Summary

Deltoid ligament repair offers significantly lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal when performed instead of transsyndesmotic screw fixation.

Abstract

Background

Ankle fractures are reported to be the fourth most common bone fracture requiring surgical management. The deltoid ligament is a complex of ligaments found on the medial aspect of the ankle. It is considered the primary stabilizer of the ankle against a valgus force. The management of the deltoid ligament in ankle fractures is currently a controversial topic and there is no current consensus if it should be repaired or not in ankle fractures. This systematic review examined the role of the deltoid ligament in ankle fractures, and when it may or may not be indicated.

Methods

A systematic database search was conducted with Medline, Pubmed and Embase. The inclusion criteria for this review included ankle fractures involving deltoid ligament rupture. We excluded patients under 18 and polytrauma patients. The papers were screened independently and in duplicate by two reviewers, and their quality was evaluated using the MINORs criteria. Data extraction included post-operative outcomes, pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction and complication rates.

Results

The database search returned 1153 potential studies after duplicate removal. After title, abstract and full text screening, 10 eligible studies published between 1987 and 2017 remained for data extraction (n = 528). The studies include 325 Weber B and 203 Weber C type fractures. The reported results demonstrated that deltoid ligament repair significantly reduced syndesmotic malreduction rates compared to non-repair groups (p < 0.05), and the rate of re-operation for hardware removal was significantly lower in patients who underwent deltoid ligament repair instead of transsyndesmotic screw fixation (p = 0.002). There was no significant difference for pain, function, ROM, MCS and complication rates (p > 0.05).

Conclusion

Deltoid ligament repair offers significantly lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal when performed instead of transsyndesmotic screw fixation. When compared to non-repair groups, there are insignificant differences in pain, function, ROM, MCS and complication rates. Deltoid ligament repair should be considered for ankle fracture patients with syndesmotic injury, especially those with Weber C fractures as they have been shown to have greater reduction of syndesmotic malreduction rates with the additional deltoid repair. A large multi-patient randomized control trial is required to further examine the outcomes of ankle fracture patients who undergo deltoid ligament repair versus transsyndesmotic screw fixation.