Evaluation of Transsyndesmotic Fixation and Primary Deltoid Ligament Repair in Ankle Fractures With Suspected Combined Deltoid Ligament Injury.

The present prospective study examined the utility of the intraoperative tap test/technique for distal tibiofibular syndesmosis in the diagnosis of deltoid ligament rupture and compared the outcomes of transsyndesmotic fixation to deltoid ligament repair with suture anchor. This diagnostic technique was performed in 59 ankle fractures with suspected deltoid ligament injury. The width of the medial clear space of 59 cases was evaluated to assess the sensitivity and specificity. Those with deltoid ligament rupture were randomly assigned to 2 groups and treated with deltoid ligament repair with a suture anchor or with syndesmosis screw fixation. All the patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, short-form 36-item questionnaire (SF-36), and visual analog scale (VAS). The tap test was positive in 53 cases. However, surgical exploration demonstrated that 51 cases (86.4%) had a combined deltoid ligament injury and fracture. The sensitivity and specificity of the tap test was 100.0% and 75.0%, respectively. Finally, 26 cases (96.3%) in the syndesmosis screw group and 22 (91.7%) in the deltoid repair group were followed up. No statistically significant differences were found in the AOFAS ankle-hindfoot scale score, SF-36 score, or VAS score between the 2 groups. The malreduction rate in the syndesmosis screw group was 34.6% and that in the deltoid repair group was 9.09%. The tap test is an intraoperative diagnostic method to use to evaluate for deltoid ligament injury. Deltoid ligament repair with a suture anchor had good functional and radiologic outcomes comparable to those with syndesmotic screw fixation but has a lower malreduction rate. We did not encounter the issue of internal fixation failure or implant removal.

Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments.

Foot and ankle surgeons often rely on the medial clear space to evaluate competency of the deep deltoid ligament when evaluating ankle fractures. This investigation assesses the integrity of the deep deltoid ligament after lateral malleolar fracture by using direct arthroscopic visualization and medial clear-space separation on plain film radiographs. The objectives of this study were to test the reliability of medial clear-space separation and the Lauge-Hansen classification scheme in predicting deep deltoid rupture in displaced lateral malleolar fractures. The medial clear space was measured on injury radiographs of 40 patients with an isolated displaced lateral malleolar fracture who underwent open reduction and internal fixation. Injury radiographs were classified according to the Lauge-Hansen scheme. Direct arthroscopic visualization was used to evaluate the deep deltoid ligament under manual stress before fracture reduction. The mean preoperative medial clear space in patients with a deep deltoid rupture (n = 13) was 6.6 +/- 2.4 mm (range, 4 to 12 mm), and in patients without a deep deltoid rupture (n = 26), it was 4.0 +/- 1.0 mm (range, 2.5 to 6 mm) (P =.002, 2-sample t test). At an injury medial clear space > or =3 mm, the false positive rate for deltoid rupture was 88.5% (P =.54, Fisher's exact test). At > or =4 mm, the false positive rate was 53.6% (P =.007). All fractures were rotational injuries according to the Lauge-Hansen system. Three fractures were not classifiable; another 3 fractures showed deltoid ligament integrity opposite the expected finding. The results indicate that, in isolated displaced fractures of the lateral malleolus, radiographic widening of the medial clear space is not a reliable indicator for deep deltoid rupture. Some fractures considered stable by the Lauge-Hansen classification may require careful scrutiny to rule out deep deltoid injury.

Operative treatment of ankle fractures.

In an unselected prospectively planned series of 611 ankle fractures 25% were of the AO (Weber) type A, 56% type B and 13% type C; 4% were impact fractures. The fractures were also classified according to Lauge Hansen's system, which was considered more complicated and not suitable for planning of operative treatment. Lauge Hansen's theory of the mechanism of the supination-eversion (SE) injury is questioned--outward rotation does not seem to be obligatory for the typical SE injury. 345 fractures were operated on, and 327 (95%) of them were followed up 1-6 years after operation. The range of motion was measured as loaded dorsal extension (normal value 33 degrees) and loaded plantar flexion (normal value 45 degrees). The clinical results were "excellent" to "good" for 81% of the dislocation fractures, 38% of the impact fractures and for two of the six combined shaft/ankle fractures. In 14% of the dislocation fractures and 50% of the impact fractures posttraumatic arthritis developed. There was a significantly higher degree of arthritis among the patients with a posterior articular surface bearing fragment. There was also a strong correlation between the degree of arthritis and poor clinical results. The clinical and radiographic results from use of the AO (ASIF) method were better than those of conservative treatment or other operative methods. According to an AID analysis the most important factors for the final outcome were: 1) type of fracture, 2) accuracy of operative reduction and 3) the patient's sex.