SLR - December 2021 - Bryan Raymond
Reference: Wiegerinck JJ, Stufkens SA. Deltoid Rupture in Ankle Fractures To Repair or Not to Repair? Foot Ankle Clin. 2021 Jun;26(2):361-371. doi: 10.1016/j.fcl.2021.03.009. Epub 2021 Apr 18. PMID: 33990258.Level of Evidence: 4
Scientific Literature Review
Reviewed By: Bryan Raymond, DPM
Residency Program: Presbyterian St. Lukes/Highlands, Denver, CO
Podiatric Relevance: The importance of the deltoid ligament in ankle fractures has been subject to many investigations. To diagnose a deltoid ligament injury correctly is of paramount importance. The failure of conservative treatment of supposedly stable ankle fractures is probably caused by the misdiagnosed medial injury. This article addresses the question of which acutely ruptured deltoid ligaments that are part of an ankle fracture could benefit from suturing in order to help restore ankle stability.
Methods: Systematically reviewed articles for and against the repair of acute deltoid ligament rupture in ankle fractures. Criteria for acute deltoid injury from the included cited articles were performed by MRI or arthroscopic examination. Additional diagnostics primarily consist of conventional imaging focusing on the medial clear space (MCS) where widening can be found; 4 mm in a nonstressed mortise view and/or a superior tibiotalar clear space greater than 1 mm are considered pathologic. The article compared outcome measures between the supported studies for and against deltoid repair.
Results: The author found 4 studies not in favor of suturing the deltoid ligament. The general consensus was that only if there is interposition of the medial side after adequate reduction in the fibular fracture is an exploration of the medial clear space required and that the deltoid ligament heals sufficiently with nonoperative treatment in cases without interposed tissue.
The author also found four studies in favor of suturing the deltoid. The conclusions drawn from these reports are that deltoid repair is able to restore congruity to the ankle joint, and avoids the need to remove symptomatic syndesmotic implants, decrease malreduction rates of syndesmotic fixation, and a more favorable final follow-up medial clear space when compared to groups without a deltoid repair.
Conclusions: The literature supports both repair of the deltoid ligament and not repairing the deltoid in ankle fracture. When primary ligamentous repair is achieved, the consensus is to use an absorbable suture material. There also may be selected cases in which the deltoid ligament repair adds to the strength of the construct. In cases of doubt, arthroscopy can be of assistance to determine interposition when medial clear space remains wide.