Deltoid Ligament Repair Dont ignore when to repair

Deltoid Ligament Repair: Don’t ignore & when to repair Paul E. Matuszewski, MD Director, Orthopaedic Trauma Research Assistant Professor Orthopaedic Traumatology Department of Orthopedic Surgery and Sports Medicine University of Kentucky College of Medicine

Disclosures • No relevant disclosures

Background • Deltoid ligament plays role in maintaining medial tether of talus during motion • Deltoid ligament consists of two components – Superficial – Anterior, restraint to hindfoot eversion – Deep – Primary restraint to external rotation (Valgus tilt requires both superficial/deep disruption)

Background Cont. • In rotational ankle fractures…. – Two options for medial sided injury: • the medial malleolus fails (e. g. fracture) • deltoid ligament tears • When the deltoid tears – Typically injury represents an avulsion type injury from the medial malleolus

Diagnosis? • Physical exam? => Not helpful (De. Angelis et al JOT 2007) • MRI? => Too much variability (Nortunen et al JBJS 2014) • Xrays? => Sometimes… – An asymmetrical mortise e. g. A wide medial clear space (>4 mm, or >1 more than tibiotalar clearspace), is considered “unstable” (Baird et al JBJS 1987, Park et al JOT 2006) • Stress exam => better (dynamic exam, vs static) – For lateral malleolus fractures which have a symmetrical mortise, stress radiography helps discern “stability”. E. g. Deep deltoid tear

The Injuries • Bimalleolar equivalent w/ syndesmotic injury • Also trimalleolar equivalent, high fibula fracture, etc.

The Question? • Why? • If = Unstable = Fix Medial + Lateral • Also…. unstable • Both medial lateral constraints “broken” • Why not repair deltoid, just like medial malleolus? ? ?

Background Cont. • 1972 – Weber recommended exploration and repair of deltoid ligament – Often Interposed fibers of deltoid can prevent anatomic reduction • Exploration makes intuitive sense: – If “stuff” in the joint => get it out • What about repair? ?

Anti-Repair Camp • Some earlier studies suggested repair not necessary. . • If you fix lateral side, medial side will ‘scar in’ • Baird et al 1987 – repair vs no repair (3 repairs, 21 no repair) 90% of no repair group did well – – Not really a fair comparison Harp et al Clin Orthop Rel Res 1988 De Souza et al JBJS 1985 Zeegers et al Injury 1989 • Later down the road… • Stromsoe et al 1995 – Randomized trial, no difference between the groups – …but was it powered? ? • Maynou et al 1997 – Retrospective Comparative study 18/17 No difference if mortise restored

The Whole Story? • What about residual instability? • Remember: Even 1 mm instability can result in 42% reduction of contact area (Ramsey et al JBJS 1976) • Is the followup…not enough? • Zeegers 1989 Injury: 28 fractures treated without medial repair – 25% (7/28) developed osteoarthritis…but asymptomatic, so concluded…not important • Johnson et al 1988 – Residual medial sided tenderness • Some patients in early studies didn’t do so well… what about those patients? ?

Repair It’s the 2000’s No repair

Evidence Starts to Surface… • Hsu et al 2015 Foot ankle Int – NFL players return to play 86% with deltoid repair • Yu Guang-rong et al 2015 Foot and Ankle Surg. 4 Centers, retrospective, 106 pts, AOFAS, VAS, SF-36 better with deltoid repair and no instability • Gu et al Int J Clin Exp Med 2017 – 40 pts, randomized trial. Better AOFAS, decreased VAS with repair • Zhao et al 2017 BMC Musculoskelet Disord – Retrospective comparison review: 74 patients, decreased medial clear space, malreduction

More Early Evidence • Woo et al Foot Ankle Int 2018 – Comparative: 78 patients repair vs not repair – Patients with concomitant syndesmotic injury and deltoid repair had superior AOFAS, VAS, medial sided pain • Jones et al JOT 2018 – Retrospective, 27 patients, Deltoid repair rather than syndesmosis => similar functional, similar radiographic results • Schottel et al 2016 JOT – Cadaveric study – ligamentous repair has equivalent restoration of rotation to syndesmosis repair

Biomechanical Evidence • Butler et al 2019 – ORIF +/- repair – repair restores normal motion

Deltoid repair? • Review of the literature: – A large number of “conservatively” treated deltoid injuries do well… BUT NOT ALL (29%, roughly) – Not everything is black and white – However…perhaps not all of these scar in the right place • Leading to: – Residual instability? – Medial Gutter pain? – Post traumatic arthritis?

So When to Fix? • Is there an injury pattern to identify? – Maybe – Woo et al 2018 – Injuries with concomitant syndesmotic injuries do better with repair • Residual instability following fixation. . • Clearly something else going on…

Now What? ? • Just… let it scar? Chances of scarring correctly? • Following a treatment algorithm can help identify these possible “Bad actors”

Recommended Sequence • Fix lateral malleolus • Restoration of mortise? – No => critically assess reduction and possibly check medial side • Assess syndesmosis for instability (Cotton, ER stress) – Fix if need be • Reperform stress exam to assess for instability +/- talus tilt test – If positive, repair

Summary • Deltoid injuries can often be treated “conservatively” • However, a subset of patients have persistent issues • Likely related to latent instability • Repair of the deltoid following fracture fixation in persistently unstable fractures can improve markers of instability, medial sided pain and possibly clinical outcome

Thank you