Repair of Acute Deltoid Complex Avulsion During Ankle Fracture Fixation in National Football League Players
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1 Repair of Acute Deltoid Complex Avulsion During Ankle Fracture Fixation in National Football League Players Andrew R. Hsu, MD, Craig R. Lareau, MD, and Robert B. Anderson, MD
2 Disclosures: Andrew R. Hsu, MD: None Craig R. Lareau, MD: None Robert B. Anderson, MD: Amniox, Arthrex, Inc., DJ Orthopaedics, Wright Medical Technology, Inc. All disclosures are listed in the Final AOFAS Mobile App
3 Is acute deltoid complex avulsion off of the medial malleolus an under-recognized injury in athletes? Medial * * = bare medial mal = deltoid complex avulsion * *
4 Level IV Study: 12 active NFL players who underwent ankle ORIF with deltoid complex repair : All active NFL players undergoing ankle ORIF Excluded: chronic deltoid injuries, ankle fractures >2 mo old Surgical protocol: 1.) Ankle scope with extensive debridement 2.) Fibula ORIF with plate and screws (Ortholoc 3Di, Wright Medical) 3.) Syndesmosis fixation with suture button devices (TightRope, Arthrex, Inc.) 4.) Open deltoid complex repair (SutureTak with 2-0 Fiberwire, Arthrex, Inc.) Min 12 month f/u: serial clinical exams Variables: demographics, position played, time from injury to surgery, playing experience before and after surgery, ability to return to play (RTP, 1 regular season game), complications
5 Surgical Technique: Stress exam Scope with debridement (5 min, no OCD microfractures) Medial clear space Syndesmosis disruption Medial ecchymosis Deltoid injury
6 Surgical Technique: Fibula + Syndesmosis ORIF Deltoid complex direct repair Lag screws + nonlocking/locking screws + plate Bare medial mal 2 divergent Tightropes 2-4 cm above joint Deltoid complex avulsion Rongeur used to create bleeding bony surface 1-2 suture anchors in medial mal 5mm above tip 2-0 Fiberwire sutures for horizontal mattress stitches Ankle slightly inverted during suture tying Repair reinforced with remaining 2-0 Fiberwire
7 Post-operative rehabilitation: Weeks 0-2: non-weight bearing (NWB) splint Weeks 2-4: suture removal, NWB cast Weeks 4-6: partial-weight bearing in tall CAM boot Week 6: initial physical therapy, range of motion exercises Weeks 6-12: wean out of CAM boot, lace-up ASO, WBAT Weeks 12-16: increasing impact activity 5-6 months: return to running, cutting, RTP
8 *83% (10/12) of NFL players able to RTP Positions: 1 wide receiver 1 tight end 1 safety 1 running back 1 linebacker 7 offensive linemen No post-op complications No residual medial pain or instability Outcomes NFL Players (n = 12) Ave age (years) 25 2 Ave BMI Ave f/u (years) Injury to surgery (days) Operative time (min) Return to play (RTP) 83% *No significant differences in playing experience before vs. after surgery
9 Summary: Complete avulsion of the superficial and deep components of the deltoid complex off of the medial mal during high-energy ankle fractures in athletes is relatively common Acute deltoid complex avulsion may benefit from direct repair with suture anchors Limitations: retrospective, small cohort, ave f/u 9 months, no clinical or functional outcomes, no control group, many factors influencing RTP The majority (83%) of NFL players with this injury pattern are able to RTP with min pain and no medial ankle symptoms Future studies needed to evaluate the benefits of deltoid repair during ankle ORIF in the general population
10 References: 1. Hintermann B, Valderrabano V, Boss A, Trouillier HH, Dick W. Medial ankle instability: an exploratory, prospective study of fifty-two cases. Am J Sports Med. 2004;32(1): Campbell KJ, Michalski MP, Wilson KJ, et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am. 2014;96(8):e Zeegers AV, van der Werken C. Rupture of the deltoid ligament in ankle fractures: should it be repaired? Injury. 1989;20(1): Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries: diagnosis and management. Foot Ankle Clin. 2006;11(3): Jeong MS, Choi YS, Kim YJ, et al. Deltoid ligament in acute ankle injury: MR imaging analysis. Skeletal Radiol. 2014;43(5):
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