The Clinical Outcomes Comparison Between Trans-Syndesmotic Fixation and Deltoid Ligament Repair in Unstable Ankle Fractures with Medial Clear Space Widening: A Systematic Review and Meta-Analysis
Authors: Sogard Oliver , McDonald John , Elder Waters Michael , Lee Wonyong 
Published: December 2024

Category: Ankle; Trauma Introduction/Purpose: Ankle instability associated with fractures have increased surgical complexity and worse outcomes. Both the deltoid ligament and the syndesmotic ligament complex play pivotal roles in maintaining ankle stability. Medial clear space (MCS) widening serves as an indicator for ankle instability. Trans-syndesmotic fixation following open reduction and internal fixation of distal fibula has been used commonly to restore stability in unstable ankle fractures with MCS widening. Alternatively, anatomic repair of the deltoid ligament offers another approach for addressing MCS widening. However, there is no consensus on the best method for stabilizing the ankle. This study aims to provide a comprehensive analysis of current literature to compare the outcomes of trans-syndesmotic fixation and anatomic deltoid ligament repair in the treatment of unstable ankle fractures with MCS widening. Methods: This comprehensive literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing databases such as PubMed, Embase, Web of Science, and the Cochrane Library. The search was conducted on October 15, 2023. The criteria for including articles in this study were: (1) Patients who had undergone surgical fixation for unstable ankle fractures with medial clear space (MCS) widening, (2) Studies comparing clinical outcomes between trans-syndesmotic fixation and anatomic deltoid ligament repair to address MCS widening, (3) Studies reporting on at least one of the following outcomes: malreduction rates, necessity for hardware removal, wound complications, reoperation rates, and functional outcomes, including AOFAS (American Orthopaedic Foot and Ankle Society) scores and VAS (Visual Analog Scale) pain scores. Exclusion criteria eliminated studies involving: (1) Patients with medial malleolar fractures, (2) Revision surgeries, (3) Non-English publications, and (4) Case reports, systematic reviews, comments, editorials, surveys, or cadaver studies. Results: In this meta-analysis, a total of five studies were included. Medial clear space widening was treated with trans-syndesmotic screw fixation in 165 unstable ankle fractures, while 115 ankles underwent anatomic repair of the deltoid ligament. Anatomic deltoid ligament repair was significantly associated with a reduced risk of syndesmotic malreduction (Risk Ratio (RR)=0.26, 95% Confidence Interval (CI) = [0.10, 0.68]) and a lower likelihood of postoperative hardware removal (RR=0.06, 95% CI = [0.02, 0.14]). No significant differences were found in minor or major wound complications, reoperation rate, AOFAS and VAS scores. These findings highlight the advantages of anatomic deltoid ligament repair, which provides a more precise reduction of unstable ankle injuries with MCS widening and a reduced need for postoperative hardware removal, compared to trans-syndesmotic fixation. Conclusion: This study evaluated postoperative outcomes between trans-syndesmotic fixation and anatomic deltoid ligament repair in addressing MCS widening. Our analysis revealed that anatomic deltoid ligament repair resulted in a significantly lower rate of malreduction and a decreased necessity for postoperative hardware removal compared to trans-syndesmotic screw fixation. Both techniques showed similar rates of wound complications, reoperation, and equivalent functional and pain scores. These results call into question the trans-syndesmotic fixation alone for unstable ankle fractures with MCS widening. Anatomic repair of the deltoid ligament should be considered as a viable option to restore stability in unstable ankle fractures with MCS widening.