deltoid_ligament_injury.pdf
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DELTOID LIGAMENT DELTOID LIGAMENT INJURYINJURY
Raymond Tsukuda, D.P.M., F.A.C.F.A.S.Raymond Tsukuda, D.P.M., F.A.C.F.A.S.
Department of PodiatryDepartment of Podiatry
Kaiser Baldwin Park Medical CenterKaiser Baldwin Park Medical Center
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ObjectivesObjectives
1) Historical and recent perspective on deltoid injuries2) Update review on anatomy of deltoid complex3) Review evaluation and presentation of injury4) Discuss controversy on treatment of injury5) Review recent literature6) Determine need to change treatment protocol7) Case presentations8) Discuss potential need for further research
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HistoryHistory
treatment protocol for deltoid ligament injuries have varied fortreatment protocol for deltoid ligament injuries have varied for yearsyears
many feel deltoid ligament tears do not have to be repaired due many feel deltoid ligament tears do not have to be repaired due to functional anatomy of ankle jointto functional anatomy of ankle joint
recent interest in medial ankle instability has made us rerecent interest in medial ankle instability has made us re-- evaluate if these injuries should be primarily repaired evaluate if these injuries should be primarily repaired (Hintermann B and Porter DA)(Hintermann B and Porter DA)
does recognizing injury in acute versus chronic state make a does recognizing injury in acute versus chronic state make a difference?difference?
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IncidenceIncidence
1515--20% 0f all athletic injuries involve the ankle (Garrick JG, Requ20% 0f all athletic injuries involve the ankle (Garrick JG, Requa RK. Clin a RK. Clin Sports Med 1988:7(1)29Sports Med 1988:7(1)29--36)36)
2020--40% of ankle injuries will lead to chronic instability and disab40% of ankle injuries will lead to chronic instability and disability (Renstrom P. ility (Renstrom P. J Am Acad Orthop Surg 1994:2(5):270J Am Acad Orthop Surg 1994:2(5):270--80)80)
deltoid ligament injuries are seen with syndesmotic injuries anddeltoid ligament injuries are seen with syndesmotic injuries and can occur up to can occur up to 18% of the time with ankle sprains (Lin et al. J Orthop Sports P18% of the time with ankle sprains (Lin et al. J Orthop Sports Phys Ther 2006; hys Ther 2006; 36:37236:372--384)384)
deltoid insufficiency can be seen after chronic posterior tibialdeltoid insufficiency can be seen after chronic posterior tibial tendon dysfunction, tendon dysfunction, trauma, triple arthrodesis, and total ankle arthroplastytrauma, triple arthrodesis, and total ankle arthroplasty
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OccurrenceOccurrenceseen either acute or chronicseen either acute or chronic
Isolated injuries are rareIsolated injuries are rare
seen with syndesmotic sprains and inversion sprainsseen with syndesmotic sprains and inversion sprains
associated mostly with fractures associated mostly with fractures
DanisDanis--Weber B and CWeber B and C
SER, PER, and PABSER, PER, and PAB
Bimalleolar equivalent fractures (Porter)Bimalleolar equivalent fractures (Porter)
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TerminologyTerminology
Medial Ankle Instability (Hintermann)Medial Ankle Instability (Hintermann)
Deltoid InsufficiencyDeltoid Insufficiency
Bimalleolar Equivalent Fracture Injury (Porter)Bimalleolar Equivalent Fracture Injury (Porter)
Invisible InjuryInvisible Injury (Staples)(Staples)
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Anatomy Anatomy
Deltoid LigamentDeltoid Ligament
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AnatomyAnatomy
various descriptions in literature and researchvarious descriptions in literature and research
all agree multiall agree multi--bandedbanded
most agree there is a superficial and deep componentmost agree there is a superficial and deep component
cadaver studies show difficulty to distinguish separate cadaver studies show difficulty to distinguish separate ligamentsligaments
studies also show inconsistency on what components studies also show inconsistency on what components are present in all specimensare present in all specimens
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AnatomyAnatomyPankovich AM, Shivaram MS. 1979; Acta Orthop Scand, 50:217Pankovich AM, Shivaram MS. 1979; Acta Orthop Scand, 50:217--223223
cadaver study to detail medial anatomy of anklecadaver study to detail medial anatomy of ankle
16 specimens16 specimens
2 deep portions of deltoid:2 deep portions of deltoid:
deep anterior talotibial deep anterior talotibial
deep posterior talotibial ligamentsdeep posterior talotibial ligaments
3 superficial portions:3 superficial portions:
naviculotibial naviculotibial
calcaneotibialcalcaneotibial
superficial talotibialsuperficial talotibial
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AnatomyAnatomy
Milner CE, Soames RW. Foot Ankle Int 1998;19:289Milner CE, Soames RW. Foot Ankle Int 1998;19:289--9292
studies 40 cadaversstudies 40 cadavers
found 6 componentsfound 6 components
superficial (4)superficial (4)
tibiospring, tibionavicular, tibiocalcaneal, superficial posteritibiospring, tibionavicular, tibiocalcaneal, superficial posterior or tibiotalartibiotalar
Deep (2)Deep (2)
deep posterior tibiotalar and deep anterior tibiotalardeep posterior tibiotalar and deep anterior tibiotalar
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Williams & Wilkins 1998. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 2
The Medial Collateral Ligaments of the Human Ankle Joint: Anatomical Variations.Milner, Clare; Soames, Roger
Foot & Ankle International. 19(5):289-292, May 1998.
Fig. 1 . The bands of the medial collateral ligament of the human ankle joint: medial ligament intact. A, Tibial spring ligament. B, Tibionavicular ligament. C, Tibiocalcaneal ligament.
Tibiospring
TibionavicularTibiocalcaneal
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Williams & Wilkins 1998. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 3
The Medial Collateral Ligaments of the Human Ankle Joint: Anatomical Variations.Milner, Clare; Soames, Roger
Foot & Ankle International. 19(5):289-292, May 1998.
Fig. 2 . Tibiospring ligament reflected, tibionavicular (B), and tibiocalcaneal (C) ligaments visible beneath.
tibionavicular
tibiocalcaneal
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Williams & Wilkins 1998. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 4
The Medial Collateral Ligaments of the Human Ankle Joint: Anatomical Variations.Milner, Clare; Soames, Roger
Foot & Ankle International. 19(5):289-292, May 1998.
Fig. 3. Tibiospring and tibionavicular ligaments reflected, tibiocalcaneal ligament (C) visible beneath.
Tibiocalcaneal
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Williams & Wilkins 1998. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 5
The Medial Collateral Ligaments of the Human Ankle Joint: Anatomical Variations.Milner, Clare; Soames, Roger
Foot & Ankle International. 19(5):289-292, May 1998.
Fig. 4 . Tibiospring, tibionavicular, and tibiocalcaneal ligaments reflected, deep posterior tibiotalar ligament (D) visible beneath.
Deep Posterior Tibiotalar
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Williams & Wilkins 1998. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 7
The Medial Collateral Ligaments of the Human Ankle Joint: Anatomical Variations.Milner, Clare; Soames, Roger
Foot & Ankle International. 19(5):289-292, May 1998.
Fig. 6 . Tibiospring and tibionavicular ligaments reflected, superficial posterior tibiotalar ligament (E) visible beneath.
Superficial Posterior Tibiotalar
Deep Posterior Tibiotalar
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Williams & Wilkins 1998. All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc. 8
The Medial Collateral Ligaments of the Human Ankle Joint: Anatomical Variations.Milner, Clare; Soames, Roger
Foot & Ankle International. 19(5):289-292, May 1998.
Fig. 7 . Location of the deep anterior tibiotalar ligament (F): tibiospring and tibionavicular ligaments reflected, deep posterior tibiotalar ligament (D) also visible.
Deep Anterior Tibiotalar
Deep Posterior Tibiotalar
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AnatomyAnatomy
Boss AP, Hintermann B; 2002, Foot Ankle Int 23(6)547Boss AP, Hintermann B; 2002, Foot Ankle Int 23(6)547--5353
12 cadaver studied12 cadaver studied
found 5 ligaments in superficial and deep layersfound 5 ligaments in superficial and deep layers
strongest are tibiocalcaneal and deep posterior tibiotalar, nextstrongest are tibiocalcaneal and deep posterior tibiotalar, next is is tibiospringtibiospring
tibiocalcaneal is longest and thickesttibiocalcaneal is longest and thickest
tibionavicular is more capsulartibionavicular is more capsular
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Function of Deltoid Function of Deltoid LigamentLigament
limits talar abduction when isolated (Close; Grath)limits talar abduction when isolated (Close; Grath)
stabilizes ankle against plantar flexion, external rotation and stabilizes ankle against plantar flexion, external rotation and pronation pronation (Rasmussen; Harper; Nigg)(Rasmussen; Harper; Nigg)
prevents external rotation and valgus stress to subtalar joint (prevents external rotation and valgus stress to subtalar joint (Michelson, et al. Michelson, et al. Foot Ankle Int; 2004, 25(9):639Foot Ankle Int; 2004, 25(9):639--46)46)
superficial component crosses both ankle and subtalar jointssuperficial component crosses both ankle and subtalar joints
deep component crosses only ankle jointdeep component crosses only ankle joint
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Mechanism of InjuryMechanism of Injury
pronation (eversion) trauma leading to forced external pronation (eversion) trauma leading to forced external rotation and abduction of anklerotation and abduction of ankle
running downstairsrunning downstairs
landing on uneven surfaceslanding on uneven surfaces
simultaneous rotation (soccer, dancing, simultaneous rotation (soccer, dancing, football)football)
SER, PAB, or PER ankle fracturesSER, PAB, or PER ankle fractures
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Pankovich StudyPankovich Study
1979; Acta Orthop Scand, 50:2251979; Acta Orthop Scand, 50:225--236236
described various medial ankle injuries and clinical implicationdescribed various medial ankle injuries and clinical implicationss
studied 102 ankle fractures and found 6 patterns:studied 102 ankle fractures and found 6 patterns:
rupture of deep and superficial deltoid ligamentsrupture of deep and superficial deltoid ligaments
fracture of anterior colliculusfracture of anterior colliculus
fracture of anterior colliculus and rupture of deep deltoidfracture of anterior colliculus and rupture of deep deltoid
fracture of posterior colliculusfracture of posterior colliculus
supracollicular fracture (most common)supracollicular fracture (most common)
avulsion chip fractureavulsion chip fracture
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Tornetta StudyTornetta Study2000; J Bone Joint Surg, 82A(6):8432000; J Bone Joint Surg, 82A(6):843--4848
in vivo study of 27 anklesin vivo study of 27 ankles
evaluated competence of deltoid ligament after medial malleolar evaluated competence of deltoid ligament after medial malleolar fixationfixation
26% deltoid incompetence with external stress after fixation26% deltoid incompetence with external stress after fixation
caused by size and height of medial malleolus fragmentcaused by size and height of medial malleolus fragment
thus can have both fracture and ligamentous injury thus can have both fracture and ligamentous injury
did not talk discuss repair deltoid did not talk discuss repair deltoid
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Subjective FindingsSubjective Findings
history of mechanism of injury (acute or chronic)history of mechanism of injury (acute or chronic)
unable to weight bear after injury (acute)unable to weight bear after injury (acute)
ankle feels like it ankle feels like it gives waygives way (chronic)(chronic)
pain located to anteromedial and/or lateral ankle pain located to anteromedial and/or lateral ankle (acute and chronic)(acute and chronic)
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Physical FindingsPhysical Findings
tenderness over ligament tenderness over ligament -- how reliable?how reliable?
hematoma common (acute)hematoma common (acute)
pain over medial gutter or anterior margin of fibulapain over medial gutter or anterior margin of fibula
rearfoot valgus and over pronation on stance rearfoot valgus and over pronation on stance reducible with active posterior tibial tendon firing reducible with active posterior tibial tendon firing (chronic)(chronic)
positive stress tests of the ankle positive stress tests of the ankle
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Medial ankle pain Medial ankle pain reliability?reliability?
DeAngelis NA, Eskander MS, French BG J Orthop Trauma 2007; 21(4)DeAngelis NA, Eskander MS, French BG J Orthop Trauma 2007; 21(4):244:244--47.47.
55 patients with Weber B fracture and normal medial clear space 55 patients with Weber B fracture and normal medial clear space evaluated evaluated
25% had medial tenderness and a positive stress test25% had medial tenderness and a positive stress test
25% had no medial tenderness but had a positive stress test25% had no medial tenderness but had a positive stress test
42% accuracy42% accuracy
should we stress all fractures?should we stress all fractures?
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Clinical Exam of Chronic Clinical Exam of Chronic Medial Ankle InstabilityMedial Ankle Instability
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Clinical Stress TestsClinical Stress Tests
Anterior drawer testAnterior drawer test
Inversion stressInversion stress
External rotationExternal rotation
Squeeze (not accurate)Squeeze (not accurate)
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Clinical Stress TestClinical Stress Test
external rotation to external rotation to evaluate integrity of evaluate integrity of deltoiddeltoid
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Imaging EvaluationImaging Evaluation
Plain x raysPlain x rays
Stress viewsStress views
ArthrographyArthrography
CT scanCT scan
MRIMRI
UltrasoundUltrasound
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RadiographsRadiographs
standard AP, mortise and lateral (weight bearing if standard AP, mortise and lateral (weight bearing if possible)possible)
medial clear space (MCS) medial clear space (MCS)
most reliable radiographic measurementmost reliable radiographic measurement
> than 2> than 2--5 mm MCS is documented as 5 mm MCS is documented as pathologicpathologic
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X ray imagesX ray images
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Stress RadiographsStress RadiographsMichelson described gravity stress technique in 2001Michelson described gravity stress technique in 2001
manual and gravity stress radiographs equivalent in manual and gravity stress radiographs equivalent in evaluation of deltoid ligament injury (Gill JB, et al. J evaluation of deltoid ligament injury (Gill JB, et al. J Bone Joint Surg Am. 2007; 89:994Bone Joint Surg Am. 2007; 89:994--9)9)
physician does not have to be present at time of physician does not have to be present at time of gravity stress testgravity stress test
does not account for muscle firingdoes not account for muscle firing
how often do we perform this test?how often do we perform this test?
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The Gravity Stress ViewThe Gravity Stress View
Michelson JD, Varner KE, Checcone M; 2001 Clin Orthop Rel Res, 3Michelson JD, Varner KE, Checcone M; 2001 Clin Orthop Rel Res, 387:17887:178--8282
to aid in diagnosing deltoid injury to determine if surgery is nto aid in diagnosing deltoid injury to determine if surgery is neededeeded
studied 8 cadavers under serial stress under sequential conditiostudied 8 cadavers under serial stress under sequential conditionsns
showed combined transection of superficial and deep deltoid showshowed combined transection of superficial and deep deltoid showed ed talus shift and valgus tilttalus shift and valgus tilt
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Stress RadiographsStress Radiographs
Park SD, Kubiak EN, et al. J Orthop Trauma 2006;20(1):11Park SD, Kubiak EN, et al. J Orthop Trauma 2006;20(1):11--18.18.
cadaver study cadaver study
looked at ankle position to measure clear space with stresslooked at ankle position to measure clear space with stress
found ankle in dorsiflexion and external stress with >5mm medialfound ankle in dorsiflexion and external stress with >5mm medial clear space was most predictiveclear space was most predictive
feels Michelson gravity view does not account for syndesmotic feels Michelson gravity view does not account for syndesmotic injuryinjury
gravity stress does not account for muscle firinggravity stress does not account for muscle firing
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Gravity Stress TechniqueGravity Stress Technique
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MRI ImagesMRI Images
NormalNormal
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MRIMRI
Normal T2Normal T2
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MRIMRI
Deltoid Sprain T1Deltoid Sprain T1
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MRIMRI
Deltoid SprainDeltoid Sprain
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MRIMRI
Deltoid Partial Tear T1Deltoid Partial Tear T1
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MRIMRI
Deltoid Partial Tear T2Deltoid Partial Tear T2
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MRIMRI
Deltoid Complete Tear Deltoid Complete Tear T1T1
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MRIMRI
Deltoid Complete Tear Deltoid Complete Tear T2T2
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MRIMRIAdvantages:Advantages:
identify more detail about extent of injuryidentify more detail about extent of injury
nonnon--invasiveinvasive
less risk of increase injuryless risk of increase injury
no need for anesthesiano need for anesthesia
Disadvantages:Disadvantages:
higher costhigher cost
not always availablenot always available
does it change prognosis???does it change prognosis???
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MRI StudiesMRI Studies
Cheung Y, Perrich KD, et al. Am J Roent 2009; 192:W1Cheung Y, Perrich KD, et al. Am J Roent 2009; 192:W1--W7W7
used MRI to identify ligaments injured in isolated fibular fractused MRI to identify ligaments injured in isolated fibular fracturesures
retrospective look at 19 patients with widened medial clear spacretrospective look at 19 patients with widened medial clear spacee
anterioranterior--inferior tibiofibular ligament (aitfl) torn in all inferior tibiofibular ligament (aitfl) torn in all
83% had a partially torn deltoid 83% had a partially torn deltoid
challenges prior studies that the deep deltoid ligament must be challenges prior studies that the deep deltoid ligament must be completely completely torn to have a wide medial clear spacetorn to have a wide medial clear space
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MRI StudiesMRI Studies
Nielson JH, Gardner MJ, et al. Clin Orthop Rel Res 2005;436:216Nielson JH, Gardner MJ, et al. Clin Orthop Rel Res 2005;436:216--2121
used MRI to evaluate accuracy of x ray measurementsused MRI to evaluate accuracy of x ray measurements
a prospective study of 70 patientsa prospective study of 70 patients
evaluated tibiofibular clear space, tibiofibular overlap, and meevaluated tibiofibular clear space, tibiofibular overlap, and medial dial clear spaceclear space
found only medial clear space >4 mm correlated with MRI found only medial clear space >4 mm correlated with MRI pathology and deltoid injurypathology and deltoid injury
MRI useful adjunctive toolMRI useful adjunctive tool
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Positive Stress Test and Positive Stress Test and MRIMRI
Koval KJ, Egol KA, et al. J Orthop Trauma 2007 21(7)449Koval KJ, Egol KA, et al. J Orthop Trauma 2007 21(7)449--55.55.
retrospective review using MRI to evaluate need for surgery afteretrospective review using MRI to evaluate need for surgery after r positive stress testpositive stress test
21 patients with positive stress of Weber B fractures21 patients with positive stress of Weber B fractures
if MRI showed complete rupture, then surgery was performedif MRI showed complete rupture, then surgery was performed
90% showed partial rupture and were treated non90% showed partial rupture and were treated non--operativelyoperatively
all had good to excellent functional outcome after one yearall had good to excellent functional outcome after one year
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ArthroscopyArthroscopy
Schuberth JM, Collman DR, et al. J Foot Ankle Surg; 2004, 43(1):Schuberth JM, Collman DR, et al. J Foot Ankle Surg; 2004, 43(1):2020--2929
evaluated if medial clear space (MCS) was an accurate predictor evaluated if medial clear space (MCS) was an accurate predictor of deltoid injuryof deltoid injury
MCS measured on 40 patients over 4 years with isolated displacedMCS measured on 40 patients over 4 years with isolated displaced fibular fracturesfibular fractures
false positive rates: false positive rates:
MCS MCS >> 3mm (88.5%) 3mm (88.5%)
MCS MCS > > 4 mm (53.6%) 4 mm (53.6%)
MCS MCS >> 5mm (26.9%)5mm (26.9%)
MCS > 6mm (7.7%)MCS > 6mm (7.7%)
therefore, MCS is not an accurate predictor of deltoid ligament therefore, MCS is not an accurate predictor of deltoid ligament injuryinjury
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ArthroscopyArthroscopy
Hintermann B, Boss A, Schafer D 2002; Am J Sports Med, Hintermann B, Boss A, Schafer D 2002; Am J Sports Med, 30(3):40230(3):402--99
arthroscopic exam of 148 patients with ankle arthroscopic exam of 148 patients with ankle instabilityinstability
40% had a rupture or elongation of deltoid ligament40% had a rupture or elongation of deltoid ligament
98% of ankles with deltoid injury also had cartilage 98% of ankles with deltoid injury also had cartilage injuryinjury
created grading systemcreated grading system
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Arthroscopy Arthroscopy
Hintermann B, Boss A, et al. Am J Sports Med; 2002 30(3):402Hintermann B, Boss A, et al. Am J Sports Med; 2002 30(3):402--9.9.
Stage 1Stage 1
stable; cannot open tibiotalar joint more than 2 mmstable; cannot open tibiotalar joint more than 2 mm
Stage 2Stage 2
moderately unstable; able to introduce 5 mm scope into spacemoderately unstable; able to introduce 5 mm scope into space
Stage 3Stage 3
severely unstable, able to see posterior ankle joint with severely unstable, able to see posterior ankle joint with tractiontraction
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UltrasoundUltrasoundChen PY, et al. 2008; Foot Ankle Int, 29(9):883Chen PY, et al. 2008; Foot Ankle Int, 29(9):883--8686
examined 15 patients with isolated fibular examined 15 patients with isolated fibular fracturesfractures
6 patients found to have complete rupture6 patients found to have complete rupture
if ruptured, ORIF of fibula and deltoid if ruptured, ORIF of fibula and deltoid ligament repair was performedligament repair was performed
no analgesia or anesthesia required to study no analgesia or anesthesia required to study patientpatient
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Medial Ankle InstabilityMedial Ankle Instability
Hintermann B, et al. Am J Sports Med; 2004, 32(1):183Hintermann B, et al. Am J Sports Med; 2004, 32(1):183--9090
prospective study of 52 casesprospective study of 52 cases
identified by arthroscopic and surgical explorationidentified by arthroscopic and surgical exploration
100% had pain in the medial gutter 100% had pain in the medial gutter
77% associated with lateral instability77% associated with lateral instability
3 types identified arthroscopically3 types identified arthroscopically
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Classification of Anterior Classification of Anterior Deltoid InjuryDeltoid Injury
Hintermann B. 2003; Foot Ankle Clin N Am 8:723Hintermann B. 2003; Foot Ankle Clin N Am 8:723--3838
Type I: proximal tear of or avulsion of deltoidType I: proximal tear of or avulsion of deltoid
Type II: intermediate tear of deltoidType II: intermediate tear of deltoid
Type III: distal tear or avulsion of deltoid and Type III: distal tear or avulsion of deltoid and spring spring
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Hintermann Surgical Hintermann Surgical OptionsOptionsTypeType LocationLocation IncidenceIncidence ProcedureProcedure Post opPost op
II ProximalProximal 72%72% repair, repair, reattachmentreattachment CAM walkerCAM walker
IIII IntermediateIntermediate 9%9%repair, repair,
reattachmentreattachmenttwo flaptwo flap
plasterplaster
IIIIII DistalDistal 19%19% repair, repair, reattachmentreattachment plasterplaster
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Hintermann Hintermann TechniquesTechniques
Presentation at AOFAS Presentation at AOFAS Conference, May 2009.Conference, May 2009.
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Deltoid and Syndesmosis Deltoid and Syndesmosis InjuryInjury
Porter DA; 2009, AAOS Instr Course Lect 58:575Porter DA; 2009, AAOS Instr Course Lect 58:575--8181
seen in athletic populationseen in athletic population
challenging to detect and treatchallenging to detect and treat
1%1%--18% of ankle sprains involve syndesmosis18% of ankle sprains involve syndesmosis
must evaluate thoroughlymust evaluate thoroughly
poor outcome if missedpoor outcome if missed
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Classification of Classification of Syndesmosis InjurySyndesmosis Injury
Jelinek JA, Porter DA, 2009. Foot Ankle Clin N Am Jelinek JA, Porter DA, 2009. Foot Ankle Clin N Am
Grade I (stable): injury to anterior deltoid Grade I (stable): injury to anterior deltoid ligament and distal syndesmosis, no diastasisligament and distal syndesmosis, no diastasis
Grade II (unstable): injury to anterior and deep Grade II (unstable): injury to anterior and deep deltoid and syndesmosis, diastasis with stressdeltoid and syndesmosis, diastasis with stress
Grade III (unstable): injury to deltoid and Grade III (unstable): injury to deltoid and syndesmosis with proximal fibular fracture, syndesmosis with proximal fibular fracture, obvious obvious
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TreatmentTreatment
Grade I injury treated conservatively with bootGrade I injury treated conservatively with boot
Grade II and III syndesmotic injury and bimalleolar Grade II and III syndesmotic injury and bimalleolar equivalent fractures are primarily repairedequivalent fractures are primarily repaired
uses #2 and #0 vicryl in horizontal suture uses #2 and #0 vicryl in horizontal suture pattern to repair deltoid ligamentpattern to repair deltoid ligament
dondont be afraid to ret be afraid to re--examine periodicallyexamine periodically
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Advantage of RepairAdvantage of Repair
Porter: (Jelinek JA, Porter DA Foot Ankle Clin N Am Porter: (Jelinek JA, Porter DA Foot Ankle Clin N Am 2009; 14:2772009; 14:277--98)98)
can evaluate joint for osteochondral injurycan evaluate joint for osteochondral injury
allows earlier range of motionallows earlier range of motion
deters laxitydeters laxity
do not have to address potential deltoid do not have to address potential deltoid insufficiency in the futureinsufficiency in the future
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Treatment of Chronic Treatment of Chronic InstabilityInstability
Nelson DR, Younger A; 2003 Foot Ankle Clin N Am, Nelson DR, Younger A; 2003 Foot Ankle Clin N Am, 8:5218:521--3737
repair of superficial deltoid in conjunction repair of superficial deltoid in conjunction with NCJ arthrodesis and lateral column with NCJ arthrodesis and lateral column procedure for post traumatic planovalgus procedure for post traumatic planovalgus deformitydeformity
Deland JT, de Asla RJ, Segal A 2004 Foot Ankle Int Deland JT, de Asla RJ, Segal A 2004 Foot Ankle Int 25(11):79525(11):795--9999
used peroneus longus tendon graftused peroneus longus tendon graft
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Deltoid Ligament Repair Not Deltoid Ligament Repair Not NecessaryNecessary
many studies that support good functional outcome of many studies that support good functional outcome of bimalleolar equivalent ankle fractures treated with no deltoid bimalleolar equivalent ankle fractures treated with no deltoid ligament repairligament repair
Tourne, et al. (J Foot Ankle Surg, 1999)Tourne, et al. (J Foot Ankle Surg, 1999)
Stromsoe K, et al. (J Bone Joint Surg, 1995)Stromsoe K, et al. (J Bone Joint Surg, 1995)
Harper M (Clin Orthop Rel Res, 1988)Harper M (Clin Orthop Rel Res, 1988)
Baird R, et al. (J Bone Joint Surg, 1987)Baird R, et al. (J Bone Joint Surg, 1987)
key is good anatomic reduction of fibular fracture and key is good anatomic reduction of fibular fracture and syndesmosissyndesmosis
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Repair Not neededRepair Not needed
Tejwani NC, McLaurin TM, et al. J Bone Joint Surg Am. 2007; 89:Tejwani NC, McLaurin TM, et al. J Bone Joint Surg Am. 2007; 89:14381438--4141
evaluated functional outcomes of bimalleolar and bimalleolar evaluated functional outcomes of bimalleolar and bimalleolar equivalent fractures surgically repairedequivalent fractures surgically repaired
266 patients 266 patients
evaluated at 3, 6, and 12 monthsevaluated at 3, 6, and 12 months
no deltoid ligaments were repairedno deltoid ligaments were repaired
those with bimalleolar fractures had worse functional outcome scthose with bimalleolar fractures had worse functional outcome scoresores
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Long Term OutcomeLong Term Outcome
Stufkens SAS, Knupp M, et al. J Bone Joint Surg (Br) 2009; 91B:1Stufkens SAS, Knupp M, et al. J Bone Joint Surg (Br) 2009; 91B:1607607--1111
long term outcome after SER IV ankle fractureslong term outcome after SER IV ankle fractures
13 year mean follow up, 36 patients13 year mean follow up, 36 patients
evaluated SER with deltoid ligament injury versus with medial evaluated SER with deltoid ligament injury versus with medial malleolus fracturemalleolus fracture
All evaluated arthroscopically and found increase loose bodies wAll evaluated arthroscopically and found increase loose bodies with ith medial malleolus fracture groupmedial malleolus fracture group
found SER IV with deltoid ligament injury had better functional found SER IV with deltoid ligament injury had better functional outcome than medial malleolar fracture group base on AOFAS outcome than medial malleolar fracture group base on AOFAS hindfoot scorehindfoot score
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ComplicationsComplications
chronic instabilitychronic instability
osteoarthritisosteoarthritis
posterior tibial tendon dysfunctionposterior tibial tendon dysfunction
loss of functional activityloss of functional activity
osteochondral defectsosteochondral defects
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Treatment AlgorithmIsolated lateral Isolated lateral
malleolus fracturemalleolus fracture
Clinical and Xray Clinical and Xray evaluationevaluation
Ankle Ankle dislocateddislocated
??
MCS MCS < < 4 4 mmmm
no
yes
Medial Medial SymptomsSymptoms
yes
Stress testStress test
MCS MCS >> 5 5 mmmm
Get MRIGet MRI
NonNon--operativeoperativeTreatmentTreatment
Operative Operative TreatmentTreatment
yes
no
no
Deep Deltoid Deep Deltoid Ligament IntactLigament Intact
Deep Deltoid Deep Deltoid Ligament Ligament RupturedRuptured
no
yes
Adopted from Adopted from Koval et al. Koval et al.
2007; J Orthop 2007; J Orthop TraumaTrauma
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Isolated Lateral malleolus fractureIsolated Lateral malleolus fracture
Clinical and x ray examClinical and x ray exam
Ankle dislocatedAnkle dislocated
MCS MCS >> 4 mm4 mm
Medial SymptomsMedial Symptoms
Stress TestStress Test
MCS MCS >> 5mm5mm
Get MRIGet MRI Deep Deltoid Deep Deltoid RuptureRupture
Deep Deep Deltoid Deltoid IntactIntact
OperativeOperativeTreatmentTreatment
NonNon--operativeoperativeTreatmentTreatment
yesyes
yesyes
nononono
nono
yesyes
yesyes
nono
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ConclusionsConclusions
critical to do thorough examination of deltoid ligament injury wcritical to do thorough examination of deltoid ligament injury with ith acute eventsacute events
if anatomic reduction of fibula and syndesmosis is stable, nonif anatomic reduction of fibula and syndesmosis is stable, non-- operative care is acceptableoperative care is acceptable
careful recareful re--examination for questionable deltoid integrity is examination for questionable deltoid integrity is importantimportant
MRI and/or arthroscopy can be beneficial adjunctive toolsMRI and/or arthroscopy can be beneficial adjunctive tools
avoid potential for chronic instabilityavoid potential for chronic instability
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Case #1Case #1
41 yo female seen at 41 yo female seen at ER after twisting fall ER after twisting fall off tableoff table
initial exam and initial exam and diagnosed with stable diagnosed with stable SER ankle fractureSER ankle fracture
placed in CAM walker placed in CAM walker with crutcheswith crutches
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Case #1Case #1
follow up exam one follow up exam one week later in fracture week later in fracture clinicclinic
still significant medial still significant medial tenderness and paintenderness and pain
stress exam and view stress exam and view taken (5 mm MCS)taken (5 mm MCS)
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Case #1Case #1
had ORIFhad ORIF
no laxity or widened no laxity or widened MCS after fibular MCS after fibular fixationfixation
deltoid not repaireddeltoid not repaired
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Case #2Case #2
17 yo male soccer 17 yo male soccer athleteathlete
division one recruitdivision one recruit
intermittent medial intermittent medial ankle painankle pain
recent aggravation recent aggravation due to rotational injurydue to rotational injury
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Case study #2Case study #2
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Case #2Case #2
immobilized for 10immobilized for 10--14 days in CAM walker14 days in CAM walker
medial edema and pain resolvedmedial edema and pain resolved
sent for aggressive proprioceptive physical therapysent for aggressive proprioceptive physical therapy
currently deciding which college to attend and playing currently deciding which college to attend and playing at full functional capacityat full functional capacity
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Research Research
correlate and compare arthroscopic and MRI findings as predictivcorrelate and compare arthroscopic and MRI findings as predictive value toolse value tools
is deltoid ligament alone strong enough repairis deltoid ligament alone strong enough repair
proprioceptive benefit of muscle groupsproprioceptive benefit of muscle groups
establish treatment protocol and long term outcome based studyestablish treatment protocol and long term outcome based study
lateral ankle instability has shown to be effectively treated wilateral ankle instability has shown to be effectively treated with stabilization th stabilization procedures when necessary with good long term outcomesprocedures when necessary with good long term outcomes
medial ankle instability still has poor objective data to suppormedial ankle instability still has poor objective data to support repair or no repair t repair or no repair in acute settingin acute setting
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Thanks!Thanks!
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Article ReviewsArticle ReviewsResidents from Providence Tarzana Podiatric Residents from Providence Tarzana Podiatric Residency ProgramResidency Program
Van den Bekerom MPJ, Mutsaerts E, van Dijk CN. Evaluation of thVan den Bekerom MPJ, Mutsaerts E, van Dijk CN. Evaluation of the intergrity of the deltoid e intergrity of the deltoid ligament in supination external rotation ankle fractures: a systligament in supination external rotation ankle fractures: a systemic review of literature. Arch Orthop emic review of literature. Arch Orthop Trauma Surg 129:227Trauma Surg 129:227--235, 2009.235, 2009.
Stufkens SAS, Knupp M, Lampert, et al. LongStufkens SAS, Knupp M, Lampert, et al. Long--term outcome after supinationterm outcome after supination--external rotation external rotation typetype--4 fracture of ankle. J Bone Joint Surg Br. 914 fracture of ankle. J Bone Joint Surg Br. 91--B(12):1607B(12):1607--1611, 2009.1611, 2009.
Tejwani NC, McLaurin TM, Walsh M, et al. Are outcomes of bimallTejwani NC, McLaurin TM, Walsh M, et al. Are outcomes of bimalleolar fractures poorer than eolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injthose of lateral malleolar fractures with medial ligamentous injury? J Bone Joint Surg Am ury? J Bone Joint Surg Am 89(7):143889(7):1438--41, 2007.41, 2007.
Hintermann B, Knupp M, Pagenstert G. Deltoid ligament injuries:Hintermann B, Knupp M, Pagenstert G. Deltoid ligament injuries: diagnosis and management. diagnosis and management. Foot Ankle Clin N Am 11:625Foot Ankle Clin N Am 11:625--637, 2006.637, 2006.
Hintermann B, Valderrabano V, Boss A, et al. Medial ankle instaHintermann B, Valderrabano V, Boss A, et al. Medial ankle instability. An exploratory prospective bility. An exploratory prospective study of fifty two cases. Am J Sports Med 32:183study of fifty two cases. Am J Sports Med 32:183--190, 2004.190, 2004.
-
Bibliography Baird RA, Jackson ST. Fractures of the distal part of the fibula with associated disruption of the deltoid ligament. Treatment without repair of the deltoid ligament. J Bone Joint Surg 69A:1346-1352, 1987. Boss A, Hintermann B. Anatomical study of the medial ankle ligament complex. Foot Ankle Int 23:547-553, 2002.
Chen PY, Wang TG, Wang CL. Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures. Foot Ankle Int 29(9):883-886, 2008.
Cheung Y, Perrich KD, et al. MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted? Am J Roent 192:W7-12, 2009.
Clarke HJ, Michelson JD, Cox QG, Jinnah RH. Tibiotalar stability in bimalleolar ankle fractures: a dynamic in vitro contract area study. Foot Ankle 11:222- 227, 1993.
DeAngelis NA, Eskander MS, French BG. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma 21(4):244-247, 2007.
Deland JT, de Asla RJ, Segal A. Reconstruction of the chronically failed deltoid ligament: a new technique. Foot Ankle Int 25:795-799, 2004.
Ebraheim NA, Hossein E, Padanilam T. Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orthop 409:260-267, 2003.
Ferran NA, Olivia F, Maffulli N. Ankle instability. Sports Med Arthrosc Rev 17(2):139-145, 2009.
Fotiadis E, Kenanidis E, et al. Surgical management of closed tibiotalar dislocation: a case report and 2- year follow-up. J Foot Ankle Surg 48(6):690e13- 17, 2009.
Gill JB, Risko T, et al. Comparison of Manual and gravity stress radiographs for the evaluation of supination-external rotation fibular fractures. J Bone Joint Surg Am 89:994-999, 2007.
Grath G. Widening of the ankle mortise. A clinical and experimental study. Chapter III. Interactions of the ligaments of the ankle joint in preventing widening of the mortise. Acta Chir Scand Supp 263:13-40, 1960.
Harper MC. Deltoid ligament: an anatomical evaluation of function. Foot Ankle 8:19-22, 1987.
-
Bibliography Harper MC. The deltoid ligament. An evaluation of need for surgical repair. Clin Orthop 226:156-168, 1988.
Harper MC. Talar shift. The stabilizing role of the medial, lateral, and posterior ankle structures. Clin Orthop 257:177-183, 1990.
Hintermann B, Boss a, Schafer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med 30:402-409, 2002.
Hintermann B. Medial ankle instability. Foot Ankle Clin 8:723-738, 2003
Hintermann B, Valderrabano V, Boss A, et al. Medial ankle instability. An exploratory, prospective study of fifty two cases. Am J Sports Med 32:183-190, 2004.
Hintermann B, Knupp M, Pagenstert. Deltoid ligament injuries: diagnosis and management. Foot Ankle Clin N Am 11:625-637, 2006.
Jackson R, Willis RE, Jackson R. Rupture of deltoid ligament without involvement of the lateral ligament. Am J Sports Med 16:541-543, 1988.
Jelinek JA, Porter DA. Management of unstable ankle fractures and syndesmotic injuries in athletes. Foot Ankle Clin N Am 14:277-298, 2009.
Kish B, Shabat S, Nyska M. Technique Tip: Percutaneous release of deltoid ligament entrapment. Foot Ankle Int 23:1141-1142, 2002.
Kragh JF, Ward JA. Radiographic indicators of ankle instability: changes with plantar flexion. Foot Ankle Int 27(1):23-28, 2006.
Koval KJ, Egol KA, et al. Does a positive stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma 21(7):449-455, 2007.
McCullough CJ, Burge PD. Rotatory stability of the load-bearing ankle. An experimental study. J Bone Joint Surg 62B:460-464, 1980.
Michelson JD, Clarke HJ, Jinnah RH. The effect of loading on tibiotalar alignment in cadaver ankles. Foot Ankle 10:280-284, 1990.
Michelson JD, Hamel AJ, Buczek FL, Sharkey NA. The effect of ankle injury on subtalar motion. Foot Ankle Int 25(9):639-646, 2004.
-
Bibliography Michelson JD, Hamel AJ, Buczek FL, Sharkey NA. Kinematic behavior of the ankle following malleolar fracture repair in a high-fidelity cadaver model.
J Bone Joint Surg Am 84:2029-2038, 2002.
Michelson JD, Varner KE, Checcone M. Diagnosing deltoid injury in ankle fractures. The gravity stress view. Clin Orthop 387:178-182, 2001.
Milner CE, Soames RW. The medial collateral ligaments of the human ankle joint: anatomical variations. Foot Ankle Int 19:289-292, 1998.
Mosier-La Clair SM, Monroe MT, Manoli, II A. Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus. Foot Ankle Int 21:385-391, 2000.
Nelson DR, Younger A. Acute post traumatic planovalgus foot deformity involving hindfoot ligamentous pathology. Foot Ankle Clin 8:521- 537, 2003.
Nielson H, Gardner MJ, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures. An MRI study. Clin Orthop Rel Res 436:216-221, 2005.
Nigg BM, Skarvan G, Frank CB, Yeadon MR. Elongation and forces of ankle ligaments in a physiological range of motion. Foot Ankle 11:30- 40, 1990.
Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. I. Anatomical studies. Acta Orthop Scand 50:217-223, 1979
Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. II. Anatomical studies. Acta Orthop Scand 50:225-236, 1979.
Park SS, Kubiak EN, et al. Stress radiographs after ankle fracture: The effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma 20(1):11-18, 2006.
Porter DA. Evaluation and treatment of ankle syndesmosis injuries. AAOS Instr Course Lec 58:575-581, 2009.
Rasmussen O, Kromann-Anderson C, Boe S. Deltoid ligament. Functional analysis of the medial collateral ligamentous apparatus of the ankle joint. Acta Orthop Scand 54:36-44, 1983.
-
Bibliography Rasmussen O. Stability of the ankle joint: analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand 56(Suppl):1-75, 1985.
Renstrom PAFH. Persistently painful sprained ankle. J Am Acad Orthop Surg 2:270-280, 1994.
Sammarco GJ, Burstein AH, Frankel VH. Biomechanics of the ankle: a kinematic study. Orthop Clin North Am 4:75-96, 1973.
Sasse M, Nigg BM, Stefanyshyn DJ. Tibiotalar motion-effect of fibular displacement and deltoid ligament transaction: in vitro study. Foot Ankle Int 20:733-737, 1999.
Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg 43:20-29, 2004.
Siegler S, Block J, Schneck C. The mechanical characteristics of the collateral ligaments of the human ankle joint. Foot Ankle 8:234-242, 1988.
Staples OS. Injuries to the medial ligaments of the ankle. J Bone Joint Surg 42A:1287-1307, 1960.
Stoffel K, Wysocki D, et al. Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am 91:2646-2652, 2009.
Stromsoe K, Hoqevold HE, Skjeldal S, et al. The repair of ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg 77:920-921, 1995.
Stufkens SAS, Knupp M, et al. Long term outcome after supination-external rotation type-4 fractures of the ankle. J Bone Joint Surg 91B:1607-11, 2009.
Tejwani NC, McLaurin TM, et al. Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury? J Bone Joint Surg Am 89:138-41, 2007.
Tochigi Y, Yoshinaga K, Wada Y, Moriya H. Acute inversion injury of the ankle: magnetic resonance imaging and clinical outcomes. Foot Ankle Int 19(11):730-734, 1998.
Tornetta P III. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am
-
Bibliography
Tourne Y, Charbel A, Picard F, et al. Surgical treatment of bi- and trimalleolar ankle fractures: should the medial collateral ligament be sutured or not? J Foot Ankle Surg 38:24-29, 1999.
van den Bekerom, MPJ, Mutsaerts E, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systemic review of the literature. Arch Orthop Trauma Surg 129:227-235, 2009.
DELTOID LIGAMENT INJURYObjectivesHistoryIncidenceOccurrenceTerminologyAnatomy AnatomyAnatomyAnatomySlide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16AnatomyFunction of Deltoid LigamentMechanism of InjuryPankovich StudyTornetta StudySubjective FindingsPhysical FindingsMedial ankle pain reliability?Clinical Exam of Chronic Medial Ankle InstabilityClinical Stress TestsClinical Stress TestImaging EvaluationRadiographsX ray images Stress RadiographsThe Gravity Stress ViewStress RadiographsGravity Stress TechniqueMRI ImagesMRIMRIMRIMRIMRIMRIMRIMRIMRI StudiesMRI StudiesPositive Stress Test and MRIArthroscopyArthroscopyArthroscopy UltrasoundMedial Ankle InstabilityClassification of Anterior Deltoid InjuryHintermann Surgical OptionsHintermann TechniquesDeltoid and Syndesmosis InjuryClassification of Syndesmosis InjuryTreatmentAdvantage of RepairTreatment of Chronic InstabilityDeltoid Ligament Repair Not NecessaryRepair Not neededLong Term OutcomeComplicationsTreatment AlgorithmSlide Number 65ConclusionsCase #1Case #1Case #1Case #2Case study #2Case #2Research Thanks!Article ReviewsBibliographyBibliographyBibliographyBibliographyBibliography
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