Sprain of the Medial Ankle Ligament Complex

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.

Deltoid ligament reconstruction with autologous gracilis tendon in chronic medial ankle instability after ankle fracture surgery: A case report

INTRODUCTION

The repair of a deltoid ligament injury, following an ankle fracture with involvement of the syndesmosis, has no univocal consensus. Also the surgical strategies in case of a subsequent chronic instability are still under debate. In this work the result of a double bundle anatomic reconstruction of deltoid ligament with ipsilateral autologous gracilis muscle tendon is presented.

CASE REPORT

A 50 year old active male patient came to our attention with a catastrophic medial ankle instability, a severe pronation of the hindfoot and disabling ankle pain. He reported a Weber type B fracture of the left ankle with a lesion of the syndesmosis treated with anatomic plate and screws and a transyndesmotic screw 8 months before. The imaging showed a complete deltoid ligament lesion. Due to the impossibility of a direct repair of the ligament, we performed the reconstruction of the medial ligamentous complex with an autologous gracilis tendon graft. 10 months after the medial ligamentous complex reconstruction, the patient showed an excellent recovery of walking ability, disappearance of pain under load and resumed an active lifestyle.

DISCUSSION

The deltoid ligament has a key role in ankle joint stability and its integrity promotes the recovery after ankle fractures. However, its lesion is often left untreated in the acute setting. The result of a chronic untreated deltoid ligament injury could be extremely disabling and the ligament reconstruction, when an optimal native deltoid ligament repair is not achievable, is the choice to restore ankle function and stability.

CONCLUSION

In the delayed treatment of a deltoid ligament rupture the described double bundle anatomic reconstruction with autologous tendon graft can be an effective and suitable option.

Clinical Appearance of Medial Ankle Instability

Whereas tenderness, ecchymosis, and swelling over the deltoid ligament have relatively poor sensitivity, resulting valgus and pronation deformity that is seen to disappear when the patient is asked to activate the posterior tibial muscle or to go in tiptoe position is the hallmark for the presence of medial ankle instability. A pain on palpation at anteromedial edge of the ankle confirms the diagnosis. Various stress tests permit to confirm and specify the injury pattern. A pseudo hallux rigidus is the consequence of a hyperactivity of flexor hallucis longus muscle to protect the foot against the valgus and pronation deformity.

Arthroscopic Assessment and Treatment of Medial Collateral Ligament Complex

An increased interest in ankle instability has led to description of new concepts such as ankle microinstability or rotational ankle instability and the development of new arthroscopic techniques treating ankle instability. Ankle instability is constantly associated to intraarticular pathologies that contribute to generate pain and dysfunction. Arthroscopy plays an important role in identifying and treating all intraarticular abnormalities including ligament injuries. Despite a few studies are available in literature on arthroscopic treatment of medial collateral ligament injury, an arthroscopic all-inside repair of lateral and medial ankle ligaments has been proposed showing promising clinical results.

Medial Ankle Instability: The Deltoid Dilemma

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.

The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures

The treatment of isolated lateral malleolar fractures with deltoid ligament rupture remains controversial. We prospectively analysed 35 patients with isolated lateral malleolar fractures during 2006-2013. Radiography and magnetic resonance imaging (MRI) were performed to assess the degree of reduction, ligament damage, and stability. Internal fixation was performed for all unstable valgus fractures with unacceptable fracture parameters. Fractures with residual valgus instability after fixation underwent anterior deltoid repair. The mean anterior deltoid ligament grade based on MRI was significantly different between the high-grade unstable group and the stable and low-grade unstable groups (p=0.037 and 0.004, respectively). Postoperative medial clear space measurements were not significantly different between groups. MRI was shown to be a useful tool in the preoperative identification of isolated lateral malleolus fractures prone to valgus instability. In the case of high-grade unstable fractures of the lateral malleolus, repair of the anterior deltoid ligament is adequate for restoring medial stability.

Reconstruction of superficial deltoid ligaments with allograft tendons in medial ankle instability: A technical report

BACKGROUND

Deltoid ligament insufficiency can cause arthritic changes with various symptoms in the ankle joint. However, reconstruction procedures of the medial collateral and deltoid ligaments have drawn less attention than those of the lateral ankle ligaments. Few techniques for reconstructing deltoid ligaments are available, and those that are can be complex.

OBJECTIVE

We introduce a new surgical method for reconstructing superficial deltoid ligaments that is simple and straightforward.

CONCLUSION

With this method, the tibionavicular and tibiocalcaneal ligaments can be reconstructed efficiently and easily.