Deltoid Ligament Injuries Associated With Ankle Fractures: Arguments For and Against Direct Repair

Ankle fractures are an extremely common orthopaedic injury treated by surgeons on a routine basis. The deltoid ligament is torn in a large number of these fractures and is commonly seen with associated radiographic changes of medial clear space widening. The clinical relevance of addressing the injured deltoid ligament with acute surgical repair has been debated for decades. The early literature documenting repair or reconstruction of the deltoid ligament dates back to the 1950s. Most commonly, orthopaedic surgeons restore the lateral column directly with fibula fracture fixation. The injury may then be further evaluated intraoperatively by stress testing to ensure syndesmosis integrity and mortise stability with indirect medial column reduction, which allows for secondary healing of the medial deltoid ligamentous complex. This popular treatment paradigm is based primarily on literature from the 1980s and has not been thoroughly evaluated with modern surgical implants, techniques, and research methods. A review and background of the supportive literature for and against deltoid ligament repair in the setting of acute ankle fractures is presented. Undeniably, the deltoid ligament complex has been proven to confer some element of stability to maintaining a congruent ankle mortise. The commonly cited data in favor of not repairing the deltoid ligament warrants careful consideration to allow accuracy in obtaining the best patient outcomes with the most predictable surgical methods available.