SLR - May 2021 - Jeffrey C. Paruszewski

The Role of Deltoid Repair and Arthroscopy in Ankle Fractures

Reference: Cooper, MT. The Role of Deltoid Repair and Arthroscopy in Ankle Fractures. Clin Sports Med. 2020 Oct;39(4):733-743. doi: 10.1016/j.csm.2020.06.003. Epub 2020 Aug 13. PMID: 32892964.

Level of Evidence: Level II

Scientific Literature Review

Reviewed By: Jeffrey C. Paruszewski, DPM
Residency Program: Roxborough Memorial Hospital – Philadelphia, PA

Podiatric Relevance: This article is relevant to podiatry because it reviews prospective and retrospective studies evaluating the benefits of various imaging modalities for assessment of deltoid ligament injury sustained during ankle fractures. Moreover, this article reviews studies of deltoid repair and ankle arthroscopy in concomitance with ankle fractures and long-term results. The author is attempting to create a decision-making rubric for when to repair deltoid ligament for ankle fractures. 

• The Author reviewed multiple retrospective studies, prospective studies, and case series in order to attempt to create an algorithm on when to repair deltoid ligaments in concomitance with ankle fractures. 
• An SER IV equivalent fracture consists of a fibula fracture with injury to the medial structures that leaves the ankle mortise unstable and requires surgical treatment. It has been shown that clinically, medial tenderness is neither sensitive nor specific for identifying deltoid incompetence.
• MRI has also been shown to be extremely accurate in diagnosing deltoid injuries. In cases where the medial clear space was less than 5 millimeters on initial (non-stress) injury films, MRI was more accurate than stress radiography for determining deltoid ligament ruptures. MRI evaluation is recommended in patients with initial injury radiographs with MCS less than 5 mm as opposed to stress radiographs. There was no difference in the MRI findings of deep deltoid ligament injuries between stable, low-grade unstable, or high-grade unstable fractures. 

In cases where the fibula is anatomically reduced and the syndesmosis is stable, there should not be lateral translation of the talus with stress testing. However, there may still be valgus instability or external rotation instability. The author’s preferred management strategy is to explore and repair the deltoid ligament in the following circumstances.
1. Patients with frank dislocation or significant MCS widening on stress radiographs;
2. Cases in which the reduction of the talus is prevented by interposed tissue;
3. Cases in which external rotation or valgus instability is still present after anatomic fibula fixation;
4. Cases in which complete deltoid rupture is confirmed arthroscopically.

Conclusions: This article has changed the way I intend to assess and treat deltoid ligament pathology in concomitance with ankle fractures. The aims of repairing the deltoid ligament injury are to improve stability of the ankle joints, specifically in valgus and external rotation, as well as to decrease residual medial pain, which has been found to commonly occur.

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