SLR - July 2015 - Robert Bertram

Deltoid Ligament Repair Versus Syndesmotic Fixation in Bimalleolar Equivalent Ankle Fractures

Reference: Jones CR, Nunley JA. Deltoid ligament repair versus syndesmotic fixation in bimalleolar equivalent ankle fractures. J Orthop Trauma. 2015; 29: 245-249.

Scientific Literature Review

Reviewed By: Robert Bertram, DPM
Residency Program: Detroit Medical Center

Podiatric Relevance: Ankle fractures continue to be encountered and treated by a growing number of podiatric surgeons. Supination-external rotation (SER) fractures are the most common ankle fractures seen. SER-4 ankle fractures with a lateral malleolus fracture but without any medial malleolus fracture represent a medial deltoid ligament injury. Standard of care indicates ORIF of the lateral malleolus followed by syndesmotic repair through various different fixation techniques. However, there is no clear consensus to the optimal way repair the syndesmosis and stabilize the talus within the ankle mortise. While the majority of podiatric and orthopaedic surgeons will utilize a syndesmotic screw or screws, some surgeons believe stabilization of the syndesmosis is best achieved through primary repair of the deep deltoid rupture. The following paper compared lateral malleolus ORIF with syndesmotic screw fixation or with medial deltoid repair.

Methods: Subjects with bimalleolar equivalent ankle fractures were eligible for enrollment. Group 1 consisted of fifteen subjects who underwent lateral malleolus ORIF (standard lag screw technique with neutralization plate) with syndesmotic screw fixation. Group 2 consisted of twelve subjects who underwent lateral malleolus ORIF with deltoid ligament repair. Patients were allowed protective weightbearing at six weeks. Measurement outcomes were based off of questionnaires including the Lower Extremity Function Scale, Foot and Ankle Disability Index, Short Musculoskeletal Function Assessment, Foot and Ankle Outcome Score, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, Visual Analog Pain Scale, and overall function of lower extremity.

Results: Outcome questionnaires demonstrated no statistically significant differences between the 2 groups. However, all subjects in Group 1 underwent a subsequent procedure for removal of the syndesmotic implant. Additionally, there were 2 complications in the syndesmotic group that required repeat operative intervention.
Conclusions: When treating bimalleolar equivalent ankle fractures, podiatric surgeons must be aware that the syndesmosis may be violated and must be assessed. The diagnosis needs to be made and reduction of the syndesmosis performed to prevent reinjury, loss of reduction, or future posttraumatic arthritis. Repair using syndesmotic screws or direct medial deltoid repair can be performed to reduce the syndesmosis. According to the above results, no clinical difference is present between syndesmotic screw fixation or deltoid ligament repair for syndesmotic stabilization. However, there was a higher incidence of repeat operations for syndesmotic screw removals. Repairing the deltoid ligament may avoid the costs and risks that occur during a subsequent operation for removal of the syndesmotic implant. Further studies, including larger cohorts, are needed to determine whether there is a true benefit between either of the mentioned syndesmotic repair techniques.

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