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

Argument not to Repair the Deltoid Ligament

Some argue that surgical repair or reconstruction of the deltoid ligament may be unnecessary, and the medial ligament complex can be effectively disregarded in the setting of traumatic ankle fractures. The practice not to directly address the ligament seems to be derived primarily from literature of the 1980s and 1990s. Early studies suggested that the most important and clinically relevant aspect of ankle mortise stability came from anatomic reduction of the lateral column with fibula fracture restoration, as long as the MCS was statically restored. This approach relies on the assumption that the medial ligamentous complex will heal indirectly. De Souza et al published results in 1985 supporting such practice. The authors presented a cohort of 24 fibula fractures with concurrent MCS widening; 22 of 24 patients were treated with fibula fixation without deltoid ligament repair. Multiple subjective criteria were reported and patients were divided into either "satisfactory" or "unsatisfactory" outcomes based on a nonvalidated 100-point outcome scale, of which all 24 patients reportedly had "satisfactory" results at the 3-year follow-up. A satisfactory result was defined as at least 80 points of 100, with the point system divided between pain scale, function, range of motion, and radiographic analysis. The article did not report on functional instability.[16]

Foregoing deltoid ligament repair can likely lead to a functional ankle in most patients with bimalleolar equivalent fractures. In 1987, Baird and Jackson reported the 2-year follow-up in 24 patients with fibula fracture and concomitant deltoid ligament disruption. Twenty-one of 24 patients with deltoid ligament disruption did not have direct repair. No ankle instability existed, and 90% had good or excellent outcomes and no pain with ADLs. Ten percent of patients had a fair or poor result.[17] Harper,[18] in 1988, reported on 36 surgically treated lateral malleolus fractures without deltoid repair. Most patients reported satisfactory results, but more than 20% of patients reported fair or poor results with talus shift or loss of reduction. The study did not evaluate ankle stability or medial ligamentous pain. In 1995, Stromsoe et al done surgical fixation in 50 stress positive Weber B and Weber C fibula fractures with a ruptured deltoid ligament. The ankles were randomized to undergo direct ligament repair or to have indirect reduction of the medial ligaments. The authors reported no outcome differences between the two groups except increased surgical time in the repair group. No assessment of instability existed. Similar to most of the early reports, the study lacked power to draw notable conclusions.[19] Given the available literature to orthopaedic surgeons at this point in time, it would certainly be believable that most patients would have near similar results despite the added effort of directly addressing a medial ligamentous injury.

Native bone congruency of the plafond may provide inherent stability with loading. Cadaveric studies have biomechanically evaluated the ankle under differing ligamentous pathologic conditions. In 2012, Stewart evaluated fracture stability in ankles with fibular osteotomy, deltoid transection, or both. The ankles were axially loaded under the three conditions to simulate weight-bearing in a neutral or dorsiflexed position. No radiographic talar shift existed in any of the three conditions.[20] The study suggested that routine direct repair even with early weight-bearing may be unnecessary, and although repair may radiologically restore the MCS, functional outcomes and complications have not shown notable differences with repair.[21] Herein, lies the crux of the argument in defining clinical significance or functional instability that would benefit from direct repair.