Review Article
Deltoid Ligament Rupture in
Simon Lee, MD
Johnny Lin, MD
Kamran S. Hamid, MD, MPH
Daniel D. Bohl, MD, MPH
From the Department of Orthopaedic
Surgery, Rush University Medical
Center, Chicago, IL.
Dr. Lee or an immediate family
member serves as a board member,
owner, officer, or committee member
of the American Orthopaedic Foot and
Ankle Society. Dr. Lin or an immediate
family member has received research
or institutional support from Arthrex
and has received nonincome support
(such as equipment or services),
commercially derived honoraria, or
other non–research-related funding
(such as paid travel) from Medwest.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in a com-
mercial company or institution related
directly or indirectly to the subject of
this article: Dr. Hamid and Dr. Bohl.
J Am Acad Orthop Surg 2018;00:1-11
DOI: 10.5435/JAAOS-D-18-00198
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
Month 2018, Vol 00, No 00
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ankle Fracture: Diagnosis and
Management
Abstract
The last stage of a supination-external rotation ankle fracture involves
either transverse fracture of the medial malleolus or rupture of the
deltoid ligament. When the deltoid ligament ruptures, a “bimalleolar
equivalent” ankle fracture occurs, and the surgeon is presented with
several diagnostic and therapeutic challenges. In the native ankle,
the deltoid ligament provides restraint to eversion and external
rotation of the talus on the tibia. In bimalleolar equivalent ankle
fractures, there is often gross medial instability even after fibular
reduction. Retraction of the deltoid with subsequent healing in a
nonanatomic position theoretically may cause instability, persistent
medial gutter pain, and loss of function with risk of early arthritis.
In mild cases, deltoid injury may not be obvious, and potential
diagnostic techniques include preoperative and intraoperative stress
radiography, MRI, and ultrasonography. The most common injury
pattern is avulsion from the medial malleolus, and most current repair
techniques involve direct repair of the capsular and deltoid injuries
involving suture anchors in the medial malleolus and imbrication of
the superficial and deep deltoid fibers. To date, there is limited
evidence of superior clinical outcomes with the addition of deltoid
repair compared with open reduction and internal fixation of the fibula
alone.
M ost rotational injuries about
the ankle fit the supination-
external rotation (SER) model of the
reduction and internal fixation (ORIF)
of both malleoli is indicated to restore
stability to the mortise. However,
landmark 1950 study by Lauge-Han- when the deltoid ruptures and the
sen.1,2 According to this model, with medial malleolus remains intact, the
the foot supinated, external rotation of injury is termed a bimalleolar equiv-
the talus on the tibia produces (1) alent ankle fracture, indicating that
rupture of the anterior-inferior tibio- although the medial malleolus re-
fibular ligament, (2) oblique fracture mains intact, the ruptured deltoid
of the lateral malleolus, (3) rupture of ligament renders the ankle function-
the posterior-inferior tibiofibular lig- ally unstable. ORIF of the fibula is
ament (or posterior malleolar frac- recommended in these cases, and the
ture), and (4) either transverse fracture syndesmosis is typically repaired with
of the medial malleolus or rupture of syndesmotic fixation if unstable.
the deltoid ligament. When the medial However, controversy remains re-
malleolus fractures before the deltoid garding the assessment of deltoid
ligament ruptures, the injury is called a integrity and long-term consequences
bimalleolar ankle fracture, and open of deltoid repair.
1
Deltoid Ligament Rupture in Ankle Fracture
Figure 1
Schematics showing the anatomy of the deltoid ligament. A, The superficial
deltoid ligament consists of the superficial posterior tibiotalar ligament,
tibiocalcaneal ligament, the tibiospring ligament, and the tibionavicular ligament.
B, The deep deltoid ligament consists of the deep posterior tibiotalar ligament
and the deep anterior tibiotalar ligament.
Anatomy and
Biomechanics
The tibiotalar joint has been described
as a mortise and tenon joint because of
its similarity to the woodworking joint
of the same name. The medial, lateral,
and posterior malleoli, together with
their supporting ligaments and the
contours of the tibial plafond and talar
dome, stabilize the talus under the
tibia.3,4 The syndesmotic ligaments
stabilize the fibula within the incisura.
On the lateral side, the anterior and
posterior talofibular ligaments and
the calcaneofibular ligament pro-
vide restraint to talar inversion and
anterior/posterior talar translation.
On the medial side, the deltoid com-
plex stabilizes the talus against the
medial malleolus.
The deltoid complex is a large, fan-
like structure that originates from the
medial malleolus and inserts broadly
onto the talus, calcaneus, and navic-
ular5 (Figure 1). The deltoid can be
divided into two ligaments based on its
insertion sites. First, the superficial
ligament originates primarily from the
anterior malleolus of the medial mal-
leolus, fanning out to include the
superficial posterior tibiotalar, tibio-
2 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
calcaneal, tibiospring, and tibiona-
vicular ligaments (Figure 1, A). Second,
the deep ligament is confluent with
the tibiotalar joint capsule and inserts
onto the medial aspect of the talus as
the deep anterior tibiotalar ligament
(originating from the anterior malleo-
lus just deep to the tibionavicular and
tibiospring ligaments) and deep pos-
terior tibiotalar ligament (originating
from the posterior malleolus and in-
tercollicular groove) (Figure 1, B).
The deltoid ligament is critical in the
normal biomechanics of the ankle,
serving as the tether of the talus to the
medial malleolus to guide the talus
through normal physiologic motion.6-8
The superficial deltoid is understood to
be the primary restraint to hindfoot
eversion, whereas the deep deltoid is
understood to be the primary restraint
to talar external rotation.7 Valgus tilt-
ing of the talus within an intact mortise
requires complete ruptures of both the
deep and superficial ligaments.6,9
Pathoanatomy and
Pathomechanics
In the Lauge-Hansen1,2 model of SER
injury, the deltoid is ruptured sec-
ondary to external rotation force.
Either the superficial or the deep
deltoid ligament can rupture as an
avulsion from the medial malleolus
(majority), as an avulsion from the
distal insertion (minority), or as a
midsubstance tear (least common).10-12
Ruptures are most commonly of both
the superficial and deep portions but
can also be isolated to either portion
alone.
Michelson et al13 conducted a
cadaver study of different stages of
SER ankle injuries in which they
transected ligaments and/or made
bony osteotomies to simulate frac-
tures and then subjected the cadaver
specimens to axial loading through
physiologic motions. These authors
demonstrated that the talus continues
to move in a physiologic manner
following SER stages I-III, presum-
ably because the deltoid functions as
an effective medial tether, stabilizing
the talus sufficiently to guide its
motion. It is only when the deltoid
ligament is rendered incompetent
(SER stage IV) that talar motion be-
comes abnormal.
In another important cadaver study,
Ramsey and Hamilton14 demonstrated
the implications of small changes in
tibiotalar alignment. These authors
showed that even a 1-mm lateral
deviation of the talus on the tibia re-
sults in a 42% reduction in the tibio-
talar contact area. This phenomenon
represents a dramatic alteration in
joint kinematics that has the potential
to lead to abnormal cartilage wear and
degenerative change.
Diagnostic Techniques
Distinguishing bimalleolar equivalent
ankle fractures from isolated lateral
malleolar fractures is critical because
isolated lateral malleolar fractures can
generally be managed nonsurgically,
whereas lateral malleolar fractures
associated with deltoid incompetence
constitute unstable injuries requiring

ORIF in most patients.15 The avail-
able methods of testing for rupture
of the deltoid ligament are reviewed
here.
Physical Examination
Swelling, ecchymosis, and medial ten-
derness are physical examination find-
ings that have been advocated for use
in determining whether there is injury
to the deltoid ligament in the setting
of a lateral malleolar fracture with a
normal medial clear space.16 Using
stress radiography (discussed later)
as the benchmark, McConnell et
al17 determined that each of these
physical exam modalities had little
utility in detecting deltoid injury.
DeAngelis et al18 reported similar
results.
Plain Radiography
Examination of the medial clear space
on a static (unstressed) mortise radio-
graph view is another method that has
been advocated for identifying deltoid
ligament ruptures. On neutral or dor-
siflexion mortise views, a wide medial
clear space is defined as .4 mm and at
least 1 mm more than the superior
tibiotalar clear space.18,19 Ankles
with a fibula fracture and a wide
medial clear space are generally con-
sidered to have deltoid disruption
requiring surgical treatment. Notably,
a normal medial clear space is likely
not sufficient to exclude deltoid liga-
ment injury because a subset of ankles
with a normal static medial clear space
will have widening with external
rotation stress (discussed later). Of
note, in an interesting study, Nwosu
et al20 described the “medial malleolus
fleck sign,” thought to represent a
small avulsion of bone from the
medial malleolus in bimalleolar equiv-
alent ankle fractures.
Stress Radiography
The benchmark for preoperative eval-
uation of deltoid ligament integrity has
Month 2018, Vol 00, No 00
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become the external rotation stress
test.21,22 Park et al21 took radiographs
of six fresh cadaver ankles with sim-
ulated SER ankle fractures and found
that a medial clear space of $5 mm
with manual dorsiflexion and external
rotation was a reliable predictor of
deep deltoid ligament status. Michel-
son et al22 conducted a similar study
with respect to gravity stress views
(where the patient lies in the lateral
position and gravity is allowed to
induce an external rotation and lateral
translation stress) and demonstrated
similar results.
Of note, some have speculated that
if the mortise is stable to weight bear-
ing, there is adequate stability to the
mortise and that stress or gravity stress
images are not necessary. However,
congruent weight bearing does not
maximally stress the syndesmosis
because the vast majority of weight
passes directly from the talar dome to
the tibial plafond regardless of the
presence of the fibular lateral buttress.
On the basis of the current literature,
stress or gravity stress films appear to
be superior to simple weight-bearing
films for evaluation of syndesmotic
integrity.
One algorithm is to perform either
gravity or manual external rotation
stress testing on all patients with a
Weber B fibula fracture and a normal
medial clear space. Manual external
rotation testing consists of a patient
lying supine with the ankle internally
rotated by 10° to obtain a mortise
view of the ankle in neutral dorsi-
flexion. The tibia is stabilized and
an external rotation force is applied
to the foot. Gravity stress testing is
achieved by having the patient lie
in the lateral decubitus position with
the injured extremity down such that
the weight of the foot induces an
external rotation and lateral trans-
lation stress. For both manual and
gravity tests, the medial clear space is
considered to have widened if it
is .4 and .1 mm greater than the
superior tibiotalar joint space.
Simon Lee, MD, et al
Magnetic Resonance
Imaging
Nortunen et al23 identified 61 patients
with isolated lateral malleolar frac-
tures resulting from SER mechanisms.
Patients were evaluated with a manual
external rotation stress test, and the
anterior and posterior portions of the
deep deltoid ligament were investi-
gated using MRI. The authors found
that all 61 patients had injuries to the
deltoid ligament on MRI. These were
typically just partial tears or edema;
complete tears were rare, even among
patients who had positive stress tests.
There was a high degree of variability
of medial clear space in patients with
similar MRI findings, and the inter-
rater reliability of MRI findings was
much lower than the interrater reli-
ability of stress test findings. On the
basis of these results, the authors rec-
ommended against use of MRI in
choosing between surgical and non-
surgical management of SER fractures.
Of note, one group used MRI to
evaluate the ability of the Lauge-
Hansen classification system to
predict ligament injuries in ankle
fractures.24 They found that the Lauge-
Hansen system correctly predicted lig-
amentous injuries in 94% of cases.
Surgical Management
Surgical Sequence
Surgical management of bimalleolar
equivalent ankle fractures typically
begins with ORIF of the fibula
through a lateral or posterolateral
approach. The deltoid ligament or
posterior tibial tendon can become
impinged between the talus and
medial malleolus, preventing closure
of the medial clear space and/or
reduction of the fibula. In these ca-
ses, clearance of the medial gutter
through a separate medial incision is
recommended. After the fibula has
been fixed, the syndesmosis should be
evaluated using the Cotton test, in
3
Deltoid Ligament Rupture in Ankle Fracture

Figure 2 matics. Other surgeons repair the

deltoid only if medial-sided exposure
is already required to clear soft tissue
from the medial gutter. One group
advocates deltoid ligament repair
among high-level athletes and only
after arthroscopic confirmation of
complete deltoid ligament rupture.27
Others have used intraoperative
stress radiography to evaluate for
persistent medial-sided instability at
the end of the case, indicating repair
only among those who are intra-
operatively unstable after ORIF.12
Intraoperative stress testing can be in
the form of external rotation and talar
tilt stress12 or syndesmotic distraction
using a transfibular tap.28
One algorithm is to perform intra-
operative stress radiography after the
fibular (and, if indicated by the Cotton
test, syndesmotic) ORIF.12 An external
rotation stress is applied on the mor-
tise view, and the medial clear space
is evaluated for widening of .4
and .1 mm greater than the superior
tibiotalar clear space. Patients who
meet both of these parameters are
considered to have a positive intra-
operative external rotation stress test.
Intraoperative fluoroscopic images showing the eversion stress test. A, Importantly, this is supplemented
Unstressed ankle after fibular and syndesmotic open reduction and internal with an eversion stress test in which
fixation (ORIF). B, Eversion-stressed ankle after fibular and syndesmotic ORIF an eversion stress is applied and the
showing 9° of talar eversion. C, Unstressed ankle after fibular ORIF. D, Eversion-
stressed ankle after fibular ORIF showing 7° of talar eversion. A–D, Along with talus is evaluated for tilt (which evi-
talar eversion, one observes corresponding increases in the distances between dence suggests indicates a complete
the tip of the medial malleolus and the distal-medial radiographic projections of rupture of both the deep and super-
the talus. ficial deltoid ligaments6,9) (Figure 2).
This eversion stress test functions
similarly to the lateral talar tilt test
which a lateral distracting force is Indication for Deltoid used in patients with potential lateral
applied to the fibula and the syndes- Ligament Repair ligament instability. Corresponding
mosis is evaluated for dynamic wid- Even among those advocating deltoid to talar tilt with eversion stress, one
ening on the mortise view.25,26 If ligament repair, it remains contro- also observes increases in the dis-
the syndesmosis widens on Cotton versial in which patients deltoid tances between the tip of the medial
test, the syndesmosis should be re- repair should be performed. One malleolus and the distal-medial radio-
duced and transsyndesmotic fixation argument is that deltoid repair should graphic features of the talus. $7°
should be placed. For many sur- be performed in all patients with bi- of talar tilt is used as the cutoff to
geons, the operation is considered malleolar equivalent ankle fractures. declare a positive intraoperative ever-
complete at this point; however, for The rationale is that if the deltoid was sion stress test. This value was arrived
others, the final step in the procedure incompetent enough to consider the at as follows: All patients were stressed
consists of evaluation for deltoid fracture unstable, the deltoid should intraoperatively; the deltoid was re-
incompetence and/or potential per- be repaired to restore the medial paired only on patients for whom it
formance of deltoid ligament repair. tether and optimize tibiotalar kine- was felt that “meaningful” tilt had

4 Journal of the American Academy of Orthopaedic Surgeons

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 Simon Lee, MD, et al

Table 1
Published Techniques for Deltoid Repair in the Setting of Ankle Fracturea
Authors Year of Publication Technique Summary

Lack et al11 2012 A suture anchor is placed in the talus to secure suture running up within
the intercollicular groove to a screw in the distal-medial tibial
metaphysis, creating an anchor-to-post reinforcement of the
subsequent repair. The sutures are then continued from the tibial
screw down to the superficial and deep deltoid fibers in a fan-like
fashion. Alternatively, if the deep ligament is avulsed from its insertion
on the talus, two sutures from the talar suture anchor are used to
repair the deep ligament to the talus; all four sutures (including the
two from the knot on the deep ligament) are then brought up within the
intercollicular groove to a distal-medial tibia screw to create a similar
anchor-to-post reinforcement.
Yu et al29 2015 One or two suture anchors in the medial malleolus are used to reattach
the superficial deltoid fibers to their anatomic origin. If the deep
ligament is avulsed from its insertion on the talus, two anchors are
placed in the medial aspect of the talus and attached to the deep
deltoid ligament.
Luckino and Hardy30 2015 One suture anchor is placed in the medial talus, and the associated
suture is run up within the medial gutter and from deep to superficial
through an oblique drill hole in the medial malleolus. The sutures are
secured to a suture button on the superficial aspect of the medial
malleolus, creating an anchor-to-button reinforcement against talar
tilt. No specific suture repair of the deltoid ligament itself was
described.
Hsu et al27 2015 One or two suture anchors are placed in the medial malleolus and used
to reattach the superficial deltoid fibers to their anatomic origin.
Woo et al12 2017 One or two suture anchors are placed on the medial malleolus nearest
to the rupture site. If the superficial and deep ligaments are both
avulsed from the medial malleolus, an anterior suture anchor is
placed for the superficial deltoid and a posterior suture anchor is
placed for the deep deltoid. If the deep deltoid is avulsed from the
talus, one or two suture anchors are placed into the medial aspect of
the talus and used to reattach the deep deltoid.
a
The studies by Stromsoe et al31 and Baird and Jackson19 are not included in this table because the authors did not describe their technique for
deltoid repair.

occurred. The handful of cases for
which intraoperative stress films were
available postoperatively were retro-
spectively reviewed. It was found that
the cutoff for fixing the deltoid had
generally been about 7°; hence, this
was adopted as the threshold. Little
work has been done in the literature
to establish a threshold value for
such a measurement; establishing
this threshold should be an area for
future research. Widespread adop-
tion of any specific threshold should
not be encouraged until studies
have born such a threshold out.
Of note, after anatomic reduction of
the fibula and syndesmosis (if neces-
sary), meaningful lateral talar trans-
lation does not occur. Fibular and
syndesmotic fixation appear not to
allow for widening medially unless the
syndesmosis or fibula was malreduced
or fixation was inadequate. However,
meaningful talar tilt, nevertheless, oc-
curs in about half of these patients. In
patients with positive intraoperative
stress radiographs, deltoid repair is
indicated and performed.
Technique for Deltoid Repair
Techniques for deltoid ligament repair
in ankle fracture have been described
by several different groups (Table 1),
although the techniques have not been
compared with each other.11,12,27,29,30
All recent descriptions have in com-
mon the anchoring of suture to the
distal-medial tibia with anatomic
repair of the deltoid fibers to the
medial malleolus. The authors vary in
the location of their skin incision,
whether they incorporate the superfi-
cial versus deep deltoid fibers, how
they address avulsion from the cal-
caneus, the number and position of
suture anchors, and the inclusion of
anchor-to-post or anchor-to-button
reinforcement.
Deltoid repair is performed as
follows. A 5-cm curvilinear incision
is made midline over the medial
malleolus, and the corresponding
skin flaps are mobilized to facilitate

Month 2018, Vol 00, No 00 5

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Deltoid Ligament Rupture in Ankle Fracture

Figure 3 and a scalpel is used to elevate 1 cm

of tissue proximally. A drill hole of
appropriate size is created in the medial
malleolus for placement of the desired
suture anchor(s) (Figure 3, A). One or
two suture anchors are placed for
fixation of two or four sets of braided
nonabsorbable suture (Figure 3, B).
Once the anchor(s) is secured within
bone, the capsule, deep deltoid, and
superficial deltoid are imbricated and
reduced to the medial malleolus in a
“vest-over-pants” technique (Figure 3,
C and D). Suture is used to directly
repair the capsular disruption as well.
The ankle is then gently stressed in
external rotation and eversion to
confirm adequate stability.
Although much less common, it is
also worth discussing distal avulsion of
the deep deltoid from the talus. In these
circumstances, it is recommended to
use the technique described by Yu
et al29 for repair. In this technique, the
exposure is extended distally using the
same interval, but taking increased
care not to injure the posterior tibial
tendon, posterior tibial artery, and
tibial nerve. Two anchors are placed
on the medial aspect of the talus at the
Photographs showing the deltoid ligament repair technique. A, The distal tip of sites of insertion of the deep anterior
the medial malleolus is identified (arrow), and a scalpel is used to elevate 1 cm of and deep posterior tibiotalar ligaments
tissue proximally. A drill hole of appropriate size is created in the medial (Figure 1, B). These anchors are
malleolus for placement of the desired suture anchor(s). B, One or two suture
anchors are placed for fixation of two or four sets of braided nonabsorbable sutured to the deep anterior and deep
suture. C, Once the anchor is secured within bone, the capsule, deep deltoid, posterior tibiotalar ligaments, respec-
and superficial deltoid (arrow head) are imbricated and reduced to the medial tively. Depending on the location of
malleolus in a “vest-over-pants” technique. D, The defect in the deltoid ligament rupture of the superficial deltoid, that
is obliterated, and the deltoid tissue is in mild tension with the ankle in neutral
after repair. structure is repaired by either direct
suture repair (if midsubstance) or a
single suture anchor into the fibula
visualization. At this point, hori- wire may be used (traditional Pridie (if a fibular avulsion).
zontal rents in the superficial deltoid drilling), a dedicated microfracture
ligament, joint capsule, and/or deep awl is an alternative (more current
Outcomes
deltoid ligament can often be visu- technique). The advantage is of the
alized. The posterior tibial tendon is awl technique is that the small diam-
identified and retracted posteriorly eter wire may heat the bone, which
Studies Suggesting
and inferiorly. The talus and medial will not occur with the microfracture Adequate Results Without
tibia are often visible through the awl. Deltoid Repair
rent and are inspected for traumatic In cases of deltoid avulsion from A number of retrospective studies
osteochondral lesions. If sizable le- the medial malleolus (most common), (published mostly during the 1980s)
sions are identified, they are treated attention is turned to preparing the introduced the idea that ORIF of bi-
with microfracture using a Kirschner medial malleolus for repair. The distal malleolar equivalent ankle fractures
wire. Of note, although a Kirschner tip of the medial malleolus is identified, without deltoid repair has acceptable

6 Journal of the American Academy of Orthopaedic Surgeons

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 Simon Lee, MD, et al

Table 2
Studies Directly Comparing Deltoid Repair to No Deltoid Repair
Number
Repaired/ Mean
Level of Not Follow-up
Authors Year Evidence Repaired (mo) Main Result Conclusion Limitations

Baird and 1987 IV (case series, 3/21 36 90% of patients in Exploration of the Only three
Jackson19 included the no repair group medial side of the patients in
patients with had good or ankle and repair of deltoid repair
and without excellent results. the deltoid group; no
deltoid repair Patients in the ligament are not statistical
but did not repair group necessary unless comparison;
statistically reportedly did lateral malleolar no
compare not do as well, but reduction fails to postoperative
groups) the sample size close the medial stress testing.
reportedly was clear space.
not sufficient to
statistically
compare the
nonrepaired
and repaired
groups.
Stromsoe 1995 II (lesser quality 25/25 17 No difference Deltoid repair is No power
et al31 randomized between the two unnecessary analysis; no
controlled trial) groups in terms of assuming that the postoperative
working ability, talus is reduced to stress testing;
sports activities, the medial no subjective
pain, swelling, malleolus and the assessment
and overall anatomy of the of medial
movement. fibula is restored. instability.
Longer surgical
time was reported
for the deltoid
repair cohort.
Maynou 1997 III (retrospective 18/17 56 Subjective and Repair of the deltoid No power
et al36 comparative objective ligament is analysis.
study) assessments did unnecessary if
not differ between fibular reduction
the groups. Medial reconstitutes the
instability (defined mortise.
using a system of Exploration of the
static and stress medial side is
radiographs at indicated only
final follow-up) when fibular
was observed in reduction fails to
four patients (ie, close the medial
two in the repair clear space.
group and two in
the nonrepair
group).
Radiographically,
one posttraumatic
osteoarthritis
developed in
the nonrepair
group and
none in the repair
group.
(continued )

Month 2018, Vol 00, No 00 7

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Deltoid Ligament Rupture in Ankle Fracture

Table 2 (continued )
Studies Directly Comparing Deltoid Repair to No Deltoid Repair
Number
Repaired/ Mean
Level of Not Follow-up
Authors Year Evidence Repaired (mo) Main Result Conclusion Limitations

Woo et al12 2018 III (retrospective 41/37 17 Final follow-up Radiographic Clinical
comparative medial clear space medial stability is significance
study) on gravity stress improved with of medial
examination was deltoid ligament clear space
smaller in patients repair. No clinical widening on
managed with benefit is realized postoperative
deltoid repair, for those patients stress view is
although clinical without uncertain.
outcomes were syndesmotic
similar. However, injury; however,
when restricted for patients
only to patients who requiring
also underwent syndesmotic
syndesmotic repair,
repair, medial clear supplementing
space was smaller, with deltoid repair
and clinical results in
outcomes were improvements in
superior in the patient-reported
deltoid repair outcomes. Hence,
group. deltoid repair may
be beneficial in
patients with
concurrent
syndesmotic
injury.

long-term results.32-35 The theory
behind these studies is that by re-
approximating the deltoid tissue
through anatomic reconstitution of
the mortise (through fibular and
syndesmotic ORIF), the deltoid
should have the opportunity to scar
in and heal into a functional liga-
ment without direct repair. In a good
example of one of these early studies,
Zeegers and van der Werken retro-
spectively studied 28 lateral malleo-
lar fractures that were associated
with ruptures of the deltoid ligament
that all received lateral malleolar
ORIF without exploration or repair
of the deltoid ligament. After an
average of 18 months, no patient had
medial laxity either clinically or on
eversion stress testing. However,
early signs of osteoarthritis were seen
in seven patients, five of whom were
noted to have had anatomic resto-
ration of the mortise at the time of
surgical treatment. Because all but
one of the osteoarthritic patients was
asymptomatic at final follow-up, the
authors concluded that there is no
need to explore or repair a ruptured
deltoid in an ankle that has been
anatomically reduced.
Later studies suggesting adequate
results without deltoid repair were
improved in design in that they were
more commonly comparative stud-
ies19,31,36 (Table 2). For example,
Maynou et al36 retrospectively
studied 35 patients with bimalleolar
equivalent ankle fractures whose
surgical treatment did include (n =
18) or did not include (n = 17) del-
toid repair. Subjective and objective
assessments did not differ between
the groups. Medial instability (defined
using a system of static and stress
radiographs at final follow-up) was
observed in two patients in each
group. Radiographically, one patient
developed posttraumatic osteo-
arthritis—this was in the nonrepair
group. On the basis of these findings,
the authors concluded that they could
not support deltoid ligament repair in
cases in which fibular reduction and
fixation achieves an anatomic recon-
stitution of the mortise.
The first and only randomized study
that analyzed the utility of deltoid
repair in ankle fractures was conducted
in 1995 by Stromsoe et al.31 These
authors randomized 50 patients with
Weber B and C fractures and a rup-
tured deltoid ligament to receive ORIF
either with (n = 25) or without (n = 25)
repair of the deltoid. At mean 17-
month follow-up, the authors found
no difference in terms of working
ability, sports activities, pain, swelling,
and movement. The only difference

8 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

they reported was longer surgical time
for the deltoid repair cohort. The au-
thors concluded that deltoid repair
was unnecessary assuming that the
talus was reduced to the medial mal-
leolus and the anatomy of the fibula
was restored. However, the reader
should note that no power analysis
was reported and no assessment of
medial instability (either subjective or
objective) was performed.
Studies Suggesting Superior
Outcomes With Deltoid
Repair
Although most patients in the studies
mentioned earlier did well without
deltoid repair, there have been pub-
lished and anecdotal reports of sub-
populations of patients that had less
than optimal outcomes.19,31-37 These
included reports of medial instabil-
ity, persistent medial gutter pain, and
loss of function with early develop-
ment of posttraumatic arthritis. The
concern is that these outcomes were
related to failure of the deltoid liga-
ment to heal in an anatomic position.
It is in this setting that a number of
orthopaedic foot and ankle surgeons
have been performing primary del-
toid repair in subsets of patients with
bimalleolar equivalent ankle fractures.
Several published studies support
deltoid repair. Yu et al29 studied 106
patients with distal fibular fractures
associated with deltoid ligament rup-
tures that underwent deltoid repair
as part of the primary ORIF. At an
average of 27 months, clinical out-
comes scores were acceptable, post-
operative stress radiographs were all
negative, and no cases of posttrau-
matic arthritis were seen.
Hsu et al27 report their experience
repairing the deltoid in 14 National
Football League players with bi-
malleolar equivalent ankle fractures.
All patients underwent ankle arthros-
copy and débridement as a first step to
confirm deltoid ligament rupture.
After arthroscopy, patients with con-
Month 2018, Vol 00, No 00
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
firmed deltoid rupture underwent
fibular ORIF, syndesmotic fixation,
and open deltoid repair. Eighty-six
percent of players returned to play,
and no players reported of medial
pain or instability at final follow-up.
Finally, Woo et al12 retrospec-
tively evaluated 78 consecutive ca-
ses of ORIF of bimalleolar equivalent
ankle fracture over a 15-year period.
The authors changed their clinical
practice half way through this period;
patients in the early group (2001–
2008, n = 37) were managed without
deltoid repair, whereas patients in the
late group (2009–2016, n = 41) were
managed with deltoid repair. Inter-
estingly, the authors found that the
gravity stress view medial clear space
at final follow-up was significantly
smaller in patients managed with
deltoid repair (3.2 6 0.5 versus 3.7 6
0.6 mm; P , 0.001). Clinical out-
comes were similar between the
groups. The authors conducted a
post hoc subgroup analysis in which
they included only patients who also
had syndesmotic injury detected in-
traoperatively and consequently had
undergone syndesmotic fixation (27
in the deltoid repair group and 17 in
the no deltoid repair group). In this
subgroup analysis, clinical outcomes
including the AOFAS score, VAS
pain score, and medial-sided pain
were all superior in the deltoid re-
pair group. These results suggest that
deltoid repair may be clinically
beneficial in patients who not only
have deltoid rupture but also have
syndesmotic injury for which they
are undergoing syndesmotic repair.
That is, the two repairs may work in
concert to reinforce each other and
facilitate healing in these patients.
A Note on the Syndesmosis
In one recent study, a group of au-
thors argued that if the deltoid liga-
ment is repaired, syndesmotic repair
may not be necessary.38 In their ret-
rospective study of 27 patients with
Simon Lee, MD, et al
bimalleolar equivalent ankle frac-
tures, they found that repairing the
deltoid ligament at the time of lateral
malleolus fixation has outcomes that
are comparable to lateral malleolus
fixation plus syndesmotic fixation.
They state that the former avoids the
costs and risks of any subsequent
operation for removal of a syn-
desmotic implant, as well as the risk
of syndesmotic malreduction. Pro-
spective studies are needed to con-
firm these results.
Future Work
The field of orthopaedic foot and ankle
surgery is lacking a well-powered, rig-
orous, randomized, controlled trial
evaluating the utility of deltoid repair
in bimalleolar equivalent ankle frac-
tures. This review uncovered only
one randomized study attempting
to address this subject. That study
included only 25 patients in each
group, lacked a description of statis-
tical power, had minimum follow-up
of only 5 months, and lacked any
form of assessment of medial insta-
bility. The ideal study would be
powered to detect a difference both in
patient-reported outcomes and in
medial clear space widening on stress
views, would have follow-up of at
least 2 years (to evaluate for early
development of posttraumatic arthri-
tis), and would carefully exclude or
stratify on the basis of syndesmotic
injury to minimize the impact of con-
founding. Such a study would enable a
more conclusive answer to this set of
controversial questions.
Summary
Manual or gravity external rotation
stress radiography is the benchmark
to differentiate isolated lateral mal-
leolar fractures from bimalleolar
equivalent fractures of the ankle. If
the medial clear space widens on
stress radiography, the patient is
9
Deltoid Ligament Rupture in Ankle Fracture
diagnosed with rupture of the deltoid
ligament, and surgical intervention is
recommended. Surgical treatment
consists of fibular ORIF (with syn-
desmotic fixation if the syndesmosis
widens on the Cotton test after fibu-
lar ORIF) with or without deltoid
repair depending on surgeon prefer-
ence and intraoperative findings.
When performed, deltoid repair is
undertaken after fibular ORIF (and
after syndesmotic repair, if per-
formed). Deltoid repair most com-
monly involves placement of a suture
anchor (or anchors) in the medial
malleolus and imbrication of the deep
and superficial ligaments to the mal-
leolar anchor. The only randomized
study to evaluate the utility of deltoid
ligament repair in ankle fracture
could not support the procedure, but
this study was severely limited. The
field would benefit from an appro-
priately powered, rigorous, ran-
domized, controlled trial of deltoid
ligament repair with both patient-
reported outcome and stress radio-
graphic outcome evaluation.
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