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Deltoid Ligament Injuries Associated with Ankle Fractures—

Argument for Repair of the Deltoid Ligament
Vinod K Panchbhavi

A b s t r ac t​
Deltoid ligament ruptures are frequently associated with ankle fractures. Poor outcomes are associated with inadequate healing of the deltoid
ligament. Repair of the deltoid ligament has potential to improve outcomes in a subset of patients with ankle fractures where medial ankle
instability persists and medial ankle space remains wide even after the ankle fracture is stabilized.
Keywords: Ankle fractures, Ankle injury, Deltoid ligament, Fibula fracture.
Journal of Foot and Ankle Surgery (Asia Pacific) (2020): 10.5005/jp-journals-10040-1120

The deltoid ligament complex provides stability to the ankle joint.

It resists translation of the talus within the ankle mortise especially
in the posterior and in the lateral directions. In addition, it controls
external and internal rotation.1 The superficial fibers of the deltoid
resist eversion of the hind foot, while the deep fibers of the deltoid
serve as the primary restraint to external rotation of the talus.2
It has been noted that the deltoid ligament ruptures are
associated with ankle fractures in about 40% of ankle fractures
on intraoperative arthroscopic examination. Such injuries have
been documented to be a source of persistent pain or a pronation
deformity.3
There are several previous studies that have reported
satisfactory results when the deltoid ligament rupture was not
repaired along with open reduction and internal fixation of ankle
fractures. These studies however lacked objective measures and
additionally the outcomes reported were suboptimal in about 29%
(10–29%). Further more details on severity of the residual pain and
deformity were not provided.4–7 Another study documented that
over 60% patients showed tenderness over the deltoid ligament,
and 38% patients showed medial instability.8
Department of Orthopaedic Surgery and Rehabilitation, University of
Texas Medical Branch, Galveston, Texas, USA
Corresponding Author: Vinod K Panchbhavi, Department of Orthopaedic
Surgery and Rehabilitation, University of Texas Medical Branch,
Galveston, Texas, USA, Phone: +2147483647, e-mail: vkpanchb@utmb.
edu
How to cite this article: Panchbhavi VK. Deltoid Ligament Injuries
Associated with Ankle Fractures—Argument for Repair of the Deltoid
Ligament. J Foot Ankle Surg (Asia Pacific) 2020;7(1):5–7.
Source of support: Nil
Conflict of interest: None
On the other hand, operative reconstruction of the deltoid
ligament complex using suture anchors resulted in good to
excellent results in most of the cases in a prospective study by
Hintermann et al.9 In the National Football League (NFL), players
with high-energy unstable ankle fractures, the deltoid complex was
found to be impinged in the medial gutter or retracted distally in
a study by Hsu et al. They reviewed their results in 14 NFL players

Figs 1A to C: (A) A Weber B ankle fracture; (B) Stabilized with a locking plate; (C) A loss of medial clear space on follow-up radiographs

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
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 Deltoid Repair

who underwent ankle fracture fixation with open deltoid complex

Figs 2A to D: (A) A Weber B ankle fracture; (B) A wide MCS after fixation of the fibular fracture with a locking plate and a drill for suture anchor placement on medial wall of the talus; (C) With
repair. Operative intervention for all patients consisted of ankle
arthroscopy and debridement, followed by fixation of the fibula
with plate and screws, fixation of the syndesmosis with suture-
endobutton devices, and repair of the deltoid complex with suture
anchors. All NFL players were able to return to running and cutting
maneuvers by 6 months after surgery. There were no significant
differences in playing experience compared to before surgery and
after surgery. About 86% of these elite class players successfully
returned to play and participated in at least one full regular-
season NFL game after surgery. There were no intraoperative
or postoperative complications, and none of the players had
clinical evidence of medial pain or instability at final follow-up.
On final follow-up radiographs, the ankle mortise alignment was
maintained.10
Woo et al. noted that when the deltoid ligament was not
repaired, some patients complained of persistent pain and
swelling around the medial malleolus over the deltoid ligament.
These findings continued even after an anatomic healing of the
ankle fracture. Additionally, there were symptoms of medial ankle

reduction of the MCS on fluoroscopic image; (D) Maintenance of anatomic reduction of MCS on 6 months’ follow-up radiographs
instability, associated with feelings of the ankle giving way and
findings of medial clear space widening on follow-up radiographs.
These authors therefore changed their practice and started direct
repair of the deltoid ligament complex after fixation of the ankle
fracture. Then they subsequently compared their results in patients
with and without deltoid ligament repair. The outcome measures
included radiographic findings, the American Orthopedic Foot
and Ankle Society ankle hind foot scores, visual analog scale
scores, and the Foot Function Index. At an average of 17 months,
the medial clear space (MCS) was significantly smaller when the
deltoid ligament was repaired (p < 0.01). Clinical outcomes were
similar between the two groups (p > 0.05). But in the subset who
underwent syndesmotic fixation there was a significantly smaller
final follow-up MCS, and all clinical outcomes were better in when
deltoid ligament was repair (p < 0.05). The linear regression analysis
showed that the final follow-up MCS had a significant influence on
clinical outcomes (p < 0.05).11
Zhao et al.12 reviewed 74 patients with Weber B and C ankle
fractures and deltoid ligament injury (MCS > 6 mm). Twenty patients
were treated with open reduction and internal fixation (ORIF) of
lateral malleolus and deltoid repair was accomplished with suture
anchors and bone sutures. Fifty-four patients were treated with
ORIF only. The mean follow-up was 53.7 months (range, 14–97).
Outcomes measured were preoperative, postoperative, and final
follow-up MCS, and the AOFAS and VAS scores. The results did
not show a difference between the two groups; however, when
patients with Weber C fractures were considered, the deltoid
ligament repair group showed better reduction in the MCS when
compared to the nonrepair group (p = 0.03). More significantly,
complications of malreduction (11/54) and failure and reoperation
due to symptomatic malreduction were limited to the nonrepair
group. No complications were reported in the deltoid repair group.
The authors concluded that surgical repair of the DL is helpful in
decreasing the postoperative MCS and the rate of malreduction,
especially for the Weber C ankle fractures.
A recent meta-analysis13 concluded that there is no clear
indication for deltoid repair in setting of acute ankle fractures, but
recent studies show that there are advantages of adding deltoid
ligament repair in certain subset of patients, especially those
with high fibular fractures (Weber C) or those with concomitant
syndesmotic injury.

6 Journal of Foot and Ankle Surgery (Asia Pacific), Volume 7 Issue 1 (January–June 2020)
 Deltoid Repair
Nonanatomic or suboptimal healing in the deltoid ligament is
associated with poor outcomes, residual pain and tenderness over
medial malleolus (Fig. 1). With the current evidence, therefore, it is
clear that deltoid repair (Fig. 2) should be in consideration by the
operating surgeon and is necessary in a subset of patients with
ankle fractures.
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