deltoid_ligament_injury.pdf

DELTOID LIGAMENT DELTOID LIGAMENT INJURYINJURY

Raymond Tsukuda, D.P.M., F.A.C.F.A.S.Raymond Tsukuda, D.P.M., F.A.C.F.A.S.

Department of PodiatryDepartment of Podiatry

Kaiser Baldwin Park Medical CenterKaiser Baldwin Park Medical Center

ObjectivesObjectives

1) Historical and recent perspective on deltoid injuries2) Update review on anatomy of deltoid complex3) Review evaluation and presentation of injury4) Discuss controversy on treatment of injury5) Review recent literature6) Determine need to change treatment protocol7) Case presentations8) Discuss potential need for further research

HistoryHistory

treatment protocol for deltoid ligament injuries have varied fortreatment protocol for deltoid ligament injuries have varied for yearsyears

many feel deltoid ligament tears do not have to be repaired due many feel deltoid ligament tears do not have to be repaired due to functional anatomy of ankle jointto functional anatomy of ankle joint

recent interest in medial ankle instability has made us rerecent interest in medial ankle instability has made us re-- evaluate if these injuries should be primarily repaired evaluate if these injuries should be primarily repaired (Hintermann B and Porter DA)(Hintermann B and Porter DA)

does recognizing injury in acute versus chronic state make a does recognizing injury in acute versus chronic state make a difference?difference?

IncidenceIncidence

1515--20% 0f all athletic injuries involve the ankle (Garrick JG, Requ20% 0f all athletic injuries involve the ankle (Garrick JG, Requa RK. Clin a RK. Clin Sports Med 1988:7(1)29Sports Med 1988:7(1)29--36)36)

2020--40% of ankle injuries will lead to chronic instability and disab40% of ankle injuries will lead to chronic instability and disability (Renstrom P. ility (Renstrom P. J Am Acad Orthop Surg 1994:2(5):270J Am Acad Orthop Surg 1994:2(5):270--80)80)

deltoid ligament injuries are seen with syndesmotic injuries anddeltoid ligament injuries are seen with syndesmotic injuries and can occur up to can occur up to 18% of the time with ankle sprains (Lin et al. J Orthop Sports P18% of the time with ankle sprains (Lin et al. J Orthop Sports Phys Ther 2006; hys Ther 2006; 36:37236:372--384)384)

deltoid insufficiency can be seen after chronic posterior tibialdeltoid insufficiency can be seen after chronic posterior tibial tendon dysfunction, tendon dysfunction, trauma, triple arthrodesis, and total ankle arthroplastytrauma, triple arthrodesis, and total ankle arthroplasty

OccurrenceOccurrenceseen either acute or chronicseen either acute or chronic

Isolated injuries are rareIsolated injuries are rare

seen with syndesmotic sprains and inversion sprainsseen with syndesmotic sprains and inversion sprains

associated mostly with fractures associated mostly with fractures

DanisDanis--Weber B and CWeber B and C

SER, PER, and PABSER, PER, and PAB

Bimalleolar equivalent fractures (Porter)Bimalleolar equivalent fractures (Porter)

TerminologyTerminology

Medial Ankle Instability (Hintermann)Medial Ankle Instability (Hintermann)

Deltoid InsufficiencyDeltoid Insufficiency

Bimalleolar Equivalent Fracture Injury (Porter)Bimalleolar Equivalent Fracture Injury (Porter)

Invisible InjuryInvisible Injury (Staples)(Staples)

Anatomy Anatomy

Deltoid LigamentDeltoid Ligament

AnatomyAnatomy

various descriptions in literature and researchvarious descriptions in literature and research

all agree multiall agree multi--bandedbanded

most agree there is a superficial and deep componentmost agree there is a superficial and deep component

cadaver studies show difficulty to distinguish separate cadaver studies show difficulty to distinguish separate ligamentsligaments

studies also show inconsistency on what components studies also show inconsistency on what components are present in all specimensare present in all specimens

AnatomyAnatomyPankovich AM, Shivaram MS. 1979; Acta Orthop Scand, 50:217Pankovich AM, Shivaram MS. 1979; Acta Orthop Scand, 50:217--223223

cadaver study to detail medial anatomy of anklecadaver study to detail medial anatomy of ankle

16 specimens16 specimens

2 deep portions of deltoid:2 deep portions of deltoid:

deep anterior talotibial deep anterior talotibial

deep posterior talotibial ligamentsdeep posterior talotibial ligaments

3 superficial portions:3 superficial portions:

naviculotibial naviculotibial

calcaneotibialcalcaneotibial

superficial talotibialsuperficial talotibial

AnatomyAnatomy

Milner CE, Soames RW. Foot Ankle Int 1998;19:289Milner CE, Soames RW. Foot Ankle Int 1998;19:289--9292

studies 40 cadaversstudies 40 cadavers

found 6 componentsfound 6 components

superficial (4)superficial (4)

tibiospring, tibionavicular, tibiocalcaneal, superficial posteritibiospring, tibionavicular, tibiocalcaneal, superficial posterior or tibiotalartibiotalar

Deep (2)Deep (2)

deep posterior tibiotalar and deep anterior tibiotalardeep posterior tibiotalar and deep anterior tibiotalar

Williams & Wilkins 1998. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 2

The Medial Collateral Ligaments of the Human Ankle Joint: Anatomical Variations.Milner, Clare; Soames, Roger

Foot & Ankle International. 19(5):289-292, May 1998.

Fig. 1 . The bands of the medial collateral ligament of the human ankle joint: medial ligament intact. A, Tibial spring ligament. B, Tibionavicular ligament. C, Tibiocalcaneal ligament.

Tibiospring

TibionavicularTibiocalcaneal




Fig. 2 . Tibiospring ligament reflected, tibionavicular (B), and tibiocalcaneal (C) ligaments visible beneath.

tibionavicular

tibiocalcaneal




Fig. 3. Tibiospring and tibionavicular ligaments reflected, tibiocalcaneal ligament (C) visible beneath.

Tibiocalcaneal




Fig. 4 . Tibiospring, tibionavicular, and tibiocalcaneal ligaments reflected, deep posterior tibiotalar ligament (D) visible beneath.

Deep Posterior Tibiotalar




Fig. 6 . Tibiospring and tibionavicular ligaments reflected, superficial posterior tibiotalar ligament (E) visible beneath.

Superficial Posterior Tibiotalar





Fig. 7 . Location of the deep anterior tibiotalar ligament (F): tibiospring and tibionavicular ligaments reflected, deep posterior tibiotalar ligament (D) also visible.

Deep Anterior Tibiotalar


AnatomyAnatomy

Boss AP, Hintermann B; 2002, Foot Ankle Int 23(6)547Boss AP, Hintermann B; 2002, Foot Ankle Int 23(6)547--5353

12 cadaver studied12 cadaver studied

found 5 ligaments in superficial and deep layersfound 5 ligaments in superficial and deep layers

strongest are tibiocalcaneal and deep posterior tibiotalar, nextstrongest are tibiocalcaneal and deep posterior tibiotalar, next is is tibiospringtibiospring

tibiocalcaneal is longest and thickesttibiocalcaneal is longest and thickest

tibionavicular is more capsulartibionavicular is more capsular

Function of Deltoid Function of Deltoid LigamentLigament

limits talar abduction when isolated (Close; Grath)limits talar abduction when isolated (Close; Grath)

stabilizes ankle against plantar flexion, external rotation and stabilizes ankle against plantar flexion, external rotation and pronation pronation (Rasmussen; Harper; Nigg)(Rasmussen; Harper; Nigg)

prevents external rotation and valgus stress to subtalar joint (prevents external rotation and valgus stress to subtalar joint (Michelson, et al. Michelson, et al. Foot Ankle Int; 2004, 25(9):639Foot Ankle Int; 2004, 25(9):639--46)46)

superficial component crosses both ankle and subtalar jointssuperficial component crosses both ankle and subtalar joints

deep component crosses only ankle jointdeep component crosses only ankle joint

Mechanism of InjuryMechanism of Injury

pronation (eversion) trauma leading to forced external pronation (eversion) trauma leading to forced external rotation and abduction of anklerotation and abduction of ankle

running downstairsrunning downstairs

landing on uneven surfaceslanding on uneven surfaces

simultaneous rotation (soccer, dancing, simultaneous rotation (soccer, dancing, football)football)

SER, PAB, or PER ankle fracturesSER, PAB, or PER ankle fractures

Pankovich StudyPankovich Study

1979; Acta Orthop Scand, 50:2251979; Acta Orthop Scand, 50:225--236236

described various medial ankle injuries and clinical implicationdescribed various medial ankle injuries and clinical implicationss

studied 102 ankle fractures and found 6 patterns:studied 102 ankle fractures and found 6 patterns:

rupture of deep and superficial deltoid ligamentsrupture of deep and superficial deltoid ligaments

fracture of anterior colliculusfracture of anterior colliculus

fracture of anterior colliculus and rupture of deep deltoidfracture of anterior colliculus and rupture of deep deltoid

fracture of posterior colliculusfracture of posterior colliculus

supracollicular fracture (most common)supracollicular fracture (most common)

avulsion chip fractureavulsion chip fracture

Tornetta StudyTornetta Study2000; J Bone Joint Surg, 82A(6):8432000; J Bone Joint Surg, 82A(6):843--4848

in vivo study of 27 anklesin vivo study of 27 ankles

evaluated competence of deltoid ligament after medial malleolar evaluated competence of deltoid ligament after medial malleolar fixationfixation

26% deltoid incompetence with external stress after fixation26% deltoid incompetence with external stress after fixation

caused by size and height of medial malleolus fragmentcaused by size and height of medial malleolus fragment

thus can have both fracture and ligamentous injury thus can have both fracture and ligamentous injury

did not talk discuss repair deltoid did not talk discuss repair deltoid

Subjective FindingsSubjective Findings

history of mechanism of injury (acute or chronic)history of mechanism of injury (acute or chronic)

unable to weight bear after injury (acute)unable to weight bear after injury (acute)

ankle feels like it ankle feels like it gives waygives way (chronic)(chronic)

pain located to anteromedial and/or lateral ankle pain located to anteromedial and/or lateral ankle (acute and chronic)(acute and chronic)

Physical FindingsPhysical Findings

tenderness over ligament tenderness over ligament -- how reliable?how reliable?

hematoma common (acute)hematoma common (acute)

pain over medial gutter or anterior margin of fibulapain over medial gutter or anterior margin of fibula

rearfoot valgus and over pronation on stance rearfoot valgus and over pronation on stance reducible with active posterior tibial tendon firing reducible with active posterior tibial tendon firing (chronic)(chronic)

positive stress tests of the ankle positive stress tests of the ankle

Medial ankle pain Medial ankle pain reliability?reliability?

DeAngelis NA, Eskander MS, French BG J Orthop Trauma 2007; 21(4)DeAngelis NA, Eskander MS, French BG J Orthop Trauma 2007; 21(4):244:244--47.47.

55 patients with Weber B fracture and normal medial clear space 55 patients with Weber B fracture and normal medial clear space evaluated evaluated

25% had medial tenderness and a positive stress test25% had medial tenderness and a positive stress test

25% had no medial tenderness but had a positive stress test25% had no medial tenderness but had a positive stress test

42% accuracy42% accuracy

should we stress all fractures?should we stress all fractures?

Clinical Exam of Chronic Clinical Exam of Chronic Medial Ankle InstabilityMedial Ankle Instability

Clinical Stress TestsClinical Stress Tests

Anterior drawer testAnterior drawer test

Inversion stressInversion stress

External rotationExternal rotation

Squeeze (not accurate)Squeeze (not accurate)

Clinical Stress TestClinical Stress Test

external rotation to external rotation to evaluate integrity of evaluate integrity of deltoiddeltoid

Imaging EvaluationImaging Evaluation

Plain x raysPlain x rays

Stress viewsStress views

ArthrographyArthrography

CT scanCT scan

MRIMRI

UltrasoundUltrasound

RadiographsRadiographs

standard AP, mortise and lateral (weight bearing if standard AP, mortise and lateral (weight bearing if possible)possible)

medial clear space (MCS) medial clear space (MCS)

most reliable radiographic measurementmost reliable radiographic measurement

> than 2> than 2--5 mm MCS is documented as 5 mm MCS is documented as pathologicpathologic

X ray imagesX ray images

Stress RadiographsStress RadiographsMichelson described gravity stress technique in 2001Michelson described gravity stress technique in 2001

manual and gravity stress radiographs equivalent in manual and gravity stress radiographs equivalent in evaluation of deltoid ligament injury (Gill JB, et al. J evaluation of deltoid ligament injury (Gill JB, et al. J Bone Joint Surg Am. 2007; 89:994Bone Joint Surg Am. 2007; 89:994--9)9)

physician does not have to be present at time of physician does not have to be present at time of gravity stress testgravity stress test

does not account for muscle firingdoes not account for muscle firing

how often do we perform this test?how often do we perform this test?

The Gravity Stress ViewThe Gravity Stress View

Michelson JD, Varner KE, Checcone M; 2001 Clin Orthop Rel Res, 3Michelson JD, Varner KE, Checcone M; 2001 Clin Orthop Rel Res, 387:17887:178--8282

to aid in diagnosing deltoid injury to determine if surgery is nto aid in diagnosing deltoid injury to determine if surgery is neededeeded

studied 8 cadavers under serial stress under sequential conditiostudied 8 cadavers under serial stress under sequential conditionsns

showed combined transection of superficial and deep deltoid showshowed combined transection of superficial and deep deltoid showed ed talus shift and valgus tilttalus shift and valgus tilt

Stress RadiographsStress Radiographs

Park SD, Kubiak EN, et al. J Orthop Trauma 2006;20(1):11Park SD, Kubiak EN, et al. J Orthop Trauma 2006;20(1):11--18.18.

cadaver study cadaver study

looked at ankle position to measure clear space with stresslooked at ankle position to measure clear space with stress

found ankle in dorsiflexion and external stress with >5mm medialfound ankle in dorsiflexion and external stress with >5mm medial clear space was most predictiveclear space was most predictive

feels Michelson gravity view does not account for syndesmotic feels Michelson gravity view does not account for syndesmotic injuryinjury

gravity stress does not account for muscle firinggravity stress does not account for muscle firing

Gravity Stress TechniqueGravity Stress Technique

MRI ImagesMRI Images

NormalNormal

MRIMRI

Normal T2Normal T2

MRIMRI

Deltoid Sprain T1Deltoid Sprain T1

MRIMRI

Deltoid SprainDeltoid Sprain

MRIMRI

Deltoid Partial Tear T1Deltoid Partial Tear T1

MRIMRI

Deltoid Partial Tear T2Deltoid Partial Tear T2

MRIMRI

Deltoid Complete Tear Deltoid Complete Tear T1T1

MRIMRI

Deltoid Complete Tear Deltoid Complete Tear T2T2

MRIMRIAdvantages:Advantages:

identify more detail about extent of injuryidentify more detail about extent of injury

nonnon--invasiveinvasive

less risk of increase injuryless risk of increase injury

no need for anesthesiano need for anesthesia

Disadvantages:Disadvantages:

higher costhigher cost

not always availablenot always available

does it change prognosis???does it change prognosis???

MRI StudiesMRI Studies

Cheung Y, Perrich KD, et al. Am J Roent 2009; 192:W1Cheung Y, Perrich KD, et al. Am J Roent 2009; 192:W1--W7W7

used MRI to identify ligaments injured in isolated fibular fractused MRI to identify ligaments injured in isolated fibular fracturesures

retrospective look at 19 patients with widened medial clear spacretrospective look at 19 patients with widened medial clear spacee

anterioranterior--inferior tibiofibular ligament (aitfl) torn in all inferior tibiofibular ligament (aitfl) torn in all

83% had a partially torn deltoid 83% had a partially torn deltoid

challenges prior studies that the deep deltoid ligament must be challenges prior studies that the deep deltoid ligament must be completely completely torn to have a wide medial clear spacetorn to have a wide medial clear space

MRI StudiesMRI Studies

Nielson JH, Gardner MJ, et al. Clin Orthop Rel Res 2005;436:216Nielson JH, Gardner MJ, et al. Clin Orthop Rel Res 2005;436:216--2121

used MRI to evaluate accuracy of x ray measurementsused MRI to evaluate accuracy of x ray measurements

a prospective study of 70 patientsa prospective study of 70 patients

evaluated tibiofibular clear space, tibiofibular overlap, and meevaluated tibiofibular clear space, tibiofibular overlap, and medial dial clear spaceclear space

found only medial clear space >4 mm correlated with MRI found only medial clear space >4 mm correlated with MRI pathology and deltoid injurypathology and deltoid injury

MRI useful adjunctive toolMRI useful adjunctive tool

Positive Stress Test and Positive Stress Test and MRIMRI

Koval KJ, Egol KA, et al. J Orthop Trauma 2007 21(7)449Koval KJ, Egol KA, et al. J Orthop Trauma 2007 21(7)449--55.55.

retrospective review using MRI to evaluate need for surgery afteretrospective review using MRI to evaluate need for surgery after r positive stress testpositive stress test

21 patients with positive stress of Weber B fractures21 patients with positive stress of Weber B fractures

if MRI showed complete rupture, then surgery was performedif MRI showed complete rupture, then surgery was performed

90% showed partial rupture and were treated non90% showed partial rupture and were treated non--operativelyoperatively

all had good to excellent functional outcome after one yearall had good to excellent functional outcome after one year

ArthroscopyArthroscopy

Schuberth JM, Collman DR, et al. J Foot Ankle Surg; 2004, 43(1):Schuberth JM, Collman DR, et al. J Foot Ankle Surg; 2004, 43(1):2020--2929

evaluated if medial clear space (MCS) was an accurate predictor evaluated if medial clear space (MCS) was an accurate predictor of deltoid injuryof deltoid injury

MCS measured on 40 patients over 4 years with isolated displacedMCS measured on 40 patients over 4 years with isolated displaced fibular fracturesfibular fractures

false positive rates: false positive rates:

MCS MCS >> 3mm (88.5%) 3mm (88.5%)

MCS MCS > > 4 mm (53.6%) 4 mm (53.6%)

MCS MCS >> 5mm (26.9%)5mm (26.9%)

MCS > 6mm (7.7%)MCS > 6mm (7.7%)

therefore, MCS is not an accurate predictor of deltoid ligament therefore, MCS is not an accurate predictor of deltoid ligament injuryinjury

ArthroscopyArthroscopy

Hintermann B, Boss A, Schafer D 2002; Am J Sports Med, Hintermann B, Boss A, Schafer D 2002; Am J Sports Med, 30(3):40230(3):402--99

arthroscopic exam of 148 patients with ankle arthroscopic exam of 148 patients with ankle instabilityinstability

40% had a rupture or elongation of deltoid ligament40% had a rupture or elongation of deltoid ligament

98% of ankles with deltoid injury also had cartilage 98% of ankles with deltoid injury also had cartilage injuryinjury

created grading systemcreated grading system

Arthroscopy Arthroscopy

Hintermann B, Boss A, et al. Am J Sports Med; 2002 30(3):402Hintermann B, Boss A, et al. Am J Sports Med; 2002 30(3):402--9.9.

Stage 1Stage 1

stable; cannot open tibiotalar joint more than 2 mmstable; cannot open tibiotalar joint more than 2 mm

Stage 2Stage 2

moderately unstable; able to introduce 5 mm scope into spacemoderately unstable; able to introduce 5 mm scope into space

Stage 3Stage 3

severely unstable, able to see posterior ankle joint with severely unstable, able to see posterior ankle joint with tractiontraction

UltrasoundUltrasoundChen PY, et al. 2008; Foot Ankle Int, 29(9):883Chen PY, et al. 2008; Foot Ankle Int, 29(9):883--8686

examined 15 patients with isolated fibular examined 15 patients with isolated fibular fracturesfractures

6 patients found to have complete rupture6 patients found to have complete rupture

if ruptured, ORIF of fibula and deltoid if ruptured, ORIF of fibula and deltoid ligament repair was performedligament repair was performed

no analgesia or anesthesia required to study no analgesia or anesthesia required to study patientpatient

Medial Ankle InstabilityMedial Ankle Instability

Hintermann B, et al. Am J Sports Med; 2004, 32(1):183Hintermann B, et al. Am J Sports Med; 2004, 32(1):183--9090

prospective study of 52 casesprospective study of 52 cases

identified by arthroscopic and surgical explorationidentified by arthroscopic and surgical exploration

100% had pain in the medial gutter 100% had pain in the medial gutter

77% associated with lateral instability77% associated with lateral instability

3 types identified arthroscopically3 types identified arthroscopically

Classification of Anterior Classification of Anterior Deltoid InjuryDeltoid Injury

Hintermann B. 2003; Foot Ankle Clin N Am 8:723Hintermann B. 2003; Foot Ankle Clin N Am 8:723--3838

Type I: proximal tear of or avulsion of deltoidType I: proximal tear of or avulsion of deltoid

Type II: intermediate tear of deltoidType II: intermediate tear of deltoid

Type III: distal tear or avulsion of deltoid and Type III: distal tear or avulsion of deltoid and spring spring

Hintermann Surgical Hintermann Surgical OptionsOptionsTypeType LocationLocation IncidenceIncidence ProcedureProcedure Post opPost op

II ProximalProximal 72%72% repair, repair, reattachmentreattachment CAM walkerCAM walker

IIII IntermediateIntermediate 9%9%repair, repair,

reattachmentreattachmenttwo flaptwo flap

plasterplaster

IIIIII DistalDistal 19%19% repair, repair, reattachmentreattachment plasterplaster

Hintermann Hintermann TechniquesTechniques

Presentation at AOFAS Presentation at AOFAS Conference, May 2009.Conference, May 2009.

Deltoid and Syndesmosis Deltoid and Syndesmosis InjuryInjury

Porter DA; 2009, AAOS Instr Course Lect 58:575Porter DA; 2009, AAOS Instr Course Lect 58:575--8181

seen in athletic populationseen in athletic population

challenging to detect and treatchallenging to detect and treat

1%1%--18% of ankle sprains involve syndesmosis18% of ankle sprains involve syndesmosis

must evaluate thoroughlymust evaluate thoroughly

poor outcome if missedpoor outcome if missed

Classification of Classification of Syndesmosis InjurySyndesmosis Injury

Jelinek JA, Porter DA, 2009. Foot Ankle Clin N Am Jelinek JA, Porter DA, 2009. Foot Ankle Clin N Am

Grade I (stable): injury to anterior deltoid Grade I (stable): injury to anterior deltoid ligament and distal syndesmosis, no diastasisligament and distal syndesmosis, no diastasis

Grade II (unstable): injury to anterior and deep Grade II (unstable): injury to anterior and deep deltoid and syndesmosis, diastasis with stressdeltoid and syndesmosis, diastasis with stress

Grade III (unstable): injury to deltoid and Grade III (unstable): injury to deltoid and syndesmosis with proximal fibular fracture, syndesmosis with proximal fibular fracture, obvious obvious

TreatmentTreatment

Grade I injury treated conservatively with bootGrade I injury treated conservatively with boot

Grade II and III syndesmotic injury and bimalleolar Grade II and III syndesmotic injury and bimalleolar equivalent fractures are primarily repairedequivalent fractures are primarily repaired

uses #2 and #0 vicryl in horizontal suture uses #2 and #0 vicryl in horizontal suture pattern to repair deltoid ligamentpattern to repair deltoid ligament

dondont be afraid to ret be afraid to re--examine periodicallyexamine periodically

Advantage of RepairAdvantage of Repair

Porter: (Jelinek JA, Porter DA Foot Ankle Clin N Am Porter: (Jelinek JA, Porter DA Foot Ankle Clin N Am 2009; 14:2772009; 14:277--98)98)

can evaluate joint for osteochondral injurycan evaluate joint for osteochondral injury

allows earlier range of motionallows earlier range of motion

deters laxitydeters laxity

do not have to address potential deltoid do not have to address potential deltoid insufficiency in the futureinsufficiency in the future

Treatment of Chronic Treatment of Chronic InstabilityInstability

Nelson DR, Younger A; 2003 Foot Ankle Clin N Am, Nelson DR, Younger A; 2003 Foot Ankle Clin N Am, 8:5218:521--3737

repair of superficial deltoid in conjunction repair of superficial deltoid in conjunction with NCJ arthrodesis and lateral column with NCJ arthrodesis and lateral column procedure for post traumatic planovalgus procedure for post traumatic planovalgus deformitydeformity

Deland JT, de Asla RJ, Segal A 2004 Foot Ankle Int Deland JT, de Asla RJ, Segal A 2004 Foot Ankle Int 25(11):79525(11):795--9999

used peroneus longus tendon graftused peroneus longus tendon graft

Deltoid Ligament Repair Not Deltoid Ligament Repair Not NecessaryNecessary

many studies that support good functional outcome of many studies that support good functional outcome of bimalleolar equivalent ankle fractures treated with no deltoid bimalleolar equivalent ankle fractures treated with no deltoid ligament repairligament repair

Tourne, et al. (J Foot Ankle Surg, 1999)Tourne, et al. (J Foot Ankle Surg, 1999)

Stromsoe K, et al. (J Bone Joint Surg, 1995)Stromsoe K, et al. (J Bone Joint Surg, 1995)

Harper M (Clin Orthop Rel Res, 1988)Harper M (Clin Orthop Rel Res, 1988)

Baird R, et al. (J Bone Joint Surg, 1987)Baird R, et al. (J Bone Joint Surg, 1987)

key is good anatomic reduction of fibular fracture and key is good anatomic reduction of fibular fracture and syndesmosissyndesmosis

Repair Not neededRepair Not needed

Tejwani NC, McLaurin TM, et al. J Bone Joint Surg Am. 2007; 89:Tejwani NC, McLaurin TM, et al. J Bone Joint Surg Am. 2007; 89:14381438--4141

evaluated functional outcomes of bimalleolar and bimalleolar evaluated functional outcomes of bimalleolar and bimalleolar equivalent fractures surgically repairedequivalent fractures surgically repaired

266 patients 266 patients

evaluated at 3, 6, and 12 monthsevaluated at 3, 6, and 12 months

no deltoid ligaments were repairedno deltoid ligaments were repaired

those with bimalleolar fractures had worse functional outcome scthose with bimalleolar fractures had worse functional outcome scoresores

Long Term OutcomeLong Term Outcome

Stufkens SAS, Knupp M, et al. J Bone Joint Surg (Br) 2009; 91B:1Stufkens SAS, Knupp M, et al. J Bone Joint Surg (Br) 2009; 91B:1607607--1111

long term outcome after SER IV ankle fractureslong term outcome after SER IV ankle fractures

13 year mean follow up, 36 patients13 year mean follow up, 36 patients

evaluated SER with deltoid ligament injury versus with medial evaluated SER with deltoid ligament injury versus with medial malleolus fracturemalleolus fracture

All evaluated arthroscopically and found increase loose bodies wAll evaluated arthroscopically and found increase loose bodies with ith medial malleolus fracture groupmedial malleolus fracture group

found SER IV with deltoid ligament injury had better functional found SER IV with deltoid ligament injury had better functional outcome than medial malleolar fracture group base on AOFAS outcome than medial malleolar fracture group base on AOFAS hindfoot scorehindfoot score

ComplicationsComplications

chronic instabilitychronic instability

osteoarthritisosteoarthritis

posterior tibial tendon dysfunctionposterior tibial tendon dysfunction

loss of functional activityloss of functional activity

osteochondral defectsosteochondral defects

Treatment AlgorithmIsolated lateral Isolated lateral

malleolus fracturemalleolus fracture

Clinical and Xray Clinical and Xray evaluationevaluation

Ankle Ankle dislocateddislocated

??

MCS MCS < < 4 4 mmmm

no

yes

Medial Medial SymptomsSymptoms

yes

Stress testStress test

MCS MCS >> 5 5 mmmm

Get MRIGet MRI

NonNon--operativeoperativeTreatmentTreatment

Operative Operative TreatmentTreatment

yes

no

no

Deep Deltoid Deep Deltoid Ligament IntactLigament Intact

Deep Deltoid Deep Deltoid Ligament Ligament RupturedRuptured

no

yes

Adopted from Adopted from Koval et al. Koval et al.

2007; J Orthop 2007; J Orthop TraumaTrauma

Isolated Lateral malleolus fractureIsolated Lateral malleolus fracture

Clinical and x ray examClinical and x ray exam

Ankle dislocatedAnkle dislocated

MCS MCS >> 4 mm4 mm

Medial SymptomsMedial Symptoms

Stress TestStress Test

MCS MCS >> 5mm5mm

Get MRIGet MRI Deep Deltoid Deep Deltoid RuptureRupture

Deep Deep Deltoid Deltoid IntactIntact

OperativeOperativeTreatmentTreatment

NonNon--operativeoperativeTreatmentTreatment

yesyes

yesyes

nononono

nono

yesyes

yesyes

nono

ConclusionsConclusions

critical to do thorough examination of deltoid ligament injury wcritical to do thorough examination of deltoid ligament injury with ith acute eventsacute events

if anatomic reduction of fibula and syndesmosis is stable, nonif anatomic reduction of fibula and syndesmosis is stable, non-- operative care is acceptableoperative care is acceptable

careful recareful re--examination for questionable deltoid integrity is examination for questionable deltoid integrity is importantimportant

MRI and/or arthroscopy can be beneficial adjunctive toolsMRI and/or arthroscopy can be beneficial adjunctive tools

avoid potential for chronic instabilityavoid potential for chronic instability

Case #1Case #1

41 yo female seen at 41 yo female seen at ER after twisting fall ER after twisting fall off tableoff table

initial exam and initial exam and diagnosed with stable diagnosed with stable SER ankle fractureSER ankle fracture

placed in CAM walker placed in CAM walker with crutcheswith crutches

Case #1Case #1

follow up exam one follow up exam one week later in fracture week later in fracture clinicclinic

still significant medial still significant medial tenderness and paintenderness and pain

stress exam and view stress exam and view taken (5 mm MCS)taken (5 mm MCS)

Case #1Case #1

had ORIFhad ORIF

no laxity or widened no laxity or widened MCS after fibular MCS after fibular fixationfixation

deltoid not repaireddeltoid not repaired

Case #2Case #2

17 yo male soccer 17 yo male soccer athleteathlete

division one recruitdivision one recruit

intermittent medial intermittent medial ankle painankle pain

recent aggravation recent aggravation due to rotational injurydue to rotational injury

Case study #2Case study #2

Case #2Case #2

immobilized for 10immobilized for 10--14 days in CAM walker14 days in CAM walker

medial edema and pain resolvedmedial edema and pain resolved

sent for aggressive proprioceptive physical therapysent for aggressive proprioceptive physical therapy

currently deciding which college to attend and playing currently deciding which college to attend and playing at full functional capacityat full functional capacity

Research Research

correlate and compare arthroscopic and MRI findings as predictivcorrelate and compare arthroscopic and MRI findings as predictive value toolse value tools

is deltoid ligament alone strong enough repairis deltoid ligament alone strong enough repair

proprioceptive benefit of muscle groupsproprioceptive benefit of muscle groups

establish treatment protocol and long term outcome based studyestablish treatment protocol and long term outcome based study

lateral ankle instability has shown to be effectively treated wilateral ankle instability has shown to be effectively treated with stabilization th stabilization procedures when necessary with good long term outcomesprocedures when necessary with good long term outcomes

medial ankle instability still has poor objective data to suppormedial ankle instability still has poor objective data to support repair or no repair t repair or no repair in acute settingin acute setting

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Article ReviewsArticle ReviewsResidents from Providence Tarzana Podiatric Residents from Providence Tarzana Podiatric Residency ProgramResidency Program

Van den Bekerom MPJ, Mutsaerts E, van Dijk CN. Evaluation of thVan den Bekerom MPJ, Mutsaerts E, van Dijk CN. Evaluation of the intergrity of the deltoid e intergrity of the deltoid ligament in supination external rotation ankle fractures: a systligament in supination external rotation ankle fractures: a systemic review of literature. Arch Orthop emic review of literature. Arch Orthop Trauma Surg 129:227Trauma Surg 129:227--235, 2009.235, 2009.

Stufkens SAS, Knupp M, Lampert, et al. LongStufkens SAS, Knupp M, Lampert, et al. Long--term outcome after supinationterm outcome after supination--external rotation external rotation typetype--4 fracture of ankle. J Bone Joint Surg Br. 914 fracture of ankle. J Bone Joint Surg Br. 91--B(12):1607B(12):1607--1611, 2009.1611, 2009.

Tejwani NC, McLaurin TM, Walsh M, et al. Are outcomes of bimallTejwani NC, McLaurin TM, Walsh M, et al. Are outcomes of bimalleolar fractures poorer than eolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injthose of lateral malleolar fractures with medial ligamentous injury? J Bone Joint Surg Am ury? J Bone Joint Surg Am 89(7):143889(7):1438--41, 2007.41, 2007.

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Hintermann B, Valderrabano V, Boss A, et al. Medial ankle instaHintermann B, Valderrabano V, Boss A, et al. Medial ankle instability. An exploratory prospective bility. An exploratory prospective study of fifty two cases. Am J Sports Med 32:183study of fifty two cases. Am J Sports Med 32:183--190, 2004.190, 2004.

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Bibliography

Tourne Y, Charbel A, Picard F, et al. Surgical treatment of bi- and trimalleolar ankle fractures: should the medial collateral ligament be sutured or not? J Foot Ankle Surg 38:24-29, 1999.

van den Bekerom, MPJ, Mutsaerts E, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systemic review of the literature. Arch Orthop Trauma Surg 129:227-235, 2009.

DELTOID LIGAMENT INJURYObjectivesHistoryIncidenceOccurrenceTerminologyAnatomy AnatomyAnatomyAnatomySlide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16AnatomyFunction of Deltoid LigamentMechanism of InjuryPankovich StudyTornetta StudySubjective FindingsPhysical FindingsMedial ankle pain reliability?Clinical Exam of Chronic Medial Ankle InstabilityClinical Stress TestsClinical Stress TestImaging EvaluationRadiographsX ray images Stress RadiographsThe Gravity Stress ViewStress RadiographsGravity Stress TechniqueMRI ImagesMRIMRIMRIMRIMRIMRIMRIMRIMRI StudiesMRI StudiesPositive Stress Test and MRIArthroscopyArthroscopyArthroscopy UltrasoundMedial Ankle InstabilityClassification of Anterior Deltoid InjuryHintermann Surgical OptionsHintermann TechniquesDeltoid and Syndesmosis InjuryClassification of Syndesmosis InjuryTreatmentAdvantage of RepairTreatment of Chronic InstabilityDeltoid Ligament Repair Not NecessaryRepair Not neededLong Term OutcomeComplicationsTreatment AlgorithmSlide Number 65ConclusionsCase #1Case #1Case #1Case #2Case study #2Case #2Research Thanks!Article ReviewsBibliographyBibliographyBibliographyBibliographyBibliography

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