SLR - April 2020 - Michelle L. Winder

Does Routinely Repairing Deltoid Ligament Injuries in Type B Ankle Joint Fracture Influence Long-term Outcomes?

Reference:  Sun X, Li T, Sun, Li Y, Yang M, Li S, Lv Z, Jiang X, Wu Y, Wu X, Wang M. Does Routinely Repairing Deltoid Ligament Injuries in Type B Ankle Joint Fracture Influence Long-term Outcomes? Injury. 2018;49: 2312-17.

Scientific Literature Review

Reviewed By:  Michelle L. Winder, DPM
Residency Program: Hennepin County Medical Center – Minneapolis, MN

Podiatric Relevance: Ankle fractures are relatively common injuries that often require surgical management. Both superficial and deep components of the deltoid ligament can be compromised with ankle fracture injuries in up to 40 percent of patients. In the past, it has been common practice to repair the deltoid ligament; however, deltoid ligament reconstruction in Weber type B ankle fractures has more recently been a topic of debate amongst foot and ankle surgeons. Most Weber type B ankle fractures result from supination-external rotation injuries and therefore after fixation of the lateral malleolus, the syndesmosis and medial clear space should be assessed for stability. The purpose of this study was to determine whether it is necessary to routinely repair an injured deltoid ligament in Weber type B ankle fractures. 

Methods: This is a level III prospective cohort study conducted to determine whether injured deltoid ligaments should routinely be repaired in patients sustaining Weber type B ankle fractures. Patients ages 16 to 60 years with a Weber type B ankle fracture and deltoid rupture (medial clear space widening) < two weeks old were enrolled in the study. Exclusion criteria were open fracture, chronic ankle instability, pathologic fracture, and previous ankle fracture. After reduction and fixation of the fibular fracture, patients underwent one of three treatment options for deltoid injury based on which surgical ward the patient was admitted to: deep deltoid augmentation with suture anchor (group one), superficial deltoid repair (group two), or no repair (group three). Concomitant transyndesmotic fixation was utilized as necessary based on intraoperative stress views. After 4 weeks of immobilization postoperatively, patients began progressive range of motion exercises and weight bearing. Outcomes assessed included interval radiographs with medial clear space measurement, clinical ankle joint range of motion, Philips and Schwartz clinical scoring system, and AOFAS Ankle-Hind Foot Scale.

Results: A total of 41 patients were included in the study, 16 patients in group one, 12 patients in group two and 13 patients in group three. Patients were followed for  three years postoperatively. Demographics were similar between the three groups. There were no significant differences between the three groups in dorsiflexion or plantarflexion ankle joint range of motion, or radiographic medial clear space measurement on AP or oblique ankle views. The mean Philips and Schwartz score was 92.8 in group one, 94.4 in group two and 93.7 in group three. The mean AOFAS score was 92.9, 95.3 and 93.3, respectively. No statistically significant intergroup differences were noted in terms of clinical outcomes.

Conclusions: Based on the results of this study, the authors conclude that there is insufficient evidence to support routine exposure and repair of an injured deltoid ligament in Weber type B ankle fractures. The authors note that after lateral osteosynthesis and medial augmentation or repair, the syndesmosis regained stability whereas syndesmostic screw fixation was necessary in some cases for group three. Still, all three treatment groups achieved similar results indicating that a non-repaired deltoid with syndesmotic fixation as needed is adequate, and that in some cases deltoid ligament repair/augmentation can likely replace syndesmotic stabilization. 

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