Effectiveness of repairing the deep layer of deltoid ligament by suture anchor repair method in treatment of mixed medial injury associated with ankle fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LUO Gang ,  NI Weidong , GUO Shihang , GUO Shuquan

Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China;

Corresponding?author：

NI Weidong, Email: niweidong18@163.com

Keywords：

Ankle fracture; anterior colliculus fracture; deltoid ligament injury; repair

DOI：

10.7507/1002-1892.202004148

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Objective To explore the necessity of repairing the deep layer of deltoid ligament in the treatment of mixed medial injury associated with ankle fractures.Methods Between January 2016 and December 2018, 12 patients with mixed medial injury associated with ankle fractures were treated with the fixation of the lateral malleolus by bone plates, the fixation of the anterior colliculus of medial malleolus by cannulated screws, and the repair of the deltoid ligament by suture anchors. There were 8 males and 4 females, with an average age of 42 years (range, 18-56 years). According to the Lauge-Hansen classification criteria, there were 11 cases of supination-external rotation type and 1 case of pronation-external rotation type. According to the Weber classification criteria, all cases were type B. The time from injury to operation was 3-6 days, with an average of 4.7 days. In each patient, X-ray films of anteroposterior and lateral views and mortise view of ankle were taken postoperatively. The motion range of ankle joints was observed. The function of the ankle and the outcome of the treatment were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Olerud-Molander scoring system, and the visual analogue scale (VAS) score.Results All cases were followed up 12-42 months (mean, 28 months). The 12 patients returned to their pre-injury jobs. Five patients with sports injury completely recovered to their pre-injury motor function. No patient experienced persistent medial ankle pain or ankle instability. At last follow-up, the ankle range of motion in dorsiflexion was 9°-25° (mean, 17.96°), which was 0°-11° (mean, 4.02°) less than that in normal side; the range of motion in plantar flexion was 38°-50° (mean, 43.90°), which was 0°-7° (mean, 2.53°) less than that in normal side. The AOFAS score was 88-100 (mean, 96.7); the Olerud-Molander score was 90-100 (mean, 96.5); the VAS score was 0-3 (mean, 1.1).Conclusion It is necessary to repair the deep layer of deltoid ligament in the mixed medial injuries associated with ankle fracture, which include anterior colliculus fracture and deep deltoid ligament injury. A better outcome can be achieved by employing the suture anchor repair method.

Citation： LUO Gang, NI Weidong, GUO Shihang, GUO Shuquan. Effectiveness of repairing the deep layer of deltoid ligament by suture anchor repair method in treatment of mixed medial injury associated with ankle fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(11): 1387-1391. doi: 10.7507/1002-1892.202004148 Copy

1.	Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. Ⅱ. Clinical studies. Acta Orthop Scand, 1979, 50(2): 225-236.
2.	Harper MC. The deltoid ligament. An evaluation of need for surgical repair. Clin Orthop Relat Res, 1988, (226): 156-168.
3.	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 Bone Joint Surg (Br), 1995, 77(6): 920-921.
4.	Tornetta P. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg (Am), 2000, 82(6): 843-848.
5.	Hintermann B, Boss A, Sch?fer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med, 2002, 30(3): 402-409.
6.	Milner CE, Soames RW. The medial collateral ligaments of the human ankle joint: anatomical variations. Foot Ankle Int, 1998, 19(5): 289-292.
7.	Hintermann B. Medial ankle instability. Foot Ankle Clin, 2003, 8(4): 723-738.
8.	Stufkens SA, van den Bekerom MP, Knupp M, et al. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strategies Trauma Limb Reconstr, 2012, 7(2): 73-85.
9.	Boss AP, Hintermann B. Anatomical study of the medial ankle ligament complex. Foot Ankle Int, 2002, 23(6): 547-553.
10.	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 Orthop Trauma, 2006, 20(1): 11-18.
11.	Bluman EM. Deltoid ligament injuries in ankle fractures: should I leave it or fix it? Foot Ankle Int, 2012, 33(3): 236-238.
12.	Hsu AR, Lareau CR, Anderson RB. Repair of acute superficial deltoid complex avulsion during ankle fracture fixation in national football league players. Foot Ankle Int, 2015, 36(11): 1272-1278.
13.	Woo SH, Bae SY, Chung HJ. Short-term results of a ruptured deltoid ligament repair during an acute ankle fracture fixation. Foot Ankle Int, 2018, 39(1): 35-45.
14.	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 Foot Ankle Surg, 2015, 54(2): 198-202.
15.	Li T, Sun X, Li Y, et al. Clinical study of ankle fracture combined with deltoid ligament injury: Repair or not? A retrospective, comparative study. J Foot Ankle Surg, 2020, 59(4): 648-652.
16.	Stufkens SA, Knupp M, Lampert C, et al. Long-term outcome after supination-external rotation type-4 fractures of the ankle. J Bone Joint Surg (Br), 2009, 91(12): 1607-1611.
17.	張明珠, 俞光榮, 趙有光, 等. 踝關節骨折合并三角韌帶完全斷裂的手術治療——1 項多中心研究報告. 足踝外科電子雜志, 2014, (1): 26-29.
18.	Lack W, Phisitkul P, Femino JE. Anatomic deltoid ligament repair with anchor-to-post suture reinforcement: technique tip. Iowa Orthop J, 2012, 32: 227-230.
19.	Luckino FA, Hardy MA. Use of a flexible implant and bioabsorbable anchor for deltoid rupture repair in bimalleolar equivalent Weber B ankle fractures. J Foot Ankle Surg, 2015, 54(3): 513-516.
20.	孫旭, 李庭, 孫志堅, 等. 三角韌帶加強修補治療合并三角韌帶損傷及下脛腓分離的踝關節骨折. 中華醫學雜志, 2018, 98(39): 3192-3196.

1. Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. Ⅱ. Clinical studies. Acta Orthop Scand, 1979, 50(2): 225-236.
2. Harper MC. The deltoid ligament. An evaluation of need for surgical repair. Clin Orthop Relat Res, 1988, (226): 156-168.
3. 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 Bone Joint Surg (Br), 1995, 77(6): 920-921.
4. Tornetta P. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg (Am), 2000, 82(6): 843-848.
5. Hintermann B, Boss A, Sch?fer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med, 2002, 30(3): 402-409.
6. Milner CE, Soames RW. The medial collateral ligaments of the human ankle joint: anatomical variations. Foot Ankle Int, 1998, 19(5): 289-292.
7. Hintermann B. Medial ankle instability. Foot Ankle Clin, 2003, 8(4): 723-738.
8. Stufkens SA, van den Bekerom MP, Knupp M, et al. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strategies Trauma Limb Reconstr, 2012, 7(2): 73-85.
9. Boss AP, Hintermann B. Anatomical study of the medial ankle ligament complex. Foot Ankle Int, 2002, 23(6): 547-553.
10. 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 Orthop Trauma, 2006, 20(1): 11-18.
11. Bluman EM. Deltoid ligament injuries in ankle fractures: should I leave it or fix it? Foot Ankle Int, 2012, 33(3): 236-238.
12. Hsu AR, Lareau CR, Anderson RB. Repair of acute superficial deltoid complex avulsion during ankle fracture fixation in national football league players. Foot Ankle Int, 2015, 36(11): 1272-1278.
13. Woo SH, Bae SY, Chung HJ. Short-term results of a ruptured deltoid ligament repair during an acute ankle fracture fixation. Foot Ankle Int, 2018, 39(1): 35-45.
14. 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 Foot Ankle Surg, 2015, 54(2): 198-202.
15. Li T, Sun X, Li Y, et al. Clinical study of ankle fracture combined with deltoid ligament injury: Repair or not? A retrospective, comparative study. J Foot Ankle Surg, 2020, 59(4): 648-652.
16. Stufkens SA, Knupp M, Lampert C, et al. Long-term outcome after supination-external rotation type-4 fractures of the ankle. J Bone Joint Surg (Br), 2009, 91(12): 1607-1611.
17. 張明珠, 俞光榮, 趙有光, 等. 踝關節骨折合并三角韌帶完全斷裂的手術治療——1 項多中心研究報告. 足踝外科電子雜志, 2014, (1): 26-29.
18. Lack W, Phisitkul P, Femino JE. Anatomic deltoid ligament repair with anchor-to-post suture reinforcement: technique tip. Iowa Orthop J, 2012, 32: 227-230.
19. Luckino FA, Hardy MA. Use of a flexible implant and bioabsorbable anchor for deltoid rupture repair in bimalleolar equivalent Weber B ankle fractures. J Foot Ankle Surg, 2015, 54(3): 513-516.
20. 孫旭, 李庭, 孫志堅, 等. 三角韌帶加強修補治療合并三角韌帶損傷及下脛腓分離的踝關節骨折. 中華醫學雜志, 2018, 98(39): 3192-3196.

Chinese Journal of Reparative and Reconstructive Surgery

Effectiveness of repairing the deep layer of deltoid ligament by suture anchor repair method in treatment of mixed medial injury associated with ankle fractures

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