SLR - December 2021 - Thomas M. Ehlers
Reference: de Cesar Netto C, Femino JE. State of the Art in Treatment of Chronic Medial Ankle Instability. Foot Ankle Clin. 2021 Jun;26(2):329-344. doi: 10.1016/j.fcl.2021.03.007. Epub 2021 Apr 17. PMID: 33990256.Level of Evidence: IV
Scientific Literature Review
Reviewed By: Thomas M. Ehlers, DPM
Residency Program: Highlands/Presbyterian-St. Luke’s – Denver, CO
Podiatric Relevance: There is often debate in regard to fixating the medial ankle ligaments, primarily deltoid ligament in foot and ankle surgery. These authors suggest that one should maintain a high index of suspicion for medial ankle instability following many common traumas that a podiatric surgeon may see in their clinic. Their primary rationale for fixating these medial structures, especially the deltoid, is because the ligament is intracapsular, and these ligaments don’t heal well on their own because of the synovial cells which can influence myofibroblast gene expression. The authors suggest, due to this, foot and ankle surgeons should address medial ankle ligament pathology surgically, especially with a high index of suspicion.
Methods: The authors did a brief literature review and biomechanical analysis of the medial ankle ligaments. Then, the authors discussed their perioperative protocol and described several of their favorite techniques. Lastly, they discussed outcomes and offered future perspectives on the pathology.
Results: Their preferred surgical technique included utilizing arthroscopy to confirm their findings of ligament instability or damage, and can be used to rule out osteochondral lesions, syndesmotic instability, or impingement in the ankle joint. Once this is done, utilizing suture anchors and allograft or autograft, the deep deltoid is fixed first, then the superficial deltoid is repaired or reefed to further tighten the medial ligaments. With this technique, any other medial pathology can be easily corrected, if need be, for example spring ligament reconstruction if it is found to be attenuated or torn. Then, the authors recommend non weightbearing for one to two weeks, strictly for wound healing, then, active range of motion to assist with ligamentous repair and prevent adhesions.
Conclusions: The deltoid ligament complex is one of the primary stabilizers of the ankle joint and medial instability is a frequent injury that is often missed. Long term instability can lead to significant ankle joint osteoarthritis, so it is crucial to identify deltoid attenuation, rupture, or laxity quickly to prevent long term degeneration. This article describes the preferred technique for the authors to reconstruct the deep deltoid and reef or imbricate the superficial ligaments. I think the authors did an excellent job reviewing the pertinent anatomy, pathology, and biomechanics of the medial ligamentous complex and based on this information, presented their preferred surgical techniques in various situations. Everything they described or did had a reason that they backed up with literature and anatomy, which is one of the reasons that I enjoyed reading their outcomes and methodology. I think that medial ligament instability is important and commonly missed, so it is important to evaluate the medial ankle, even after lateral ankle sprains or any ankle fracture. Their technique seems solid, but might be unnecessary, and I would have liked them to compare different techniques, including just utilizing absorbable suture in a pants-over-vest fashion. Next ankle trauma I see in clinic, I will palpate the deltoid more carefully and will suggest surgical fixation if warranted.