Deep deltoid ligament injury is related to rotational instability of the ankle joint: a biomechanical study

Longo, Umile Giuseppe; Loppini, Mattia; Fumo, Caterina; Lanotte, Angela; Trovato, Ugo; Ambrogioni, L.; Candela, Vincenzo; Forriol, F.; DiGiovanni, Christopher W.; Denaro, Vincenzo

doi:10.1007/s00167-020-06308-7

Cited by 21 publications

(17 citation statements)

References 28 publications

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“…Chronic insufficiency together with concomitant deltoid insufficiency may lead to a talar shift thereby causing a decrease of the tibiotalar contact surface subsequently causing (osteo) cartilaginous damage to the ankle joint. 37 - 43 …”

Section: Discussionmentioning

confidence: 99%

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

et al. 2022

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Objective To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries. Design A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions. Results Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies. Conclusions This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome. PROSPERO Registration Number: CRD42020176641

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Section: Discussionmentioning

confidence: 99%

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

et al. 2022

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“…2,5,8,19,41,43,49 Their combined injuries are therefore frequent. 34,51 Consideration of a DPTTL lesion associated with syndesmosis injury is important because it leads to external rotation of the tibiotalar joint, worsening the instability in favor of operative management. 34,40 In addition, the integrity of the deltoid ligament is central to the decision-making process in case of a lateral malleolus fracture.…”

Section: Discussionmentioning

confidence: 99%

“…The deltoid ligament is rarely involved in isolated ligament injuries of the ankle (about 5% of cases), unlike injuries to the tibiofibular syndesmosis and the external ligament complex. 48 Nevertheless, its injury should not be underestimated because it may cause instability, 27,34,40 residual pain, 25,27 acquired flatfoot deformity in the case of an associated injury to the spring ligament, 36,47 or even early osteoarthritis of the external tibiotalar joint. 16,25…”

Section: Introductionmentioning

confidence: 99%

“…21,33,39 The deltoid ligament is rarely involved in isolated ligament injuries of the ankle (about 5% of cases), unlike injuries to the tibiofibular syndesmosis and the external ligament complex. 48 Nevertheless, its injury should not be underestimated because it may cause instability, 27,34,40 residual pain, 25,27 acquired flatfoot deformity in the case of an associated injury to the spring ligament, 36,47 or even early osteoarthritis of the external tibiotalar joint. 16,25 Ligaments have 3 main functions 3,7,9,46 : (1) a stabilizing role for the joint, regardless of its position; (2) viscoelastic properties that allow it to adapt its intraligament tension according to the stresses applied; and (3) a kinesthetic and proprioceptive function.…”

Section: Introductionmentioning

confidence: 99%

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A Preliminary Study to Assess the Relevance of Shear-Wave Elastography in Characterizing Biomechanical Changes in the Deltoid Ligament Complex in Relation to Ankle Position

et al. 2022

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Background: The purpose of this study was (1) to evaluate the biomechanical properties of the different bundles of the deltoid ligament in various ankle positions in a cohort of healthy adult volunteers; (2) describe the impact of demographic and hindfoot morphology characteristics on their stiffness; (3) to assess the reliability and reproducibility of these measurements. Methods: Deltoid ligament complex of both ankles were assessed by shear-wave elastography (SWE) in 20 healthy patients resting on hinge support. The propagation shear-wave speed (SWS) in ligaments was measured, which is related to the tissue’s elastic modulus. The following ligaments were analyzed in a neutral position and then in varus, valgus, dorsal, and plantar flexions: tibionavicular ligament (TNL), tibiocalcaneal ligament (TCL), the superficial posterior tibiotalar ligament (SPTL), the anterior tibiotalar ligament (ATTL), and the deep posterior tibiotalar ligament (DPTTL). Results: The mean SWS increased between neutral and 20 degrees valgus position for TCL (4.08 ± 0.78 m/s vs 5.56 ± 0.62 m/s, respectively; P < .0001) and for DPTTL (2.58 ± 0.52 m/s vs 3.59 ± 0.87 m/s, respectively; P < .0001). The mean SWS increased between neutral and 30 degrees plantarflexion for ATTL (2.11 ± 0.44 m/s vs 3.1 ± 0.5 m/s, respectively; P < .0001) and TNL (2.96 ± 0.66 m/s vs 4.99 ± 0.69 m/s, respectively; P < .0001). The mean SWS increased between neutral and 20 degrees dorsal flexion for SPTL (4.2 ± 1 m/s vs 5.45 ± 0.65 m/s, respectively; P < .0001). Women had less DPTTL SWS than men in the neutral position (2.37 ± 0.35 m/s vs 2.71 ± 0.49 m/s, respectively; P = .007). Other demographics had no impact on the SWS value of other ligaments. All inter- and intraobserver agreements were good to excellent. Conclusion: This study presents a reliable and reproducible SWE measurement protocol to describe the physiological function of all bundles of the medial collateral ligament in healthy adults. Clinical relevance: This examination technique can be available to orthopaedic surgeons, allowing reliable and reproducible monitoring of the SWS of the various ligaments constituting the medial collateral plane. The biomechanical values described in this study may give insight into in what position medial ankle ligament reconstruction should be tensioned.

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“…6,8,11 Functionally, the superficial DL provides the primary resistance to hindfoot eversion, while the deep DL primarily resists talar external rotation. 16,17 Complete rupture of the superficial and deep DL is required for valgus talar tilting in ankle mortise. 16 In this investigation, superficial DL injury, deep DL injury, and complete DL injury were created to represent the different grades of DL injury for MCS measurement.…”

Section: Discussionmentioning

confidence: 99%

Arthroscopic Quantitative Measurement of Medial Clear Space for Deltoid Injury of the Ankle: A Cadaveric Comparative Study With Stress Radiography

et al. 2022

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Background: The deltoid ligament (DL) is an important stabilizer of the ankle. DL injury of varying severity can occur alone or with syndesmotic injury and fibular fracture. Limited diagnostic tools are available to assess DL injury quantitatively. Purpose: To establish an arthroscopic quantitative assessment of DL injury and to compare its performance with that of external rotation stress (ERS) and gravity stress (GS) radiography. Study Design: Controlled laboratory study. Methods: In total, 24 cadaveric lower extremities were divided into 4 groups: group 1 consisted of intact DL, group 2 of superficial DL disruption, group 3 of deep DL disruption, and group 4 of complete DL (superficial and deep) disruption. All specimens underwent sequential sectioning of syndesmotic ligaments, and medial clear space (MCS) was measured with ankle arthroscopy, ERS radiography, and GS radiography at different stages of syndesmotic sectioning. Results: For noninjured deltoid (group 1) and injured deltoid (groups 2-4), area under the receiver operating characteristic curve (AUC) of measurement of MCS was 0.939 for arthroscopy, 0.932 for ERS radiography, and 0.874 for GS radiography, with a significant difference between arthroscopy and GS radiography ( P = .014). For incomplete deltoid injury (groups 1-3) and complete deltoid injury (group 4), the AUC of MCS was 0.811 for arthroscopy, 0.656 for ERS radiography, and 0.721 for GS radiography, with a significant difference between arthroscopy and ERS radiography ( P < .001) and between arthroscopy and GS radiography ( P = .035). For all stages of syndesmotic sectioning, cutoff values of arthroscopic MCS with intact fibula were ≤2.5 mm for intact DL, between 2.5 and 3.5 mm for partial DL injury (superficial or deep), and ≥3.5 mm for complete DL injury. Arthroscopy was unable to detect a difference between superficial deltoid injury (group 2) and deep deltoid injury (group 3) in partial DL injury, with a measured MCS between 2.5 and 3.5 mm. The intraclass correlation coefficient of interrater reliability was 0.975 for arthroscopy, 0.917 for ERS radiography, and 0.811 for GS radiography. Conclusion: Arthroscopic MCS measurement can differentiate intact DL, partial DL injury, and complete DL injury. Compared with ERS and GS radiography, arthroscopic MCS measurement has greater accuracy with excellent interrater reliability. Clinical Relevance: For patients with suspected DL injury, arthroscopic MCS is useful for determining deltoid lesion severity based on defined cutoff values for consideration in preoperative planning to improve surgical outcomes.

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Deep deltoid ligament injury is related to rotational instability of the ankle joint: a biomechanical study

Cited by 21 publications

References 28 publications

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

A Preliminary Study to Assess the Relevance of Shear-Wave Elastography in Characterizing Biomechanical Changes in the Deltoid Ligament Complex in Relation to Ankle Position

Arthroscopic Quantitative Measurement of Medial Clear Space for Deltoid Injury of the Ankle: A Cadaveric Comparative Study With Stress Radiography

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