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Hadley SM, Bergman R, Peabody JJ, Westvold SJ, Filler R, Patel M, Kadakia AR. Does Deltoid Ligament Repair Reduce Complications and Improve Functional Outcomes Measured by PROMIS Scores Following Ankle Fracture Surgery? FOOT & ANKLE ORTHOPAEDICS 2025; 10:24730114251330879. [PMID: 40297394 PMCID: PMC12035043 DOI: 10.1177/24730114251330879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2025] Open
Abstract
Background Deltoid repair (DR) in ankle fracture surgery remains controversial. This study aims to determine whether DR reduces complications and improves outcomes measured by Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). We hypothesized that DR would reduce complications and improve PROMIS scores. Methods This was a retrospective study of 782 patients at a single institution who underwent ankle fracture surgery between January 2016 and December 2021. Two fellowship-trained foot and ankle orthopaedic surgeons independently reviewed all radiographs and assessed reduction quality and complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. A total of 345 patients with deltoid ruptures were sent PROMIS CATs. Of those, 265 patients with minimum 1-year follow-up were analyzed for complications. Finally, 112 patients who completed CATs were analyzed for PROMIS. Wilcoxon rank-sum test compared PROMIS between groups. Linear regression modeled DR effect on PROMIS adjusted for relevant covariates and propensity scores. Results Fifty of the 265 patients (18.9%) underwent DR. The incidence of radiographic evident complications among 215 patients (81.1%) without repair (NDR) was 14.42%: 7 (3.26%) degenerative joint disease, 3 (1.40%) ankle joint malreduction, 4 (1.86%) syndesmotic malreduction, and 8 (3.72%) malleolar malunion. The DR group had no radiographic complications. Among patients who completed CATs (n = 112), DR (n = 21) was not significantly different for mean PF (54.31±9.83 vs 52.79±10.42, P = .71) or mean PI (47.21±7.82 vs 48.53±8.37, P = .59) than NDR (n=91). Adjusted regression models estimated a 1.89-point increase in PF and a 1.67-point decrease in PI for DR vs NDR. When adjusted for propensity scores, DR had PF 2.17 higher and PI 1.73 lower compared to NDR. Neither of these reach minimal clinically important difference criteria. Conclusion DR was associated with reduced radiographically evident complications following ankle fracture surgery. This study was underpowered to detect small effect sizes in PROMIS, and we remain uncertain if DR meaningfully improved patient-reported outcomes. Level of Evidence Level IV, retrospective case series study.
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Affiliation(s)
- Steven M. Hadley
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rachel Bergman
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John J. Peabody
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Ryan Filler
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Milap Patel
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anish R. Kadakia
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Kukadia S, Cho D, Eble S, Kumar P, Shamrock A, Drakos M. Comparison of Clinical and Radiographic Outcomes of Supination External Rotation Type IV Equivalent Ankle Fractures With and Without Deltoid Repair. FOOT & ANKLE ORTHOPAEDICS 2025; 10:24730114251329333. [PMID: 40297396 PMCID: PMC12035396 DOI: 10.1177/24730114251329333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2025] Open
Abstract
Background There is a lack of consensus on how deltoid injuries should be addressed in the setting of acute ankle fractures. This study aims to evaluate whether deltoid repair during lateral malleolar fracture fixation leads to improved clinical outcomes compared to fixation without deltoid repair. Methods This was a single-center retrospective study involving 13 surgeons. Inclusion criteria were patients aged 18 years or older who underwent open fixation for a supination external rotation type IV (SER IV) equivalent ankle fracture. SER IV fractures were confirmed with stress radiographs. Deltoid injury was confirmed with an intraoperative external rotation stress test. A total of 146 patients were included. Eighty patients received a deltoid repair (DR), and 66 patients did not receive a deltoid repair (NDR). Patient-reported outcomes via PROMIS scores were collected preoperatively and at least 1 year postoperatively for all patients. Preoperative and postoperative medial clear space (MCS) were reviewed for all patients. Results There were no significant differences in preoperative and postoperative PROMIS domains between the 2 cohorts. There were also no significant differences in preoperative MCS and postoperative MCS between the 2 cohorts. There were no significant differences in the incidence of subsequent procedures for removal of painful hardware, revisions, infections, progression to arthritis, and persistent pain. Conclusion This study compares short- to medium-term outcomes and complications of SER IV-equivalent ankle fractures with and without deltoid repair. No significant differences between PROMIS scores, postoperative MCS, and complication rates were observed between groups. Level of Evidence Level III, retrospective case control study.
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Affiliation(s)
| | - David Cho
- Hospital for Special Surgery, New York, NY, USA
| | | | | | | | - Mark Drakos
- Hospital for Special Surgery, New York, NY, USA
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Pirshahid AA, Brzozowski P, Sogbein O, Zdero R, Gee A, Halai M, Schemitsch E, Sanders DW, Lawendy AR, Del Balso C. Biomechanical Analysis of Ankle Stability Following Deltoid Ligament Repair and Reconstruction. BIOMED RESEARCH INTERNATIONAL 2025; 2025:6313005. [PMID: 40170794 PMCID: PMC11961274 DOI: 10.1155/bmri/6313005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Accepted: 01/13/2025] [Indexed: 04/03/2025]
Abstract
Background: The deltoid ligament has been shown to contribute to the stability of the ankle mortise, preventing valgus talar tilt, external rotation (ER), and translation. Research to date assessing the appropriateness of deltoid repair to reintroduce medial stability to a fractured ankle is unclear. Deltoid ligament reconstruction using autograft or allograft has been proposed in cases of chronic deltoid insufficiency. This biomechanical study sought to assess the stability offered by deltoid repair and reconstruction compared to the native deltoid ligament in its intact and defunctioned states. Materials and Methods: Twelve (six pairs) fresh frozen cadaveric lower extremities with intact deltoid ligaments underwent biomechanical assessment in a custom-made multiaxial testing apparatus. Each specimen was tested in plantarflexion/dorsiflexion (PF/DF), inversion/eversion (IV/EV), and internal rotation (IR)/ER and analyzed for angular range of motion (ROM) and stiffness. The specimens were tested with an intact deltoid ligament and following disruption via transection. Subsequently, paired specimens were randomized to either deltoid repair or reconstruction. A single double-loaded suture anchor was used to repair the deep and superficial deltoid ligaments. The tibialis anterior tendon was used as an autograft in the reconstruction group. Results: Normalized ROM and stiffness were significantly different in deficient specimens compared to all other groups during PF/DF. During IR/ER, the deficient ankle was significantly different from the intact and repair state. For IV/EV, deficient specimen ROM was significantly greater than the intact or repair states, while the stiffness for the deficient ankles was significantly less. Conclusion: Deltoid repair and reconstruction were comparable in returning the ankles to an intact state and conferring stability. These results suggest that in cases with insufficient or unstable deltoid ligament where repair is not possible, reconstruction has the potential to be a reliable alternative, but further studies are warranted to understand all advantages/disadvantages.
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Affiliation(s)
- Ali Ahmadi Pirshahid
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Olawale Sogbein
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Aaron Gee
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Mansur Halai
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Emil Schemitsch
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - David W. Sanders
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Abdel Rahman Lawendy
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Christopher Del Balso
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
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Kim SH, Lee SH, Cha JY, Choi SW, Lee YK. Arthroscopic Deltoid Ligament Repair as a Potential Alternative Treatment for Ankle Deltoid Ligament Injury. J Clin Med 2025; 14:1662. [PMID: 40095654 PMCID: PMC11901098 DOI: 10.3390/jcm14051662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2025] [Revised: 02/20/2025] [Accepted: 02/27/2025] [Indexed: 03/19/2025] Open
Abstract
Background: Arthroscopic deltoid ligament (DL) repair is a recently introduced technique, with few studies currently comparing the outcomes of open and arthroscopic deltoid repairs. This study compares the clinical and radiologic outcomes of patients who underwent either open or arthroscopic DL repair. Methods: Forty-one patients underwent surgical repair for a ruptured DL by a single surgeon at the study site hospital between 2013 and 2022. Clinical outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, and a visual analog scale (VAS). Radiologic outcomes were evaluated through anterior talar translation and talar tilt tests, with stress radiography conducted at 6 months and 1 year post-surgery. Results: No significant differences in sex ratio, age, or direction of injury were observed between the groups. Additionally, there were no significant differences in clinical and radiologic outcomes between the groups. However, both clinical and radiologic outcomes showed significant improvement after surgery compared to preoperative conditions in both groups. Conclusions: Considering the benefits of arthroscopic surgery, arthroscopic deltoid repair can be regarded as a suitable option for treating DL injuries.
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Affiliation(s)
| | | | | | | | - Young Koo Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170 Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Gyeonggi-do, Republic of Korea; (S.H.K.); (S.H.L.); (J.Y.C.); (S.W.C.)
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Sogard O, McDonald J, Waters ME, Lee W. The clinical outcome comparison between trans-syndesmotic fixation and anatomic deltoid ligament repair in unstable ankle fractures with medial clear space widening: A systematic review and meta-analysis. Foot Ankle Surg 2025; 31:95-104. [PMID: 39256063 DOI: 10.1016/j.fas.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 08/04/2024] [Accepted: 08/23/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Due to the variability in evidence supporting either trans-syndesmosis fixation or deltoid ligament repair in unstable ankle fractures with medical clear space (MCS) widening makes it unclear which surgical technique leads to the best patient outcomes. The goal of our systematic review and meta-analysis was to compare clinical outcomes of trans-syndesmotic fixation versus anatomic deltoid ligament repair in the management of unstable ankle fractures with MCS widening. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized in this study. A comprehensive and systematic search was conducted using the PubMed, Embase, Web of Science and Cochrane Library databases. Outcomes investigated in this review included the rates of syndesmotic malreduction, removal of hardware, postoperative complications including wound issues, and functional/pain scores. RESULTS A total of five level-3 studies were selected in this review, with 280 unstable ankle fractures with MCS widening: 165 for the trans-syndesmotic fixation group and 115 for the anatomic deltoid ligament repair group. Three out of five studies evaluated syndesmotic malreduction using CT. Compared to the trans-syndesmosis fixation group, the deltoid repair group showed significant lower rates of syndesmotic malreduction rates and removal of hardware: 6.5 % (4/61) Vs. 27 % (16/59) (RR=0.26, 95 % CI=[0.10, 0.68]), and 2.6 % (3/115) Vs.54.5 % (90/165) (RR=0.06, CI=[0.02, 0.14]), respectively. No significant differences were found between the two groups in postoperative wound complications, reoperations, and functional scores including AOFAS and VAS pain score. CONCLUSIONS Based on our findings, anatomic deltoid ligament repair was associated with a lower rate of syndesmotic malreduction and the need for hardware removal while there was no significant difference in terms of postoperative wound complications, reoperation, AOFAS score, or VAS pain score. These results should be interpreted with caution due to limitations related to heterogeneity among the studies. Further high-level RCTs with larger sample sizes are necessary to establish a robust consensus.
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Affiliation(s)
| | - John McDonald
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA.
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Koris J, Calder JDF, Dalmau‐Pastor M, Fernandez MA, Ramasamy A. Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments. Knee Surg Sports Traumatol Arthrosc 2024; 32:3052-3064. [PMID: 38796726 PMCID: PMC11605033 DOI: 10.1002/ksa.12274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. METHODS A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods. RESULTS A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available. CONCLUSION There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jacob Koris
- Trauma & Orthopaedic Specialty Registrar, John Radcliffe HospitalOxfordUK
| | - James D. F. Calder
- Department of BioengineeringImperial College LondonLondonUK
- Fortius ClinicLondonUK
| | - Miki Dalmau‐Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain
- MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society)MerignacFrance
| | | | - Arul Ramasamy
- Department of BioengineeringImperial College LondonLondonUK
- Academic Department of Military Trauma and OrthopaedicsRoyal Centre for Defence Medicine, EdgbastonBirminghamUK
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Zhang Y, Fan X, Pang K, Liu D. The clinical effect of Huoxue Huayu Recipe combined with ibuprofen in patients with postoperative pain after ankle fracture. Biotechnol Genet Eng Rev 2024; 40:2613-2627. [PMID: 37042058 DOI: 10.1080/02648725.2023.2200350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/03/2023] [Indexed: 04/13/2023]
Abstract
The curative effect of Huoxue Huayu Recipe combined with ibuprofen in the postoperative pain in patients with ankle fractures was analyzed. 68 patients with ankle fractures were divided into study group (n = 34, Huoxue Huayu Decoction combined with ibuprofen) and control group (n = 34, ibuprofen). The levels of inflammatory factors, ankle joint function, VAS score and bone metabolism indexes were compared. Complications, isokinetic muscle strength and clinical related index levels were compared after treatment. High AOFAS score and low VAS score were identified in the study group compared with the control group at 1 week, 1 month and 2 months after operation. Compared to the control group, the incidence of postoperative complications was declined in the study group. After treatment, IL-6 and TNF-α levels in both groups were significantly decreased, and the study group had lower IL-6 and TNF-α levels. After treatment, the torque acceleration energy, relative peak torque value and endurance in the study group were obviously improved. The disappearance time of swelling and pain, fracture healing time, and complete weight-bearing time in the study group were reduced compared to the control group. After treatment, BGP and BALP levels in study group were higher than control group. Huoxue Huayu Recipe combined with ibuprofen can reduce inflammatory factors levels in patients with ankle fracture, improve isokinetic muscle strength and ankle function, and accelerate the recovery of patients.
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Affiliation(s)
- Yaojun Zhang
- Department of Trauma Surgery, Fushan District People's Hospital, Yantai, China
| | - Xiaolin Fan
- Pain Department, Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital Qingdao, China
| | - Kunfang Pang
- Anesthesia Operating Room, Hiser Medical Center of Qingdao, Qingdao Hiser Hospital Affiliated to Qingdao University, Qingdao, China
| | - Deheng Liu
- Department of Hand and Foot Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, China
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Li M, Liu Z, Dong G. Could medial malleolus fracture be combined with deltoid ligament injury?: A rare case report. Medicine (Baltimore) 2024; 103:e37011. [PMID: 38277575 PMCID: PMC10817007 DOI: 10.1097/md.0000000000037011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/29/2023] [Indexed: 01/28/2024] Open
Abstract
RATIONALE Medial malleolus injuries mainly comprise of fractures and deltoid ligament ruptures. Medial malleolus fractures, as a kind of common ankle fractures, could occur separately or be accompanied by lateral and posterior malleolus fractures. It is generally agreed that medial malleolus fracture and deltoid ligament rupture could not occur simultaneously. PATIENT CONCERNS In our study, we report a case of 36 year-old man diagnosed with trimalleolar fracture accompanying ankle dislocation initially. The patient was admitted to our hospital due to traffic accident. DIAGNOSIS The patient was diagnosed with trimalleolar fracture accompanying ankle dislocation initially. We missed the diagnosis of accompanied deltoid ligament due to the arthralgia of medial ankle and the widened medial articular space in X-ray after operation. INTERVENTION As we missed the diagnosis of accompanied deltoid ligament, we only selected open reduction and internal fixation for trimalleolar fracture at first. After we realized the existence of deltoid ligament rupture, the patient refuse further diagnosis and treatment in our hospital. OUTCOMES During the rehabilitation exercise, the patient had medial arthralgia in his right ankle. He complained it and refuse further diagnosis and treatment in our hospital. LESSONS The newfound injury pattern, medial malleolus fracture accompanying deltoid ligament rupture, has not been reported in previous studies. The injury pattern needs further researches to explore the mechanism and it should be taken seriously in clinical practice.
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Affiliation(s)
- Mingyan Li
- Department of Orthopaedic Trauma, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Zihao Liu
- Department of Orthopaedic Trauma, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Guixian Dong
- Department of Orthopaedic Trauma, Harrison International Peace Hospital, Hengshui, Hebei, China
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Liang W, Zhou M, Jiang Z, Mao X, Zhou X, Wang F. Repair of deep deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture by using suture anchors into the talus combined with the transosseous suture in the medial malleolar. Front Surg 2024; 10:1287427. [PMID: 38249313 PMCID: PMC10796676 DOI: 10.3389/fsurg.2023.1287427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Purpose For deep deltoid ligament ruptures near the medial malleolar attachment, anchors were usually placed at the posterior colliculus and intercollicular groove. However, this procedure usually requires a prolonged surgical incision to fully expose the deep deltoid ligament, causing more trauma. In order to reduce surgical trauma, we explored the treatment outcomes of suture anchor into the talus combined with transosseous suture in the medial malleolar for the treatment of deep deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture. Patients and methods This is a retrospective study of patients who received suture anchor into the talus combined with transosseous suture in the medial malleolar for repairing deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture. The outcome measures include the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and the active range of motion (ROM) of the ankle at the final follow-up visit after surgery. Medial malleolus gap was evaluated by radiographic examination. Results This study included 64 patients. The mean follow-up time was 36.3 ± 15.2 months. There were 43 patients with injuries on the medial malleolar side, and 21 cases on the midsubstance. The average AOFAS and VAS were 87.5 ± 4.9 and 0.7 ± 0.5, respectively. No significance in medial malleolus gap between the contralateral side and affected side was observed. Conclusion For deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture, suture anchor into the talus combined with transosseous suture in the medial malleolar yields good clinical effect and outcome, is an optimal management of ankle syndesmosis injuries.
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Affiliation(s)
- Wei Liang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Mingping Zhou
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Zhongting Jiang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Xuanyu Mao
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
| | - Xiang Zhou
- Department of Orthopaedics, Longquan People’s Hospital, Longquan, Zhejiang, China
| | - Fei Wang
- Department of Orthopaedics, Lishui People's Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, The First Affiliated Hospital of Lishui University, Lishui, Zhejiang, China
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Yang T, Zhu F, Wang H, Wu B, Jia D, Meng C, Zhao Y. Kirschner Wire Internal Fixation of the Medial Tibiotalar Joint for Indirect Repair of Deltoid Ligament Injury: A Retrospective Comparative Study. Orthop Surg 2024; 16:140-148. [PMID: 38086605 PMCID: PMC10782261 DOI: 10.1111/os.13968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE Ankle joint fractures are often accompanied by medial deltoid ligament rupture. There is controversy over whether or how to treat deltoid ligament rupture. This study was aimed to explore the feasibility of repairing the medial deltoid ligament using Kirschner wire internal fixation of the medial tibiotalar joint combined with external fixation. METHODS Forty-six patients with ankle fractures involving deltoid ligament rupture, treated between October 2012 and February 2021, were retrospectively evaluated. Twenty-five patients were treated with a Kirschner wire to fix the tibiotalar joint and indirectly repair the deltoid ligament as the repaired group. Twenty-one patients underwent reduction and fixation of internal and external malleolus fractures, and the deltoid ligament was not repaired in the unrepaired group. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS), Medical Outcomes Short Form 36-item questionnaire score (SF-36), and Medial clear space perpendicular (preoperative, postoperative, final follow-up) were used for functional evaluations and reduction assessments. Mann-Whitney test were used to compare the differences between the groups. RESULTS The follow-up time was 13-112 months with a mean of 59.32 months for the repaired group and 11-94 months with a mean of 53.43 months for the unrepaired group. There was no significant difference in the operative time or intraoperative blood loss between the two groups (p > 0.05). At the last follow-up, the AOFAS ankle-hindfoot and SF-36 scores of the repaired group were significantly higher than those of the non-repaired group (p < 0.05). Moreover, the VAS pain score was significantly lower and the Medial clear space perpendicular was significantly narrower in the repaired group than that in the unrepaired group. CONCLUSION Tibiotalar joint fixation using Kirschner wires is a simple and effective technique that can indirectly reduce and repair the deltoid ligament and stabilize the ankle.
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Affiliation(s)
- Tao Yang
- Jining Medical UniversityJiningChina
| | - Fenghua Zhu
- Department of OncologyAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Haibin Wang
- Department of Traumatic OrthopedicsAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Bin Wu
- Department of Traumatic OrthopedicsAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Dailiang Jia
- Department of Emergency SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Chunyang Meng
- Department of Spine SurgeryAffiliated Hospital of Jining Medical UniversityJiningChina
| | - Yifeng Zhao
- Department of Traumatic OrthopedicsAffiliated Hospital of Jining Medical UniversityJiningChina
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11
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Cao S, Wang C, Chen Y, Zhang C, Huang J, Ma X, Wang X. Stress Tests for Deltoid Ligament and Syndesmosis Injury in Patients With Ankle Fracture: A Systemic Review With Meta-Analysis. J Orthop Trauma 2023; 37:e441-e446. [PMID: 37448133 DOI: 10.1097/bot.0000000000002651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES To determine the diagnostic accuracy of various stress tests for deltoid ligament and syndesmosis injury in patients with ankle fracture. DATA SOURCES A systemic literature search was conducted in the MEDLINE, Embase, and Cochrane Library databases to identify studies published from January 1990 to August 2022. STUDY SELECTION Studies that evaluated external rotation or gravity stress tests or hook or tap tests for the diagnosis of deltoid ligament or syndesmosis injury were included. DATA EXTRACTION Authors, publication years, study design, index tests, reference standards, demographic features of participants, reliability, and the numbers of true-positive, true-negative, false-positive, and false-negative subjects were extracted from 14 included studies. Article quality was assessed through the revised Quality Assessment of Diagnostic Accuracy Studies tool. DATA SYNTHESIS The pooled sensitivity and specificity of each index test for each structure were calculated with a random-effects model using the extracted data of true-positive, true-negative, false-positive, and false-negative outcomes in all relevant studies. The overall diagnostic performance of the different index tests for different structures was determined with the estimation of the area under the curve using the summary receiver operating characteristics curve. CONCLUSIONS The gravity stress test and the tap test exhibited high sensitivity and specificity in diagnosing deltoid ligament injury. The hook test has relatively high accuracy in diagnosing syndesmosis injury. Further studies with large sample sizes are warranted to confirm the results of this review. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
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12
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Tansey PJ, Chen J, Panchbhavi VK. Current concepts in ankle fractures. J Clin Orthop Trauma 2023; 45:102260. [PMID: 37872976 PMCID: PMC10589378 DOI: 10.1016/j.jcot.2023.102260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.
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Affiliation(s)
- Patrick J. Tansey
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Jie Chen
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Vinod K. Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
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13
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Brady AW, Bryniarski A, Brown JR, Waltz R, Stake IK, Kreulen CD, Haytmanek CT, Clanton TO. The Biomechanical Role of the Deltoid Ligament on Ankle Stability: Injury, Repair, and Augmentation. Am J Sports Med 2023; 51:2617-2624. [PMID: 37449714 DOI: 10.1177/03635465231181082] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Deltoid ligament injuries occur in isolation as well as with ankle fractures and other ligament injuries. Both operative treatment and nonoperative treatment are used, but debate on optimal treatment continues. Likewise, the best method of surgical repair of the deltoid ligament remains unclear. PURPOSE To determine the biomechanical role of native anterior and posterior components of the deltoid ligament in ankle stability and to determine the efficacy of simple suture versus augmented repair. STUDY DESIGN Controlled laboratory study. METHODS Ten cadaveric ankles (mean age, 51 years; age range, 34-64 years; all male specimens) were mounted on a 6 degrees of freedom robotic arm. Each specimen underwent biomechanical testing in 8 states: (1) intact, (2) anterior deltoid cut, (3) anterior repair, (4) tibiocalcaneal augmentation, (5) deep anterior tibiotalar augmentation, (6) posterior deltoid cut, (7) posterior repair, and (8) complete deltoid cut. Testing consisted of anterior drawer, eversion, and external rotation (ER), each performed at neutral and 25° of plantarflexion. A 1-factor, random-intercepts, linear mixed-effect model was created, and all pairwise comparisons were made between testing states. RESULTS Cutting the anterior deltoid introduced ER (+2.1°; P = .009) and eversion laxity (+6.2° of eversion; P < .001) at 25 degrees of plantarflexion. Anterior deltoid repair restored native ER but not eversion. Tibiocalcaneal augmentation reduced eversion laxity, but tibiotalar augmentation provided no additional benefit. The posterior deltoid tear showed no increase in laxity. Complete tear introduced significant anterior translation, ER, and eversion laxity (+7.6 mm of anterior translation, +13.8° ER and +33.6° of eversion; P < .001). CONCLUSION A complete deltoid tear caused severe instability of the ankle joint. Augmented anterior repair was sufficient to stabilize the complete tear, and no additional benefit was provided by posterior repair. For isolated anterior tear, repair with tibiocalcaneal augmentation was the optimal treatment. CLINICAL RELEVANCE Deltoid repair with augmentation may reduce or avoid the need for prolonged postoperative immobilization and encourage accelerated rehabilitation, preventing stiffness and promoting earlier return to preinjury activity.
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Affiliation(s)
- Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Justin R Brown
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Ingrid K Stake
- Steadman Philippon Research Institute, Vail, Colorado, USA
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14
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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.
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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
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15
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The effect of partial deltoid ligament injuries on the external rotation stability: A cadaveric study. Foot Ankle Surg 2022; 28:1215-1219. [PMID: 35431116 DOI: 10.1016/j.fas.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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.
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16
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McCormack DJ, Solan M, Aziz S, Faroug R, Kirmani S, Wright G, Mangwani J. Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study. World J Orthop 2022; 13:969-977. [PMID: 36439368 PMCID: PMC9685633 DOI: 10.5312/wjo.v13.i11.969] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/01/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability.
AIM To investigate the anatomical basis for fracture instability in SER type ankle fractures.
METHODS Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt.
RESULTS All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt.
CONCLUSION If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise.
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Affiliation(s)
- Daniel James McCormack
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Matthew Solan
- Department of Trauma and Orthopaedic Surgery, Royal Surrey City Hospital NHS Trust, University of Surrey, Guilford GU2 7XX, United Kingdom
| | - Sheweidin Aziz
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Radwane Faroug
- Department of Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury HP21 8AL, Buckinghampshire, United Kingdom
| | - Sayyied Kirmani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Georgina Wright
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Jitendra Mangwani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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17
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Jin XY, Xiao WY, He T, Dong YQ, Zhang C. Fracture of the lateral process of the talus with associated deltoid ligament injury: a report of 2 cases. BMC Surg 2022; 22:356. [PMID: 36195942 PMCID: PMC9533565 DOI: 10.1186/s12893-022-01781-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Fractures of the lateral process of the talus (LTPF) are rare and only rarely are associated ligamentous injuries. The injury mechanism is commonly considered to be similar with ankle sprains, where excessive varus of the hindfoot leads to avulsion fractures of the lateral process of the talus. However, previous cadaveric studies have suggested that LTPF was more likely to be caused by eversion or external rotation force with dorsiflexion of the ankle. But no clinical evidence has been provided. Case presentation Two patients presented to the emergency department with ankle pain after ankle eversion or external rotation. Physical examination revealed tenderness and swelling on both medial and lateral sides of the ankles. Plain radiographs and computed tomography revealed LTPF and medial soft tissue swelling, and magnetic resonance imaging confirmed a discontinuity of the deltoid ligament in Case 1. Surgical exploration revealed rupture of the superficial layer of the deltoid ligaments with intact deep layer in both patients. Treatment included fixation of the lateral process of the talus with headless compression screws and repair of deltoid ligaments. Both patients achieved excellent clinical outcomes 1 year post injury. Conclusion There are many possibilities of the injury mechanism of LTPF. These two cases provided clinical evidence that eversion or external rotation force, in addition to inversion, was also an important mechanism of LTPF. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01781-y.
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Affiliation(s)
- Xiang-Yun Jin
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Wei-Yuan Xiao
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Tao He
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Yu-Qi Dong
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China.
| | - Chao Zhang
- Department of Orthopedics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China.
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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: 0.3] [Reference Citation Analysis] [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.
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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
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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ankle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations. METHODS The available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores. RESULTS A total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%). CONCLUSIONS Collectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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20
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Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures. Foot Ankle Surg 2022; 28:720-725. [PMID: 34493449 DOI: 10.1016/j.fas.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/- deltoid ligament repair. METHODS A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/- deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively. RESULTS One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups. CONCLUSION Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits. LEVEL OF CLINICAL EVIDENCE Level III, retrospective cohort study.
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21
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Kakarala CL, Iyengar KP, Beale D, Botchu R. Isolated tear of the tibionavicular component of the superficial deltoid ligament: unusual cause of medial ankle pain. BMJ Case Rep 2022; 15:e251287. [PMID: 35732367 PMCID: PMC9226872 DOI: 10.1136/bcr-2022-251287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Chandra L Kakarala
- Department of Medicine and Suregry, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, Tamil Nadu, India
| | | | - David Beale
- Department of Radiology, Heath Lodge Clinic, Birmingham, UK
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK
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22
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Whitlock KG, LaRose M, Barber H, Fletcher A, Cunningham D, Menken L, Yoon RS, Gage MJ. Deltoid ligament repair versus trans-syndesmotic fixation for bimalleolar equivalent ankle fractures. Injury 2022; 53:2292-2296. [PMID: 35437167 DOI: 10.1016/j.injury.2022.03.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The role of deltoid ligament repair is controversial in the treatment of bimalleolar equivalent ankle injuries. Our purpose was to compare midterm functional outcomes and reoperation rates of unstable distal fibula fractures treated with open reduction internal fixation (ORIF) of the fibula and either deltoid ligament repair, trans-syndesmotic fixation, or combined fixation. METHODS Skeletally mature subjects were retrospectively identified after fixation of isolated unstable distal fibula fractures treated at a single academic level 1 hospital from January 2005 to May 2019. The AAOS Foot and Ankle Module outcomes questionnaire (AAOS-FAM) was obtained at a mean time from surgery of 4.6 +/- 3.1 years. Subjects underwent one of three methods of fixation including distal fibula ORIF and one of the following: trans-syndesmotic fixation (N = 66), deltoid ligament repair (N = 16), or combined trans-syndesmotic fixation and deltoid ligament repair (N = 26). Outcomes scores and Charlson Comorbidity Index scores were compared between groups by Kruskal-Wallis testing for non-normally distributed data. Rates of reoperation were compared by Fisher's exact test. Statistical significance was set to P < 0.05 for all comparisons. RESULTS There was no significant difference in AAOS-FAM scores between the three groups (P = 0.18). No subjects in the deltoid ligament repair group underwent reoperation compared to 17 (26%) in the trans-syndesmotic fixation group and six (23%) in the combined fixation group. The most common reason for reoperation was removal of hardware, which was performed in 12 (18%) subjects in the trans-syndesmotic fixation group and three (12%) subjects in the combined fixation group. CONCLUSIONS Direct deltoid ligament repair yields similar functional scores and fewer reoperations compared to trans-syndesmotic fixation at midterm follow up. Deltoid ligament repair may be a favorable treatment strategy when considering trans-syndesmotic fixation in the surgical treatment of unstable distal fibula fractures.
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Affiliation(s)
- Keith G Whitlock
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA.
| | - Micaela LaRose
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Helena Barber
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Amanda Fletcher
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Daniel Cunningham
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
| | - Luke Menken
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Richard S Yoon
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Mark J Gage
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Suite 2214, Box 104002, Durham, NC 27710, USA
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23
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Comparison of deltoid ligament repair and non-repair in acute ankle fracture: A meta-analysis of comparative studies. PLoS One 2021; 16:e0258785. [PMID: 34767584 PMCID: PMC8589189 DOI: 10.1371/journal.pone.0258785] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Background Rupture of the deltoid ligament (DL) in acute ankle fracture is very common. However, there is still insufficient evidence on whether to repair the DL in acute ankle fracture. Therefore, a systematic review and meta-analysis of comparative studies was performed to report the outcome of DL repair in acute ankle fracture. Methods The PubMed, Cochrane Library, EMBASE and Web of Science databases were searched from the inception dates to October 31, 2020, for comparative studies. The methodological quality was evaluated based on the risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials (RCTs) or the Risk-of-Bias Assessment Tool for Non-randomized Studies (RoBANS). The post-operative medial clear space (MCS), final MCS, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) score and incidence of complications were analysed. Results A total of 8 comparative studies involving 388 participants who suffered Weber type B or C ankle fractures were included in this meta-analysis. The results showed that the post-operative MCS, final MCS, AOFAS score and rate of complications were statistically superior in the DL repair group. For the VAS score, there was no significant difference between the DL repair group and the DL non-repair group. Conclusions In this meta-analysis of comparative studies, DL repair offered great advantages in terms of the post-operative MCS, final MCS, AOFAS score and rate of complications compared with non-repair. The repair of the DL in patients with acute ankle fractures might be beneficial to ankle joint stability and assist in improving the quality of ankle reduction. More high-quality and prospective studies with long follow-up durations are needed to further demonstrate the superiority of DL repair over non-repair.
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Barbachan Mansur NS, Raduan FC, Lemos AVKC, Baumfeld DS, Sanchez GT, do Prado MP, de Souza Nery CA. Deltoid ligament arthroscopic repair in ankle fractures: Case series. Injury 2021; 52:3156-3160. [PMID: 34247766 DOI: 10.1016/j.injury.2021.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Diagnosis and treatment of ankle medial ligament lesions in malleolar fractures has always been a matter of controversy. Even when deltoid involvement is clear, the direct repair of this structure is not a consensus. Recently, deltoid repair through an arthroscopic technique was described aiming to potentialize better clinical results and minimize complications. OBJECTIVE Demonstrate safety and functional results on patients with ankle fractures submitted to open reduction and internal fixation and arthroscopic deltoid repair. METHODS This is a retrospective study in patients diagnosed with ankle fractures associated with acute deltoid injuries submitted to open malleolar fixation and deltoid arthroscopic repair between June 2016 and January 2020. All patients were evaluated for pain and functionality according to the Visual Analogue Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) at a minimum of 6 months follow-up. RESULTS From January 2016 to January 2020, 20 ankles with fractures or dislocations were operated and the deltoid ligament rupture was repaired arthroscopically. A mean follow-up of 14.45 months (6-48) was observed, and patients presented an average AOFAS of 93.5 (SD 7.25) and a VAS of 0.75 (SD 1.05). Three minor complications were noticed and no signs of medial chronic instability, loss of reduction or osteoarthritis were observed. DISCUSSION The repair of the deltoid complex and the low morbidity of the arthroscopic technique used may improve the clinical outcomes of these patients. Additional studies, with a prospective and comparative methodology are required to sustain this proposal. DESIGN Level IV. Retrospective case series.
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Liu P, Chen K, Wang S, Hua C, Zhang H, Yu J. A mouse model of ankle-subtalar joint complex instability induced post-traumatic osteoarthritis. J Orthop Surg Res 2021; 16:541. [PMID: 34470616 PMCID: PMC8408979 DOI: 10.1186/s13018-021-02683-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ankle-subtalar joint complex instability is not uncommonly presented in the clinic, but symptoms and signs similar to other conditions can easily lead to its misdiagnosis. Due to the lack of appropriate animal models, research on ankle-subtalar joint complex instability is limited. The aims of the present study were to establish an animal model of ankle-subtalar joint complex instability in mice and to explore its relationship with post-traumatic osteoarthritis (PTOA). METHODS Twenty-one male C57BL/6J mice were randomly divided into three groups: SHAM group (sham surgery group), transected cervical ligament + anterior talofibular ligament (CL+ATFL) group, and transected cervical ligament + deltoid ligament (CL+DL) group. Two weeks after surgery, all mice underwent cage running training. Balance beam and gait tests were used to evaluate the changes in self-movement in the mice after ankle-subtalar ligament injury. Micro-CT and histological staining were used to evaluate the progress of PTOA. RESULTS Compared with the SHAM group, balance and gait were affected in the ligament transection group. Twelve weeks after surgery, the time required to cross the balance beam in the CL+ATFL group was 35.1% longer and the mice slipped 3.6-fold more often than before surgery, and the mean step length on the right side was 7.2% smaller than that in the SHAM group. The time required to cross the balance beam in the CL+DL group was 32.1% longer and the mice slipped 3-fold more often than prior to surgery, and the average step length on the right side was 5.6% smaller than that in the SHAM group. CT images indicated that 28.6% of the mice in the CL+DL group displayed dislocation of the talus. Tissue staining suggested that articular cartilage degeneration occurred in mice with ligament transection 12 weeks after surgery. CONCLUSIONS Transected mice in the CL+ATFL and CL+DL groups displayed mechanical instability of the ankle-subtalar joint complex, and some mice in the CL+DL group also suffered from talus dislocation due to ligament injury leading to loss of stability of the bone structure. In addition, as time progressed, the articular cartilage displayed degenerative changes, which affected the ability of animals to move normally.
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Affiliation(s)
- Peixin Liu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006, Jiangsu, People's Republic of China.,Orthopedic Institute, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006, Jiangsu, People's Republic of China
| | - Kaiwen Chen
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006, Jiangsu, People's Republic of China.,Orthopedic Institute, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006, Jiangsu, People's Republic of China
| | - Shuo Wang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006, Jiangsu, People's Republic of China.,Orthopedic Institute, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006, Jiangsu, People's Republic of China
| | - Chunzhuo Hua
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006, Jiangsu, People's Republic of China.,Orthopedic Institute, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006, Jiangsu, People's Republic of China
| | - Hongtao Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006, Jiangsu, People's Republic of China. .,Orthopedic Institute, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006, Jiangsu, People's Republic of China.
| | - Jia Yu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006, Jiangsu, People's Republic of China. .,Orthopedic Institute, Soochow University, 178 Ganjiangdong Rd, Suzhou, 215006, Jiangsu, People's Republic of China.
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Abstract
Chronic deltoid instability (CDI), or medial ankle instability, can happen following traumas of the foot and ankle, predominantly rotational injuries. CDI is frequently underdiagnosed or misdiagnosed. Long-term residual instability can lead to ankle posttraumatic arthritis. Adequate assessment of patients with suspected CDI is paramount. Conservative treatment can be tried for stable or mildly unstable cases, but surgical treatment is usually needed for the more severely unstable patients, or when conservative measures fail. Few reconstruction techniques have been proposed in the setting of posttraumatic CDI. This article describes our preferred technique for reconstruction of the deep components of the deltoid ligament.
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Affiliation(s)
- Cesar de Cesar Netto
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - John E Femino
- Foot and Ankle Services, Department of Orthopedics and Rehabilitation, University of Iowa, Carver College of Medicine, John Pappajohn Pavilion (JPP), Room 01066, Lower Level, 200 Hawkins Drive, Iowa City, IA 52242, USA
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Abstract
The most common injury mechanism for ankle fractures with concomitant deltoid ligament injury is a supination external rotation type 4 trauma. In the acute setting, malalignment, ecchymosis, and profound edema of the affected ankle can be found. Clinical examination is a poor indicator for deltoid ligament injury. There is a lack of high-quality studies with suturing the deltoid as the primary question. The authors found 4 comparative studies that found it unnecessary to explore and to reconstruct the deltoid ligament and 4 comparative studies that find it unnecessary to explore and to reconstruct the deltoid ligament.
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Affiliation(s)
| | - Sjoerd A Stufkens
- Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
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Deltoid Ligament Injuries Associated With Ankle Fractures: Arguments For and Against Direct Repair. J Am Acad Orthop Surg 2021; 29:e388-e395. [PMID: 33417379 DOI: 10.5435/jaaos-d-20-00323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 12/06/2020] [Indexed: 02/01/2023] Open
Abstract
Ankle fractures are an extremely common orthopaedic injury treated by surgeons on a routine basis. The deltoid ligament is torn in a large number of these fractures and is commonly seen with associated radiographic changes of medial clear space widening. The clinical relevance of addressing the injured deltoid ligament with acute surgical repair has been debated for decades. The early literature documenting repair or reconstruction of the deltoid ligament dates back to the 1950s. Most commonly, orthopaedic surgeons restore the lateral column directly with fibula fracture fixation. The injury may then be further evaluated intraoperatively by stress testing to ensure syndesmosis integrity and mortise stability with indirect medial column reduction, which allows for secondary healing of the medial deltoid ligamentous complex. This popular treatment paradigm is based primarily on literature from the 1980s and has not been thoroughly evaluated with modern surgical implants, techniques, and research methods. A review and background of the supportive literature for and against deltoid ligament repair in the setting of acute ankle fractures is presented. Undeniably, the deltoid ligament complex has been proven to confer some element of stability to maintaining a congruent ankle mortise. The commonly cited data in favor of not repairing the deltoid ligament warrants careful consideration to allow accuracy in obtaining the best patient outcomes with the most predictable surgical methods available.
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Thevendran G, Kadakia AR, Giza E, Haverkamp D, D'Hooghe JP, Veljkovic A, Abdelatif NMN. Acute foot and ankle injuries and time return to sport. SICOT J 2021; 7:27. [PMID: 33861196 PMCID: PMC8051311 DOI: 10.1051/sicotj/2021024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/20/2021] [Indexed: 01/18/2023] Open
Abstract
Foot and ankle sports injuries encompass a wide spectrum of conditions from simple contusions or sprains that resolve within days to more severe injuries that change the trajectory of an athlete’s sporting career. If missed, severe injuries could lead to prolonged absence from the sport and therefore a catastrophic impact on future performance. In this article, we discuss the presentation of the commonest foot and ankle sports injuries and share recent evidence to support an accurate diagnosis and best management practice.
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Affiliation(s)
- Gowreeson Thevendran
- Consultant Orthopaedic Surgeon, Mount Elizabeth Novena Hospital, 38 Irrawaddy Road, 329563, Singapore
| | - Anish R Kadakia
- Professor of Orthopedic Surgery, Northwestern Memorial Hospital, Chicago, 60611 IL, USA
| | | | - Daniel Haverkamp
- Xpert Clinics Orthopedics, Laarderhoogtweg 12, 1101 EA Amsterdam, The Netherlands
| | - Jonkheer Pieter D'Hooghe
- Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, 29222 Doha, Qatar
| | - Andrea Veljkovic
- Department of Orthopaedic Surgery, St. Paul's Hospital, Footbridge Clinic, University of British Columbia, Vancouver, V6T 1Z4 BC, Canada
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Nasrallah K, Haim S, Einal B. Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review. Orthop Rev (Pavia) 2021; 13:8987. [PMID: 33936572 PMCID: PMC8082171 DOI: 10.4081/or.2021.8987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/29/2020] [Indexed: 11/23/2022] Open
Abstract
Ankle fractures are among the most common injuries treated by orthopaedic traumatologists. These fractures range from stable, simple injuries to complex, multi-planar unstable ones. Osseo-ligamentous structures play a paramount role in maintaining the stability of the ankle joint. The deltoid ligament is among the most important ankle static stabilizers. Rupture of this ligament along with a lateral malleolar fracture is considered by many as an unstable type of injury and usually requires surgical treatment (bi-malleolar equivalent). Left untreated, it may lead to chronic pain, loss of function and secondary arthritis. Due to lack of high-quality evidence, there are no welldefined, well-accepted criteria for the diagnosis and treatment for treating this type of injury.
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Affiliation(s)
- Khalil Nasrallah
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
| | - Shtarker Haim
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
| | - Bathish Einal
- Galilee Medical Center, Department of Orthopedics, Nahariya, Israel
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Arthur D, Pyle C, Shymon SJ, Lee D, Harris T. Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures. Foot Ankle Int 2021; 42:251-256. [PMID: 33106030 DOI: 10.1177/1071100720962796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The deep deltoid ligament (DDL) is a key stabilizer to the medial ankle and ankle mortise and can be disrupted in ligamentous supination external rotation type IV (LSER4) ankle fractures. The purpose of this study was to define the medial clear space (MCS) measurement on injury mortise radiographs that corresponds with complete DDL injury. METHODS A retrospective record review at a level 1 hospital was performed identifying patients with LSER4 ankle fractures who underwent arthroscopy and open reduction internal fixation. Chart reviews provided arthroscopic images and operative reports. Complete DDL injury was defined as arthroscopic visualization of the posterior tibial tendon (PTT). Inability to completely visualize the PTT was defined as a partial DDL injury. MCS was measured on injury mortise radiographs. Eighteen subjects met inclusion criteria. RESULTS Twelve subjects had complete and 6 subjects had partial DDL injury based on arthroscopic findings. Patients with complete DDL injury and those with partial DDL injury had injury radiograph MCS ranging from 5.5 to 29.9 mm and 4.0 to 5.0 mm, respectively. All patients with MCS ≥5.5 mm on injury radiographs had complete DDL injury and all patients with MCS ≤5.0 mm on injury radiographs had partial DDL injury. CONCLUSION Complete DDL injury was found on injury ankle mortise radiographs as MCS widening of ≥5.5 mm, which correlated with arthroscopic visualization of the PTT. Using this cutoff, surgeons can surmise the presence of a complete deltoid ligament injury, allowing for improved preoperative planning. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Meng S, Tong W, Han S. Application of X-ray image measurement in the early diagnosis of sports injury of ankle ligament. Pak J Med Sci 2021; 37:1580-1584. [PMID: 34712286 PMCID: PMC8520354 DOI: 10.12669/pjms.37.6-wit.4841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To study the value of X-ray analysis method of ankle fracture based on injury mechanism to improve the imaging diagnosis level of ankle fracture. METHODS This study was conducted from January 2016 to December 2019. It included 105 cases of fractures caused by sprained ankle joints. Their age was between 21-81 years with an average of 49.5 years, The traditional X-ray analysis method (Group-A) and the injury mechanism-based ankle fracture X-ray analysis method (Group-B) were used to analyze X-ray image data. Group-B also performed Weber classification and Lauge-Hansen classification on cases. Installment. RESULTS Of the 105 patients with ankle fractures, 97 patients in Group-B were able to make Lauge-Hansen classification. Of these 97 ankle fractures, 137 were found in Group-A, and 158 were found in Group-B. The wrong diagnosis of fracture in Group-A was 18%, and the wrong diagnosis of fracture in Group-B was 0.5%. There was a statistically significant difference between the two groups (P <0.05). CONCLUSION The X-ray analysis method of ankle fractures based on injury mechanism can effectively improve the detection rate of hidden ankle fractures and high fibular fractures, and reduce the missed diagnosis, which is superior to the traditional X-ray analysis methods. At the same time, Weber classification, Lauge-Hansen classification and staging can be made for most cases, which is conducive to guiding clinical treatment.
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Affiliation(s)
- Shuqiao Meng
- Shuqiao Meng, PhD. Physical Education College of Yangzhou University, Yangzhou, 225000, Jiangsu, China
| | - Wenxia Tong
- Wenxia Tong, PhD. Physical Education College of Yangzhou University, Yangzhou, 225000, Jiangsu, China
| | - Shanshan Han
- Shanshan Han, PhD. Shangqiu University, School of Sport and Physical Education, Shangqiu, 476000, Henan, China
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