Deltoid ligament injury

 

MaisonDeltoid

 

Etiology

 

Ankle sprain

- eversion / External rotation

 

Ankle fractures

- up to 40% of ankle fractures have deltoid ligament injury

- slightly more common to injure deltoid ligament than fracture medial malleolus

- supination / external rotation (Type IV)

- pronation  / external rotation (Type IV)

 

Epidemiology

 

5% of ankle injuries involve the deltoid ligament

 

Anatomy

 

Superficial layer Deep layer
Limits external rotation Limits eversion

4 components

- tibion-navicular

- tibio-spring ligament

- tibio-calcaneum

- tibio-talar

2 components

- posterior tibiotalar

- anterior tibiotalar

 

Spring (calcaneonavicular) ligament

- sustenaculum talus to navicular

- fibrocartilage component articulates with head of talus

 

Symptoms / signs

 

Medial pain and tenderness

 

Xray

 

Syndesmotic injury with high grade deltoid injury

 

deltdelt

Ankle dislocation with soft tissue injury to Deltoid and syndesmsosis

 

Ankle fractures with deltoid ligament rupture / Bimalleolar equivalent injury

 

MaisonMaison

Maisonneuve injury with proximal fibular fracture and increased medial clear space

 

DeltoidDeltoid

Weber B with increased medial clear space on CT

 

Weber CWeber C

Weber C with increased medial clear space

 

Stress xrays

 

External rotation / valgus stress views

Gravity stress views

 

MRI

 

DeltoidDeltoid

 

DeltoidDeltoid

 

Indications for deltoid ligament repair

 

1. Failure to obtain adequate reduction of medial clear space

 

Deltoid ligament may be blocking reduction

Anchor repair of deltoid ligament to tibia or talus

 

2.  Full thickness deltoid ligament injury with anatomical reduction

 

Guo et al PLoS One 2021

- meta-analysis of operative versus non operative deltoid ligament repair 

- 400 patients with ankle fracture

- deltoid repair had better reduction, and better functional outcomes

- mostly low quality studies. Only one RCT which showed no functional difference

 

Technique

 

Vumedi open deltoid ligament repair

 

Arthroscopic technique deltoid ligament rupture

 

Chronic medial ankle instabilty / chronic deltoid ligament insufficiency

 

Symptoms

 

Medial pain

Instability

 

Signs

 

Increased valgus instability

 

Xray

 

Deltoid

Old bony avulsion of deltoid ligament

 

Operative management

 

Deltoid ligament reconstruction +/- syndesmotic fixation

 

Surgical technique PDF

 

Results

 

Pellegrini et al Foot Ankle Surg 2019

- 13 cases of chronic deltoid ligament insufficiency

- direct repair with internal brace

- scores increased from 59 to 75

- 2 implant failures