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Arthroscopically Assisted Reduction and Fixation of Deltoid Ligament Avulsion Fracture From Medial Malleolus

Open AccessPublished:September 17, 2022DOI:https://doi.org/10.1016/j.eats.2022.06.001

      Abstract

      Ankle fractures are one of the most common orthopaedic injuries. The surgical principle is to restore anatomy and stability of the ankle mortise. Repositioning of the talus under the tibia with normalization of the medial clear space is mandatory for a good outcome. Deltoid ligament injuries can present as an avulsion fracture of the medial malleolus. The purpose of this Technical Note is to describe the details of arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus. This can restore the medial stability of the ankle.

      Technique Video

      See video under supplementary data.

      Ankle fractures are one of the most common orthopaedic injuries.
      • Wang J.
      • Stride D.
      • Horner N.S.
      • et al.
      The role of deltoid ligament repair in ankle fractures with syndesmotic instability: A systematic review.
      The surgical principle is to restore anatomy and stability of the ankle mortise. Repositioning of the talus under the tibia with normalization of the medial clear space (MCS) is mandatory for a good outcome.
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      The deltoid ligament is frequently ruptured in ankle fractures.
      • Wang J.
      • Stride D.
      • Horner N.S.
      • et al.
      The role of deltoid ligament repair in ankle fractures with syndesmotic instability: A systematic review.
      ,
      • Fukuyama J.M.
      • Pires R.E.S.
      • Labronici P.J.
      • Hungria J.O.S.
      • Decusati R.L.
      Bimalleolar ankle fracture: A simple fracture?.
      • Nasrallah K.
      • Haim S.
      • Einal B.
      Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review.
      • Guo W.
      • Lin W.
      • Chen W.
      • Pan Y.
      • Zhuang R.
      Comparison of deltoid ligament repair and non-repair in acute ankle fracture: A meta-analysis of comparative studies.
      The ligament plays an important role in maintaining concentric talus reduction within the ankle mortise and stabilizes the ankle joint against eversion, external rotation, and plantar flexion forces.
      • Wang J.
      • Stride D.
      • Horner N.S.
      • et al.
      The role of deltoid ligament repair in ankle fractures with syndesmotic instability: A systematic review.
      ,
      • Bastias G.F.
      • Filippi J.
      Acute deltoid ligament repair in ankle fractures.
      • Doty J.F.
      • Dunlap B.D.
      • Panchbhavi V.K.
      • Gardner M.J.
      Deltoid ligament injuries associated with ankle fractures: Arguments for and against direct repair.
      • Butler B.A.
      • Hempen E.C.
      • Barbosa M.
      • et al.
      Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures.
      However, there is no consensus on the optimal treatment of ruptured deltoid ligament in bimalleolar equivalent ankle fractures, and there is no evidence proving superiority of suturing the deltoid ligament in all ruptures.
      • Wang J.
      • Stride D.
      • Horner N.S.
      • et al.
      The role of deltoid ligament repair in ankle fractures with syndesmotic instability: A systematic review.
      ,
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      ,
      • Nasrallah K.
      • Haim S.
      • Einal B.
      Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review.
      • Guo W.
      • Lin W.
      • Chen W.
      • Pan Y.
      • Zhuang R.
      Comparison of deltoid ligament repair and non-repair in acute ankle fracture: A meta-analysis of comparative studies.
      • Bastias G.F.
      • Filippi J.
      Acute deltoid ligament repair in ankle fractures.
      • Doty J.F.
      • Dunlap B.D.
      • Panchbhavi V.K.
      • Gardner M.J.
      Deltoid ligament injuries associated with ankle fractures: Arguments for and against direct repair.
      ,
      • James M.
      • Dodd A.
      Management of deltoid ligament injuries in acute ankle fracture: a systematic review.
      Deltoid ligament repair may be indicated in bimalleolar equivalent fractures with extensive capsuloligamentous damage, combined syndesmotic and deltoid insufficiency, or multiligamentous/multidirectional instability, especially in heavier patients with greater mechanical requirements.
      • Bastias G.F.
      • Filippi J.
      Acute deltoid ligament repair in ankle fractures.
      ,
      • Doty J.F.
      • Dunlap B.D.
      • Panchbhavi V.K.
      • Gardner M.J.
      Deltoid ligament injuries associated with ankle fractures: Arguments for and against direct repair.
      This can be manifested as persistent external rotation or valgus instability after anatomic fibula fixation.
      • Cooper M.T.
      The role of deltoid repair and arthroscopy in ankle fractures.
      In this case, deltoid ligament repair enhances ankle stability and improves the quality of MCS and ankle reduction.
      • Wang J.
      • Stride D.
      • Horner N.S.
      • et al.
      The role of deltoid ligament repair in ankle fractures with syndesmotic instability: A systematic review.
      ,
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      ,
      • Guo W.
      • Lin W.
      • Chen W.
      • Pan Y.
      • Zhuang R.
      Comparison of deltoid ligament repair and non-repair in acute ankle fracture: A meta-analysis of comparative studies.
      ,
      • Butler B.A.
      • Hempen E.C.
      • Barbosa M.
      • et al.
      Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures.
      If the deltoid ligament rupture is not repaired, retraction of the ligament with subsequent healing in a nonanatomic position may cause ankle instability, persistent medial gutter pain, and risk of early traumatic arthritis of the ankle joint.
      • Nasrallah K.
      • Haim S.
      • Einal B.
      Therapeutic approach to combined deltoid ligament disruption with lateral malleolus fracture: Current evidence and literature review.
      ,
      • Doty J.F.
      • Dunlap B.D.
      • Panchbhavi V.K.
      • Gardner M.J.
      Deltoid ligament injuries associated with ankle fractures: Arguments for and against direct repair.
      ,
      • Ramsey P.L.
      • Hamilton W.
      Changes in tibiotalar area of contact caused by lateral talar shift.
      ,
      • Choi S.J.
      • Choi Y.
      • Baek E.
      • Jo S.
      Does repair of deltoid ligament contribute to restoring a mortise in SER type IV ankle fracture with syndesmotic diastasis?.
      Persistent widened MCS after anatomical fibula and syndesmosis fixation can be indicative of interposition either of the deltoid ligament, posterior tibial tendon or loose bodies, and medial exploration and deltoid ligament repair also is indicated.
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      ,
      • Bastias G.F.
      • Filippi J.
      Acute deltoid ligament repair in ankle fractures.
      • Doty J.F.
      • Dunlap B.D.
      • Panchbhavi V.K.
      • Gardner M.J.
      Deltoid ligament injuries associated with ankle fractures: Arguments for and against direct repair.
      • Butler B.A.
      • Hempen E.C.
      • Barbosa M.
      • et al.
      Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures.
      Deltoid ligament injury can present as an avulsion fracture. It is most often seen as an avulsion off of the medial malleolus, especially for the superficial deltoid ligament. Although less common, a ligamentous avulsion off of the medial talus can occur, especially for the deep deltoid ligament.
      • Doty J.F.
      • Dunlap B.D.
      • Panchbhavi V.K.
      • Gardner M.J.
      Deltoid ligament injuries associated with ankle fractures: Arguments for and against direct repair.
      A small avulsion fracture of the medial malleolus presents in 10% cases of ligamentous supination–external–rotation ankle injuries and may be associated with extensive deltoid incompetence.
      • Fukuyama J.M.
      • Pires R.E.S.
      • Labronici P.J.
      • Hungria J.O.S.
      • Decusati R.L.
      Bimalleolar ankle fracture: A simple fracture?.
      ,
      • Nwosu K.
      • Schneiderman B.A.
      • Shymon S.J.
      • Harris T.G.
      A medial malleolar “Fleck sign” may predict ankle instability in ligamentous supination external rotation ankle fractures.
      ,
      • Tornetta 3rd, P.
      Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation.
      Moreover, this small avulsion fragment may incarcerate in the MCS and thus prevents a symmetrical mortise reduction, necessitating surgical exploration of the medial ankle gutter.
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      ,
      • Doty J.F.
      • Dunlap B.D.
      • Panchbhavi V.K.
      • Gardner M.J.
      Deltoid ligament injuries associated with ankle fractures: Arguments for and against direct repair.
      ,
      • Nwosu K.
      • Schneiderman B.A.
      • Shymon S.J.
      • Harris T.G.
      A medial malleolar “Fleck sign” may predict ankle instability in ligamentous supination external rotation ankle fractures.
      Intra-articular pathology has been shown to occur in up to 79% of ankle fractures.
      • Cooper M.T.
      The role of deltoid repair and arthroscopy in ankle fractures.
      Ankle arthroscopy is useful for assuring appropriate reduction of the fractures, assessment of the integrity of the deltoid ligament and syndesmosis, detection and treatment of subtle residual instability, guidance of anatomical reduction of the syndesmosis, determining interposition when the MCS remains wide after proper reduction, removal of loose bodies and treatment of osteochondral lesions.
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      ,
      • Bastias G.F.
      • Filippi J.
      Acute deltoid ligament repair in ankle fractures.
      ,
      • Cooper M.T.
      The role of deltoid repair and arthroscopy in ankle fractures.
      ,
      • Chiang C.C.
      • Lin C.J.
      • Tzeng Y.H.
      • Teng M.H.
      • Yang T.C.
      Arthroscopic quantitative measurement of medial clear space for deltoid injury of the ankle: A cadaveric comparative study with stress radiography.
      • Lui T.H.
      • Ip K.Y.
      • Chow H.T.
      Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture.
      • Chan K.B.
      • Lui T.H.
      Role of ankle arthroscopy in management of acute ankle fracture.
      Recently, arthroscopic and endoscopic techniques for repairing the superficial deltoid ligament and reconstruction of the superficial and deep deltoid ligaments have been described in the context of chronic medial insufficiency.
      • Lui T.H.
      Technical tips: reconstruction of deep and superficial deltoid ligaments by peroneus longus tendon in stage 4 posterior tibial tendon dysfunction.
      • Lui T.H.
      Endoscopic repair of the superficial deltoid ligament and spring ligament.
      • Acevedo J.I.
      • Kreulen C.
      • Cedeno A.A.
      • Baumfeld D.
      • Nery C.
      • Mangone P.G.
      Technique for arthroscopic deltoid ligament repair with description of safe zones.
      The purpose of this Technical Note is to describe the details of arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus, which is a form of deltoid insufficiency. It is indicated in deltoid insufficiency presented as an avulsion fracture of the medial malleolus and associated with syndesmosis disruption or the fracture fragment incarcerates in the MCS. It is contraindicated if the fragment has enough size for stable screw fixation, the avulsion fracture is from talar side of the ligament, or there is no ankle external rotation or valgus instability after anatomic fibula fixation (Table 1).
      Table 1Indications and Contraindications of Arthroscopically Assisted Reduction and Fixation of Deltoid Ligament Avulsion Fracture From Medial Malleolus
      IndicationsContraindications
      • 1.
        Deltoid insufficiency presented as an avulsion fracture of the medial malleolus. and associated with syndesmosis disruption.
      • 2.
        The fracture fragment incarcerates in the MCS.
      • 1.
        The fragment has enough size for stable screw fixation.
      • 2.
        The avulsion fracture is from the talar side of the ligament.
      • 3.
        There is no ankle external rotation or valgus instability after anatomic fibula fixation.
      MCS, medial clear space.

      Surgical Technique (With Video Illustration)

      Preoperative Assessment and Patient Positioning

      The fracture pattern, widening of the MCS, degree of displacement of the avulsed fragment, and syndesmosis disruption should be studied carefully with the ankle radiographs. Computed tomography is useful to study the size and origin of the fragment and pattern of syndesmosis disruption.
      The patient is placed in the supine position with the legs spread. A thigh tourniquet is applied to provide a bloodless operative field. A 2.7-mm, 30° arthroscope (Henke Sass Wolf GmbH, Tuttlingen, Germany) is used for this procedure. Fluid inflow is by gravity, and an arthropump is not used.

      Portal Placement

      This procedure is performed with the standard anteromedial and anterolateral ankle arthroscopy portals, which are at the medial side of the tibialis anterior tendon and lateral side of the peroneus tertius tendon, respectively (Fig 1). Open reduction and internal fixation of the fibular fracture is performed. Ankle arthroscopy is performed with the anteromedial portal as the viewing portal. If syndesmosis disruption is present, it is reduced anatomically under arthroscopic guidance and a syndesmotic screw is inserted. Medial laxity of the ankle is then confirmed under fluoroscopy by applying eversion or external rotation stress to the ankle.
      Figure thumbnail gr1
      Fig 1Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. This procedure is performed with the standard anteromedial and anterolateral ankle arthroscopy portals, which are at the medial side of the tibialis anterior tendon and lateral side of the peroneus tertius tendon, respectively. (AMP, anteromedial portal; ALP, anterolateral portal.)

      Exposure of the Avulsed Fragment

      Anterolateral portal is the viewing portal and anteromedial portal is the working portal. The inflamed synovium of the medial ankle gutter is resected with an arthroscopic shaver (DYONICS; Smith & Nephew, Andover, MA). The shaver blade should face cranially and away from the cartilage of the medial malleolus and the medial talar facet and the deltoid ligament. After synovectomy, the avulsed fragment and the deltoid ligament are exposed (Fig 2).
      Figure thumbnail gr2
      Fig 2Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. Anterolateral portal is the viewing portal and anteromedial portal is the working portal. (A) The inflamed synovium of the medial ankle gutter is resected with an arthroscopic shaver. (B) After synovectomy, the avulsed fragment and the deltoid ligament are exposed. (AF, avulsed fragment; AS, arthroscopic shaver; IS, inflamed synovium; MM, medial malleolus; TB, talar body.)

      Suturing the Deltoid Ligament

      The anterolateral portal is the viewing portal and the anteromedial portal is the working portal. A No. 2 FiberWire loop (Arthrex, Naples, FL) is passed through the deltoid ligament by means of FIRSTPASS MINI Suture Passer (Smith & Nephew, Austin, TX) (Fig 3).
      Figure thumbnail gr3
      Fig 3Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. Anterolateral portal is the viewing portal and anteromedial portal is the working portal. A No. 2 FiberWire loop (Arthrex, Naples, FL) is passed through the deltoid ligament by means of FIRSTPASS MINI Suture Passer (Smith & Nephew, Austin, TX). (AF, avulsed fragment; DL, deltoid ligament; S, suture.)

      Deltoid Ligament Locking Suture

      The anterolateral portal is the viewing portal and the anteromedial portal is the working portal. The suture limbs are passed through the suture loop and the suture is tightened to create a locking suture on the deltoid ligament (Fig 4).
      Figure thumbnail gr4
      Fig 4Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. Anterolateral portal is the viewing portal and anteromedial portal is the working portal. (A) The suture limbs are passed through the suture loop and the suture is tightened to create a locking suture on the deltoid ligament. (B) Arthroscopic view shows the locking suture on the deltoid ligament. (AF, avulsed fragment; ALP, anterolateral portal; AMP, anteromedial portal; DL, deltoid ligament; S, suture limbs; SL, suture loop.)

      Passing the Suction Tube

      Anterolateral portal is the viewing portal and anteromedial portal is the working portal. A distal medial skin incision is made at the medial malleolar fracture site and a small-caliber suction tube is passed from the distal medial incision to the anteromedial portal (Fig 5).
      Figure thumbnail gr5
      Fig 5Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. Anterolateral portal is the viewing portal and anteromedial portal is the working portal. (A) A distal medial skin incision is made at the medial malleolar fracture site and a small-caliber suction tube is passed from the distal medial incision to the anteromedial portal. (B) Arthroscopic view shows the suture tube passes from the distal medial incision to the anteromedial portal. (AF, avulsed fragment; ALP, anterolateral portal; AMP, anteromedial portal; ST, suction tube.)

      Suture Loop From Anteromedial Portal to Distal Medial Incision

      Anterolateral portal is the viewing portal and anteromedial portal is the working portal. A No. 1 polydioxanone suture loop (ETHICON, Bridgewater, NJ) is passed from the anteromedial portal to the distal medial incision via this suction tube (Fig 6). Suction is applied through the suction tube to facilitate the delivery of the suture loop.
      Figure thumbnail gr6
      Fig 6Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. Anterolateral portal is the viewing portal and anteromedial portal is the working portal. A No. 1 PDS (polydioxanone) suture loop is passed from the anteromedial portal to the distal medial incision via this suction tube. (ALP, anterolateral portal; AMP, anteromedial portal; SL, PDS (polydioxanone) suture loop; ST, suction tube.)

      Deliver the Deltoid Ligament Locking Suture to Distal Medial Incision

      Anterolateral portal is the viewing portal and anteromedial portal is the working portal. The suction tube is removed and the FiberWire suture limbs are delivered from the anteromedial portal to the distal medial incision by means of the polydioxanone suture loop (Fig 7).
      Figure thumbnail gr7
      Fig 7Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. Anterolateral portal is the viewing portal and anteromedial portal is the working portal. The suction tube is removed and the FiberWire suture limbs are delivered from the anteromedial portal to the distal medial incision by means of the PDS suture loop. (ALP, anterolateral portal; AMP, anteromedial portal; S, FiberWire suture; SL, PDS (polydioxanone) suture loop.)

      Arthroscopically Assisted Reduction and Fixation of the Avulsed Fragment

      Anterolateral portal is the viewing portal and anteromedial portal is the working portal. The sutures limbs are passed along the medial malleolar bone surface to a proximal medial incision which is about 4 cm from the distal medial incision. The fracture fragment is reduced by means of an arthroscopic probe an arthroscopic probe (ACUFEX; Smith & Nephew) and tensioning of the suture limbs (Fig 8).
      Figure thumbnail gr8
      Fig 8Arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus of the left ankle. The patient is in the supine position with the legs spread. Anterolateral portal is the viewing portal and anteromedial portal is the working portal. The sutures limbs are passed along the medial malleolar bone surface to a proximal medial incision which is about 4 cm from the distal medial incision. (A) The fracture fragment is reduced by means of an arthroscopic probe an arthroscopic probe (ACUFEX, Smith & Nephew) and tensioning of the suture limbs. (B) Normal tension of the deltoid ligament is confirmed arthroscopically. (AF, avulsed fragment; AP, arthroscopic probe; DL, deltoid ligament; MM, medial malleolus; TB, talar body.)

      Screw Post Fixation

      Anterolateral portal is the viewing portal and anteromedial portal is the working portal. The suture limbs are anchored to a tibial screw post (4-mm cancellous screw with washer) at the proximal medial incision.
      • Lack W.
      • Phisitkul P.
      • Femino J.E.
      Anatomic deltoid ligament repair with anchor-to-post suture reinforcement: Technique tip.
      Normal tension of the deltoid ligament can be confirmed arthroscopically. Free ankle dorsiflexion–plantarflexion motion is allowed immediately after the operation. Inversion–eversion motion can be started four weeks later (Fig 9, Table 2, Video 1).
      Figure thumbnail gr9
      Fig 9Anterolateral portal is the viewing portal and anteromedial portal is the working portal. (A) injury film of this illustrated case showed an ankle fracture with avulsion fracture of the medial malleolar tip. The medial clear space is grossly widened. (B) Postoperative radiograph showed the reduction of the avulsed fragment and medial clear space after the suture limbs are anchored to a tibial screw post at the proximal medial incision. (AF, avulsed fragment; SP, screw post.)
      Table 2Pearls and Pitfalls of Arthroscopically Assisted Reduction and Fixation of Deltoid Ligament Avulsion Fracture From Medial Malleolus
      PearlsPitfalls
      • 1)
        If needed, the anterolateral portal can be made at the medial side of the peroneus tertius tendon to improve the visualization of the deltoid ligament.
      • 2)
        The shaver blade should face proximally to avoid injury to the deltoid ligament and the cartilage of the medial malleolus and medial talar facet.
      • 3)
        The FiberWire suture loop should pass through the deltoid ligament as close to the avulsed fragment as possible.
      • 4)
        The FiberWire suture limbs should pass along the medial cortex of the avulsed fragment before exit to the distal medial incision.
      • 1)
        If the anterolateral portal is made at the medial side of the peroneus tertius tendon, there is a greater chance of injury to the intermediate branch of the superficial peroneal nerve.
      • 2)
        Cartilage injury by the shaver may lead to degeneration of the medial ankle gutter.

      Discussion

      Restoration of the lateral column is important in surgical management of ankle fractures. In contrast, restoration of the medial column is also important because the deltoid ligament is the medial restraint holding the talus under the tibia firmly, allowing less than 1 mm of lateralization.
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      The deltoid ligament has a close relationship with the syndesmotic ligaments. In cases of combined deltoid ligament and syndesmotic rupture and where the syndesmotic stabilization is insufficient, additional deltoid ligament repair can strengthen the construct and stabilize the mortise.
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      ,
      • James M.
      • Dodd A.
      Management of deltoid ligament injuries in acute ankle fracture: a systematic review.
      Frequently, the avulsed fragment only involves the anterior colliculus of the medial malleolus which is the insertion point of the superficial deltoid ligament. In this case, the deep deltoid ligament may have substance tear or avulsion fracture at the talar side.
      • Cooper M.T.
      The role of deltoid repair and arthroscopy in ankle fractures.
      Fixation of this small avulsed fragment may not be sufficient to restore medial stability.
      • Wiegerinck J.J.I.
      • Stufkens S.A.
      Deltoid rupture in ankle fractures. To repair or not to repair?.
      However, we believe that reduction and fixation of the medial malleolar avulsion fracture is still worthwhile as bone-to-bone healing in case of avulsion fracture is more guaranteed for restoration of normal anatomy of the superficial deltoid ligament as compared with soft-tissue healing in case of substance tear of the ligament. In contrast to previous belief that the deep deltoid ligament is a more important static stabilizer of the ankle than the superficial deltoid ligament, recent biomechanical study demonstrates that isolated rupture of either superficial or deep deltoid is enough to cause instability.
      • Hempen E.C.
      • Butler B.A.
      • Barbosa M.
      • Muriuki M.
      • Havey R.M.
      • Kadakia A.R.
      Superficial deltoid ligament and deep deltoid ligament play equally important roles in the stability of isolated lateral malleolus (OTA/AO 44-B1) fractures: A biomechanical study.
      Moreover, restoration of normal anatomy and tension of the superficial deltoid ligament may facilitate healing of the deep deltoid ligament in anatomical position.
      The deltoid ligament is sutured and the suture limbs are passed over the medial surface of the avulsed fragment. The pull vector of the suture can neutralize the plantarly directed pull of the superficial deltoid ligament and the laterally directed pull of the deep deltoid ligament. However, to allow healing of the deep deltoid ligament in physiological tension, eversion stress to the ankle should be avoided in the initial postoperative period.
      The advantages of this technique include small incisions and better cosmetic outcome, minimal soft-tissue trauma, anatomical fracture reduction under arthroscopic guidance, and assessment and treatment of concomitant intra-articular pathology. The potential risks of this technique include cutaneous nerve injury, persistent medial ankle instability, malunion, nonunion, and persistent medial ankle gutter pain (Table 3).
      • Choi S.J.
      • Choi Y.
      • Baek E.
      • Jo S.
      Does repair of deltoid ligament contribute to restoring a mortise in SER type IV ankle fracture with syndesmotic diastasis?.
      This procedure is not technically difficult and can be managed by foot and ankle arthroscopists of average experience.
      Table 3Advantages and Risks of Arthroscopically Assisted Reduction and Fixation of Deltoid Ligament Avulsion Fracture From Medial Malleolus
      AdvantagesRisks
      • 1)
        Small incisions and better cosmetic outcome
      • 2)
        Minimal soft-tissue trauma
      • 3)
        Anatomical fracture reduction under arthroscopic guidance
      • 4)
        Assessment and treatment of concomitant intra-articular pathology
      • 1)
        Cutaneous nerve injury
      • 2)
        Persistent medial ankle instability
      • 3)
        Malunion
      • 4)
        Nonunion
      • 5)
        Persistent medial ankle gutter pain

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      References

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