Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review

Dabash, Sherif; Elabd, Ahmed; Potter, Eric; Fernandez, Isaac; Gerzina, Chris; Thabet, Ahmed M.; McGarvey, William C.; Abdelgawad, Amr

doi:10.1016/j.fas.2018.11.001

Cited by 47 publications

(45 citation statements)

References 31 publications

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“…It does, however, create a biomechanical template for future clinical studies. Furthermore, similar to previous studies, 1,3,6,30 the amount of distal tibiofibular translation after sequential ligament transection varied greatly between specimens. 1,3,7,32 Future cadaveric studies may benefit from matched pairs to serve as an internal control given that recent studies about distal tibiofibular morphology in vivo highlight interpatient differences, 11,29,35 but that the contralateral side in a given patient serves as an effective comparison.…”

Section: Discussionsupporting

confidence: 87%

“…A recent systematic review investigating the indications for deltoid repair in ankle fracture concluded that patients with concomitant syndesmotic instability may benefit from additional deltoid ligament repair, leading to improved functional outcomes. 6 However, this statement was only substantiated by level III evidence comparison study. 33 Future research is required to provide clear indications for deltoid ligament repair in patients with acute syndesmotic instability.…”

Section: Discussionmentioning

confidence: 99%

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Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model

et al. 2019

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Background: Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane. Methods: Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured. Results: Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state ( P values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%). Conclusion: Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation. Clinical Relevance: These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model

et al. 2019

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“…3,14,18 Currently, repair of the deltoid ligament is recommended by some surgeons if medial instability is present, even after fixation of an isolated lateral malleolar fracture. 4,7,12 Hintermann 8 described the characteristics of medial instability as a feeling of giving way, pain in the medial gutter of the ankle, and both a valgus and pronation deformity of the foot that is usually corrected by the posterior tibial muscle. Jones and Nunley 10 have demonstrated comparable results for repairing bimalleolar equivalent ankle fractures when comparing lateral malleolus fixation with deltoid repair versus lateral malleolus fixation with syndesmotic fixation.…”

Section: Introductionmentioning

confidence: 99%

Technique for Arthroscopic Deltoid Ligament Repair With Description of Safe Zones

Acevedo¹,

Kreulen

Cedeno³

et al. 2020

Foot Ankle Int.

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Repair of the deltoid ligaments is suggested in patients with medial ankle instability after a ligamentous injury or lateral malleolar fracture fixation. Arthroscopy can be a definitive mode of determining whether there is medial instability and, therefore, help to determine whether there is a need to repair the deltoid ligaments. The authors describe a technique for the arthroscopic repair of the deltoid ligaments, using a suture passer and suture anchors. Cadaveric analysis was utilized to establish safe zones and indicate that there is a relatively wide safe zone between the posterior tibialis tendon and the saphenous vein when performing the technique. The authors have performed more than 87 arthroscopic deltoid repairs, with a greater than 90% satisfaction rate among patients. However, future studies with validated outcome measures are needed. Level of Evidence: Level V, expert opinion.

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“…According to our results visualization of most ankle ligaments with 3D orthogonal standard CT planes in bone kernel reconstruction is feasible -with excellent interreader agreement. This includes the syndesmosis and the PTTLboth of which crucial stabilizers of the ankle with potentially indication for operative repair if injured [26,27]. CT imaging of ankle ligaments takes advantage of the large gap in densities between the hypodense fat tissue surrounding most of the relatively hyperdense ligaments (68 HU on average) -causing the high contrast needed for discrimination of soft tissue components.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of ankle ligaments with CT: A feasibility study

Sterzik

Mueck

Wirth

et al. 2021

European Journal of Radiology

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This study aims to systematically investigate if normal ankle ligaments can be assessed with CT imaging, using MRI as reference standard. Methods: 35 patients (mean age: 47 ± 15 years; female n = 19) with combined CT and MRI exams and without MR-morphologic signs of ankle ligamental injury were retrospectively identified. 3 readers independently evaluated the syndesmotic, the lateral and medial ankle ligaments in terms of visibility on a 4-point Likert scale (0-3 points) in multiplanar MDCT images in standard bone kernel reconstructions. In consensus CT-based ligament density and thickness were measured and the appearance was rated for each ligament. Results were compared and validated with corresponding MRI images. Results: Almost all ankle ligaments identified in MRI images could be adequately depicted in standard multiplanar bone kernel CT images with a mean visual score of 2.7/3 (± 0.2). Difficulties in CT morphological delineation of ankle ligaments occurred in cases of filiform TNL and TCL and in cases of concurrent soft tissue edema. Interreader agreement for the CT-assessment of ankle ligaments was excellent, with Fleiss Kappa values >0.8. Mean density of evaluated medial and lateral ankle ligaments was 68 ± 2.9 HU, with substantially interand intraindividual variations. Thickness measurements and assessment of appearance of ankle ligaments showed a good concordance between CT and MRI. Conclusions: Assessment of normal ankle ligaments via standard CT in bone kernel reconstructions is feasible, with some restrictions concerning the medial collateral ligaments and in the presence of soft tissue edema.

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Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review

Cited by 47 publications

References 31 publications

Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model

Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model

Technique for Arthroscopic Deltoid Ligament Repair With Description of Safe Zones

Evaluation of ankle ligaments with CT: A feasibility study

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