Surgical treatment of ankle fractures associated with deltoid ligament rupture
Zhang Mingzhu1, He Wenbao2, Li Runmin2, Zhao Youguang2, Li Bing2, Yu Tao2, Yang Yunfeng2, You Chunfang2, Yao Ying2, Yu Guangrong2
1Department of Foot Ankle Center, Tongren Hospital, Capital Medical University, Beijing 100730, China; 2Department of Foot and Ankle Surgery, Tongji Hospital of Tongji University, Shanghai 200065, China
Abstract:Objective To investigate the surgical procedure and the clinical outcome about ankle fractures associated with deltoid ligament complete rupture.Methods From July 2011 to July 2016, 42 patients with ankle fractures associated with deltoid ligament complete rupture in the Orthopaedics of the Affliated Tongji Hospital of Tongji University School of Medicine were retrospectively analyzed. They were 28 males and 16 females with a mean age of 31.6 years (range, 18-72 years). According to the AO/OTA system, 4 fractures were 44-B2, 7 were 44-B3, 10 were 44-C1,10 were 44-C2, and 11 were 44-C3. Deep and shallow lever of the triangular ligament were determined by preoperative imaging and intraoperative exploration. All cases were treated with fracture reduction and internal fixation plus triangular ligament repair. American Orthopaedic Foot and Ankle Society(AOFAS) ankle-hindfoot scores, visual analogue scale(VAS) were used for outcome measurement.Results All wounds healed at the primary stage. Thirty patients were followed up for 18 to 72 months, with the mean follow-up of (36.4±10.3) months. The mean time of bone union was (12.4±2.4) weeks (range, 9-16 weeks). The mean AOFAS ankle-hindfoot score at last follow-up was (85.3±6.2) points (range, 79-100 points). The mean score of VAS was (1.3±0.4) points (range, 0-3 points). There was no ankle instability or arthritis.Conclusions To achieve satisfactory outcomes for patients with ankle fractures associated with deltoid ligament completely rupture, a reasonable surgical procedure should be done.Reduction and internal fixation fractures plus triangular ligament repair can lead good outcomes and prevent complications,such as postoperative pain and ankle instability.
张明珠,和文宝,李润民,赵有光,李兵,于涛,杨云峰,尤春芳,姚英,俞光荣. 踝关节骨折伴三角韧带完全断裂的手术治疗[J]. 中华解剖与临床杂志, 2019, 24(2): 118-122.
Zhang Mingzhu, He Wenbao, Li Runmin, Zhao Youguang, Li Bing, Yu Tao, Yang Yunfeng, You Chunfang, Yao Ying, Yu Guangrong. Surgical treatment of ankle fractures associated with deltoid ligament rupture. Chinese Journal of Anatomy and Clinics, 2019, 24(2): 118-122.
Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic findings in acute fractures of the ankle[J]. J Bone Joint Surg Br, 2000, 82(3): 345-351. DOI:10.1302/0301-620X.82B3.10064.
[2]
Str ms e K, H qevold HE, Skjeldal S, et al. The repair of a ruptured deltoid ligament is not necessary in ankle fractures[J]. J Bone Joint Surg Br, 1995, 77(6): 920-921. DOI:10.1016/S0883-5403(05)80227-X.
[3]
Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries: diagnosis and management[J]. Foot Ankle Clin, 2006, 11(3): 625-637. DOI:10.1016/j.fcl.2006.08.001.
[4]
Panchani PN, Chappell TM, Moore GD, et al. Anatomic study of the deltoid ligament of the ankle[J]. Foot Ankle Int, 2014, 35(9): 916-921. DOI:10.1177/1071100714535766.
[5]
Haynes JA, Gosselin M, Cusworth B, et al. The arterial anatomy of the deltoid ligament: a cadaveric study[J]. Foot Ankle Int, 2017, 38(7): 785-790. DOI:10.1177/1071100717702464.
[6]
Boss AP, Hintermann B. Anatomical study of the medial ankle ligament complex[J]. Foot Ankle Int, 2002, 23(6): 547-553. DOI:10.1177/107110070202300612.
[7]
Campbell KJ, Michalski MP, Wilson KJ, et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study[J]. J Bone Joint Surg Am, 2014, 96(8): e62. DOI:10.2106/jbjs.m.00870.
[8]
Clanton TO, Williams BT, James EW, et al. Radiographic identification of the deltoid ligament complex of the medial ankle[J]. Am J Sports Med, 2015, 43(11): 2753-2762. DOI:10.1177/0363546515605514.
[9]
van den Bekerom MP, Haverkamp D, Kerkhoffs GM, et al. Syndesmotic stabilization in pronation external rotation ankle fractures[J]. Clin Orthop Relat Res, 2010, 468(4): 991-995. DOI:10.1007/s11999-009-0823-9.
[10]
van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature[J]. Arch Orthop Trauma Surg, 2009, 129(2): 227-235. DOI:10.1007/s00402-008-0768-6.
[11]
Ashraf A, Murphree J, Wait E, et al. Gravity stress radiographs and the effect of ankle position on deltoid ligament integrity and medial clear space measurements[J]. J Orthop Trauma, 2017, 31(5): 270-274. DOI:10.1097/bot.0000000000000817.
[12]
Nortunen S, Flinkkil T, Lantto I, et al. Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination-external rotation-type lateral malleolar fractures[J]. Bone Joint J, 2015, 97-B(8): 1126-1131. DOI:10.1302/0301-620x.97b8.35062.
[13]
McConnell T, Creevy W, Tornetta P 3rd. Stress examination of supination external rotation-type fibular fractures[J]. J Bone Joint Surg Am, 2004, 86-A(10): 2171-2178.
[14]
Park SS, Kubiak EN, Egol KA, et al. Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements[J]. J Orthop Trauma, 2006, 20(1): 11-18. DOI: 10.1097/01.bot.0000189591.40267.09.
[15]
Henari S, Banks LN, Radovanovic I, et al. Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle[J]. Orthopedics, 2011, 34(10): e639-e643. DOI:10.3928/01477447-20110826-11.
[16]
Crim J, Longenecker LG. MRI and surgical findings in deltoid ligament tears[J]. AJR Am J Roentgenol, 2015, 204(1): W63-W69. DOI:10.2214/ajr.13.11702.
[17]
Hsu AR, Lareau CR, Anderson RB. Repair of acute superficial deltoid complex avulsion during ankle fracture fixation in national football league players[J]. Foot Ankle Int, 2015, 36(11): 1272-1278. DOI:10.1177/1071100715593374.
[18]
McCollum GA, van den Bekerom MP, Kerkhoffs GM, et al. Syndesmosis and deltoid ligament injuries in the athlete[J]. Knee Surg Sports Traumatol Arthrosc, 2013, 21(6): 1328-1337. DOI:10.1007/s00167-012-2205-1.
[19]
Johnson, DP. Hill J, Fracture-dislocation of the ankle with rupture of the deltoid ligament[J]. Injury, 1988.19(2): 59-61.
[20]
Stufkens SA, Knupp M, Lampert C, et al. Long-term outcome after supination-external rotation type-4 fractures of the ankle[J]. J Bone Joint Surg Br, 2009, 91(12): 1607-1611. DOI:10.1302/0301-620x.91b12.22553.
[21]
Woo SH, Bae SY, Chung HJ. Short-term results of a ruptured deltoid ligament repair during an acute ankle fracture fixation[J]. Foot Ankle Int, 2018, 39(1): 35-45. DOI:10.1177/1071100717732383.
[22]
Zhao HM, Lu J, Zhang F, et al. Surgical treatment of ankle fracture with or without deltoid ligament repair: a comparative study[J]. BMC Musculoskelet Disord, 2017, 18(1): 543. DOI:10.1186/s12891-017-1907-4.
[23]
Jones CR, Nunley JA 2nd. Deltoid ligament repair versus syndesmotic fixation in bimalleolar equivalent ankle fractures[J]. J Orthop Trauma, 2015, 29(5): 245-249. DOI:10.1097/bot.0000000000000220.
[24]
Wu K, Lin J, Huang J, et al. Evaluation of transsyndesmotic fixation and primary deltoid ligament repair in ankle fractures with suspected combined deltoid ligament injury[J]. J Foot Ankle Surg, 2018, 57(4): 694-700. DOI:10.1053/j.jfas.2017.12.007.
[25]
Jeong MS, Choi YS, Kim YJ, et al. Deltoid ligament in acute ankle injury: MR imaging analysis[J]. Skeletal Radiol, 2014, 43(5): 655-663. DOI:10.1007/s00256-014-1842-5.
[26]
Harper MC. Talar shift. The stabilizing role of the medial, lateral, and posterior ankle structures[J]. Clin Orthop Relat Res, 1990(257): 177-183.
[27]
Lee TH, Jang KS, Choi GW, et al. The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures[J]. Injury, 2016, 47(7): 1581-1585. DOI:10.1016/j.injury.2016.03.017.
[28]
Yu GR, Zhang MZ, Aiyer A, et al. Repair of the acute deltoid ligament complex rupture associated with ankle fractures: a multicenter clinical study[J]. J Foot Ankle Surg, 2015, 54(2): 198-202. DOI:10.1053/j.jfas.2014.12.013.
[29]
Beumer, A, W.L. van Hemert, B.A. Swierstra, et al. A biomechanical evaluation of the tibiofibular and tibiotalar ligaments of the ankle[J]. Foot Ankle Int, 2003, 24(5): 426-429.
[30]
Kim JG, Gwak HC, Lee MJ, et al. Arthroscopic deltoid repair: a technical tip[J]. J Foot Ankle Surg, 2017, 56(6): 1253-1256. DOI:10.1053/j.jfas.2017.07.009.