Abstract
Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is considered the primary stabilizer of the ankle against a valgus force. The management of the deltoid ligament in ankle fractures is currently a controversial topic no consensus exists regarding repair in the setting of ankle fractures. The purpose of this systematic review is to examine the role and indications for deltoid ligament repair in ankle fractures.
A systematic database search was conducted with Medline, Pubmed and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. The papers were screened independently and in duplicate by two reviewers. Study quality was evaluated using the MINORs criteria. Data extraction included post-operative outcomes, pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction and complication rates.
Following title, abstract and full text screening, 10 eligible studies published between 1987 and 2017 remained for data extraction (n = 528). The studies include 325 Weber B and 203 Weber C type fractures. Malreduction rate in studies with deltoid ligament repair was 7.4% in comparison to those without repair at 33.3% (p < 0.05). Eleven (4%) of deltoid ligament repair patients returned for re-operation to have implants removed in comparison to eighty three (42%) of those without repair (p < 0.05). There was no significant difference for pain, function, ROM, MCS and complication rates (p < 0.05). The mean operating time of deltoid ligament repair groups was 20 minutes longer than non-repair groups(p < 0.05).
Deltoid ligament repair offers significantly lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal when performed instead of transsyndesmotic screw fixation. When compared to non-repair groups, there are no significant differences in pain, function, ROM, MCS and complication rates. Deltoid ligament repair should be considered for ankle fracture patients with syndesmotic injury, especially those with Weber C. Other alternative syndesmotic fixation methods such as suture button fixation should be explored. A large multi-patient randomized control trial is required to further examine the outcomes of ankle fracture patients with deltoid ligament repair.
