Kirschner Wire Internal Fixation of the Medial Tibiotalar Joint for Indirect Repair of Deltoid Ligament Injury: A Retrospective Comparative Study

Abstract

Objective:: Ankle joint fractures are often accompanied by medial deltoid ligament rupture. There is controversy over whether or how to treat deltoid ligament rupture. This study was aimed to explore the feasibility of repairing the medial deltoid ligament using Kirschner wire internal fixation of the medial tibiotalar joint combined with external fixation.

Methods:: Forty-six patients with ankle fractures involving deltoid ligament rupture, treated between October 2012 and February 2021, were retrospectively evaluated. Twenty-five patients were treated with a Kirschner wire to fix the tibiotalar joint and indirectly repair the deltoid ligament as the repaired group. Twenty-one patients underwent reduction and fixation of internal and external malleolus fractures, and the deltoid ligament was not repaired in the unrepaired group. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS), Medical Outcomes Short Form 36-item questionnaire score (SF-36), and Medial clear space perpendicular (preoperative, postoperative, final follow-up) were used for functional evaluations and reduction assessments. Mann–Whitney test were used to compare the differences between the groups.

Results:: The follow-up time was 13–112 months with a mean of 59.32 months for the repaired group and 11–94 months with a mean of 53.43 months for the unrepaired group. There was no significant difference in the operative time or intraoperative blood loss between the two groups (p > 0.05). At the last follow-up, the AOFAS ankle-hindfoot and SF-36 scores of the repaired group were significantly higher than those of the non-repaired group (p < 0.05). Moreover, the VAS pain score was significantly lower and the Medial clear space perpendicular was significantly narrower in the repaired group than that in the unrepaired group.

Conclusion:: Tibiotalar joint fixation using Kirschner wires is a simple and effective technique that can indirectly reduce and repair the deltoid ligament and stabilize the ankle.

Keywords

Deltoid ligament injury / Kirschner wire / Medial tibiotalar joint / Retrospective study

References

[1] Loozen L, Veljkovic A, Younger A. Deltoid ligament injury and repair. J Orthop Surg (Hong Kong). 2023;31(2):10225536231182345.

[2] Salameh M, Alhammoud A, Alkhatib N, Attia AK, Mekhaimar MM, D'Hooghe P, et al. Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies. Int Orthop. 2020;44(2):341–347.

[3] Yammine K. The morphology and prevalence of the deltoid complex ligament of the ankle. Foot Ankle Spec. 2017;10(1):55–62.

[4] Takao M, Ozeki S, Oliva XM, Inokuchi R, Yamazaki T, Takeuchi Y, et al. Strain pattern of each ligamentous band of the superficial deltoid ligament: a cadaver study. BMC Musculoskelet Disord. 2020;21(1):289.

[5] Doty JF, Dunlap BD, Panchbhavi VK, Gardner MJ. Deltoid ligament injuries associated with ankle fractures: arguments for and against direct repair. J Am Acad Orthop Surg. 2021;29(8):e388–e395.

[6] Hintermann B, Regazzoni P, Lampert C, Stutz G, Gächter A. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br. 2000;82(3):345–351.

[7] Haddad SL, Dedhia S, Ren Y, Rotstein J, Zhang LQ. Deltoid ligament reconstruction: a novel technique with biomechanical analysis. Foot Ankle Int. 2010;31(7):639–651.

[8] Schlickewei C, Krähenbühl N, Dekeyser GJ, Mills M, Priemel M, Rammelt S, et al. Unstable injuries of the deltoid ligament complex in ankle fractures: how to diagnose, how to treat? Unfallchirurg. 2021;124(3):190–199.

[9] Shazadeh Safavi K, Rezvani A, Janney CF, Chen J, Cassis W, Darayan N, et al. Assessing the utility of deltoid ligament repair in ankle fracture: a systematic review. Cureus. 2022;14(7):e27040.

[10] Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries: diagnosis and management. Foot Ankle Clin. 2006;11(3):625–637.

[11] Hoshino CM, Nomoto EK, Norheim EP, Harris TG. Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int. 2012;33(2):92–98.

[12] Michelson JD, Varner KE, Checcone M. Diagnosing deltoid injury in ankle fractures: the gravity stress view. Clin Orthop Relat Res. 2001;387:178–182.

[13] Maynou C, Lesage P, Mestdagh H, Butruille Y. Is surgical treatment of deltoid ligament rupture necessary in ankle fractures? Rev Chir Orthop Reparatrice Appar Mot. 1997;83(7):652–657.

[14] Wang J, Stride D, Horner NS, Petrisor B, Johal H, Khan M, et al. The role of deltoid ligament repair in ankle fractures with syndesmotic instability: a systematic review. J Foot Ankle Surg. 2021;60(1):132–139.

[15] Guo W, Lin W, Chen W, Pan Y, Zhuang R. Comparison of deltoid ligament repair and non-repair in acute ankle fracture: a meta-analysis of comparative studies. PloS One. 2021;16(11):e0258785.

[16] Whitlock KG, LaRose M, Barber H, Fletcher A, Cunningham D, Menken L, et al. Deltoid ligament repair versus trans-syndesmotic fixation for bimalleolar equivalent ankle fractures. Injury. 2022;53(6):2292–2296.

[17] Hardy MA, Connors JC, Zulauf EE, Coyer MA. Acute deltoid ligament repair in ankle fractures: five-year follow-up. Clin Podiatr Med Surg. 2020;37(2):295–304.

[18] Tornetta P. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am. 2000;82(6):843–848.

[19] Aiyer AA, Zachwieja EC, Lawrie CM, Kaplan JRM. Management of Isolated Lateral Malleolus Fractures. J Am Acad Orthop Surg. 2019;27(2):50–59.

[20] Lee S, Lin J, Hamid KS, Bohl DD. Deltoid ligament rupture in ankle fracture: diagnosis and management. J Am Acad Orthop Surg. 2019;27(14):e648–e658.

[21] Fösel AC, Seidel A, Attinger MC, Zderic I, Gueorguiev B, Krause FG. Ankle joint pressure in supination-external rotation injuries: a biomechanical study in an unrestrained cadaver model. Foot Ankle Spec. 2020;15:330–337.

[22] Hintermann B, Sommer C, Nigg BM. Influence of ligament transection on tibial and calcaneal rotation with loading and dorsi-plantarflexion. Foot Ankle Int. 1995;16(9):567–571.

[23] Sommer C, Hintermann B, Nigg BM, van den Bogert AJ. Influence of ankle ligaments on tibial rotation: an in vitro study. Foot Ankle Int. 1996;17(2):79–84.

[24] Michelson JD, Waldman B. An axially loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res. 1996;328:285–293.

[25] Burns WC, Prakash K, Adelaar R, Beaudoin A, Krause W. Tibiotalar joint dynamics: indications for the syndesmotic screw—a cadaver study. Foot Ankle. 1993;14(3):153–158.

[26] Bloemers FW, Bakker FC. Acute ankle syndesmosis injury in athletes. European J Trauma. 2006;32(4):350–356.

[27] Lack W, Phisitkul P, Femino JE. Anatomic deltoid ligament repair with anchor-to-post suture reinforcement: technique tip. Iowa Orthop J. 2012;32:227–230.

[28] Shen JJ, Gao YB, Huang JF, Qiu QM, Cheng L, Tong SL. Suture anchors for primary deltoid ligament repair associated with acute ankle fractures. Acta Orthop Belg. 2019;85(3):387–391.

[29] Walley KC, Hofmann KJ, Velasco BT, Kwon JY. Removal of hardware after syndesmotic screw fixation: a systematic literature review. Foot Ankle Spec. 2017;10(3):252–257.

[30] Vega J, Golanó P, Pellegrino A, Rabat E, Peña F. All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int. 2013;34(12):1701–1709.

[31] Zeegers AV, van der Werken C. Rupture of the deltoid ligament in ankle fractures: should it be repaired? Injury. 1989;20(1):39–41.

[32] Stufkens SA, van den Bekerom MP, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strategies Trauma Limb Reconstr. 2012;7(2):73–85.

RIGHTS & PERMISSIONS

2023 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.