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Purpose: The purpose of this study is to provide a detailed description of the anatomy and radiology of the medial sleeve and present an approach in its management among elite athletes. Methods: Five cases of elite athletes who underwent treatment for a medial sleeve injury of which the diagnosis was confirmed through physical examination and additional magnetic resonance imaging scan are described in this study. Results: Two patients presented with isolated medial sleeve injuries, while the other three patients suffered from concomitant ankle injuries. Non‐operative treatment consisted of relative rest, soft cast immobilization and mobilization in a walking boot or kinesiotape which was successful in four of the cases with regard to the medial sleeve. One patient underwent surgery due to syndesmotic instability. Another patient presented with combined medial and lateral ankle instability which was treated surgically with an open medial and lateral ligament repair. All patients were able to return to their pre‐injury sports and at the time of the last follow‐up were still playing in their pre‐injury level of competition. Conclusion: Medial sleeve injuries of the ankle in elite athletes should be considered in the differential diagnosis for athletes presenting with medial ankle pain. Inherent knowledge regarding anatomy is essential when guiding the management of these injuries which can be treated successfully with a non‐operative approach consisting of relative rest, immobilization, kinesiotape and physical therapy. In case of persistent medial instability or rotational instability, surgical repair is a viable treatment option. Both modalities allow athletes to return to the pre‐injury level of competition. However, early diagnosis is crucial to minimize the delay of appropriate treatment and avoid potential residual symptoms. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Rotational ankle instability can be diagnosed in up to 18% of cases of chronic lateral ankle instability. It is characterised by an abnormal increase of talar rotation within the tibiofibular mortise, due to an injury in the most anterior component of the deltoid ligament secondary to a chronic deficiency of the lateral collateral ligament. The aim of this prospective observational study was to investigate the clinical outcomes following arthroscopic all‐inside medial and lateral ligament reconstruction for rotational ankle instability. Methods: A prospective observational study of consecutive patients undergoing arthroscopic all‐inside medial and lateral ligament reconstruction for rotational ankle instability with minimum 6‐month follow‐up. The primary outcome was a validated patient‐reported outcome measure (PROM), the Manchester‐Oxford Foot Questionnaire. Secondary outcomes included the EQ‐5D, European Foot and Ankle Society score and complications. Results: Between 2020 and 2023, 12 patients underwent primary arthroscopic all‐inside medial and lateral ligament reconstruction for rotational ankle instability with pre‐ and post‐operative PROMs available for all 12 patients. The mean ± standard deviation age was 33.9 ± 7.2 years and the mean follow‐up was 1.9 ± 1.2 (range: 0.5–3.8, interquartile range: 0.9–3.0) years. There was a significant improvement in all Manchester‐Oxford Foot Questionnaire domain scores (p < 0.05): Index 53.1 ± 19.1 to 26.4 ± 27.6, Pain 46.7 ± 20.3 to 26.2 ± 26.8, Walking/Standing 58.7 ± 26.0 to 27.0 ± 30.0 and Social Interaction 51.2 ± 19.5 to 25.6 ± 30.1. There were improvements in EQ‐5D‐5L Index, VAS and VAS Pain; however, these were not statistically significant. There was one complication—a superficial peroneal nerve injury which resolved with a corticosteroid injection. Conclusion: The arthroscopic all‐inside medial and lateral ligament reconstruction technique is a reliable and safe method for treating rotational ankle instability, demonstrating significant improvement in PROMs at a mean 1.9‐year follow‐up. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. Methods: A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English‐language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho‐anatomy, clinical or radiological diagnosis or treatment methods. Results: A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long‐term studies of the incidence of instability in deltoid ligament injuries were not available. Conclusion: There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long‐term follow‐up studies are needed to obtain more accurate data on the number of complications. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Although arthroscopic repair of the deltoid ligament is becoming a popular procedure, no studies have assessed which bundles of the deltoid ligament can be reached by anterior ankle arthroscopy. This study aimed to assess the feasibility of the arthroscopic repair of the deep layer of the deltoid ligament. In addition, it aimed to correlate which fascicle of the superficial layer of the deltoid ligament corresponds to the deep fascicle visualised by arthroscopy. Methods: Arthroscopy was performed in 12 fresh frozen ankles by two foot and ankle surgeons. With the arthroscope introduced through the anterolateral portal, the medial compartment and the deltoid ligament were explored in ankle dorsiflexion without distraction. Using a suture passer introduced percutaneously, the most posterior fibres of the deep deltoid ligament visualised by anterior arthroscopy were tagged. Then, the ankles were dissected to identify the deep and superficial bundles of the deltoid ligament tagged with a suture. Results: In all specimens (100%), the intermediate part of the tibiotalar fascicle, corresponding to the fibres originating from the anterior colliculus, was tagged with a suture. The posterior part of the tibiotalar fascicle was never tagged with a suture. In all specimens, the intermediate part of the tibiotalar fascicle grasped by the suture correlated with the tibiospring fascicle of the superficial layer. Conclusions: The current study demonstrates the feasibility of the arthroscopic repair of the deep fascicle of the deltoid ligament. By performing anterior arthroscopy, it is possible to visualise and repair the intermediate part of the tibiotalar fascicle (deep layer of the deltoid ligament). These fibres correspond to the tibiospring fascicle of the superficial layer. The clinical relevance of the current study is that the arthroscopic repair of the deep layer of the deltoid ligament is feasible through anterior ankle arthroscopy. Level of Evidence: Not applicable. [ABSTRACT FROM AUTHOR]

Background: Syndesmotic complex injuries are supposedly associated with injuries to the deltoid ligament (DL) complex. Several syndesmosis classifications take DL injuries into account when rating the stability of the syndesmotic injury. Still, no study has yet assessed the frequency and severity of DL injuries in unstable syndesmotic injuries. The aim of this retrospective cohort study was to assess both the severity of the syndesmotic and DL injury in patients undergoing surgery for an unstable syndesmotic injury. Methods: The integrity of the syndesmotic and DL complex of 37 patients were assessed on MRI by 2 musculoskeletal radiologists. Eligible were adult patients with an acute, isolated, unstable syndesmotic injury (ligamentous or bony avulsions) who underwent surgery. The DL complex was classified as having 3 superficial (TNL/TSL/TCL) and 2 deep (aTTL/pTTL) components. Grade 0 indicated an intact ligament; grade I showed a periligamentous edema; grade II a partial tear presenting as laxity, irregular contour, or partial discontinuity with concomitant hyperintense signaling; grade III a complete tear; or grade IV in case of an avulsion fracture. Frequency and severity of DL injuries were assessed, and possible injury combinations analyzed using an h-cluster analysis and Mann-Whitney U test. Results: Mean severity (grade 0-3) was 2.6 ± 0.8 for the syndesmotic complex and 1.6 ± 1.1 for the DL (superficial 1.5 ± 1.1, deep 1.6 ± 1.1). Seven patients (19%) had no (n = 3; 8%) or minor (grade 1: n = 4; 11%) DL injuries. Overall, 2 different patient clusters and 4 separate ligament clusters were identified. Conclusion: Unstable syndesmotic injuries can occur isolated or with an accompanying DL injury. There appears to be a great heterogeneity between the severity of syndesmotic and deltoid ligament injuries. [ABSTRACT FROM AUTHOR]

Background: Weber B fractures with concomitant deltoid ligament injury have traditionally been operated with open reduction and internal fixation of the fibular fracture. More recently, clinical studies have suggested that some fractures have concomitant partial deltoid ligament injury with the deep posterior tibiotalar ligament intact (SER4a), allowing for nonoperative treatment in this subgroup. This study explores whether plate fixation of the fibula improves ankle stability in an SER4a injury model. And if so, does it restore native ankle stability? Methods: Fifteen cadaver ankle specimens were tested in 3 states using an industrial robot: intact joint, SER4a models without plate fixation of the fibula, and SER4a models with plate fixation of the fibula. The robot measured ankle stability in lateral translation, valgus, and internal and external rotation in 3 talocrural joint positions: 10 degrees dorsiflexion, neutral, and 20 degrees plantar flexion. Furthermore, fluoroscopic mortise view radiographs were taken to measure isolated talar shift and talar tilt. Results: The talar shift and tilt tests showed no differences between the SER4a injury model with and without fibular plate fixation at neutral ankle position with a mean difference of −0.16 mm (95% CI −0.33 to 0.01 mm, P =.071) for talar shift and −0.15 degrees (95% CI −0.01 to 0.30 degrees, P =.068) for talar tilt. However, plate fixation increased external rotation stability, with mean improvements ranging from −7.43 to −9.52 degrees (P <.001 for all comparisons), but did not restore intact ankle stability. For internal rotation, plate fixation resulted in minor differences. Conclusion: The results of this suggest that plate fixation of the fibular fracture primarily improves external rotation stability but does not substantially improve lateral translation, valgus, or internal rotation stability in SER4a injury models. In this robotic cadaver model, fibular plate fixation did not fully restore intact ankle stability after simulated SER4a injury. Clinical Relevance: This study offers insights into the effects of fibular plate fixation on Weber B/SER4a injury models and may assist informed decisions when selecting treatments for these types of fractures. [ABSTRACT FROM AUTHOR]

The deltoid ligament is vitally important in the stability of the ankle and preventing excessive medial ankle movement. Historically, the impact of medial ankle instability has not been well understood in the setting of chronic ankle instability. A retrospective review of 226 patients treated for ankle instability between 2017 and 2022 identified 40 patients who required both medial and lateral repair. Decision for medial deltoid repair was based upon patient presentation, MRI findings, intraoperative fluoroscopy and final confirmation via arthroscopic positive "drive-through sign". Preoperative and postoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle scores, Patient-Recorded Outcomes Measurement Information System (PROMIS) scores, and Karlsson-Peterson Ankle Function (K&P) scores were obtained and compared. There were statistically significant improvements found in all 3 scoring systems at a mean follow-up time of 11.7 months postoperatively. In the setting of chronic ankle instability, consideration should be given to the evaluation and potential repair of the deltoid ligament in order to provide sufficient stability to the medial ankle. [ABSTRACT FROM AUTHOR]

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BackgroundInjury to the lateral collateral ligament of the ankle may cause ankle instability and, when combined with deltoid ligament (DL) injury, may lead to a more complex situation known as rotational ankle instability (RAI). It is unclear how DL rupture interferes with the mechanical function of an ankle joint with RAI.PurposeTo study the influence of DL injury on the biomechanical function of the ankle joint.MethodsA comprehensive finite element model of an ankle joint, incorporating detailed ligaments, was developed from MRI scans of an adult female. A range of ligament injury scenarios were simulated in the ankle joint model, which was then subjected to a static standing load of 300 N and a 1.5 Nm internal and external rotation torque. The analysis focused on comparing the distribution and peak values of von Mises stress in the articular cartilages of both the tibia and talus and measuring the talus rotation angle and contact area of the talocrural joint.ResultsThe dimensions and location of insertion points of ligaments in the finite element ankle model were adopted from previous anatomical research and dissection studies. The anterior drawer distance in the finite element model was within 6.5% of the anatomical range, and the talus tilt angle was within 3% of anatomical results. During static standing, a combined rupture of the anterior talofibular ligament (ATFL) and anterior tibiotalar ligament (ATTL) generates new stress concentrations on the talus cartilage, which markedly increases the joint contact area and stress on the cartilage. During static standing with external rotation, the anterior talofibular ligament and anterior tibiotalar ligament ruptured the ankle’s rotational angle by 21.8% compared to an intact joint. In contrast, static standing with internal rotation led to a similar increase in stress and a nearly 2.5 times increase in the talus rotational angle.ConclusionInjury to the DL altered the stress distribution in the tibiotalar joint and increased the talus rotation angle when subjected to a rotational torque, which may increase the risk of RAI. When treating RAI, it is essential to address not only multi-band DL injuries but also single-band deep DL injuries, especially those affecting the ATTL.

Aims: Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization. Methods: A total of 110 patients with Weber B/SER4a ankle fractures will be randomized (1:1 ratio) to receive six weeks of functional orthosis treatment or cast immobilization with a two-year follow-up. The primary outcome is patient-reported ankle function and symptoms measured by the Manchester-Oxford Foot and Ankle Questionnaire (MOxFQ); secondary outcomes include Olerud-Molander Ankle Score, radiological evaluation of ankle congruence in weightbearing and gravity stress tests, and rates of treatment-related adverse events. The Regional Committee for Medical and Health Research (approval number 277693) has granted ethical approval, and the study is funded by South-Eastern Norway Regional Health Authority (grant number 2023014). Discussion: Randomized controlled trials are needed to evaluate alternative nonoperative treatment options for Weber B/SER4a ankle fractures, as current clinical guidelines are based on biomechanical reasoning. The findings will be shared through publication in peer-reviewed journals and presentations at conferences. Cite this article: Bone Jt Open 2023;4(9):713–719.

Background: Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis. Purpose: To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury. Material and Methods: One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS). Results: Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47–79.70) sensitivity and 83.33% (55/66; 71.71–91.00) specificity, BMELI had 70.59% (24/34; 52.33–84.29) sensitivity and 95.45% (63/66; 86.44–98.82) specificity and MCS had 26.47% (9/34; 13.51–44.65) sensitivity and 92.42% (61/66; 82.50–97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7). Conclusion: BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis. [ABSTRACT FROM AUTHOR]

Background: Deltoid ligament reconstruction of the ankle can be considered when the ruptured ligament is insufficient for direct repair. Purpose: To compare the safety of talar tunnels oriented toward 4 different anatomic landmarks on the lateral malleolus during reconstruction of the deep layer of the deltoid ligament (DDL). Study Design: Descriptive laboratory study. Methods: A total of 30 computed tomography scans of the ankle joint in healthy adults were collected to generate 3-dimensional models. Virtual talar tunnels with a diameter of 5 mm and with different lengths (20.0, 25.0, and 30.0 mm) were created from the talar insertion of the DDL and were oriented toward the talar neck as well as the most anterior, the most distal, and the most posterior points of the distal fibula. The minimal safe distance (MSD) of a drilling route was calculated for the tunnels, and the safe distance from the end of the tunnel to the bone surface was measured for each tunnel. The nonpaired Student t test was used to detect differences among the safe distances of the 4 different bone tunnels. Results: For the 20.0-mm tunnels, the safe distance of the tunnel oriented toward the talar neck (5.90 ± 1.16 mm) did not meet the MSD (6.0 mm). For the 25.0-mm tunnels, the safe distances of the tunnels oriented toward the talar neck (4.53 ± 1.13 mm) and the anterior point of the fibula (5.91 ± 1.52 mm) did not meet the MSD (6.9 mm). Conclusion: Tunnels that were 5 mm in diameter and 20.0 and 25.0 mm in length, oriented toward the most distal or most posterior point of the distal fibula, were safe for DDL reconstruction. Clinical Relevance: Knowledge of safe talar tunnel placement is important, especially to avoid bone surface penetration during DDL reconstruction. [ABSTRACT FROM AUTHOR]

BACKGROUND: Ankle fracture complicated with deltoid ligament injury is clinically common, and one stage repair of deltoid ligament with internal fracture fixation has gradually become a main therapeutic method, which can significantly reduce the long-term complications of ankle joint. In recent years, new progress has been made in anatomical structure characteristics and dynamic biomechanical research of deltoid ligament, thus greatly improving repairing techniques for injury in the deep layer of deltoid ligament, but there are still some controversies. OBJECTIVE: To explore the clinical efficacy of suture anchor and medial malleolus repair in the treatment of ankle joint fractures with the deep layer of deltoid ligament. METHODS: A total of 56 patients with ankle joint fractures and complete fracture of the deep and superficial layer of deltoid ligament treated in Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University from January 2017 to January 2022 were selected, and they were divided into two groups according to different treatment methods in repairing the deep layer of deltoid ligament with suture anchor: suture anchor repair group (n=32) and medial malleolus repair group (n=24). The medial clear space of ankle joint and American Orthopedic Foot and Ankle Society Score of patients in the two groups were evaluated before and after operative treatment. RESULTS AND CONCLUSION: (1) All the 56 patients finished the surgery smoothly and were followed up for more than 12 months after operation. Their ankle fracture healed, and the time for fracture healing was 8-12 weeks, with a mean of 10.5 weeks. (2) The medial clear space of ankle joint in the two groups 12 months after operation was remarkably narrower than that before operation, and the difference was statistically significant (P < 0.001). The medial clear space of ankle joint in the two groups maintained a normal range 12 months after operation, and there was no statistically significant difference between the two groups (P > 0.05). (3) The AOFAS scale of patients in the two groups 6 and 12 months after operation was obviously bigger than that before operation (P < 0.001), but there was no statistically significant difference in the American Orthopedic Foot and Ankle Society Score of patients between the two groups at corresponding time points (P > 0.05). (4) It is concluded that both suture anchor and medial malleolus repair in the treatment of injury in the deep layer of deltoid ligament can recover the medial clear space of ankle joint, effectively keep the stability of ankle, and thus achieve good clinical efficacy. [ABSTRACT FROM AUTHOR]

Background: The importance of the deltoid ligament in the congruency and coupling of the tibiotalar joint is well known. The current trend is to repair it in cases of acute injuries in the context of ankle fractures; however, there is limited information on how it should be reconstructed. The objective of this study was to compare different deltoid ligament repair types in an ankle fracture cadaveric model. Methods: Sixteen cadaveric foot-ankle-distal tibia specimens were used. All samples were prepared as a supination external rotation ankle fracture model. Axial load and cyclic axial rotations were applied on every specimen using a specifically designed frame. This test was performed without deltoid injury, with deltoid injury, and after repair. The reconstruction was performed in 4 different ways (anterior, posterior, middle, and combined). Medial clear space (MCS) was measured for each condition on simulated weightbearing (WB) and gravity stress (GS) radiographs. Reflective markers were used in tibia and talus, registering the kinematics through a motion analysis system to record the tibiotalar uncoupling. Results: After deltoid damage, in all cases the MCS increased significantly on GS radiographs, but there was no increase in the MCS on WB radiographs. After repair, in all cases, the MCS was normalized. Kinematically, after deltoid damage, the tibiotalar uncoupling increased significantly. All isolated repairs achieved a similar tibiotalar uncoupling value as its baseline condition. The combined repair resulted in a significant decrease in tibiotalar uncoupling. Conclusion: Our results show that deltoid repair recovers the tibiotalar coupling mechanism in an ankle fracture model. Isolated deltoid repairs recovered baseline MCS and tibiotalar uncoupling values. Combined repairs may lead to overconstraint, which could lead to postoperative stiffness. Clinical studies are needed to prove these results and show clinically improved outcomes. Clinical Relevance: This study helps in finding the optimum deltoid repair to use in an acute trauma setting. [ABSTRACT FROM AUTHOR]

Background: Conventionally, transsyndesmotic fibula fractures with concomitant signs of deltoid ligament injury have been considered unstable and thus treated operatively. Recent studies have indicated that partial deltoid ligament rupture is common and may allow for nonoperative treatment of stress-unstable ankles if normal tibiotalar alignment is obtained in the weightbearing position. Biomechanical support for this principle is scarce. The purpose of this study was to evaluate the biomechanical effects of gradually increasing deltoid ligament injury in transsyndesmotic fibula fractures. Methods: Fifteen cadaveric ankle specimens were tested using an industrial robot. All specimens were tested in 4 states: native, SER2, SER4a, and SER4b models. Ankle stability was measured in lateral translation, valgus, and internal and external rotation stress in 3 talocrural joint positions: 20 degrees plantarflexion, neutral, and 10 degrees dorsiflexion. Talar shift and talar valgus tilt in the talocrural joint was measured using fluoroscopy. Results: In most tests, SER2 and SER4a models resulted in a small instability increase compared to native joints and thus were deemed stable according to our predefined margins. However, SER4a models were unstable when tested in the plantarflexed position and for external rotation in all positions. In contrast, SER4b models had large-magnitude instability in all directions and all tested positions and were thus deemed unstable. Conclusion: This study demonstrated substantial increases in instability between the SER4a and SER4b states. This controlled cadaveric simulation suggests a significant ankle-stabilizing role of the deep posterior deltoid after oblique transsyndesmotic fibular fracture and transection of the superficial and anterior deep deltoid ligaments. Clinical Relevance: The study provides new insights into how the heterogenicity of deltoid ligament injuries can affect the natural stability of the ankle after Weber B fractures. These findings may be useful in developing more targeted and better treatment strategies. Graphical Abstract This is a visual representation of the abstract. [ABSTRACT FROM AUTHOR]

Background: Deltoid ligament injuries occur in isolation as well as with ankle fractures and other ligament injuries. Both operative treatment and nonoperative treatment are used, but debate on optimal treatment continues. Likewise, the best method of surgical repair of the deltoid ligament remains unclear. Purpose: To determine the biomechanical role of native anterior and posterior components of the deltoid ligament in ankle stability and to determine the efficacy of simple suture versus augmented repair. Study Design: Controlled laboratory study. Methods: Ten cadaveric ankles (mean age, 51 years; age range, 34-64 years; all male specimens) were mounted on a 6 degrees of freedom robotic arm. Each specimen underwent biomechanical testing in 8 states: (1) intact, (2) anterior deltoid cut, (3) anterior repair, (4) tibiocalcaneal augmentation, (5) deep anterior tibiotalar augmentation, (6) posterior deltoid cut, (7) posterior repair, and (8) complete deltoid cut. Testing consisted of anterior drawer, eversion, and external rotation (ER), each performed at neutral and 25° of plantarflexion. A 1-factor, random-intercepts, linear mixed-effect model was created, and all pairwise comparisons were made between testing states. Results: Cutting the anterior deltoid introduced ER (+2.1°; P =.009) and eversion laxity (+6.2° of eversion; P <.001) at 25 degrees of plantarflexion. Anterior deltoid repair restored native ER but not eversion. Tibiocalcaneal augmentation reduced eversion laxity, but tibiotalar augmentation provided no additional benefit. The posterior deltoid tear showed no increase in laxity. Complete tear introduced significant anterior translation, ER, and eversion laxity (+7.6 mm of anterior translation, +13.8° ER and +33.6° of eversion; P <.001). Conclusion: A complete deltoid tear caused severe instability of the ankle joint. Augmented anterior repair was sufficient to stabilize the complete tear, and no additional benefit was provided by posterior repair. For isolated anterior tear, repair with tibiocalcaneal augmentation was the optimal treatment. Clinical Relevance: Deltoid repair with augmentation may reduce or avoid the need for prolonged postoperative immobilization and encourage accelerated rehabilitation, preventing stiffness and promoting earlier return to preinjury activity. [ABSTRACT FROM AUTHOR]

The deltoid ligament is a complex structure composed of multiple ligaments located on the medial side of the ankle joint that can be injured by ankle sprains. Although there have been previous reports on ultrasound imaging of the injured deltoid ligament, a systematic method for depicting each ligament component has not been established. This study aimed to clarify the ultrasound findings of the deltoid ligament in ankle sprains using a systematic scanning protocol. We examined the tenderness of the medial ankle and evaluated the ultrasound findings of the deltoid ligament in 169 sprained ankles with no fracture, within 3 days after injury. Observation and evaluation of the six components of the deltoid ligament were performed using a systematic scanning protocol with four probe positions. Of the 169 ankles, 48 ankles had tenderness in the deltoid ligament. Ultrasonography confirmed deltoid ligament damage in 13 of these 48 ankles. Of the 13 ankles, 3 ankles had damages only in the superficial layer, 3 ankles only in the deep layer, and 7 ankles in both the superficial and deep layers. We clarified the details of the damage pattern of the deltoid ligament in acute ankle sprains. It was possible to identify the superficial and deep layers of the ligament and to observe the damage pattern of each ligament component in detail, and it appeared that ultrasonography could be used as a tool to evaluate the damage pattern of the deltoid ligament in acute ankle sprains. [ABSTRACT FROM AUTHOR]

Purpose: To compare the clinical and magnetic resonance imaging (MRI) results after arthroscopic deltoid ligament (DL) repair versus DL nonrepair in patients with rotational ankle instability. Methods: All patients with rotational ankle instability were enrolled in this retrospective cohort study. Clinical evaluation was performed by the American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score preoperatively and at a minimum follow-up of 2 years. MRI at follow-up was performed to evaluate the DL morphology. Results: A total of 50 patients were enrolled in this study. Among them, 24 patients received DL repair (the repair group), whereas 26 patients did not (the nonrepair group). No significant difference was found in the AOFAS score (98 ± 4 vs. 97 ± 4; n.s.), KAFS (94 ± 7 vs. 93 ± 9; n.s.), or Tegner activity score (5 ± 2 vs. 5 ± 1; n.s.) between the repair group and the nonrepair group at the final follow-up. However, the repair group had a significantly shorter return-to-sport time than the nonrepair group (4.6 ± 1.6 mo vs. 6.0 ± 2.5 mo; p = 0.03). Comparison of the postoperative deltoid ligament showed that the repair group had a lower signal intensity than the nonrepair group. Conclusion: Arthroscopic treatment of rotational ankle instability revealed good to excellent clinical results. However, patients who underwent DL repair had a significantly earlier return to sports as well as a lower signal intensity of DL than those who did not undergo DL repair. Level of evidence: Level III. [ABSTRACT FROM AUTHOR]

Category: Trauma; Sports Introduction/Purpose: The objective of this work was to investigate the utility of a suture augmented deep deltoid ligament (DDL) stabilization with different accepted treatments of distal tibiofibular syndesmosis injuries. We hypothesized that adding DDL stabilization would improve the rotational stability of the ankle. Also, that flexible syndesmotic stabilization using suture button fixation, AITFL suture stabilization, with DDL stabilization would restore the kinematics of an intact ankle most closely during external rotation stress (ERS). Methods: Ten matched pairs of through-the-knee cadaveric ankle specimens were mechanically tested in 5 Nm of ERS under 750 N of axial load. Specimens were tested intact, after transection of all the syndesmotic and deep deltoid ligaments and after each iteration of one of two stabilization sequences: 1) AITFL + suture button (SB) stabilization; AITFL+SB + DDL suture stabilization; syndesmotic screw with or without DDL stabilization; or 2) AITFL+SB+DDL; AITFL+SB; syndesmotic screw with or without DDL stabilization. Optical motion tracking was used to capture the kinematics of the tibia, fibula, and talus. CT scans of each specimen with markers were used to transform kinematic data into an anatomic coordinate system. Individual bony kinematics were extracted by decomposing the transformation matrices needed to align the starting test position to the ending test position and tracking points on the anterior medial and anterior lateral talus. Results: The average axial rotation of the talus was significantly increased after destabilization from 5.15 to 9.02 as compared to the intact state (P< 0.001). All the four fixation constructs reduced the axial rotation of the talus without significant difference when compared to intact (figure 1). Addition of DDL stabilization reduced the talar axial rotation with both screw and flexible stabilization. The axial plane translation direction changed from 16.22 degrees in intact stage to 53.21 after destabilization (P=0.044). The range of axial plane translation direction after all stabilizations was 35.02 to 44.43, however, they were not significantly different as compared to the intact state. Conclusion: DDL stabilization improved rotational stability of the talus. Although there were no significant changes in the axial plane translation direction of the talus after any stabilizations, there was a 19 to 28 degree difference as compared to the intact stage. This could be clinically significant over the course of years since the latency period of posttraumatic ankle arthritis is known to be approximately 20 years. The apparent over-tightening of both flexible and screw stabilization of syndesmosis with DDL stabilization should be thought of as time zero due to creep of flexible fixation that was observed at the conclusion of testing. [ABSTRACT FROM AUTHOR]

Category: Ankle; Trauma Introduction/Purpose: Ankle instability associated with fractures have increased surgical complexity and worse outcomes. Both the deltoid ligament and the syndesmotic ligament complex play pivotal roles in maintaining ankle stability. Medial clear space (MCS) widening serves as an indicator for ankle instability. Trans-syndesmotic fixation following open reduction and internal fixation of distal fibula has been used commonly to restore stability in unstable ankle fractures with MCS widening. Alternatively, anatomic repair of the deltoid ligament offers another approach for addressing MCS widening. However, there is no consensus on the best method for stabilizing the ankle. This study aims to provide a comprehensive analysis of current literature to compare the outcomes of trans-syndesmotic fixation and anatomic deltoid ligament repair in the treatment of unstable ankle fractures with MCS widening. Methods: This comprehensive literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing databases such as PubMed, Embase, Web of Science, and the Cochrane Library. The search was conducted on October 15, 2023. The criteria for including articles in this study were: (1) Patients who had undergone surgical fixation for unstable ankle fractures with medial clear space (MCS) widening, (2) Studies comparing clinical outcomes between trans-syndesmotic fixation and anatomic deltoid ligament repair to address MCS widening, (3) Studies reporting on at least one of the following outcomes: malreduction rates, necessity for hardware removal, wound complications, reoperation rates, and functional outcomes, including AOFAS (American Orthopaedic Foot and Ankle Society) scores and VAS (Visual Analog Scale) pain scores. Exclusion criteria eliminated studies involving: (1) Patients with medial malleolar fractures, (2) Revision surgeries, (3) Non-English publications, and (4) Case reports, systematic reviews, comments, editorials, surveys, or cadaver studies. Results: In this meta-analysis, a total of five studies were included. Medial clear space widening was treated with trans-syndesmotic screw fixation in 165 unstable ankle fractures, while 115 ankles underwent anatomic repair of the deltoid ligament. Anatomic deltoid ligament repair was significantly associated with a reduced risk of syndesmotic malreduction (Risk Ratio (RR)=0.26, 95% Confidence Interval (CI) = [0.10, 0.68]) and a lower likelihood of postoperative hardware removal (RR=0.06, 95% CI = [0.02, 0.14]). No significant differences were found in minor or major wound complications, reoperation rate, AOFAS and VAS scores. These findings highlight the advantages of anatomic deltoid ligament repair, which provides a more precise reduction of unstable ankle injuries with MCS widening and a reduced need for postoperative hardware removal, compared to trans-syndesmotic fixation. Conclusion: This study evaluated postoperative outcomes between trans-syndesmotic fixation and anatomic deltoid ligament repair in addressing MCS widening. Our analysis revealed that anatomic deltoid ligament repair resulted in a significantly lower rate of malreduction and a decreased necessity for postoperative hardware removal compared to trans-syndesmotic screw fixation. Both techniques showed similar rates of wound complications, reoperation, and equivalent functional and pain scores. These results call into question the trans-syndesmotic fixation alone for unstable ankle fractures with MCS widening. Anatomic repair of the deltoid ligament should be considered as a viable option to restore stability in unstable ankle fractures with MCS widening. [ABSTRACT FROM AUTHOR]

Category: Ankle; Trauma Introduction/Purpose: The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others reported persistent medial clear space widening and higher malreduction when deltoid ligaments went without repair. This malreduction can lead to chronic ankle instability and pain. Talar shift as little as 1mm is reported to lead to a 49% increase in ankle joint pressure, a detrimental factor for developing post-traumatic ankle arthritis. The purpose of this study was to compare deltoid ligament repair to no repair in a homogenous group of surgically treated isolated Weber C fibula fractures exclusively. Methods: A retrospective chart review of prospectively collected data was carried out to identify consecutive surgically treated Weber C lateral malleolus fractures and syndesmosis stabilization with associated deltoid ligament injury between February 2013-December 2023. Associated posterior/medial malleolus fractures other than avulsions, Weber A/B fractures, fibula fixation constructs besides plate and screws, Charcot neuropathy, pes planovalgus with incompetent deltoid ligament, and revisions were excluded. Those meeting inclusion criteria were split into two groups: deltoid ligament suture repair vs. no repair. Collected data included demographics, smoking and diabetes status, surgical procedure and patient reported outcome measures (PROMs).. Primary outcomes were oblique medial clear space (MCS) and valgus talar tilt angle (TTA) on weightbearing radiographs. All radiographs were independently reviewed by a fellowship trained foot and ankle orthopedic surgeon. Secondary outcomes were fracture union, complications, reoperations, and PROMs: Foot and Ankle Ability Measure (FAAM), Veterans-Rand 12 (VR12) General Health Survey, visual analog pain scale (VAS). Results: Seventy-nine fractures were included; 49 underwent deltoid ligament repair while 30 did not. The mean follow-up was 18.5 months. There was a statistically significant post-op improvement in most study outcomes within the groups. The valgus TTA in the repair vs no repair groups were 0.1±0.9 vs. 1.2±2.1 degrees, respectively (p=0.007). The MCS in the repair vs. no repair groups was 3.5±0.6 vs. 3.9±1.4mm, respectively (p=0.107). There were no statistically significant differences between deltoid repair and no repair groups in post-operative VR12 MCS (p=0.194), VR12 PCS (p=0.077), VAS (p=0.231), FAAM ADL (p=0.109), FAAM sport (p=0.314), or patient satisfaction (p=0.33). The union rate was 100% in the repair vs. 96% in the no repair groups (p=0.163). There were no complications related to repairing the deltoid ligament. Conclusion: Deltoid ligament repair led to a superior ankle coronal alignment in comparison to no repair. There were no complications or revisions related to the medial approach and repairing the deltoid ligament. While there were trends toward better functional outcomes with deltoid ligament repair, this did not reach statistical significance. Long term studies may be required before recommending deltoid ligament repair as the gold standard in isolated Weber C fractures. Meanwhile, we recommend valgus stressing the ankle at the end of the procedure and decide whether deltoid repair is needed on individual basis. Outcomes of deltoid repair group vs no deltoid repair group. [ABSTRACT FROM AUTHOR]

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Aim and objective: To assess the effectiveness of standalone weight-bearing radiographs (WBR) in guiding the management of Supination External Rotation (SER), type of isolated lateral malleolar fractures in Indian population. Materials and methods: In a prospective study involving 19 consecutive patients with SER type of isolated lateral malleolar fractures, stability of the ankle was assessed using both WBR and external rotation stress radiographs. The decision toward conservative or surgical management was made solely on the assessment of ankle stability on WBR alone. Fractures with a medial clear space of 8 weeks) was seen in three patients in the conservative group. Four patients (21%), who would have been operated had external rotation stress views been used in decision making, were managed conservatively with successful clinical outcome and excellent AOFAS scores. Patient compliance was good with WBR as compared to external rotation stress radiographs. Conclusion: Standalone WBR are feasible, and reliable in detecting injury of the deep deltoid ligament and the consequent instability of the tibiotalar joint, in Weber type B fractures. They are associated with better patient compliance. Clinical significance: Standalone WBR serve as a useful guide in decision making between conservative and surgical treatment, in SER type isolated lateral malleolar fractures.

Background: Internal malleolus fractures and postoperative functional limitations are serious complications of deltoid ligament repair, reconstruction, while studies on conducting beak. Anatomical structure classification of medial malleolus at home and abroad is reported rarely. Hence, this morphological study is mainly designed to investigate the anatomical morphological classification and clinical significance of medial malleolus based on computed tomography (CT) three--dimensional reconstruction. Materials and methods: From October 2018 to January 2021, 373 patients who underwent CT examination of malleolus medialis joint in the Jiang'an Hospital of Traditional Chinese Medicine were observed. The medial malleolus was observed and classified; then, geometric parameters were measured according to different medial malleolus types. Results: According to the results of 373 cases, medial malleolus can be divided into four types: omega type (66%), radical sign type (16%), inverted triangle type (14%), and wave type (4%). Conclusions: There are four main shapes: omega, inverted triangle, radical sign, and wave in the medial malleolus of all normal ankles. The measurement of medial malleolus parameters according to medial malleolus in different shapes was of importance to guide smooth operation of medial malleolus fixation and deltoid ligament reconstruction and epidemiological. [ABSTRACT FROM AUTHOR]

The anterior and posterior part of the deltoid ligament have different functions during ankle flexion motion. Partial ligament injuries have been demonstrated in previous clinical reports. However, the efficacy of external rotation stress test in partial injured cases is unavailable till now. Thirty-two fresh cadaveric specimens were included and allocated into two destabilization groups. In the first group, the anterior portion of deltoid ligament (DL) and syndesmotic ligament were sequentially severed, while in the second group, the posterior portion of DL and syndesmotic ligament were sequentially severed. Mortise view radiographs were taken after each destabilization stage when the ankles were placed at plantarflexion and dorsiflexion positions and stressed in standard external rotation force. The medial clear space (MCS) and talar tilt (TT) angle were measured and compared among different destabilization stages. When the ankles were placed at neutral position, the TT significantly increased in all destabilization stages. The MCS significantly increased after the partial deltoid ligament ruptures only with presence of syndesmotic ligament injuries. There was no significant difference of MCS at plantarflexion for all stages of destabilization if the anterior portion of DL is preserved. Similarly, no significant increase of MCS was detected at dorsiflexion if the posterior portion of DL and posterior inferior tibiofibular ligament are intact. Partial DL rupture causes ankle rotational instability at different ankle joint positions, especially when combined with syndesmotic injuries. The neutral position is recommended for diagnosis of partial DL ruptures under external rotation stress. [ABSTRACT FROM AUTHOR]

To properly diagnose and treat injuries to the ankle or foot, the physician must have good anatomical knowledge of the ligaments involved. The bundles can be distinguished and identified by ultrasound examination of the medial aspect, but this may be a challenging task. In the present illustrated study, we discuss how a detailed ultrasound examination can be made of the different ligaments within the medial aspect of the ankle and foot. [ABSTRACT FROM AUTHOR]

Background: It remains unclear whether repairing the deltoid ligament (DL) is beneficial in acute ankle fractures. The aim of this review is to critically review the developments in deltoid ligament repair (DLR) in ankle fractures over the course of 44 years., Method: An electronic search was conducted on the PubMed and Embase database including comparative studies evaluating the effect of performing DLR in adults suffering from a closed acute ankle fracture with suspected rupture of the DL., Results: A total of 27 studies were retrieved, of which only one was a randomized study. A total of 1327 patients were reviewed (663 undergoing DLR and 664 receiving non-DLR treatment for an acute ankle fracture). Although earlier studies concluded that DLR holds little necessity in ankle fracture treatment if the anatomy of the ankle is restored, more recent studies support DLR due to more favorable clinical and radiographic outcomes., Discussion: All studies agree that restoration of the ankle anatomy to its pre-fracture state is necessary to achieve the best clinical outcome. However, there is still controversy in whether to standardize DLR in ankle fracture treatment. The literature shows a clear shift toward more frequent restoration of the DL, and in light of improved surgical techniques and implants, there is a need for more rigorous studies to provide a clear indication for DLR in acute ankle fracture treatment., Level of Evidence: III ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Length change pattern of the ankle deltoid ligament during physiological ankle motion is still confused currently and had not been studied in vivo.Methods: The deltoid ligaments from 7 cadaveric specimens were dissected. Lengths of each band during 30° plantarflexion to 20° dorsiflexion were measured. A dual fluoroscopy imaging system was utilized to capture the images of hindfoot joint of 7 healthy subjects during the stance phase of walking. 3D bone models were reconstructed from CT images. Lengths of each band were calculated after model-image registration utilizing a solid modeling software. Percentage of length variation and poses when the bands were in maximum extension were documented among each band.Results: The anterior border of tibiocalcaneal ligament (TCL) had only 1.7% length variation in vitro and 5.7% length variation in vivo. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension at 30° plantarflexion, however, superficial posterior tibiotalar ligament, deep posterior tibiotalar ligament, and the posterior border of TCL were in maximum extension at 20° dorsiflexion. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension during foot flat. The TCL was in maximum extension during midstance. The superficial posterior tibiotalar ligament and deep posterior tibiotalar ligament were in maximum extension during heel off and toe off.Conclusion: The length of TCL did not change during ankle dorsiflexion and plantarflexion. The bands anterior to and posterior to the TCL showed different length change pattern during physiological ankle dorsiflexion and plantarflexion. [ABSTRACT FROM AUTHOR]

Background: Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/- deltoid ligament repair.Methods: A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/- deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively.Results: One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups.Conclusion: Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits.Level Of Clinical Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: The majority of the ankle injuries involves the lateral ankle ligaments, while deltoid ligament injuries are seen in 5%. Both deltoid and spring ligament are primary medial stabilizer of ankle and foot and can be injured simultaneously. Purpose: In this article, we explain a method for combined deltoid and spring ligament reconstruction using Internal Brace™ (Arthrex, Naples, USA) fibertape which mimics the anatomical ligament complex along with the lateral ligament reconstruction. Conclusion: It is a safe and simple technique with promising results at 1 year follow-up.

Category: Hindfoot; Sports Introduction/Purpose: Adult Acquired Flatfoot Deformity (AAFD)/Progressive collapsing foot deformity (PCFD) starts with failure of the medial longitudinal arch. Determining which feet progress to anteromedial instability of the tibiotalar joint, prior to complete deltoid ligament rupture, is not fully understood. We have observed clinically that, in the presence of anterior talofibular ligament (ATFL) laxity, deep deltoid ligament (DD) laxity and anteromedial ankle instability does not develop (indicated by a negative neutral heel external rotation test/anteromedial drawer test). To date, the protective effect that ATFL rupture/laxity (the most common foot ligament injury) has on preventing DD laxity and anteromedial ankle instability developing in AAFD/PCFD has not been investigated. This understanding is crucial for accurate staging, treatment, and prognosis of both AAFD/PCFD and ATFL repairs. Methods: Unstable planus was induced in 12 cadaveric feet from 6 donors by complete sectioning of the plantar fascia, spring ligament and the plantar 1st tarsometatarsal joint. Paired feet were randomly assigned to having ATFL sectioned or ATFL intact. Feet underwent cyclic loading (2000 cycles) on a custom mounted jig and photos were taken with positional markers on the medial malleolus, fibula, and the talus before and after antero-posterior force application. ImageJ quantified anteromedial and anterolateral ankle joint displacement to reflect DD and ATFL laxity respectively. Results: In ATFL-intact feet, anteromedial displacement increased by 3.46 ± 0.41 µm/cycle (mean ± SD; P = 0.000005; two-tailed, one-sample t-test). In ATFL-sectioned feet, displacement increased 0.61 ± 0.66 µm/cycle (p = 0.072), an 82% reduction in DDL laxity development (P = 0.00006; two-tailed, paired t-test). There was minimal cycle-induced change in anterolateral displacement (ATFL-intact: 0.50 ± 0.50 µm/cycle (p = 0.06); ATFL-sectioned: -0.04 ± 0.90 µm/cycle (p = 0.17). However, absolute anterolateral displacement increased in ATFL-sectioned feet by 7.40 ± 0.12 mm (p = 0.00002). Conclusion: These findings corroborate our clinical findings; in AAFD/PCFD, feet with ATFL laxity paradoxically do not develop DD instability (negative heel external test and anteromedial draw test), which we ascribe the 'deep deltoid paradox sign'. This phenomenon has significant implications in determining which feet progress to DD laxity in AAFD/PCFD and ultimately DD rupture. Furthermore, surgical management of ATFL ruptures may require patient counselling regarding the development of DD laxity after ATFL repair if AAFD/PCFD is also present. Finally, we propose putative mechanisms based on differential axes of talar rotation and navicular abduction during stance, straining DD when ATFL is intact. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was (1) to evaluate the biomechanical properties of the different bundles of the deltoid ligament in various ankle positions in a cohort of healthy adult volunteers; (2) describe the impact of demographic and hindfoot morphology characteristics on their stiffness; (3) to assess the reliability and reproducibility of these measurements. Methods: Deltoid ligament complex of both ankles were assessed by shear-wave elastography (SWE) in 20 healthy patients resting on hinge support. The propagation shear-wave speed (SWS) in ligaments was measured, which is related to the tissue's elastic modulus. The following ligaments were analyzed in a neutral position and then in varus, valgus, dorsal, and plantar flexions: tibionavicular ligament (TNL), tibiocalcaneal ligament (TCL), the superficial posterior tibiotalar ligament (SPTL), the anterior tibiotalar ligament (ATTL), and the deep posterior tibiotalar ligament (DPTTL). Results: The mean SWS increased between neutral and 20 degrees valgus position for TCL (4.08 ± 0.78 m/s vs 5.56 ± 0.62 m/s, respectively; P <.0001) and for DPTTL (2.58 ± 0.52 m/s vs 3.59 ± 0.87 m/s, respectively; P <.0001). The mean SWS increased between neutral and 30 degrees plantarflexion for ATTL (2.11 ± 0.44 m/s vs 3.1 ± 0.5 m/s, respectively; P <.0001) and TNL (2.96 ± 0.66 m/s vs 4.99 ± 0.69 m/s, respectively; P <.0001). The mean SWS increased between neutral and 20 degrees dorsal flexion for SPTL (4.2 ± 1 m/s vs 5.45 ± 0.65 m/s, respectively; P <.0001). Women had less DPTTL SWS than men in the neutral position (2.37 ± 0.35 m/s vs 2.71 ± 0.49 m/s, respectively; P =.007). Other demographics had no impact on the SWS value of other ligaments. All inter- and intraobserver agreements were good to excellent. Conclusion: This study presents a reliable and reproducible SWE measurement protocol to describe the physiological function of all bundles of the medial collateral ligament in healthy adults. Clinical Relevance: This examination technique can be available to orthopaedic surgeons, allowing reliable and reproducible monitoring of the SWS of the various ligaments constituting the medial collateral plane. The biomechanical values described in this study may give insight into in what position medial ankle ligament reconstruction should be tensioned. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the radiographic and clinical outcomes of deltoid ligament repair, we studied 34 supination external rotation type IV ankle fracture patients with deltoid ruptures who required syndesmosis fixation. Methods: We retrospectively evaluated 34 cases of ruptured deltoid ligaments with associated supination external rotation type IV ankle fractures with a widening of the syndesmosis between 2011 and 2017. All of the ankle fractures were treated with a similar surgical protocol (plate and screw fixation). Syndesmotic fixations were performed on all patients. The deltoid ligaments were surgically repaired in 19 patients and in 15 patients, they were not. The preoperative, immediate postoperative, and final follow-up radiographic outcomes (medial clear space, overlap space, and clear space) and clinical scores (Foot and Ankle Outcome Scores and the Foot Function Index) were compared. Patients were followed for an average of 13.6 months. Results: There was no significant difference in radiographic and clinical outcomes between the deltoid repair group and the unrepair group (P > 0.05). In both groups, the mean immediate postoperative radiographic outcomes were satisfactory, showing reduced MCS, reduced CS, and increased OS to within-normal ranges that were maintained at the final follow-up. Clinical outcomes were similar between the two groups (P > 0.05). The rate of complications, such as intra-articular lesions, malunions, nonunions, and arthrosis was comparable between the two groups. Conclusion: In both groups, the postoperative and final follow-up radiographic measures were within normal ranges and the radiographic and clinical outcomes were not significantly different between the two groups. Syndesmotic reduction could be much more important than deltoid repair in regard to mortise restoration and medial stability. [ABSTRACT FROM AUTHOR]

Background: The deltoid ligament (DL) is an important stabilizer of the ankle. DL injury of varying severity can occur alone or with syndesmotic injury and fibular fracture. Limited diagnostic tools are available to assess DL injury quantitatively. Purpose: To establish an arthroscopic quantitative assessment of DL injury and to compare its performance with that of external rotation stress (ERS) and gravity stress (GS) radiography. Study Design: Controlled laboratory study. Methods: In total, 24 cadaveric lower extremities were divided into 4 groups: group 1 consisted of intact DL, group 2 of superficial DL disruption, group 3 of deep DL disruption, and group 4 of complete DL (superficial and deep) disruption. All specimens underwent sequential sectioning of syndesmotic ligaments, and medial clear space (MCS) was measured with ankle arthroscopy, ERS radiography, and GS radiography at different stages of syndesmotic sectioning. Results: For noninjured deltoid (group 1) and injured deltoid (groups 2-4), area under the receiver operating characteristic curve (AUC) of measurement of MCS was 0.939 for arthroscopy, 0.932 for ERS radiography, and 0.874 for GS radiography, with a significant difference between arthroscopy and GS radiography (P =.014). For incomplete deltoid injury (groups 1-3) and complete deltoid injury (group 4), the AUC of MCS was 0.811 for arthroscopy, 0.656 for ERS radiography, and 0.721 for GS radiography, with a significant difference between arthroscopy and ERS radiography (P <.001) and between arthroscopy and GS radiography (P =.035). For all stages of syndesmotic sectioning, cutoff values of arthroscopic MCS with intact fibula were ≤2.5 mm for intact DL, between 2.5 and 3.5 mm for partial DL injury (superficial or deep), and ≥3.5 mm for complete DL injury. Arthroscopy was unable to detect a difference between superficial deltoid injury (group 2) and deep deltoid injury (group 3) in partial DL injury, with a measured MCS between 2.5 and 3.5 mm. The intraclass correlation coefficient of interrater reliability was 0.975 for arthroscopy, 0.917 for ERS radiography, and 0.811 for GS radiography. Conclusion: Arthroscopic MCS measurement can differentiate intact DL, partial DL injury, and complete DL injury. Compared with ERS and GS radiography, arthroscopic MCS measurement has greater accuracy with excellent interrater reliability. Clinical Relevance: For patients with suspected DL injury, arthroscopic MCS is useful for determining deltoid lesion severity based on defined cutoff values for consideration in preoperative planning to improve surgical outcomes. [ABSTRACT FROM AUTHOR]

Aim: Supination-external rotation (SER) ankle fractures account for the majority of ankle fractures and can be divided into stable or unstable fractures, based on the state of the deltoid ligament. The objective of this review was to appraise the available literature concerning diagnostic tools to evaluate deltoid ligament integrity in patients with SER-type ankle fractures.Methods: A comprehensive literature search of Pubmed and Embase was performed up to December 2020. The outcome measures were sensitivity, specificity and positive and negative predictive value of the diagnostic tools. A meta-analysis was performed to obtain an overview of sensitivity, specificity and area under the curve (AUC). The methodological quality of the articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies.Results: A total of 12 studies investigating tools for deltoid ligament rupture in patients with SER-type ankle fractures were included. The present study found sensitivity (and specificity) ranges of 0.20-0.90 (and 0.38-0.97) for clinical features, Magnetic Resonance Imaging (MRI) 0.57-0.85 (and 0.81-1.00), ultrasonography 1.00 (and 0.89-1.00), Malleolar Medial Fleck Sign (MMFS) 0.25 (and 0.99), conventional ankle mortise radiography 0.33-0.57 (and 0.60-0.94), gravity stress radiography 0.71-1.00 (and 0.72-0.88) and manual stress ankle radiography 0.65-1.00 (and 0.00-0.77). The largest AUC was found for ultrasonography, followed by MMFS, gravity stress radiography and MRI.Conclusion: Ultrasonography and gravity stress radiography seem the most accurate diagnostic tools to evaluate deltoid ligament integrity. To strengthen this conclusion, future research should use an identical reference test to ensure comparability of results. Nevertheless, present study is of high value to close the knowledge gap about which presently available diagnostic tool is to be preferred to evaluate deltoid ligament integrity in patients with SER-type ankle fractures. [ABSTRACT FROM AUTHOR]

To have biodynamic features, the feet have bones located in a special posture, the joints that keep together those bones, the ligaments that provide linkage to those joints, and tendons of muscles particularly which end the foot. This study aimed to research the morphology of the medial side and plantar ligaments. The study was conducted on a total of 30 feet belonging to 2 women and 13 men cadavers that exist at the Anatomy Department of the Medical Faculty of Uludag University. After the dissections, 61 parameters that belonging to the ligaments and general features of the foot, were evaluated. The statistical analysis of the collected data was evaluated by SPSS 20.0. According to the findings, while the descriptive statistics of the foot and the ligaments related to the foot, the statistically significant difference of any of the parameters wasn't observed when they were compared between the right and left sides of the foot. In terms of the correlative relations, the parameters that showed high correlation were chosen and 28 formulas were developed using regression analysis. We foresee that our findings of the features belonging to normal anatomic structures will deepen our knowledge besides providing important benefits before or during orthopedic and plastic surgery operations related to the region. Also, our findings were discussed by comparing the findings of similar studies belonging to many other researchers in literature, and our study's contribution to the literature was evaluated. [ABSTRACT FROM AUTHOR]

When an ankle lateral malleolar fracture is accompanied by a deltoid ligament rupture without a medial malleolar fracture, such an injury is called a bimalleolar equivalent fracture. This means that even if there is no bony injury on the medial side, there may be functional instability of the ankle joint due to damage to the deltoid ligament. Manual or gravity external rotational stress radiography is used to differentiate an ankle bimalleolar equivalent fracture from an isolated lateral malleolar fracture. If the medial joint gap is widened on the stress radiography, the deltoid ligament injury can be diagnosed, and surgical treatment for fibula fractures is recommended. After open reduction of the fibula fracture (with syndesmotic fixation if needed), a decision on the repair of the deltoid ligament is taken depending on the surgeons' preference and intraoperative findings. The deltoid ligament repair is performed by inserting a suture anchor (or anchors) in the medial malleolus and fixing the deep and superficial deltoid ligaments to the medial malleolus. The only randomized study to evaluate the utility of deltoid ligament sutures in ankle fractures did not support the deltoid ligament suture, but the study itself had many limitations. An appropriately powered, randomized, controlled trial of the deltoid ligament repair with both patient-reported outcome and radiographic outcome evaluation is needed in the future. [ABSTRACT FROM AUTHOR]

Background: Double hindfoot arthrodesis is a reliable treatment option in lower extremity deformity and arthritis. Single (medial) and 2-incision techniques have been described. The purpose of this study was to evaluate the extent of cartilage debrided in each approach and to evaluate the competency of the deltoid ligament. Methods: Eight matched pairs of cadaveric specimens were acquired. One limb from each pair was randomly assigned to the single medial incision and the other to the 2-incision technique. Stress radiographs were obtained prior to dissection to evaluate for valgus tibiotalar tilt. The talonavicular and subtalar articular surfaces were denuded of cartilage and the joints disarticulated. The percentage of cartilage debrided was determined using ImageJ software. Postoperative tibiotalar tilt was measured with a technique and threshold previously described by our group. The intraclass correlation coefficient was calculated to determine inter- and intraobserver reliability. Results: The single medial incision demonstrated significantly less cartilage denuded than the 2-incision technique at the talar head (61.1% ± 20.4% vs 88.1% ± 6.1%, P <.001), and the posterior facets of the talus (53.5% ± 7.6% vs 73.6% ± 7.0%, P <.001) and calcaneus (55.3% ± 16.5% vs 81.0% ± 7.4%, P =.001). Overall, 75% of specimens that underwent a single medial incision approach demonstrated increased valgus tibiotalar tilt postdissection, whereas none that underwent the 2-incision technique developed increased tibiotalar tilt (P <.01). The average tibiotalar tilt among these specimens was 4.6 ± 1.3 degrees (range 2.5-5.7 degrees). For all measurements, the intraclass correlation coefficient was greater than 0.8. Conclusion: The posterior facet of the subtalar joint and talar head are at risk of subtotal debridement, as well as increased tibiotalar tilt with the single medial incision technique. Adequate debridement may require greater soft tissue dissection, possibly at the expense of medial ankle stability. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Purpose: Deltoid ligament injuries appear with isolated or even no displacement of the lateral malleolus fracture which could easily lead to misdiagnosis, which frequently brings about ankle medial instability and talus shift that eventually lead to the occurrence of ankle osteoarthritis. This study is aimed to investigate the value of the tap test for assessing the integrity of the deltoid ligament intraoperatively. Methods: Ninety-two patients with malleolar fractures and possible acute deltoid ligament injury treated in our hospital from March 2013 to May 2016 were enrolled in this prospective study. The gravity stress test and tap test were performed preoperatively by three physicians independently before and after fixation of the fibula. The sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates of both tests were determined based on medial malleolus exploration for the integrity of the deltoid ligament. The inter-observer consistency was also analyzed. Results: Forty seven (51.1%) versus fifty two (56.5%) of the 92 patients tested positive for deltoid ligament injury according to the preoperative gravity stress test or the subsequent tap test. Forty-eight cases (52.2%) were confirmed during surgery. The sensitivity of gravity stress test was lower than that of tap test (95.8% vs 100%), and specificity of gravity stress test was the same as tap test (97.7% vs 97.7%). Between gravity stress test and tap test, the positive and negative predictive values were 97.9% vs 92.3% and 95.6% vs 100%, and the false-positive and false-negative rates were 2.3% vs 9.09% and 4.2% vs 0%, respectively. Between the two tests results, the percentage of inter-observer agreement was > 90% (kappa coefficient > 0.80). Conclusion: The tap test has the advantages of high sensitivity, simple operation, and less radiation exposure, suggesting that it is of high diagnostic value for assessing the integrity of the acute deltoid ligament. [ABSTRACT FROM AUTHOR]