti, Italy
| | - Miki Dalmau-Pastor
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain
- Faculty of Health Sciences at Manresa, University of Vic-Central University of Catalonia, Manresa, Barcelona, Spain
| |
Collapse
|
30
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
31
|
Pitakveerakul A, Kungwan S, Arunakul P, Arunakul M. Radiographic parameters in gravity stress view of the ankle: Normative data. Foot Ankle Surg 2019; 25:819-825. [PMID: 30803817 DOI: 10.1016/j.fas.2018.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/23/2018] [Accepted: 10/22/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND In rotational ankle injury with isolated fibular fracture, deltoid integrity is important for determining stability of ankle. Medial clear space and superior clear space in gravity stress view are parameters widely used to predict deltoid ligament tear. The purpose of this study is to report radiographic parameters in gravity stress view in normal population. METHODS 120 persons were enrolled. Non weight-bearing ankle mortise and gravity stress view were obtained. Radiographic measurements were made by 2 investigators, including medial clear space (MCS), superior clear space (SCS), tibiofibular overlaps, tibiofibular clear space and talocrural angle. Statistical analysis included mean, mean difference, SD, 95%CI, paired T-test were calculated and subgroup analysis by foot length. Intraclass correlation coefficients were used to determine intra/interobserver reliability of measurement. RESULTS Mean MCS in gravity stress view was 3.19mm (95%CI 3.1-3.31). This compared to mean MCS of 3.01mm (95%CI 2.9-3.12) in mortise view which was statistically significant (P=0.02). Mean difference was 0.18mm (95%CI 0.07-0.3). SCS in gravity stress view was 3.29mm (95%CI 3.19-3.39) and when compared to MCS in gravity stress view, no statistical significance was found (P=0.158). Mean difference was 0.1mm (95%CI 0.03-0.21). In subgroup analysis by foot length, no significant difference was found in any parameters. CONCLUSIONS This study provides normative radiographic data for a gravity stress radiograph and supports that if measurable MCS >4mm on gravity stress view, it should be aware of an unstable ankle in supination-external rotation injury.
Collapse
Affiliation(s)
- Akaradech Pitakveerakul
- Department of Orthopaedic Surgery, Sirindhorn Hospital, 20 Onnuch 90, Prawet, Bangkok 10250, Thailand.
| | - Supoj Kungwan
- Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University, 99 Moo 18 Paholyothin Road, Klong Luang, Pathumthani 12121, Thailand
| | - Preeyaphan Arunakul
- Department of Anesthesia, Faculty of Medicine, Thammasat University, 99 Moo 18 Paholyothin Road, Klong Luang, Pathumthani 12121, Thailand
| | - Marut Arunakul
- Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University, 99 Moo 18 Paholyothin Road, Klong Luang, Pathumthani 12121, Thailand.
| |
Collapse
|
32
|
Bi C, Kong D, Lin J, Wang Q, Wu K, Huang J. Diagnostic value of intraoperative tap test for acute deltoid ligament injury. Eur J Trauma Emerg Surg 2019; 47:921-928. [PMID: 31624856 DOI: 10.1007/s00068-019-01243-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Deltoid ligament injuries appear with isolated or even no displacement of the lateral malleolus fracture which could easily lead to misdiagnosis, which frequently brings about ankle medial instability and talus shift that eventually lead to the occurrence of ankle osteoarthritis. This study is aimed to investigate the value of the tap test for assessing the integrity of the deltoid ligament intraoperatively. METHODS Ninety-two patients with malleolar fractures and possible acute deltoid ligament injury treated in our hospital from March 2013 to May 2016 were enrolled in this prospective study. The gravity stress test and tap test were performed preoperatively by three physicians independently before and after fixation of the fibula. The sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates of both tests were determined based on medial malleolus exploration for the integrity of the deltoid ligament. The inter-observer consistency was also analyzed. RESULTS Forty seven (51.1%) versus fifty two (56.5%) of the 92 patients tested positive for deltoid ligament injury according to the preoperative gravity stress test or the subsequent tap test. Forty-eight cases (52.2%) were confirmed during surgery. The sensitivity of gravity stress test was lower than that of tap test (95.8% vs 100%), and specificity of gravity stress test was the same as tap test (97.7% vs 97.7%). Between gravity stress test and tap test, the positive and negative predictive values were 97.9% vs 92.3% and 95.6% vs 100%, and the false-positive and false-negative rates were 2.3% vs 9.09% and 4.2% vs 0%, respectively. Between the two tests results, the percentage of inter-observer agreement was > 90% (kappa coefficient > 0.80). CONCLUSION The tap test has the advantages of high sensitivity, simple operation, and less radiation exposure, suggesting that it is of high diagnostic value for assessing the integrity of the acute deltoid ligament.
Collapse
Affiliation(s)
- Chun Bi
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China
| | - Dechao Kong
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China
| | - Jian Lin
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China
| | - Qiugen Wang
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China
| | - Kai Wu
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China.
| | - Jianhua Huang
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China.
| |
Collapse
|
33
|
Abstract
Poor clinical results are seen with syndesmotic injuries in the setting of ankle sprains and ankle fractures. The goal of syndesmosis repair is to restore the normal anatomic relationship of the distal tibiofibular joint and prevent ankle arthritis. Indications for surgical intervention for isolated syndesmotic injuries include frank syndesmosis diastasis, medial clear space widening on plain radiographs, significant radiographic syndesmosis diastasis during stress examination, or subtle syndesmotic diastasis detected by arthroscopic evaluation. Complications after syndesmosis repair include symptomatic hardware, malreduction, and arthritis. Anatomic reduction of the syndesmosis leads to better outcomes following surgery.
Collapse
Affiliation(s)
- Craig C Akoh
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health Madison, 600 Highland Avenue, Room 6220, Madison, WI 53705-2281, USA.
| | - Phinit Phisitkul
- Tri-State Specialists, LLP, 2730 Pierce Street, Suite 300, Sioux City, IA 51104, USA
| |
Collapse
|
34
|
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: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
35
|
Amaha K, Nimura A, Yamaguchi R, Kampan N, Tasaki A, Yamaguchi K, Kato R, Akita K. Anatomic study of the medial side of the ankle base on the joint capsule: an alternative description of the deltoid and spring ligament. J Exp Orthop 2019; 6:2. [PMID: 30689117 PMCID: PMC6890913 DOI: 10.1186/s40634-019-0171-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/17/2019] [Indexed: 01/14/2023] Open
Abstract
Background Adult acquired flatfoot deformity (AAFD) is caused by impaired medial ligamentous structures and posterior tibialis tendon dysfunction (PTTD). Although degeneration and trauma could separately cause AAFD, how these factors interact in the pathomechanism of AAFD is unclear. The joint capsule in the medial ankle is considered an important structure, providing passive stability by limiting joint movement. Previous reports on the joint capsule suggest its involvement in pathological changes of the ankle, but because of the high priority placed on the ligaments, few reports address the ankle joint from the joint capsule standpoint. The current study aimed to anatomically examine the medial ankle joint, focusing on the deltoid and spring ligaments in perspective of the joint capsule. Methods We conducted a descriptive anatomical study of 19 embalmed cadavers (mean 82.7 years, range 58 to 99). We included 22 embalmed cadaveric ankles. We detached the joint capsule in 16 ankles from the anterior to posteromedial joint, analyzed the capsular attachments of the ankle and adjacent joints, and measured the widths of the bony attachments. We histologically analyzed the joint capsule using Masson’s trichrome staining in 6 ankles. Results The capsule could be separated as a continuous sheet, including 3 different tissues. The anterior capsule was composed of fatty tissue. Between the medial malleolus and talus, the capsule was strongly connected and was composed of fibrous tissue, normally referred to as the deep deltoid ligament. The tibial attachment formed a steric groove, and the talar side of the attachment formed an elliptical depressed area. On the medial part of the subtalar and talonavicular joints, the capsule covered the joints as cartilaginous tissue, normally referred to as the superomedial ligament of the spring ligament. The outer side of the cartilaginous and fibrous tissue formed the sheath floor of the posterior tibialis tendon. Histological analysis revealed three different tissue types. Conclusions The capsules of the ankle, subtalar, and talonavicular joints could be detached as a continuous sheet. The deltoid and the superomedial ligament of the spring ligaments could be interpreted as a part of the continuous capsule, which had different histological features. Level of evidence Descriptive Laboratory Study.
Collapse
Affiliation(s)
- Kentaro Amaha
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopaedic Surgery, St. Luke's International Medical center, Tokyo, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Reiko Yamaguchi
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Natnicha Kampan
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Tasaki
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopaedic Surgery, St. Luke's International Medical center, Tokyo, Japan
| | - Kumiko Yamaguchi
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Kato
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,JA Kyosai Research Institute, Tokyo, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
36
|
Abstract
This article reviews the imaging aspects relevant to ligamentous instabilities of the foot and ankle with a focus on MRI and ultrasound imaging. A pictorial review of the anatomy of the medial and lateral ankle ligaments, syndesmosis, spring ligament, Lisfranc complex, hallux sesamoid complex, and lesser toe plantar plate as seen on MRI is presented. Selected cases of ligamentous pathology relevant to foot and ankle instability are presented. The value of imaging in the assessment of foot and ankle instability is reviewed.
Collapse
Affiliation(s)
- Peter Salat
- Department of Radiology, University of Calgary, 2500 University Drive Northwest, Calgary, Alberta T2N 1N4, Canada; Mayfair Diagnostics, 6707 Elbow Drive Southwest 132, Calgary, Alberta T2V 0E3, Canada.
| | - Vu Le
- Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Andrea Veljkovic
- Department of Orthopaedics, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Mark E Cresswell
- Department of Radiology, St Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| |
Collapse
|
37
|
Sun X, Li T, Sun Z, Li Y, Yang M, Li S, Lv Z, Jiang X, Yong W, Wu X, Wang M. Does routinely repairing deltoid ligament injuries in type B ankle joint fractures influence long term outcomes? Injury 2018; 49:2312-2317. [PMID: 30526926 DOI: 10.1016/j.injury.2018.11.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Deltoid ligament reconstruction following type B ankle fractures continues to generate a vivid discussion amongst trauma surgeons. There is a difference of opinion as to whether operative or non operative treatment should prevail. We therefore conducted a prospective comparative cohort study to determine whether it is necessary to routinely repair the injured deltoid ligaments. 41 Type B ankle joint fracture patients were enrolled, all the patients were associated with deltoid ligament ruptures and lateral/posterior-lateral dislocation of talus. After fixation of the lateral malleolus fracture, 12 patients were treated by superficial deltoid ligaments repairing, 16 patients with deep components augmentation, 13 patients had no direct surgical intervention. In the deep components group, the planter and the dorsi flexion was 3.2° (0-10°) and 8.8° (0-15°) less than the normal side. In the superficial components group, plantar and dorsi flexion was 0.8° (0-5°) and 4.2° (0-15°) less than the normal side. In the non-repairing group, the plantar and dorsi flexion was 2.4° (0-10°) and 5.6° (0-20°) less than the normal side. Overall, no significant statistical difference was observed comparing the 3 groups. In addition, no statistically significant inter-group differences were evident in terms of measurement of the ankle medial clear space and the clinical and functional outcomes recorded. In conclusion, the results of this study do not support routine exposure and repairing of the injured deltoid ligaments.
Collapse
Affiliation(s)
- Xu Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Zhijian Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Yuneng Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Minghui Yang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Shaoliang Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Zhenbang Lv
- Department of Orthopaedics, Tsinghua University First Hospital, Beijing, China
| | - Xieyuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Wu Yong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| | - Xinbao Wu
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China.
| | - Manyi Wang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035 China
| |
Collapse
|
38
|
Abstract
Diagnosis and treatment of medial ankle instability (MAI) are still controversial and poorly discussed in literature. The purpose of this review is to highlight different clinical presentations of MAI and develop a guide for its management. The deltoid ligament complex is injured more commonly than expected, because deltoid ligament injuries may either be isolated or occur in combination with other lesions, such as lateral ankle ligament injury, posterior tibial tendon insufficiency, osteochondral lesion, and others. The presence of a pes planovalgus deformity in a patient without posterior tibial tendon insufficiency may indicate MAI.
Collapse
Affiliation(s)
- Saud Alshalawi
- Prince Sultan Military Medical City, PO Box 13225-6604, Riyadh 12233, Saudi Arabia
| | - Ahmed E Galhoum
- Department of Orthopedic, Nasser Institute for Research and Treatment, Nile Corniche Street, Cairo 1351, Egypt
| | - Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, PO Box 30001, Medina 42353, Saudi Arabia
| | - Martin Wiewiorski
- Head Foot and Ankle Unit, Orthopaedic and Trauma Department, Kantonsspital Winterthur, Winterthur 8401, Switzerland
| | - Mario Herrera
- Head Foot and Ankle Unit, Orthopaedic Department, University of La Laguna, Tenerife 38200, Spain
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Victor Valderrabano
- Orthopaedic Department, Swiss Ortho Center, Swiss Medical Network, Schmerzklinik Basel, Hirschgässlein 15, Basel 4010, Switzerland.
| |
Collapse
|
39
|
Sun X, Li T, Sun ZJ, Li SL, Sun N, Cao QY, Li N, Yang MH, Zhu SW, Wu Y, Wu XB. [ Deltoid ligament augmentation and repairing in ankle fracture associated with deltoid ligament injury and syndesmosis diastasis]. Zhonghua Yi Xue Za Zhi 2018; 98:3192-3196. [PMID: 30392281 DOI: 10.3760/cma.j.issn.0376-2491.2018.39.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To evaluate the outcome of the deep component augmentation and superficial component repairing and syndesmosis screw fixation in treating ankle fracture associated with deltoid ligament injury and syndesmosis diastasis. Methods: From January 2014 to December 2017, 16 patients with ankle fracture combined with deltoid ligament injury and syndesmosis diastasis were treated with the deep component augmentation and superficial component repairing in Beijing Jishuitan Hospital.Of the patients, 13 were males and 3 were females, with an average age of (38±10) years (21-57 years). Nine cases were athletic injuries, 4 cases were daily-life injuries and 3 cases were traffic injuries.According to the Weber classification, 6 cases were type B, 10 cases were type C. According to the Lauge-Hansen classification, 6 cases were supination external rotation Ⅳ injury, 9 cases were pronation external rotation Ⅳ injury, 1 case was pronation abduction Ⅲ injury.The surgical treatment method was rigid fixation of the lateral malleolus and deep deltoid ligament augamentation instead of syndesmosis screw fixation.The effect of the surgical method was observed. Results: The average follow up was (24±12) months (6-40 months). The mean degree of dorsiflexion was 17.8°±6.8° (5°-30°), with 3.8°±6.0° (0°-15°) less than that in normal side, the mean degree of plantar flexion was 46.9°±7.9°, with 1.9°±3.9° (0°-10°) less than that in normal side.The mean Philips and Schwartz score was 96.8±5.1 (82-100), the American Orthopaedic Foot and Ankle Society (AOFAS) Score was 97.4±4.6 (84-100). Conclusion: In the treatment of ankle fracture associated with deltoid ligament injury and syndesmosis diastasis, the deep component augmentation and superficial component repairing and proper rehabilitation can benefit the functional recovery.
Collapse
|
40
|
Li BH, Wang SX, Li J, Huang FG, Xiang Z, Fang Y, Zhong G, Yi M, Zhao XD, Liu L. Early and mid-term results of transarticular external fixation in the treatment of supination-external rotation type IV equivalent ankle fractures. Chin J Traumatol 2018; 21:193-196. [PMID: 30017542 PMCID: PMC6085192 DOI: 10.1016/j.cjtee.2018.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/30/2018] [Accepted: 04/07/2018] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice. METHODS This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded. RESULTS All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases). CONCLUSION In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials.
Collapse
Affiliation(s)
- Bo-Hua Li
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Shan-Xi Wang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jun Li
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Fu-Guo Huang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Zhou Xiang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yue Fang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Gang Zhong
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Min Yi
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Xiao-Dan Zhao
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Lei Liu
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China.
| |
Collapse
|
41
|
Abstract
The medial collateral ligament (MCL) complex is characterized by a complex anatomical arrangement of the individual ligamentous structures including three joints and the spring ligament complex. Biomechanically it serves as the main stabilizing structure in the ankle region against rotational and pronating forces. Lesions in the region of the MCL complex are more frequent than previously thought and like lesions of the spring ligament complex can lead to pain and instability. A thorough examination including the patient history with possible injury mechanisms often yields valuable information on the diagnosis of injuries to the MCL or spring ligament complex. In many cases these are primarily overlooked and concomitant lesions, such as fractures, syndesmotic and lateral ligament lesions frequently occur; however, the clinical assessment of stability is often primarily impossible in an acute setting. High-resolution magnetic resonance imaging (MRI) plays a key role in identifying the ligamentous components. In addition, MRI plays a supportive role in the preoperative planning before reconstruction of acute and especially chronic lesions. In most cases the surgical treatment of acute ruptures of the MCL is not indicated. Various options for treatment of acute and chronic lesions of the MCL and spring ligament complex are available including the use of free tendon grafts. Controversy exists regarding the operative treatment of MCL lesions in the case of ankle fractures. It is recommended for cases with impinging tissue in the medial gutter serving as a barrier to adequate reduction of the joint and in cases of unstable fractures after reduction.
Collapse
|
42
|
Zhao HM, Lu J, Zhang F, Wen XD, Li Y, Hao DJ, Liang XJ. Surgical treatment of ankle fracture with or without deltoid ligament repair: a comparative study. BMC Musculoskelet Disord 2017; 18:543. [PMID: 29268724 PMCID: PMC5740931 DOI: 10.1186/s12891-017-1907-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/13/2017] [Indexed: 01/17/2023] Open
Abstract
Background Deltoid ligament (DL) rupture is commonly seen in clinical practice; however the need to explore and surgically repair it is still in debate. The objective of the current study is to compare the outcomes of surgical treatment of ankle fracture with or without DL repair. Methods Between 2009 and 2015, Seventy-four ankle fractures with DL rupture were identified and followed. Twenty patients were treated with surgical repair of the DL, while 54 were not. The pre- and post-operative medial clear space (MCS) were measured and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) were used for functional evaluation. According to the radiological malreduction of MCS, the odds ratio (OR) and 95% confidence interval (CI) for each potential relative factor were calculated. Results The mean followup time was 53.7 months. The mean MCS preoperatively, postoperatively, and at last followup time were 8.7 ± 2.4 (range, 6.2–14.8) mm, 3.7 ± 0.9 (range, 2.6–6.4) mm, 3.6 ± 1.0 (range, 2.6–6.8) mm, respectively. The mean AOFAS score was 86.4 ± 8.1 (range, 52–100) points, and the mean VAS was 1.4 ± 1.4 (range, 0–7) points. During followup, 14.9% (11/74) cases were found to be malreduced (MCS>5 mm), and 5.4% (4/74) went on to failure. Surgical repair of DL can significantly decrease the postoperative MCS (P<0.05), and can also decrease the malreduction rate (P<0.05). AO/OTA type-C ankle fractures showed a positive correlation with malreduction (OR = 4.38, P = 0.03). In this type of injury, surgical repair of the DL can significantly decrease the malreduction rate (P<0.05). No significant difference was found between the AO/OTA type-B fracture with or without DL repair. Conclusions Surgical repair of the DL is helpful in decreasing the postoperative MCS and malreduction rate, especially for the AO/OTA type-C ankle fractures.
Collapse
Affiliation(s)
- Hong-Mou Zhao
- Department of Foot and Ankle Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, China
| | - Jun Lu
- Department of Foot and Ankle Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, China
| | - Feng Zhang
- School of Public Health, Xi'an Jiaotong University College of Medicine, Xi'an, 710061, China
| | - Xiao-Dong Wen
- Department of Foot and Ankle Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, China
| | - Yi Li
- Department of Foot and Ankle Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, China
| | - Ding-Jun Hao
- Department of Spinal Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, China.
| | - Xiao-Jun Liang
- Department of Foot and Ankle Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, China.
| |
Collapse
|
43
|
Gougoulias N, Sakellariou A. When is a simple fracture of the lateral malleolus not so simple? how to assess stability, which ones to fix and the role of the deltoid ligament. Bone Joint J 2017; 99-B:851-855. [PMID: 28663388 DOI: 10.1302/0301-620x.99b7.bjj-2016-1087.r1] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 02/28/2017] [Indexed: 12/16/2022]
Abstract
Stable fractures of the ankle can be safely treated non-operatively. It is also gradually being recognised that the integrity of the 'medial column' is essential for the stability of the fracture. It is generally thought that bi- and tri-malleolar fractures are unstable, as are pronation external rotation injuries resulting in an isolated high fibular fracture (Weber type-C), where the deltoid ligament is damaged or the medial malleolus fractured. However, how best to identify unstable, isolated, trans-syndesmotic Weber type-B supination external rotation (SER) fractures of the lateral malleolus remains controversial. We provide a rationale as to how to classify SER distal fibular fractures using weight-bearing radiographs, and how this can help guide the management of these common injuries. Cite this article: Bone Joint J 2017;99-B:851-5.
Collapse
Affiliation(s)
- N Gougoulias
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Portsmouth Road, Frimley, Surrey, GU16 7UJ, UK
| | - A Sakellariou
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Portsmouth Road, Frimley, Surrey, GU16 7UJ, UK
| |
Collapse
|
44
|
Wang X, Zhang C, Yin JW, Wang C, Huang JZ, Ma X, Wang CW, Wang X. Treatment of Medial Malleolus or Pure Deltoid Ligament Injury in Patients with Supination-External Rotation Type IV Ankle Fractures. Orthop Surg 2017; 9:42-48. [PMID: 28296225 DOI: 10.1111/os.12318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/23/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To investigate the effect of internal fixation on postoperative ankle function in patients with supination-external rotation type IV ankle fractures, including medial malleolus fractures and deltoid ligament injury. METHODS Between January 2012 and June 2014, patients with medial structure injuries were enrolled in this study and assigned to the medial malleolus fracture group or the deltoid ligament group. The surgical procedures for the two groups were documented. The follow-up endpoint was the time point when the steel plate or screw was removed from the lateral ankle. The Olerud-Molander ankle scoring system was used to assess ankle function. RESULTS A total of 84 patients with supination-external rotation type IV ankle fractures had complete medical records and were included in this study. The average age of the patients was 44.16 years (range, 15-75). The patient sample included 39 males and 45 females. Overall, 49 patients (19 males and 30 females) suffered a medial malleolus fracture. The average age of these patients was 40.20 years (range, 15-75). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 81.6% (40 patients) of these patients. Overall, 35 patients (20 males and 15 females) experienced a deltoid ligament injury. The average age of these patients was 44.21 years (range, 17-73). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 11.5% (four patients) of these patients. Open reduction was performed in patients with medial malleolus fractures, and two 4.0-mm cannulated screws were used to fixate the posterior malleolus and the medial malleolus. The suture-anchor technique was used to repair the ligaments in patients with deltoid ligament injuries. The follow-up endpoint was the time point when the steel plate and screws were removed from the lateral ankle in patients. The average follow-up period was 13.4 months (range, 11-17). The Olerud-Molander ankle scoring system was used to assess postoperative ankle function. The average score for the patients in the medial malleolus fracture group was 90.3 points (range, 85-95). The average score for the patients in the deltoid ligament injury group was 87.7 points (range, 80-95). No significant differences were found in the scores between the two groups. CONCLUSION Medial malleolus fracture and deltoid ligament injury are two different presentations of supination-external rotation type IV ankle fractures. Anatomic reduction of the articular surface concurrent with restoration of ankle stability can achieve favorable results for these two injuries.
Collapse
Affiliation(s)
- Xu Wang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Chao Zhang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jian-Wen Yin
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jia-Zhang Huang
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopaedic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Cheng-Wei Wang
- Department of Orthopaedic Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xue Wang
- Department of Orthopaedic Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| |
Collapse
|
45
|
Abstract
Abnormalities of the medial ligaments and posterior tibial tendon can occur because of acute injury or chronic instability or malalignment. Medial ankle injuries may occur because of pronation or supination-external rotation injuries. Deltoid ligament injuries have a significant impact on lateral ankle instability but can be overlooked in patients with lateral ligament injuries. Posterior tibial tendon dysfunction is usually associated with spring ligament or flexor retinaculum injury. Tarsal tunnel syndrome, accessory flexor muscles, and subtalar coalition should be considered as well as ligament and tendon tears in differential diagnosis of chronic medial ankle pain.
Collapse
Affiliation(s)
- Julia Crim
- Department of Radiology, University of Missouri, 3801 Kinsey Court, Columbia, MO 65203, USA.
| |
Collapse
|
46
|
Chun KY, Choi YS, Lee SH, Kim JS, Young KW, Jeong MS, Kim DJ. Deltoid Ligament and Tibiofibular Syndesmosis Injury in Chronic Lateral Ankle Instability: Magnetic Resonance Imaging Evaluation at 3T and Comparison with Arthroscopy. Korean J Radiol 2015; 16:1096-103. [PMID: 26356649 PMCID: PMC4559781 DOI: 10.3348/kjr.2015.16.5.1096] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 06/02/2015] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To evaluate the prevalence of deltoid ligament and distal tibiofibular syndesmosis injury on 3T magnetic resonance imaging (MRI) in patients with chronic lateral ankle instability (CLAI). MATERIALS AND METHODS Fifty patients (mean age, 35 years) who had undergone preoperative 3T MRI and surgical treatment for CLAI were enrolled. The prevalence of deltoid ligament and syndesmosis injury were assessed. The complexity of lateral collateral ligament complex (LCLC) injury was correlated with prevalence of deltoid or syndesmosis injuries. The diagnostic accuracy of ankle ligament imaging at 3T MRI was analyzed using arthroscopy as a reference standard. RESULTS On MRI, deltoid ligament injury was identified in 18 (36%) patients as follows: superficial ligament alone, 9 (50%); deep ligament alone 2 (11%); and both ligaments 7 (39%). Syndesmosis abnormality was found in 21 (42%) patients as follows: anterior inferior tibiofibular ligament (AITFL) alone, 19 (90%); and AITFL and interosseous ligament, 2 (10%). There was no correlation between LCLC injury complexity and the prevalence of an accompanying deltoid or syndesmosis injury on both MRI and arthroscopic findings. MRI sensitivity and specificity for detection of deltoid ligament injury were 84% and 93.5%, and those for detection of syndesmosis injury were 91% and 100%, respectively. CONCLUSION Deltoid ligament or syndesmosis injuries were common in patients undergoing surgery for CLAI, regardless of the LCLC injury complexity. 3T MRI is helpful for the detection of all types of ankle ligament injury. Therefore, careful interpretation of pre-operative MRI is essential.
Collapse
Affiliation(s)
- Ka-Young Chun
- Department of Radiology, Eulji Hospital, Eulji University, Seoul 01830, Korea
| | - Yun Sun Choi
- Department of Radiology, Eulji Hospital, Eulji University, Seoul 01830, Korea
| | - Seok Hoon Lee
- Department of Radiology, Eulji Hospital, Eulji University, Seoul 01830, Korea
| | - Jin Su Kim
- Department of Orthopedic Surgery, Eulji Hospital, Eulji University, Seoul 01830, Korea
| | - Ki Won Young
- Department of Orthopedic Surgery, Eulji Hospital, Eulji University, Seoul 01830, Korea
| | - Min-Sun Jeong
- Department of Radiology, Eulji Hospital, Eulji University, Seoul 01830, Korea
| | - Dae-Jung Kim
- Department of Radiology, Eulji Hospital, Eulji University, Seoul 01830, Korea
| |
Collapse
|
47
|
Wang X, Ma X, Zhang C, Wang C, Huang JZ. Treatment of chronic deltoid ligament injury using suture anchors. Orthop Surg 2015; 6:223-8. [PMID: 25179357 DOI: 10.1111/os.12125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/30/2014] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To explore the efficacy of overlapping suture-anchor fixation for treatment of chronic deltoid ligament injury. METHODS Seventeen patients (11 men, 6 women of mean age 32.1 years [range, 18-58 years]) who had undergone surgery for chronic deltoid ligament injury from January 2007 to December 2011 were retrospectively analyzed. Preoperatively, they had undergone bilateral weight-bearing posterior-anterior radiographs, (MRI) and ultrasound examinations of the ankle. Ankle arthroscopy was performed to confirm the diagnosis, followed by surgery to clear intra-articular proliferating synovial tissues and remove cartilage debris and scar tissue. The deep layer of the deltoid ligament was sutured onto the tip of the medial malleolus and its superficial layer sutured onto its periosteum and fixed with suture anchors. American Orthopedic Foot and Ankle Society (AOFAS) scoring system for the ankle-hindfoot was used to evaluate the ankles pre- and post-operatively. RESULTS The 17 patients were followed up for 12-34 months (mean 20.1 months). The angle between the long axes of the talus and first metatarsal and the hindfoot angle measured in a hindfoot alignment view (as described by Saltzman) were reduced from 5.4° ± 1.8° and 8.2° ± 2.6° preoperatively to 4.0° ± 0.9° and 5.3° ± 1.3° postoperatively, respectively. The mean AOFAS ankle-hindfoot score was 76.8 ± 7.0 preoperatively and 94.1 ± 3.3 at the last follow-up visit. Ten patients were scored as excellent, six as good, and one as fair. Pain was relieved in all patients and no patients had recurrent deltoid ligament injury. CONCLUSION Using suture anchors to treat chronic deltoid ligament injury has relatively satisfactory outcomes.
Collapse
Affiliation(s)
- Xu Wang
- Department of Orthopaedics, Huashan Hospital, University of Fudan, Shanghai, China
| | | | | | | | | |
Collapse
|
48
|
Lui TH. Technical tips: reconstruction of deep and superficial deltoid ligaments by peroneus longus tendon in stage 4 posterior tibial tendon dysfunction. Foot Ankle Surg 2014; 20:295-7. [PMID: 25457670 DOI: 10.1016/j.fas.2014.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/18/2014] [Indexed: 02/04/2023]
Abstract
The deltoid ligament is composed of the superficial and deep layers. Disruption of the deltoid ligament can occur in rotational ankle fracture, chronic ankle instability, or stage 4 posterior tibial tendon dysfunction. Correcting valgus tilt at the time of flatfoot reconstruction in case of stage 4 posterior tibial tendon dysfunction may prevent future collapse and the need for ankle arthrodesis or possibly ankle arthroplasty. We describe a technique of reconstruction of both the superficial and deep deltoid ligaments by peroneus longus tendon.
Collapse
Affiliation(s)
- T H Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong Special Administrative Region.
| |
Collapse
|