SLR - April 2020 - Jeffrey Tucci

Outcome of Primary Deltoid Ligament Repair in Acute Ankle Fractures: A Meta-Analysis of Comparative Studies 

Reference: Salameh, M., Alhammoud, A., Alkhatib, N. et al. Outcome of Primary Deltoid Ligament Repair in Acute Ankle Fractures: A Meta-Analysis of Comparative Studies. International Orthopaedics (SICOT) (2019). 

Scientific Literature Review 

Reviewed By: Jeffrey Tucci, DPM 
Residency Program: Hennepin County Medical Center – Minneapolis, MN 

Podiatric Relevance: Ankle fractures without medial malleolus fracture but increased medial clear space (MCS)- indicative of deltoid ligament (DL) injury, are a common occurrence seen by foot and ankle surgeons. Despite the commonality of this problem, many differences in opinion remain with regards to DL treatment. While historic literature tends to favor a non-operative approach, more recent studies show favorable results with open repair. The current study provides a meta-analysis of comparative studies focusing on operative and non-operative treatment outcomes of deltoid ligament management by evaluating qualitative measures of MCS reduction, functional outcomes, and complication rates. 

Methods: A level III meta-analysis of comparative studies were performed of database journals through May 2018 focusing on deltoid ligament repair outcomes in acute ankle fractures. Two hundred twenty articles were identified in total, but only three studies met inclusion criteria and had sufficient data for qualitative analysis. The three eligible studies had a total of 192 patients with ankle injuries, which included a DL repair group (n=81) and a non-repair group (n=111). The primary outcome was MCS maintained at final follow-up, with secondary measures being MCS correction immediately postoperative, American Orthopedic and Ankle Society (AOFAS) score, pain scores using visual analog scale (VAS), and complication rates. 

Results: VAS scores, MCS correction immediately post operative, and MCS at final follow up were found to be superior and statistically significant in the DL repair group compared to the non-repair group. There were no statistically significant differences in AOFAS functionality scores or complication rates between the two groups despite longer operative times and greater blood loss noted in the DL repair group. 

Conclusions: The DL repair group showed a better anatomic reduction of the ankle (immediate and at 12 months follow up) better pain scores, and no significant increases in complications. 

A limitation of this study was the included studies were not uniform in design, making data pooling difficult, and sometimes limiting the overall scope of the information. Ankle fracture types, for example, were not pooled as part of the data. Additionally, primary studies may contain unknown author bias which is difficult to account for in a meta-analysis. The inclusion of only three studies and only those published in English are other limitations to this study. Despite limitations, this analysis provides information that may be useful in designing future randomized clinical trials on the topic of deltoid ligament repair in ankle fractures. 

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