Arthroscopically Assisted Deep Deltoid Ligament Reconstruction Utilizing Suture Tape Augmentation for Treatment of Medial Ankle Instability in Acute Ankle Fractures: A Novel Technique and Case Series
Authors: Roggy Conner S. , Washburn Frederick J. , Pyle Casey W. 
Published: December 2024

Category:

Arthroscopy; Ankle

Introduction/Purpose:Objective:

To present a novel technique for deep deltoid ligament reconstruction using suture tape augmentation for medial ankle instability in acute ankle fractures and conduct a case series.

Background:

Circular movements involving ankle supination-external rotation, pronation-external rotation, or pronation-abduction are among the most common mechanisms behind acute ankle fractures. As a result of rotational fractures, the deltoid ligament–consisting of a superficial and deep component–is often damaged or ruptured. Disruption of the deltoid ligament is associated with medial ankle instability, thus warranting further repair; which has been historically done open. Using an arthroscopic approach will allow for direct visualization and increased accuracy of surgical management . Combining arthroscopy and with our novel suture tape augmentation technique may improve postoperative functional outcomes, stability, and decrease post-traumatic arthritis.

Methods:

This is a retrospective case study using de-identified patient data from 2 separate hospital systems. Data was obtained via chart review including pre-operative, intraoperative, and post-operative follow ups. Variables such as age, weight, body mass index (BMI), sex, side, history of previous ankle surgery, preoperative ambulatory status, length of hospital stay, as well as disposition were documented. Radiographs were reviewed for evidence of restoration of the medial clear space as well as hardware position and bony union. In addition, a technique guide was developed using two expert surgeons experience and opinion for using suture tape augmentation with the Arthrex InternalBrace system (Naples, FL). In addition, we present a novel technique for reconstruction of the deep deltoid ligament complex using our experience from these cases. Included in this guide are details on indications, setup, technique, postoperative protocol, and radiographic assessment.

Results:

We retrospectively reviewed 12 patients who had bimalleolar equivalent, tri-malleolar equivalent, or Maisonneuve-type fractures of the ankle with increased medial clear space widening and were surgically treated with this novel technique. All patients were initially non-ambulatory after their fracture and prior to their procedure. All patients had significant reduction in the medial clear space postoperatively. Additionally, all patients progressed to walking without assistance and returned to full weight bearing postoperatively. One patient developed a keloid scar that required a corticosteroid injection. One patient showed widening of the syndesmosis on follow up x-rays; which was managed with a CT scan of the ankle, and bilateral weight bearing radiographs. The patient was clinically asymptomatic and advanced to weight bearing as tolerated before 6 months.

Conclusion:

Arthroscopically assisted deep deltoid ligament reconstruction utilizing suture tape augmentation is a successful procedure for restoring ankle function and radiographic parameters of the medial clear space when used in conjunction with accepted open reduction and internal fixation (ORIF) techniques for bimalleolar ankle fracture equivalents or tri-malleolar fractures. Since this procedure is performed with a minimally invasive arthroscopic approach, it may be a preferred technique in the future with direct visualization of the superficial and deep deltoid ligament. We have also presented a novel technique for reconstruction of the deep deltoid ligament complex utilizing suture tape augmentation via an arthroscopically-assisted approach. Arthroscopic deltoid technique Drill sleeve arthroscopically, radiographic confirmation of talus K-wire, and insertion of FiberTak/ sutures arthroscopically