Arthroscopic Approach to Deltoid Injuries.

Introduction: Rotational ankle instability (RAI), involving combined medial and lateral ligament insufficiency, is an increasingly recognized clinical entity. While open surgery has traditionally been the mainstay for treating deltoid ligament injuries, recent developments in arthroscopic techniques offer a minimally invasive alternative. This systematic review aimed to evaluate the current evidence on the arthroscopic management of medial and rotational ankle instability, focusing on surgical techniques, clinical outcomes, and complications. Methods: A systematic literature search was conducted following PRISMA guidelines using the PubMed, Scopus, and Web of Science databases. The search strategy included the following terms: ((rotation instability) OR (deltoid) OR (medial ankle instability)) AND (ankle arthrosc*). Eligible studies included adult patients undergoing arthroscopic repair of medial ankle instability with a mean 26.4 months follow-up and reported clinical outcomes. Ten studies met the inclusion criteria, encompassing 336 patients and 346 ankles. Results: The mean patient age was 32.6 ± 5.0 years, with 80.6% being male. MRI was the primary diagnostic tool across most studies. Ankle sprains were the most common cause of instability. Lateral ligament insufficiency was frequently associated with medial injuries, reported in all studies evaluating this parameter. All patients underwent prior conservative treatment (mean duration: 5.6 months). Surgical management involved all-inside arthroscopic repair using knotless suture anchors. Additional procedures were performed in 90% of studies, including osteophyte resection (33.3%) and microfracture (22.2%). The mean follow-up period was 26.4 months. The mean postoperative AOFAS score was 95.3, with return to sport generally achieved between 3 and 5 months. Complications were minimal, primarily consisting of superficial wound issues and transient nerve irritation; no major complications or revision surgeries were reported. Discussion: Arthroscopic management of medial and rotational ankle instability is associated with excellent functional outcomes, low complication rates, and early return to sport. Compared to open procedures, arthroscopic techniques offer advantages including reduced soft tissue trauma, fewer wound complications, and the ability to address concomitant intra-articular lesions in a single session. Although technically demanding, this approach is particularly beneficial in athletic populations. However, high-quality prospective studies are still needed to validate these findings and establish long-term comparative outcomes with open reconstruction techniques.

Deltoid Ligament Injuries in Athletes: Techniques of Repair and Reconstruction

Ankle sprains are extremely common. It is important to have a clear insight of the course of recovery after such injury to evaluate the effective strategies to guide management decisions, and understand the potential risk factors involved in the development of chronic problems and recurrent ankle sprains. When a prompt diagnosis is not formulated, ligament tears can remain untreated, and chronic ankle instability can result after acute lateral or medial ankle sprain. When the medial ligament complex (MLC), in particular the anterior fascicle of the deltoid ligament, is involved, rotational ankle instability (RAI) can develop. Generally, a tear of the anterior fibres of the MCL accompanied by anterior talofibular ligament (ATFL) insufficiency has been associated with RAI, while injury of the intermediate fibres of the MLC has been associated with medial ankle instability (MAI). Conservative management is the first line of treatment, with surgery reserved for special cases or if rehabilitation has failed. Regarding surgery, several options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Ankle arthroscopy is increasingly used to address ligament insufficiency and to identify and treat intra-articular pathologies. Repair of MLC tears by an arthroscopic all-inside procedure is effective in both MAI and RAI.

Chronic Rotational Ankle Instability- A case series study

The treatment of chronic ankle sprains has largely focused on lateral ankle instability in the literature. There is a scarcity of data regarding the diagnosis and management of chronic medial ankle instability secondary to deltoid ligament injury. A literature search was performed using the National Center for Biotechnology Information (NCBI) database for studies evaluating chronic ankle instability (CAI) involving deltoid ligament pathology. Studies were evaluated for workup including clinical presentation, imaging, treatment algorithm and operative techniques. Descriptive statistical analysis was conducted across the pooled data set. Nine studies representing 516 patients with CAI were included in our analysis. Plain radiographs assessed talar-tilt angle in 440 patients (85%) and anterior displacement in 296 patients (57%). A total of 465 patients underwent magnetic resonance imaging, with deltoid injuries identified in 289 (62%) of patients. Of these 289 patients, superficial deltoid involvement was specified in 61 patients and deep deltoid in 146 patients. Surgical treatment most commonly included arthroscopy in 255 patients with open deltoid ligament repair in 199 patients. Repair method included suture anchors in 173 patients (87%), bone tunnels in 23 patients (12%), and unspecified technique in 3 patients (1.5%). Thirteen patients (6.5%) had suture anchor repairs augmented with an internal brace. Three patients underwent deltoid reconstruction with plantaris tendon autograft. Deltoid ligament injuries are common in patients with CAI. These data improve our understanding of chronic deltoid injuries and can help patients and surgeons better comprehend the pathoanatomy of chronic ankle instability. Level III, retrospective cohort study.

Concomitant Syndesmotic Instability and Medial Ankle Instability Are Risk Factors for Unsatisfactory Outcomes in Patients With Chronic Ankle Instability

Injury to the lateral collateral ligament of the ankle may cause ankle instability and, when combined with deltoid ligament (DL) injury, may lead to a more complex situation known as rotational ankle instability (RAI). It is unclear how DL rupture interferes with the mechanical function of an ankle joint with RAI. To study the influence of DL injury on the biomechanical function of the ankle joint. A comprehensive finite element model of an ankle joint, incorporating detailed ligaments, was developed from MRI scans of an adult female. A range of ligament injury scenarios were simulated in the ankle joint model, which was then subjected to a static standing load of 300N and a 1.5Nm internal and external rotation torque. The analysis focused on comparing the distribution and peak values of von Mises stress in the articular cartilages of both the tibia and talus and measuring the talus rotation angle and contact area of the talocrural joint. The dimensions and location of insertion points of ligaments in the finite element ankle model were adopted from previous anatomical research and dissection studies. The anterior drawer distance in the finite element model was within 6.5% of the anatomical range, and the talus tilt angle was within 3% of anatomical results. During static standing, a combined rupture of the anterior talofibular ligament (ATFL) and anterior tibiotalar ligament (ATTL) generates new stress concentrations on the talus cartilage, which markedly increases the joint contact area and stress on the cartilage. During static standing with external rotation, the anterior talofibular ligament and anterior tibiotalar ligament ruptured the ankle's rotational angle by 21.8% compared to an intact joint. In contrast, static standing with internal rotation led to a similar increase in stress and a nearly 2.5 times increase in the talus rotational angle. Injury to the DL altered the stress distribution in the tibiotalar joint and increased the talus rotation angle when subjected to a rotational torque, which may increase the risk of RAI. When treating RAI, it is essential to address not only multi-band DL injuries but also single-band deep DL injuries, especially those affecting the ATTL.

Deltoid ligament reconstruction with autologous gracilis tendon in chronic medial ankle instability after ankle fracture surgery: A case report

ABSTRACTBackgroundDeltoid ligament (DL) injuries are increasingly recognized in chronic ankle instability (CAI), drawing clinical attention to rotational ankle instability (RAI). Cadaveric studies have shown that RAI can increase ankle rotation; however, current examination methods for RAI remain limited. As they neither provide adequate insight into ligamentous structural damage nor clearly characterize the rotational instability. This study aimed to evaluate the characteristic rotational instability of RAI and, based on this indicator, investigate which postural control parameters best represent rotational instability and how these parameters can be quantified to assess diagnostic utility using postural control parameters and establish quantitative diagnostic thresholds.MethodsWe included 32 patients with CAI who underwent a postural control assessment, combining center of pressure (COP) analysis with the sensory organization test (SOT). Talar tilt angle and medial clear space were also measured via anteroposterior radiographs and magnetic resonance imaging (MRI) to assess DL injuries. Final diagnoses of RAI or CAI were made in the DL based on arthroscopic findings. Receiver operating characteristic (ROC) curves were constructed to determine the diagnostic performance of each indicator.ResultsIn RAI, the ratio of coronal‐plane sway to sagittal‐plane sway amplitude during motion was significantly elevated, a phenomenon we term “coronal instability.” Coronal instability emerged as a strong predictor of RAI, with an area under the ROC curve (AUC) of 0.95 (95% CI, 0.810–0.996; p < 0.0001). Its optimal cutoff value of 0.81 yielded a sensitivity of 83.33% and a specificity of 100%, surpassing imaging‐based measures such as radiography and MRI (AUC = 0.567–0.844).ConclusionCoronal instability, measured through a noninvasive postural control assessment, demonstrates high sensitivity and specificity for diagnosing RAI. This method offers a valuable clinical tool for accurately identifying RAI and may complement or outperform traditional imaging techniques in certain cases.

Rotational ankle instability is a multiligamentous injury defined as an overload injury of the deltoid ligament caused by a long-standing injury of the lateral collateral ligament in patients affected by chronic ankle instability. The purpose of the study was to compare the clinical outcomes of combined arthroscopic repair of lateral and medial ankle ligaments for rotational ankle instability versus isolated arthroscopic lateral ligament repair for lateral ankle instability at 2 years' follow-up. Between 2019 and 2021, 108 patients with chronic ankle instability were consecutively treated by arthroscopy. Of this group, 83 patients (77%) [median age: 26 (range, 14-77) years] underwent an isolated all-inside lateral ligament repair for lateral ankle instability (group A). In the remaining 25 patients (23%) [median age: 27 (range, 17-58) years], rotational ankle instability was clinically suspected and confirmed during arthroscopy; thus, a combined all-inside repair of lateral and medial ligaments was performed (group B). Thesame postoperative protocol was utilised for both groups. Patients were prospectively evaluated before surgery, at 3, 6, 12 and 24 months with Foot Functional Index (FFI) score, visual analogue scale (VAS) and Foot and Ankle Ability Measure-Sports subscale (FAAM-SS). At the latest follow-up, the satisfaction rate and complications were also recorded. In both groups, FFI, VAS and FAAM-SS scores significantly improved compared to preoperative values (p < 0.001). In addition, according to all the scores evaluated, there was no significative difference (n.s) between groups at the final follow-up or at any of the intermediate follow-up. No major complications were observed in both groups. Arthroscopic ligament repair in case of ankle multiligamentous injuries, such as in rotational ankle instability, provides excellent clinical outcomes and is comparable to isolated lateral ligament repair at 2 years' follow-up. Therefore, when treating ankle instability, arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes and is the recommended treatment. Level II, prospective comparative.

Category:Arthroscopy; Ankle; Sports; TraumaIntroduction/Purpose:The deltoid ligament complex is the main stabilizing structure of the ankle mortise and is often disrupted in rotational ankle injuries. Current treatment involves open techniques for the acute repair of the superficial deltoid layer, however, repair or reconstruction of the deep deltoid ligament (DDL) has proven to be challenging using open techniques. Our described arthroscopically-assisted technique allows for better intra-articular visualization and durable reconstruction of the ruptured DDL with suture and knotless bone anchors. The goal of this new, minimally invasive approach is to facilitate a faster and more reliable recovery and prevent long-term dysfunction and degeneration from medial and rotational ankle instability. We believe it has the potential to provide improved immediate ankle stability and decrease overall surgical morbidity compared to open treatments.Methods:Case of a 48-year-old male with ligamentous-equivalent Massioneuve fracture with medial clear space (MCS) measuring 11 millimeters. Arthroscopy revealed unstable syndesmosis and rupture of the DDL. After syndesmotic fixation, there was persistent MCS widening on stress exam. Arthroscopically-assisted DDL reconstruction was performed using an accessory anteromedial (AAM) portal between the tibialis anterior tendon and posterior tibial tendon. Needle localization identified the sagittal midpoint of the medial wall of the talus, inferior to articular cartilage. Anchor sites at both the medial talar wall and midportion of the distal medial malleolus (insertion and origin of the DDL, respectively) were then drilled via the AAM portal under arthroscopic and fluoroscopic guidance respectively at the isometric point. A suture anchor was placed into the talus and tails were loaded and secured to the medial malleolus with a bioabsorbable anchor. Ankle mortise was stable to stress exam and there were no restraints to physiologic motion.Results:The patient was kept non-weight bearing on his right lower extremity for a total of 6 weeks postoperatively and was seen in the clinic for routine follow-up visits at 2 weeks, 6 weeks, and 3 months post-procedure. Sutures were removed at 2 weeks, without any wound complications, and he was transitioned from splint to a short leg cast. He required only three days of oral narcotic analgesia. Weight-bearing in a controlled ankle motion (CAM) boot and physical therapy were both initiated at 6 weeks post-op. Radiographs at each follow-up visit were without abnormalities. At 3 months post-op, he was graduated from the CAM boot into a lace-up ankle brace, without any complaints of ankle pain or instability. The patient progressed well with full weight-bearing and physical therapy and was seen for a final visit at 5 months post-op with stable MCS. No complications were encountered.Conclusion:Acute DDL rupture is a common occurrence in ankle fractures and can be diagnosed radiographically and by arthroscopy. Known sequelae of untreated DDL disruption include medial instability and late valgus collapse. This case report demonstrates a novel, minimally invasive technique to successfully reconstruct the DDL, which may minimize the surgical morbidity compared to open dissection methods and allow for decreased recovery time postoperatively. This approach may also be utilized for cases of chronic instability. Future work includes larger case series with long-term follow-up and refinement of the technique as instrumentation advances.

When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique. During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up. Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. Level IV, retrospective case series.

Complete avulsion of the superficial deltoid complex off the medial malleolus can occur during high-energy ankle fractures in young patients. Partial deltoid ligament injuries can also occur with avulsion fractures off the tip of the medial malleolus in low-energy ankle fractures in the elderly. Infolding and retraction of the avulsed deltoid complex can cause persistent widening of the medial clear space and lead to ankle fracture malreduction, postoperative medial gutter pain, and medial ankle instability. It is important for physicians to recognize and repair superficial deltoid ligament injuries in the setting of ankle fractures in order to restore ankle collateral ligament anatomy and help improve clinical outcomes. The deep deltoid ligament is generally difficult to repair in the acute setting and reconstructed later on if chronic ankle instability and valgus deformity develop in the future. Level of Evidence: Level V—Expert Opinion.

Arthroscopic Deltoid Ligament Reconstruction in Rotational Ankle Instability

Medial Ankle Instability: The Deltoid Dilemma