Deltoid Ligament Injuries Associated With Ankle Fractures

Arguments For and Against Direct Repair

Jesse F. Doty, MD; Burton D. Dunlap, MD; Vinod K. Panchbhavi, MD, FACS; Michael J. Gardner, MD


J Am Acad Orthop Surg. 2021;29(8):e388-e395. 

In This Article

Abstract and Introduction


Ankle fractures are an extremely common orthopaedic injury treated by surgeons on a routine basis. The deltoid ligament is torn in a large number of these fractures and is commonly seen with associated radiographic changes of medial clear space widening. The clinical relevance of addressing the injured deltoid ligament with acute surgical repair has been debated for decades. The early literature documenting repair or reconstruction of the deltoid ligament dates back to the 1950s. Most commonly, orthopaedic surgeons restore the lateral column directly with fibula fracture fixation. The injury may then be further evaluated intraoperatively by stress testing to ensure syndesmosis integrity and mortise stability with indirect medial column reduction, which allows for secondary healing of the medial deltoid ligamentous complex. This popular treatment paradigm is based primarily on literature from the 1980s and has not been thoroughly evaluated with modern surgical implants, techniques, and research methods. A review and background of the supportive literature for and against deltoid ligament repair in the setting of acute ankle fractures is presented. Undeniably, the deltoid ligament complex has been proven to confer some element of stability to maintaining a congruent ankle mortise. The commonly cited data in favor of not repairing the deltoid ligament warrants careful consideration to allow accuracy in obtaining the best patient outcomes with the most predictable surgical methods available.


Ankle fractures are among one of the most common orthopaedic injuries. Many of these fractures are associated with a concomitant deltoid ligament injury. The deltoid ligament complex is the primary soft-tissue stabilizer of the ankle mortise. It resists translation of the talus in posterior and lateral directions and provides restraint to external and internal rotation and valgus tilt.[1] The superficial fibers primarily resist coronal plane eversion, whereas the deep fibers are considered a primary restraint of transverse plane rotation.[2]

Early radiographic reports suggested deltoid ligament injuries occur in about 10% of all ankle fractures.[3] More recently, arthroscopic evaluations reveal that deltoid ligament injuries likely occur in up to 40% of ankle fractures.[4] In addition, 37% to 65% of all isolated Weber B fibula fractures have a positive stress test demonstrated by medial clear space (MCS) widening or valgus tilt.[5]

Acceptable outcomes have been reported with repair, reconstruction, or indirect reduction to allow secondary healing of the torn deltoid ligament. The paradigm of not directly addressing the ligament is based on small case series with limited patient enrollment in the 1980s and 1990s. In Duvries' Surgery of the Foot, published in 1959, primary deltoid repair in the setting of degeneration, sprains, and ankle fractures was reported.[6] Decades later, in 1988, Johnson and Hill[7] published their technique on doing primary deltoid ligament repair in the setting of acute ankle fracture fixation. Similarly, in the mid-1980s, other authors further recognized the deltoid ligament's contribution to chronic pathologic conditions. Kelikian and Kelikian[8] documented their technique for doing deltoid ligament reconstruction in cases with degenerative soft-tissue instability, such as adult acquired flatfoot deformity. Evidence and quality outcome studies continued to be limited, and questions remain regarding best practices for acute injuries and chronic insufficiency. Even with a high incidence of deltoid ligament injuries, predicting the clinical impact on subjective outcomes and accurately correlating long-term functional instability with acute objective radiographic measures has proven difficult.