Deltoid Ligament Research Articles

Repairing the Deltoid Ligament in Ankle Fractures Is it time for a Paradigm Shift?

It remains unclear whether repairing the deltoid ligament (DL) is beneficial in acute ankle fractures. The aim of this review is to critically review the developments in deltoid ligament repair (DLR) in ankle fractures over the course of 44 years. An electronic search was conducted on the PubMed and Embase database including comparative studies evaluating the effect of performing DLR in adults suffering from a closed acute ankle fracture with suspected rupture of the DL. A total of 27 studies were retrieved, of which only one was a randomized study. A total of 1327 patients were reviewed (663 undergoing DLR and 664 receiving non-DLR treatment for an acute ankle fracture). Although earlier studies concluded that DLR holds little necessity in ankle fracture treatment if the anatomy of the ankle is restored, more recent studies support DLR due to more favorable clinical and radiographic outcomes. All studies agree that restoration of the ankle anatomy to its pre-fracture state is necessary to achieve the best clinical outcome. However, there is still controversy in whether to standardize DLR in ankle fracture treatment. The literature shows a clear shift toward more frequent restoration of the DL, and in light of improved surgical techniques and implants, there is a need for more rigorous studies to provide a clear indication for DLR in acute ankle fracture treatment. III.

Deltoid ligament injuries: When and how to repair

AbstractPurposeThis study aims to illustrate the assessment and treatment strategies of acute and chronic deltoid ligament injuries, providing a treatment algorithm for each scenario.MethodsA retrospective review was conducted on 39 patients, who had either an acute deltoid ligament injury or suffered chronic deltoid ligament insufficiency. All patients were operated on between January 2016 and December 2022. The cases represent a range of different clinical scenarios, including acute trauma, chronic insufficiency or instability situations. Clinical and imaging evaluation, surgical techniques and clinical outcomes are presented.ResultsThe mean follow‐up time was 21.3 months (±4.5). Acute trauma represented 18 (46%) of the ankles, while 21 (54%) had chronic instability. Treatment options were tailored according to the aetiology, patient characteristics, injury pattern and associated lesions. In 11 of the 18 acute deltoid ruptures (64%), repair was performed using suture anchors, while the remaining 7 cases were treated with direct suture. In chronic deltoid insufficiency, re‐tensioning with suture anchor was performed in 14 (67%) ankles, suture imbrication in 5 (24%) and reconstruction in 6 (9%). The most common associated injuries were syndesmotic injuries (n = 12, 56%) and osteochondral lesions (n = 13, 36%). The complication rate was 18% (n = 7), the majority related to persistent stiffness (n = 4, 10%).ConclusionThe decision on when and how to repair the deltoid ligament should be guided by the characteristics of the injury and the individual patient. The current treatment rationale may serve as a working basis for evaluating and treating these ankles.Level of EvidenceLevel IV.

Cadaveric Diagnostic Study of Subtle Syndesmotic Instability Using a 3-Dimensional Weight-Bearing CT Distance Mapping Algorithm.

The diagnosis of syndesmotic instability is challenging, and chronically unstable injuries can potentially lead to ankle arthritic degeneration. The objective of this cadaveric study was to utilize a 3-dimensional (3D) weight-bearing computed tomography (WBCT) distance mapping algorithm for the detection of subtle syndesmotic instability, induced by complete syndesmotic ligament sectioning and stressed by isolated axial load. We hypothesized that this algorithm would accurately detect subtle syndesmotic instability. Nineteen matched pairs of through-the-knee cadaveric specimens (38 legs) were utilized. Specimens were mounted in a frame that allowed simulated axial weight-bearing (356 N). Specimens were scanned using cone-beam WBCT in the normal pre-injury state and after complete syndesmotic ligament sectioning. The deltoid ligament was kept intact, and no external rotational stress was applied. Syndesmotic incisura and lateral gutter distances were assessed and compared between pre-injury ipsilateral, contralateral, and injured states using a 3D WBCT distance mapping algorithm. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were calculated for the comparison of syndesmotic distance measurements between injured specimens and controls. P values of <0.05 were considered significant. Overall, significantly increased distances were observed in injured specimens when compared with controls, with average relative syndesmotic widening in injured specimens of 16.9% (p = 0.0003), 11.3% (p = 0.0015), 6.4% (p = 0.0027), and 2.9% (p = 0.037) at the first 1, 3, 5, and 10 cm (proximal to the apex of the distal tibial articular surface), respectively. Widening was more pronounced in the anterior aspect of the syndesmosis, where the diagnostic accuracy was found to be highest at the first 1 and 3 cm of the syndesmotic incisura, with AUC values ranging from 80.9% to 83.0% (p < 0.0001) and with threshold diagnostic values of relative syndesmotic widening as low as 0.43 mm. The newly proposed 3D WBCT distance mapping algorithm was able to accurately detect subtle syndesmotic instability in a cadaveric model of complete syndesmotic sectioning under isolated axial weight-bearing load. This algorithm needs to be further validated in patients with suspected traumatic syndesmotic instability. This cadaveric study demonstrated high diagnostic accuracy of a 3D WBCT distance mapping algorithm to detect subtle syndesmotic instability when stressed with isolated axial loading and in the absence of deltoid injury. The future use of this algorithm in patients with suspected unilateral traumatic syndesmotic instability could hopefully optimize the diagnosis and treatment decision-making.

The deltoid ligament complex is reliably visualised as four fascicles in two layers with 3D volumetric MRI in the ankles of 20 asymptomatic volunteers.

The anatomy of the deltoid ligament is complex. There is agreement on the presence of superficial and deep layers but the number and frequency of fascicles remains controversial. Identifying injuries to specific components of the deltoid ligament may inform decision-making on their management. The anatomy was reviewed to establish the number and dimension of fascicles visible with three-dimensional (3D) volumetric magnetic resonance images (MRI). Twenty ankles from asymptomatic healthy volunteers were imaged with 3D volumetric MRI. The presence of individual fascicles was recorded and measured in 3D. The median age of participants was 26 years (range: 20-37) of which 13 (65%) were female. All 20 ankles had a deltoid ligament formed of four fascicles in two layers: three fascicles in the superficial layer; tibionavicular (mean dimensions 22.5 × 10.0 × 2.4 mm), tibiospring (16.6 × 6.7 × 1.9 mm) and tibiocalcaneal (23.8 × 4.6 × 1.8 mm) and a deep layer consisting of the tibiotalar fascicle, which could be divided into two parts: anterior tibiotalar (mean dimensions 10 × 5.6 × 4.1 mm) and the significantly larger posterior tibiotalar (14.2 × 13.8 × 17.5 mm, p < 0.01). There were no additional fascicles observed. The deltoid ligament complex was consistently visualised as four fascicles (tibionavicular, tibiospring, tibiocalcaneal, tibiotalar) in two layers (superficial and deep) in all 20 ankles. The posterior part of the tibiotalar fascicle was the thickest of all the fascicles in the deltoid ligament. It is, therefore, possible to accurately identify the components of the deltoid ligament, and 3T MRI can be used to assess fascicle-specific injury, which will guide treatment and rehabilitation. Level III.

Arthroscopic repair is an effective treatment for dynamic medial ankle instability secondary to posttraumatic and partial injury of the deltoid ligament deep fascicle.

When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique. Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique. A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up. Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI. Level IV.

Acquired Pes Planovalgus : Current Concepts - "From Adult Acquired Pes Planovalgus to Progressive Collapsing Foot Deformity".

The clinical disorder traditionally known as pes planovalgus due to posterior tibial tendon insufficiency or adult-acquired pes planovalgus has been the subject of several publications over the past two decades. Now, it is understood that the problem does not lie in the posterior tibial tendon per se and may even occur without tendon injury. Studies have brought new concepts and understanding that question the views on this subject, culminating in the replacement of existing classifications with one that is more assertive and discriminative of the potential presentation patterns of the deformity. In addition, a change in the name of the disorder to progressive collapsing foot deformity (PCFD) has been proposed. Regarding surgical treatment, the concept of an à la carte approach persists, emphasizing axis realignment through osteotomies, arthrodeses, and soft tissue balancing, which consists of tendon transpositions/repairs and reconstruction of ligament structures, especially the deltoid ligament complex and the spring ligament.

Risk Factors for Chronic Syndesmotic Instability After the First Episode of Acute Ankle Sprain: A Cross-Sectional Study of 356 Cases.

Chronic syndesmotic instability (CSI) can be associated with severe long-term pain and disability. This study aimed to investigate the risk factors associated with the development of CSI in patients who underwent conservative treatment after the first episode of acute ankle sprain (AAS) that did not result in a satisfactory outcome. We retrospectively analyzed the clinical data of patients who underwent ankle arthroscopy for suspected CSI between January 2020 and September 2023. The patients were divided into the instability and stability groups based on the syndesmotic space width measured under arthroscopy, with 3 mm as the critical value. Demographic, arthroscopic, and imaging information such as the anterior talofibular ligament (ATFL), calcaneofibular ligament, posterior talofibular ligament (PTFL), anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), deltoid ligament (DL), interosseous membrane, height of the syndesmotic fluid, injuries of the talus, calcaneus, tibia, and fibula, effusion of the tibiotalar and talocalcaneal joints, fibular morphology, and fibular incisura features, were recorded. Univariate and multivariate analyses were performed successively to identify the risk factors. Of the 356 patients, 102 developed CSI after the first episode of AAS. In the multivariate analysis, development of CSI was associated with 5 clinical factors: DL injury (odds ratio [OR] 7.453, 95% CI 3.007-18.471; P < .001), positive bandage-binding test (OR 7.196, 95% CI 2.942-17.599; P < .001), grade 2 to 3 injury of the PITFL (OR 2.727, 95% CI 1.044-7.124; P = .041), positive squeeze test (OR 2.455, 95% CI 1.045-5.770; P = .039), and body mass index (BMI) (OR 1.306, 95% CI 1.121-1.522; P < .001). Five key factors were associated with CSI development in patients who underwent conservative treatment after the first episode of AAS that did not result in a satisfactory outcome: DL injury, positive bandage-binding test, grade 2 to 3 injury of the PITFL, positive squeeze test, and BMI.

Modified double-row suture bridge technique for anterior colliculus fractures combined with deltoid ligament injury: a retrospective study

BackgroundThe management of anterior colliculus fractures in combination with deltoid ligament injuries is a topic of debate, and there is a need to improve surgical outcomes. The purpose of the present study was to describe the application of a modified double-row suture bridge technique and evaluate its early clinical outcomes in the management of anterior colliculus fracture combined with deltoid ligament injury.MethodsFrom 2020 to 2022, 12 patients with anterior colliculus fracture combined with deltoid ligament injury were treated using a modified double-row suture bridge technique. For clinical outcome evaluation, objective data are presented through clinical examination findings; radiographic assessments, including X-rays and computed tomography (CT); and follow-up analysis utilizing American Orthopaedic Foot & Ankle Society ankle‒hindfoot (AOFAS) scores, Olerud Molander Ankle Scores (OMAS), and visual analogue scale (VAS) scores. Preoperative and follow-up scores were compared with Student’s t test. (p < .05).ResultsThe mean age of the patients was 52.67 ± 9.42 years (range: 39–74). The mean duration of follow-up was 14.42 ± 1.51 months (range: 12–17). At the final follow-up, the mean AOFAS score (P < 0.001) improved to 91.50 ± 2.65 points (range: 87–96), the mean OMAS (P < 0.001) improved to 77.08 ± 3.97 points (range: 70–85), and the mean VAS score (P < 0.001) improved to 0.25 ± 0.45 points (range: 0–1). Nine patients achieved excellent outcomes, and three achieved good outcomes according to the AOFAS score. Follow-up imaging evaluation indicated satisfactory alignment of the fracture and complete healing. Clinical examination suggested good mobility of the ankle. At the last follow-up, ankle dorsiflexion mobility was 14–18 degrees, plantar flexion mobility was 42–45 degrees, inversion mobility was 27–32 degrees, and eversion mobility was 22–25 degrees.ConclusionsThe modified double-row suture bridge technique is effective for achieving anatomic reduction of anterior colliculus fractures, and the technique also provides substantial benefit to the injured deltoid ligament. With this technique, the clinical outcomes can be significant and encouraging, indicating a new stage in its application and development.

Congruent Weber-B ankle fractures do not alter tibiotalar contact mechanics.

Current treatment strategy for managing Weber B ankle fractures is mainly governed by mortise congruency, malleolar alignment, deltoid ligament competence and fracture stability. While nonoperative treatment has yielded good functional outcomes in satisfactorily aligned stable injuries, a biomechanical rationale is not firmly established. Furthermore, current radiographic analysis is obscured by observer inaccuracy and beam rotation. This study aimed to utilize weightbearing CT and computational biomechanics to analyse 3D mortise displacement and contact mechanics in Weber-B ankle fractures and compare them with the uninjured contralateral side. 32 patients were included who sustained a Weber-B ankle fracture and underwent bilateral weightbearing CT imaging at injury. Segmentation into 3D models of bone was performed semi-automatically, and individualized cartilage layers were modeled based on a previously validated methodology. The 3D mortise congruency was evaluated by use of following parameters: alpha angle, fibular length, talocrural angle, medial gutter- and tibiofibular clear space- distance mapping. Contact mechanics were evaluated by the mean and maximum contact stress of the tibiotalar articulation. Statistical analysis revealed that there were no significant differences for all anatomical parameters. There was also no significant difference between the mean contact stress of the injured (2.10 ± 0.42 MPa) and uninjured side (2.10 ± 0.41 MPa), nor the maximum contact stress of the injured (7.67 ± 1.55 MPa) and uninjured (7.47 ± 1.67), respectively. Contact mechanics were unaffected in congruent Weber-B fractures. These findings support consideration of nonoperative management in such cases, given their presumably low risk for posttraumatic arthritic development in the long term. Level of Evidence: Level III; retrospective case-control study.

High-Energy Transsyndesmotic Ankle Fracture Dislocation-Does Deltoid Ligament Repair Influence the Progression of Posttraumatic Arthritis in Logsplitter Injuries?

To determine the effect of deltoid ligament repair on the development of posttraumatic arthritis in logsplitter ankle injuries. Retrospective cohort. Academic, Level I trauma center. Patients ≥18 years of age with logsplitter injuries (OTA/AO 44B, 44C) treated with open reduction internal fixation (ORIF) with or without deltoid ligament repair from January 2008 to October 2021. The rate of posttraumatic arthritis (PTOA) development at the final follow-up (minimum 6 months) after ORIF was evaluated using the Kellgren-Lawrence scale. The achievement of acceptable reduction indicated by articular reduction <2 mm, and a medial clear space ≤4 mm was assessed at 6 weeks postoperatively with weight-bearing radiographs. The effect of deltoid ligament repair on the development of PTOA was investigated. Fifty-nine patients aged 49.1 ± 17.2 years met inclusion criteria with a mean follow-up of 16.6 months (range = 6 to 96). Twenty-six of 59 patients (44%) had developed PTOA at the final follow-up. Acceptable reduction was achieved in 83.1% (49/59) of fractures. The acceptable reduction rate in fractures undergoing deltoid ligament repair was 100% versus 78% in those without deltoid ligament repair (13/13 vs. 36/46, P = 0.017). The rate of PTOA development was significantly lower in patients who underwent deltoid ligament repair (15%) than those who did not (52%), P = 0.026. Patients who underwent deltoid ligament repair had a significantly reduced rate of PTOA development leading to arthrodesis compared with those who did not (0% vs. 17%, P = 0.013). Logsplitter injuries resulted in a high rate of development of posttraumatic arthritis. An acceptable reduction is required to minimize the risk of development of PTOA and progression to arthrodesis. Deltoid ligament repair during ORIF may facilitate acceptable reduction and decrease the rate of PTOA and progression to arthrodesis in these injuries. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Deltoid Ligament Repair in Surgically Treated Weber C Fibula Fractures with Deltoid Ligament Injury. A Retrospective Comparative Radiographic and Functional Outcomes Study

Category: Ankle; Trauma Introduction/Purpose: The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others reported persistent medial clear space widening and higher malreduction when deltoid ligaments went without repair. This malreduction can lead to chronic ankle instability and pain. Talar shift as little as 1mm is reported to lead to a 49% increase in ankle joint pressure, a detrimental factor for developing post-traumatic ankle arthritis. The purpose of this study was to compare deltoid ligament repair to no repair in a homogenous group of surgically treated isolated Weber C fibula fractures exclusively. Methods: A retrospective chart review of prospectively collected data was carried out to identify consecutive surgically treated Weber C lateral malleolus fractures and syndesmosis stabilization with associated deltoid ligament injury between February 2013-December 2023. Associated posterior/medial malleolus fractures other than avulsions, Weber A/B fractures, fibula fixation constructs besides plate and screws, Charcot neuropathy, pes planovalgus with incompetent deltoid ligament, and revisions were excluded. Those meeting inclusion criteria were split into two groups: deltoid ligament suture repair vs. no repair. Collected data included demographics, smoking and diabetes status, surgical procedure and patient reported outcome measures (PROMs).. Primary outcomes were oblique medial clear space (MCS) and valgus talar tilt angle (TTA) on weightbearing radiographs. All radiographs were independently reviewed by a fellowship trained foot and ankle orthopedic surgeon. Secondary outcomes were fracture union, complications, reoperations, and PROMs: Foot and Ankle Ability Measure (FAAM), Veterans-Rand 12 (VR12) General Health Survey, visual analog pain scale (VAS). Results: Seventy-nine fractures were included; 49 underwent deltoid ligament repair while 30 did not. The mean follow-up was 18.5 months. There was a statistically significant post-op improvement in most study outcomes within the groups. The valgus TTA in the repair vs no repair groups were 0.1±0.9 vs. 1.2±2.1 degrees, respectively (p=0.007). The MCS in the repair vs. no repair groups was 3.5±0.6 vs. 3.9±1.4mm, respectively (p=0.107). There were no statistically significant differences between deltoid repair and no repair groups in post-operative VR12 MCS (p=0.194), VR12 PCS (p=0.077), VAS (p=0.231), FAAM ADL (p=0.109), FAAM sport (p=0.314), or patient satisfaction (p=0.33). The union rate was 100% in the repair vs. 96% in the no repair groups (p=0.163). There were no complications related to repairing the deltoid ligament. Conclusion: Deltoid ligament repair led to a superior ankle coronal alignment in comparison to no repair. There were no complications or revisions related to the medial approach and repairing the deltoid ligament. While there were trends toward better functional outcomes with deltoid ligament repair, this did not reach statistical significance. Long term studies may be required before recommending deltoid ligament repair as the gold standard in isolated Weber C fractures. Meanwhile, we recommend valgus stressing the ankle at the end of the procedure and decide whether deltoid repair is needed on individual basis. Outcomes of deltoid repair group vs no deltoid repair group.

The Clinical Outcomes Comparison Between Trans-Syndesmotic Fixation and Deltoid Ligament Repair in Unstable Ankle Fractures with Medial Clear Space Widening: A Systematic Review and Meta-Analysis

Category: Ankle; Trauma Introduction/Purpose: Ankle instability associated with fractures have increased surgical complexity and worse outcomes. Both the deltoid ligament and the syndesmotic ligament complex play pivotal roles in maintaining ankle stability. Medial clear space (MCS) widening serves as an indicator for ankle instability. Trans-syndesmotic fixation following open reduction and internal fixation of distal fibula has been used commonly to restore stability in unstable ankle fractures with MCS widening. Alternatively, anatomic repair of the deltoid ligament offers another approach for addressing MCS widening. However, there is no consensus on the best method for stabilizing the ankle. This study aims to provide a comprehensive analysis of current literature to compare the outcomes of trans-syndesmotic fixation and anatomic deltoid ligament repair in the treatment of unstable ankle fractures with MCS widening. Methods: This comprehensive literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing databases such as PubMed, Embase, Web of Science, and the Cochrane Library. The search was conducted on October 15, 2023. The criteria for including articles in this study were: (1) Patients who had undergone surgical fixation for unstable ankle fractures with medial clear space (MCS) widening, (2) Studies comparing clinical outcomes between trans-syndesmotic fixation and anatomic deltoid ligament repair to address MCS widening, (3) Studies reporting on at least one of the following outcomes: malreduction rates, necessity for hardware removal, wound complications, reoperation rates, and functional outcomes, including AOFAS (American Orthopaedic Foot and Ankle Society) scores and VAS (Visual Analog Scale) pain scores. Exclusion criteria eliminated studies involving: (1) Patients with medial malleolar fractures, (2) Revision surgeries, (3) Non-English publications, and (4) Case reports, systematic reviews, comments, editorials, surveys, or cadaver studies. Results: In this meta-analysis, a total of five studies were included. Medial clear space widening was treated with trans-syndesmotic screw fixation in 165 unstable ankle fractures, while 115 ankles underwent anatomic repair of the deltoid ligament. Anatomic deltoid ligament repair was significantly associated with a reduced risk of syndesmotic malreduction (Risk Ratio (RR)=0.26, 95% Confidence Interval (CI) = [0.10, 0.68]) and a lower likelihood of postoperative hardware removal (RR=0.06, 95% CI = [0.02, 0.14]). No significant differences were found in minor or major wound complications, reoperation rate, AOFAS and VAS scores. These findings highlight the advantages of anatomic deltoid ligament repair, which provides a more precise reduction of unstable ankle injuries with MCS widening and a reduced need for postoperative hardware removal, compared to trans-syndesmotic fixation. Conclusion: This study evaluated postoperative outcomes between trans-syndesmotic fixation and anatomic deltoid ligament repair in addressing MCS widening. Our analysis revealed that anatomic deltoid ligament repair resulted in a significantly lower rate of malreduction and a decreased necessity for postoperative hardware removal compared to trans-syndesmotic screw fixation. Both techniques showed similar rates of wound complications, reoperation, and equivalent functional and pain scores. These results call into question the trans-syndesmotic fixation alone for unstable ankle fractures with MCS widening. Anatomic repair of the deltoid ligament should be considered as a viable option to restore stability in unstable ankle fractures with MCS widening.

Assessment of the Biomechanical Effects of Hindfoot Alignment in Supination External Rotation Malleolar Fractures in a Cadaveric Model

Category: Trauma; Hindfoot Introduction/Purpose: Pressure distribution in the ankle joint is known to be dependent on various factors, including hindfoot alignment. We seek to evaluate how hindfoot alignment affects contact pressures in the ankle joint in the setting of supination external rotation (SER) type ankle fractures. Methods: SER fractures were created in 10 human cadaver lower extremity specimens, simulating progressive stages of injury: without fracture (step 0), SER fracture and intact deltoid ligament (step1), superficial deltoid ligament disruption (step2) and deep deltoid ligament disruption (step3). At each step, varus and valgus alignment was simulated by displacing the calcaneal tuberosity 7mm medial or lateral. Each limb was axially loaded following each osteotomy at a static load of 350N. The center of force (COF), contact area (CA), and peak contact pressure (PP) under load were measured, and x-rays of the ankle mortise were taken to analyze the medial clear space (MCS) and talar tilt (TT). Results: The COF (5.3mm, p=0.030) and the CA (-188.4 mm2, p=0.015) changed in step 3 in the valgus hindfoot alignment compared to baseline parameters, indicating the importance of deep deltoid ligament integrity in maintaining normal ankle joint contact stress in the valgus hindfoot. These changes were not seen in the setting of varus alignment (COF: 2,3mm, p=0.059; CA -121mm2, p=0.133). PP were found to not change significantly in either varus or valgus (varus:-4.9N, p=0.132;valgus:-4N, p =0.464). The MCS demonstrated widening in step 3 compared to step 2 (0.7mm, p=0.020) in both varus and valgus hindfoot. The TT increased significantly in step 3 in the valgus hindfoot (2.8°, p=0.020) compared to step 0. Conclusion: SERIV fractures with valgus hindfoot alignment showed significant changes in pressure distribution and radiographic parameters when compared to SER IV fractures with varus hindfoot alignment. Based on this cadaver modelling study, patients with SERIV fracture with varus hindfoot alignment and complete deltoid ligament lesion may not need fracture fixation, whereas those with valgus hindfoot alignment likely need fracture fixation. Results of the measurements of COF (center of force), CA (contact area), PP (peak contact pressure) MCS (medical clear space) in mm, TT (talar tilt) in degree in varus and valgus hindfoot alignment in the different steps. It shows the mean and (standard deviation)

Arthroscopically Assisted Deep Deltoid Ligament Reconstruction Utilizing Suture Tape Augmentation for Treatment of Medial Ankle Instability in Acute Ankle Fractures: A Novel Technique and Case Series

Category: Arthroscopy; Ankle Introduction/Purpose:Objective: To present a novel technique for deep deltoid ligament reconstruction using suture tape augmentation for medial ankle instability in acute ankle fractures and conduct a case series. Background: Circular movements involving ankle supination-external rotation, pronation-external rotation, or pronation-abduction are among the most common mechanisms behind acute ankle fractures. As a result of rotational fractures, the deltoid ligament–consisting of a superficial and deep component–is often damaged or ruptured. Disruption of the deltoid ligament is associated with medial ankle instability, thus warranting further repair; which has been historically done open. Using an arthroscopic approach will allow for direct visualization and increased accuracy of surgical management . Combining arthroscopy and with our novel suture tape augmentation technique may improve postoperative functional outcomes, stability, and decrease post-traumatic arthritis. Methods: This is a retrospective case study using de-identified patient data from 2 separate hospital systems. Data was obtained via chart review including pre-operative, intraoperative, and post-operative follow ups. Variables such as age, weight, body mass index (BMI), sex, side, history of previous ankle surgery, preoperative ambulatory status, length of hospital stay, as well as disposition were documented. Radiographs were reviewed for evidence of restoration of the medial clear space as well as hardware position and bony union. In addition, a technique guide was developed using two expert surgeons experience and opinion for using suture tape augmentation with the Arthrex InternalBrace system (Naples, FL). In addition, we present a novel technique for reconstruction of the deep deltoid ligament complex using our experience from these cases. Included in this guide are details on indications, setup, technique, postoperative protocol, and radiographic assessment. Results: We retrospectively reviewed 12 patients who had bimalleolar equivalent, tri-malleolar equivalent, or Maisonneuve-type fractures of the ankle with increased medial clear space widening and were surgically treated with this novel technique. All patients were initially non-ambulatory after their fracture and prior to their procedure. All patients had significant reduction in the medial clear space postoperatively. Additionally, all patients progressed to walking without assistance and returned to full weight bearing postoperatively. One patient developed a keloid scar that required a corticosteroid injection. One patient showed widening of the syndesmosis on follow up x-rays; which was managed with a CT scan of the ankle, and bilateral weight bearing radiographs. The patient was clinically asymptomatic and advanced to weight bearing as tolerated before 6 months. Conclusion: Arthroscopically assisted deep deltoid ligament reconstruction utilizing suture tape augmentation is a successful procedure for restoring ankle function and radiographic parameters of the medial clear space when used in conjunction with accepted open reduction and internal fixation (ORIF) techniques for bimalleolar ankle fracture equivalents or tri-malleolar fractures. Since this procedure is performed with a minimally invasive arthroscopic approach, it may be a preferred technique in the future with direct visualization of the superficial and deep deltoid ligament. We have also presented a novel technique for reconstruction of the deep deltoid ligament complex utilizing suture tape augmentation via an arthroscopically-assisted approach. Arthroscopic deltoid technique Drill sleeve arthroscopically, radiographic confirmation of talus K-wire, and insertion of FiberTak/ sutures arthroscopically

Concurrent Calcaneal Osteotomy with Hindfoot Arthrodesis for Pes Planovalgus: Outcomes and Alignment

Category: Hindfoot; Other Introduction/Purpose: Severe, rigid deformities of the hindfoot related to pes planovalgus are commonly treated with hindfoot arthrodesis. Deformity recurrence and ankle valgus deformity can occur due to attenuated and often incompetent medial soft tissues. While the addition of a medial displacing calcaneal osteotomy (MDCO) to a hindfoot arthrodesis has been described, the complication profile and the effect on alignment parameters including ankle alignment has not been well elucidated. There is biomechanical data to suggest that the addition of MDCO to a triple arthrodesis will reduce the force on the deltoid ligament by 56% (Okereke et al). The purpose of this study is to evaluate the clinical and radiographic outcomes of combined calcaneal osteotomy with hindfoot arthrodesis, and compare to a group that had hindfoot arthrodesis alone. Methods: We performed an IRB-approved single institution retrospective review of all patients who had undergone double or triple arthrodesis for pes planovalgus over a 6-year period from 1/1/2016 to 12/31/2021, and comparing those who had concurrent MDCO and those with arthrodesis alone, via CPT code. We included those who were &gt;/= age 18 and had undergone double or triple arthrodesis, and had a minimum of 3 months follow up with radiographs. Patients were excluded if they had prior hindfoot arthrodesis surgery, charcot arthropathy, or documented neuropathy. We collected basic demographic data, surgical data including length of surgery, type of implant(s) and grafting used, pre-operative and post-operative radiographic parameters, complications, reoperations and presence of union of any and all arthrodesis and osteotomy sites. The primary outcome variable was successful arthrodesis of the subtalar (ST) joint, with secondary outcomes including successful union of the remaining sites. Results: A total of 22 patients (26 surgeries) had undergone concurrent hindfoot arthrodesis and MDCO versus 145 patients (150 surgeries) for hindfoot arthrodesis alone. Follow up was 10.6 and 10.8 months on average, respectively. The MDCO cohort surgical duration was 27 minutes longer than the control group (p=0.0079). Pre-operative and post-operative talonavicular (TN) coverage, AP and lateral Meary’s angle, cuboid height, calcaneal pitch, and post-operative AP ankle alignment were not significantly different between the groups. There were no failures of the MDCO or wound issues with the MDCO incision. The nonunion rate for the ST joint was 3.8% and 4.7%, respectively with TN nonunion rate of 15.4% and 16.7%, respectively (p&gt;0.99). Reoperation rates were 23.1% and 20.7%, respectively. Conclusion: In conclusion, this study has demonstrated that when deemed appropriate based on intraoperative or preoperative findings, the addition of an MDCO to either a double or triple arthrodesis is a safe and effective adjunct. There is a slightly longer surgical time, without any additional surgical complication risks. Longer term radiographic follow up is needed to determine if this helps to protect against late ankle valgus collapse.

‘Deep Deltoid Paradox Sign’ - Anterior Talofibular Ligament Laxity Prevents Development of Deep Deltoid Ligament Laxity in the Presence of Unstable Planus - A Cadaveric Study

Category: Hindfoot; Sports Introduction/Purpose: Adult Acquired Flatfoot Deformity (AAFD)/Progressive collapsing foot deformity (PCFD) starts with failure of the medial longitudinal arch. Determining which feet progress to anteromedial instability of the tibiotalar joint, prior to complete deltoid ligament rupture, is not fully understood. We have observed clinically that, in the presence of anterior talofibular ligament (ATFL) laxity, deep deltoid ligament (DD) laxity and anteromedial ankle instability does not develop (indicated by a negative neutral heel external rotation test/anteromedial drawer test). To date, the protective effect that ATFL rupture/laxity (the most common foot ligament injury) has on preventing DD laxity and anteromedial ankle instability developing in AAFD/PCFD has not been investigated. This understanding is crucial for accurate staging, treatment, and prognosis of both AAFD/PCFD and ATFL repairs. Methods: Unstable planus was induced in 12 cadaveric feet from 6 donors by complete sectioning of the plantar fascia, spring ligament and the plantar 1st tarsometatarsal joint. Paired feet were randomly assigned to having ATFL sectioned or ATFL intact. Feet underwent cyclic loading (2000 cycles) on a custom mounted jig and photos were taken with positional markers on the medial malleolus, fibula, and the talus before and after antero-posterior force application. ImageJ quantified anteromedial and anterolateral ankle joint displacement to reflect DD and ATFL laxity respectively. Results: In ATFL-intact feet, anteromedial displacement increased by 3.46 ± 0.41 µm/cycle (mean ± SD; P = 0.000005; two-tailed, one-sample t-test). In ATFL-sectioned feet, displacement increased 0.61 ± 0.66 µm/cycle (p = 0.072), an 82% reduction in DDL laxity development (P = 0.00006; two-tailed, paired t-test). There was minimal cycle-induced change in anterolateral displacement (ATFL-intact: 0.50 ± 0.50 µm/cycle (p = 0.06); ATFL-sectioned: -0.04 ± 0.90 µm/cycle (p = 0.17). However, absolute anterolateral displacement increased in ATFL-sectioned feet by 7.40 ± 0.12 mm (p = 0.00002). Conclusion: These findings corroborate our clinical findings; in AAFD/PCFD, feet with ATFL laxity paradoxically do not develop DD instability (negative heel external test and anteromedial draw test), which we ascribe the ‘deep deltoid paradox sign’. This phenomenon has significant implications in determining which feet progress to DD laxity in AAFD/PCFD and ultimately DD rupture. Furthermore, surgical management of ATFL ruptures may require patient counselling regarding the development of DD laxity after ATFL repair if AAFD/PCFD is also present. Finally, we propose putative mechanisms based on differential axes of talar rotation and navicular abduction during stance, straining DD when ATFL is intact.

The Prognosis of the Posterior Malleolar Fracture in the Syndesmosis Injury

Category: Trauma; Ankle Introduction/Purpose: Syndesmosis injuries, often involving the posterior malleolus (PM), are common in rotational ankle fractures. Concomitant intra-articular involvement, along with deltoid ligament rupture and open reduction and internal fixation (ORIF) affects outcomes predisposing to postoperative complications. Our study aims to investigate the outcomes of posterior malleolar fractures with concomitant syndesmosis injuries and identify prognostic factors associated with these injuries. Methods: This retrospective study investigated posterior malleolar ankle fractures with syndesmotic injury in 71 patients between January 2004 and March 2021. Among these, there were 54 cases of trimalleolar fractures and 17 cases of trimalleolar equivalent fractures. After receiving IRB approval from a single Korean center institution, demographic data, revision surgeries, syndesmotic implant removal, deltoid ligament rupture, deltoid ligament repair, types of implants, and insurance status were evaluated by an expert surgeon affiliated with the institution. Weight-bearing plain radiographs were analyzed for various parameters including superior and medial clear space (MCS), tibiofibular overlap, tibiofibular clear space, implant height, fibular shortening, and synostosis. Radiographic parameters were recorded preoperatively, postoperatively, at 3-month follow-up, and final follow-up. CT scans were utilized to assess posterior malleolar fracture involvement and evaluated using the Haraguchi classification. The severity of ankle joint obliteration was determined. Fibular shortening and synostosis presence were assessed from follow-up radiographs. Results: All radiographic parameters showed significant improvement over time (p-=0.001). No significant differences were found between groups with and without deltoid ligament rupture, except for postoperative 3-month TFO, which showed a significantly higher value in group of the deltoid ligament rupture (p=0.001). Fixation of the posterior malleolar fracture was significantly associated with a preoperative MCS with optimal cut off value of 3.72 mm as absolute value and 84% as the percent divided by the superior clear space as in area under curve (p=0.001, AUC=0.717). Male sex was significantly associated with unexpected syndesmotic implant removal. Deltoid rupture was significantly associated with postoperative ankle osteoarthritis. Preoperative TFC and ORIF of the posterior malleolar fracture were negatively associated with postoperative ankle osteoarthritis. Conclusion: A preoperative medial clear space measurement of 3.72 mm or more in posterior malleolar fractures with syndesmotic injury may be beneficial in deciding the fixation approach for posterior malleolar fractures. Male gender is identified as a risk factor for unplanned removal of syndesmotic implants. Deltoid ligament rupture, preoperative tibiofibular clear space (TFC), and the need for posterior malleolar fixation may be regarded as risk factors for postoperative ankle osteoarthritis.

Ultrasound Shear Wave Elastography of the Arch-Supporting Structures in Symptomatic Flatfoot: A Pilot Study.

The posterior tibial tendon (PTT), deltoid ligament, and spring ligament are often torn or attenuated in patients with progressive collapsing foot deformity. The goal of this pilot study was to measure the ultrasound shear wave velocity (SWV) of these arch-supporting structures in feet with varying degrees of deformity to improve our understanding of their role in the progression of deformity. Two observers measured the SWV of the supramalleolar and inframalleolar PTT in long and short axes, in the tibiospring portion of the deltoid ligament, and in the superomedial band of the spring ligament in 8 neutrally aligned feet, 5 asymptomatic flatfeet, and 7 symptomatic flatfeet. Each measurement was repeated 3 times both with and without an applied eversion stress. Average SWV was lower at all locations in the symptomatic flatfeet compared with normal feet, but these differences were statistically significant only for the inframalleolar PTT and the spring ligament. Externally applied stress led to an increase in the SWV of the ligaments but a paradoxical decrease in the SWV in the supramalleolar PTT. The SWV of the PTT was lower along the short axis compared with the long axis. SWV may be useful in evaluating the severity of degenerative disease of arch-supporting structures, but further study is needed before this technique can be applied clinically. Level III, case-control study.

Comparison of Prevalence of Arthroscopically Detected Intra-Articular Pathologies Between Supination and Pronation Type Ankle Fractures

Category: Arthroscopy; Ankle Introduction/Purpose: Ankle fractures are among the most common fractures of the lower extremity. Most unstable ankle fractures have good outcomes following operative fixation; however, residual pain and swelling are not uncommon despite anatomical bone reduction. Untreated associated injuries, including syndesmotic injury, deltoid ligament injury, and osteochondral injury, are potential causes for suboptimal outcomes. These pathologies are often underappreciated. The Lauge-Hansen classification is used to categorize fractures based on the mechanism of injury and thus has the potential to predict intra-articular pathology. To date, there is limited literature reporting the comprehensive prevalence of arthroscopically diagnosed intra-articular pathologies in acute ankle fractures based on the mechanism of injury. This study aims to report the prevalence of each intra-articular pathology between different fracture patterns. Methods: A retrospective database review was conducted on 203 patients with rotational ankle fractures who underwent arthroscopic-assisted open reduction and internal fixation for unstable acute ankle fractures between 2016 and 2023. Patients with open fractures, pilon fractures, delayed treatment, and children with open physes were excluded from the study. The patients were categorized into groups according to the Lauge-Hansen classification: Supination-Adduction (SA), Supination-External Rotation (SER), Pronation-External Rotation (PER), and Pronation-Abduction (PA). Syndesmotic injuries were determined by the arthroscopic drive-through sign with a 3mm shaver, while deltoid ligament injuries and osteochondral injuries were identified using arthroscopic visualization. Results: There were 3 patients (1.48%) with SA fractures, 143 patients (70.44%) with SER fractures, 6 patients (2.96%) with PA fractures, and 51 patients (25.12%) with PER fractures. The prevalence of arthroscopically diagnosed syndesmotic instability following malleoli fixation was extremely high in most fracture patterns except the SA mechanism (PER: 98.04%, PA: 100%, SER: 89.51%, SA: 33.33%). The prevalence of osteochondral injury was higher in pronation-type injuries than supination-type injuries (73.78% vs 53.9%, p=0.03). Deltoid ligament injury was found in 56.74% of SER fractures and 68.42% of PA/PER fractures. Conclusion: The prevalence of intra-articular pathologies in ankle fracture was higher in pronation-type injuries. However, the prevalence of these pathologies, especially syndesmotic instability, in SER fracture patterns was also alarming. The authors advocate for routine ankle arthroscopy simultaneously with ankle fixation to provide adequate treatment and predict prognosis.

2024 J. Leonard Goldner Award Winner: Semi-Automated 3D Distance Mapping of Conventional Non-Weightbearing CT Scan with External Rotation Stress Demonstrates High Diagnostic Accuracy for Subtle Syndesmotic Instability

Category: Ankle; Sports Introduction/Purpose: Subtle syndesmotic instabilities are often under-diagnosed and pose long-term implications for ankle joint health. Previous studies have assessed the diagnostic accuracy of conventional Computed Tomography (CT) in patients with syndesmotic instability. However, these measurements were obtained manually and only at 1 cm proximal to the tibiotalar joint. To fully leverage the three-dimensional (3D) advantages of CT imaging, automated 3D distance mapping algorithms can provide a more comprehensive analysis. Further, while previous studies have demonstrated the sensitivity of these algorithms when analyzing syndesmotic instability using weightbearing CT (WBCT), many clinics do not have access to WBCT. Therefore, the aim of this study was to develop a distance mapping algorithm and scan protocol that can detect subtle syndesmotic instability using the more accessible imaging modality, conventional CT. Methods: Forty-five patients with rotational ankle injuries (21 syndesmotic injuries and 24 lateral collateral ligament injuries) diagnosed via radiologist MRI read, were analyzed. Each patient underwent three ankle CT protocols: neutral position; 45° external rotation with dorsiflexion and extended knees (Stress B); and 45° external rotation with dorsiflexion and flexed knees (Stress C). Semi-automatic CT scan segmentation was performed using a commercially available software, and syndesmosis volume and distances were calculated using MATLAB (Figure 1A). Distance was defined as the normal distance between the tibial subchondral surface and its opposing surface on the fibula or talus. Medial and lateral talar gutters were also studied. The syndesmosis was sectioned at 1 cm, 3 cm, and 5 cm proximal to the tibiotalar joint, and into anterior and posterior regions (Figure 1B). Receiver-operating characteristic (ROC) curves and area under the curve (AUC) were calculated to compare measurements and assess diagnostic accuracy (α = 0.05). Results: Significant differences were observed between syndesmotic and lateral collateral ligament injuries at 1 cm, 3 cm, and 5 cm proximal to the tibiotalar joint under stressed positions. The highest diagnostic accuracy was noted at 1 cm and 3 cm within the syndesmotic incisura, with AUC values of 0.91 for Stress B at 1 cm (Figure 1C), and 0.92 for Stress B and C at 3 cm (Figure 1D). In the anterior syndesmotic incisura, AUCs were 0.83 for Stress B and 0.89 for Stress C at 1 cm (Figure 1E), and 0.85 for Stress B and 0.93 for Stress C at 3 cm (Figure 1F). AUCs of 0.90 for Stress B and 0.83 for Stress C were observed in the posterior gutter medial to the talus. Conclusion: This proposed automated 3D distance mapping CT algorithm, enhanced by external rotational ankle stress maneuvers, demonstrates high diagnostic accuracy in detecting subtle syndesmotic instability, distinguishing well between syndesmotic and lateral collateral ligament injuries. A significant posterior widening at the medial gutter in the syndesmotic injury group may implicate concomitant deltoid ligament injury. Most importantly, however, this study suggests that weightbearing CT may not be essential for diagnosing subtle syndesmotic instabilities and that conventional CT imaging and external rotational stress can allow for high diagnostic accuracy of these injuries. Further validation of this algorithm is warranted to confirm its clinical utility.