DELTOID LIGAMENT REPAIR IN ANKLE FRACTURES: ANATOMY, BIOMECHANICS, INJURY MECHANISMS, AND TREATMENT APPROACHES

G. D’Andrea¹, M. Alessio-Mazzola^2,3, G. Placella¹, N. Barducci¹, S. Mosca¹ and V. Salini¹

¹University Vita-Salute San Raffaele, Milan, Italy;
²Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy;
³IRCCS Orthopaedic Clinic, Policlinic Hospital, San Martino, Genoa, Italy

Correspondence to:
Mattia Alessio Mazzola, MD
Department of Surgical Sciences and Integrated Diagnostic (DISC),
University of Genoa,
Viale Benedetto XV n. 6,
16132 Genova, Italy;
IRCCS Orthopaedic Clinic,
Policlinic Hospital San Martino,
Largo Rosanna Benzi 10,
16132 Genova, Italy
e-mail: mattia.alessio@hotmail.com

Received:  07 April 2022 Accepted: 29 April 2022

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ABSTRACT

The deltoid ligament (DL) is a complex structure that provides medial stability to the ankle joint. Injuries to the DL, particularly in association with ankle fractures such as Weber B and C fractures, are often challenging to manage. The presence of a DL sprain generally worsens the prognosis, requiring thorough clinical and radiographic evaluation to determine whether surgical intervention is necessary to restore stability. A combination of clinical and radiographic methods is often employed to evaluate DL injuries in the context of ankle fractures. Plain radiographs are primarily used to exclude fractures or other bony abnormalities, while weight-bearing radiographs help assess any deformities, particularly in chronic cases. The surgical management of bimalleolar equivalent ankle fractures typically begins with open reduction and internal fixation (ORIF) of the fibula, performed through a lateral or posterolateral approach. However, in cases where the DL or posterior tibial tendon becomes entrapped between the talus and the medial malleolus, it can prevent proper closure of the medial clear space or obstruct fibular reduction. The common aspect of surgical techniques for DL repair is the use of suture anchors to reattach ligament fibers to their anatomic origin on the medial malleolus or medial tibia. However, variations exist regarding the location of the incision, whether both the superficial and deep fibers of the deltoid are repaired, and how avulsions (particularly from the talus or from calcaneus) are managed. The purpose of this narrative review is to provide a comprehensive overview of the ligament’s anatomy, mechanics, common injury patterns, and treatment options, focusing on the surgical repair of the ligament in ankle fractures.

KEYWORDS: deltoid ligament, ankle joint, fracture, Weber B and C fractures, ligament repair