Deltoid Ligament Injuries Associated With Ankle Fractures

Arguments For and Against Direct Repair

Jesse F. Doty, MD; Burton D. Dunlap, MD; Vinod K. Panchbhavi, MD, FACS; Michael J. Gardner, MD


J Am Acad Orthop Surg. 2021;29(8):e388-e395. 

In This Article

Surgical Technique

The earliest deltoid ligament repairs were reported in the 1960s. The technique described in Duvries' Surgery of the Foot refers to a semilunar incision behind the medial malleolus extending to the navicular tuberosity. An anterior skin flap is raised to expose the ligamentous tissue. Although the foot is inverted, the deltoid ligament is then sutured to the periosteum and remaining tissue just above the bony origin.[6] Subsequent articles up to the year 2000 mimicked this technique but none give technical details aside from ligament suturing or end-to-end repair.

Surgical implants and techniques for collateral ligament repair have recently evolved. A curvilinear incision is made over the medial malleolus (see Supplemental Digital Content, Image 2, or directly over the anterior portion of the ligament including the tibionavicular, anterior tibiotalar, tibiospring, and tibiocalcaneal bundles. The deltoid ligament is most often seen as an avulsion off of the medial malleolus (see Supplemental Digital Content, Image 3, One or two suture anchors are placed anteriorly above the tip of the medial malleolus (see Supplemental Digital Content, Images 4 and 5, With the ankle inverted, full thickness horizontal mattress stitches can be passed through the superficial ligament complex to reapproximate the tissue directly to bone, and then pants-over-vest reinforcement can be done to reapproximate any remaining tissue (see Supplemental Digital Content, Images 6 and 7, The repair is often tensioned and reinforced with figure-of-eight absorbable sutures (see Supplemental Digital Content, Image 8, Finally, an intraoperative stress ankle mortise radiograph can be obtained to demonstrate restoration of stability (see Supplemental Digital Content, Image 9, Current techniques described by articles published in the 2010s may contribute to more satisfactory results. Although less common, a ligamentous avulsion off of the medial talus can occur. A similar approach is used as described above. One suture anchor can be placed in the medial talar body with the suture tunneled through an obliquely drilled hole in the medial malleolus. The sutures can be tied or secured to a suture button on the medial malleolus to resist talar tilt.[15]