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


Historical evidence suggests that direct repair of the deltoid ligament in ankle fracture treatment may be unnecessary. The treatment paradigm of allowing the ligament to heal indirectly is predominantly based on small case series without validated outcome scores. These studies suggest that patients who did not have direct ligament repair did relatively well. However, on detailed evaluation, data from the same study groups reveal unsatisfactory outcomes in up to 30% of patients based on current treatment standards. Functional outcomes seemed to be less predictable than stated, and long-term ankle mortise stability was often compromised. For example, De Souza et al[16] reported satisfactory results in all ankles without deltoid repair, although radiographic evidence of 2 mm of lateral talus translation was considered a "satisfactory" result by the study parameters. It is now known that 2 mm lateral displacement can decrease tibiotalar contact by more than 50%, which accelerates arthritis.[34]

Two distinct layers of the deltoid ligament complex provide differing contributions to ankle mortise biomechanical integrity. Cadaveric studies reveal that transection of the superficial fibers contributes mostly to valgus instability, whereas transection of the deep fibers contributes mostly to external rotation instability.[31] No available literature delineates superficial versus deep deltoid repair specifically. Often a component of syndesmotic compromise is involved in the pathophysiology of deltoid ligament injuries in bimalleolar equivalent ankle fractures. Biomechanical studies have attempted to test stability of the talus after simulating fixation of the syndesmosis versus repair of the deltoid ligament. Mococain demonstrated that isolated repair of the deltoid ligament may provide better restraint to anterior displacement than a syndesmotic screw, and similar stability was achieved in other planes of motion with either deltoid ligament repair or syndesmotic fixation. However, not until both components were addressed was normal stability achieved. Therefore, deltoid ligament repair may be an acceptable alternative to syndesmotic fixation, but both fixation methods are likely necessary to fully restore native stability.[35,36]

Many surgeons suggest that there may be a specific subset of patients that warrant direct visualization and repair of the deltoid ligament. Based on the available literature, indications to do a deltoid repair include medial gutter fracture fragmentation precluding talus reduction, persistent dynamic widening of the MCS despite lateral column fixation, high energy rotational ankle injuries in athletes or patients who want to maintain active lifestyles, and weber C ankle fractures. A randomized prospective study with adequate power comparing outcomes of bimalleolar equivalent ankle fractures would provide further validation of direct repair in certain patient populations.

Table 1 provides a brief review of the surgical studies evaluating deltoid ligament repair in the setting of acute ankle fractures.