SLR - May 2022 - Samuel Clellen, DPM
Reference: James M, Dodd A. Management of Deltoid Ligament Injuries in Acute Ankle Fracture: A Systematic Review. Can J Surg. 2022 Jan11;65(1):E9-E15.Level of Evidence: 1=III
Scientific Literature Review
Reviewed by: Samuel Clellen, DPM
Residency Program: HCA Florida Northwest – Margate, FL
Podiatric Relevance: Ankle fractures represent one of the most common orthopedic ailments in podiatric medicine. Concomitant ligamentous injury, if left unaddressed, may lead to chronic ankle instability and post-traumatic arthritis. While the syndesmotic ligament has received the bulk of attention in literature, the deltoid ligament and its role in supporting the medial ankle through resistance of eversion (superficial deltoid) and external rotation (deep deltoid) is underrecognized. Historically, the repair of the deltoid is largely only performed when the medial malleolus does not reduce properly. While some believe deltoid repair (DLR) is crucial to ankle joint stability, others believe it to be cumbersome with no clinical value. The authors in this study perform a systematic review, assessing efficiency, safety, and financial implications of DLR when performed with modern techniques.
Methods: A systematic review was conducted assessing studies with DLR relative to acute ankle fractures, >50 percent adult population, and studies with >five patients, with exclusion criteria including reviews, technical papers, radiographic assessments of deltoid ligament integrity, studies related to chronic deltoid ligament insufficiency repair, studies not in English, and those lacking a comparison group. The systematic review was then performed by each author, and inclusion or exclusion was based on agreement or disagreement. After articles were selected, one author collected both basic and specific data. Descriptive statistics were used to compare studies and draw conclusions.
Results: A total of eight (three randomized control trials, five retrospective cohort studies) of the 362 reviewed articles were included in final analysis, with a total of 403 ankles reviewed. Articles were comprised of DLR vs. no repair, and DLR vs. syndesmotic fixation with or without DLR. Average follow up was 31 months. Compromised deltoid ligaments were measured by medial clear space (MCS) widening, either intraoperatively or preoperatively. The most prevalent fixation type was suture anchor fixation. Many of the studies found favoring radiographic (MCS, syndesmosis reduction) and functional (AOFAS, VAS, FFI scores) outcomes in the DLR groups compared to those without DLR.
Conclusions: While these studies vary in their fixation techniques, comparison groups, and diagnostic variables, they show that DLR in acute ankle fractures is backed by high-quality evidence. Although the functional outcomes showed no difference whether DLR was or was not performed, existing foot and ankle functional outcome measures only find significance in large differences in overall function. More subtle, but relevant, differences are likely unrecognized at this time. The study also shows clear, superior radiographic outcomes of DLR in acute ankle fractures, compared to those who did not have DLR. Further studies of this topic should include variables such as fracture fixation types, DLR, posterior malleolus and syndesmotic fixation. These studies will make advances to lessen the morbidity of ankle fractures and their sequalae alike.