Instabile Verletzungen des Deltabandkomplexes bei Sprunggelenkfrakturen

Wie erkennen, wie behandeln?

Unstable injuries of the deltoid ligament complex in ankle fractures

How to diagnose, how to treat?

Zusammenfassung

Instabile Verletzungen des Deltabandkomplexes beeinflussen maßgeblich die Prognose und die Therapie von Verletzungen des oberen Sprunggelenks. Läsionen des medialen Bandapparats werden, sowohl isoliert als auch in Kombination mit komplexeren Sprunggelenkverletzungen, häufig übersehen. Nichtadressierte, instabile Läsionen des medialen Bandapparats können, insbesondere nach regelgerechter Versorgung von Frakturen und lateralen Bandverletzungen, zu chronischen Instabilitäten führen. Diese gehen mit Bewegungseinschränkungen, persistierenden Schmerzen, geminderter Belastbarkeit und Arthrose einher. Trotz der möglichen Folgeschäden wird die Therapie instabiler Verletzungen des Deltabandkomplexes kontrovers diskutiert. Obwohl bei den meisten Bandverletzungen am oberen Sprunggelenk konservative Behandlungen sehr gute Ergebnisse erzielen, werden, gerade bei instabilen Verletzungen, zunehmend operative Therapieverfahren postuliert, um sekundäre Instabilitäten und die damit einhergehenden Folgeschäden zu vermeiden. Nicht ausreichend geklärt ist, ab wann eine operative Behandlung der konservativen Therapie vorzuziehen ist. Diese Arbeit gibt anhand der aktuellen Literatur einen Überblick über die Diagnose und Therapie von Verletzungen des Deltabandkomplexes bei Patienten mit Sprunggelenkfrakturen.

Abstract

Unstable injuries of the deltoid ligament complex can have a substantial negative effect on the prognosis and treatment of ankle injuries. Lesions of the deltoid ligament are often overlooked at the initial presentation, both as isolated ruptures and in combination with more complex injuries of the ankle. Neglected unstable injuries of medial ankle ligaments may result in chronic instability, especially following correct treatment of fractures and lateral ligament injuries. These are accompanied by reduced ankle mobility, persisting pain, reduced load bearing and osteoarthritis. Despite the possible subsequent damage, the need for surgical repair of the deltoid ligament in patients with ankle fractures is controversially discussed. Although in most cases of ligament injuries of the upper ankle joint conservative treatment leads to very good results, there is increased interest in acute surgical treatment particularly for unstable injuries in order to avoid secondary instability and the associated sequelae. When surgical treatment should be given priority over conservative treatment has not yet been sufficiently clarified. This article gives an overview of the diagnosis and treatment of injuries of the deltoid ligament complex in patients with ankle fractures based on the current literature.

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Literatur

  1. 1.

    Barg A (2015) Natives Röntgen vom Rückfuß und Saltzman-Aufnahme. Fuss Sprungg 13:58–77

    Google Scholar 

  2. 2.

    Barg A, Bailey T, Richter M, de Cesar Netto C, Lintz F, Burssens A et al (2018) Weightbearing computed tomography of the foot and ankle: emerging technology topical review. Foot Ankle Int 39:376–386

    PubMed  Google Scholar 

  3. 3.

    Bartoníček J, Rammelt S, Kašper Š, Malík J, Tuček M (2019) Pathoanatomy of Maisonneuve fracture based on radiologic and CT examination. Arch Orthop Trauma Surg 139:497–506

    PubMed  Google Scholar 

  4. 4.

    Bluman EM (2012) Deltoid ligament injuries in ankle fractures: should I leave it or fix it? Foot Ankle Int 33:236–238

    PubMed  Google Scholar 

  5. 5.

    Brage ME, Bennett CR, Whitehurst JB, Getty PJ, Toledano A (1997) Observer reliability in ankle radiographic measurements. Foot Ankle Int 18:324–329

    CAS  PubMed  Google Scholar 

  6. 6.

    Burssens A, Vermue H, Barg A, Krähenbühl N, Victor J, Buedts K (2018) Templating of syndesmotic ankle lesions by use of 3D analysis in weightbearing and nonweightbearing CT. Foot Ankle Int 39:1487–1496

    PubMed  Google Scholar 

  7. 7.

    Cheung Y, Perrich KD, Gui J, Koval KJ, Goodwin DW (2009) MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted? AJR Am J Roentgenol 192:W7–12

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Court-Brown CM, McBirnie J, Wilson G (1998) Adult ankle fractures—an increasing problem? Acta Orthop Scand 69:43–47

    CAS  PubMed  Google Scholar 

  9. 9.

    Dabash S, Elabd A, Potter E, Fernandez I, Gerzina C, Thabet AM et al (2019) Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review. Foot Ankle Surg 25:714–720

    PubMed  Google Scholar 

  10. 10.

    Ebraheim NA, Elgafy H, Padanilam T (2003) Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orthop Relat Res 409:260–267. https://doi.org/10.1097/01.blo.0000052935.71325.30. https://pubmed.ncbi.nlm.nih.gov/12671510/

    Article  Google Scholar 

  11. 11.

    Egol KA, Amirtharajah M, Tejwani NC, Capla EL, Koval KJ (2004) Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am 86:2393–2398

    PubMed  Google Scholar 

  12. 12.

    Golano P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Gotzens V et al (2016) Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 24:944–956

    PubMed  Google Scholar 

  13. 13.

    Gosselin-Papadopoulos N, Hébert-Davies J, Laflamme GY, Beauséjour M, Ménard J, Leduc S et al (2019) Intraoperative torque test to assess syndesmosis instability. Foot Ankle Int 40:408–413

    PubMed  Google Scholar 

  14. 14.

    Haraguchi N, Haruyama H, Toga H, Kato F (2006) Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 88:1085–1092

    PubMed  Google Scholar 

  15. 15.

    Hardy MA, Connors JC, Zulauf EE, Coyer MA (2020) Acute deltoid ligament repair in ankle fractures: five-year follow-up. Clin Podiatr Med Surg 37:295–304

    PubMed  Google Scholar 

  16. 16.

    Hintermann B, Golano P (2014) The anatomy and function of the deltoid ligament. Tech Foot Ankle 13:67–72

    Google Scholar 

  17. 17.

    Hintermann B, Regazzoni P, Lampert C, Stutz G, Gächter A (2000) Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br 82:345–351

    CAS  PubMed  Google Scholar 

  18. 18.

    Jastifer JR, Jaykel M (2017) Results of the gravity stress examination in the normal patient population. Foot Ankle Spec 10:398–401

    PubMed  Google Scholar 

  19. 19.

    Krähenbühl N, Bailey TL, Weinberg MW, Davidson NP, Hintermann B, Presson AP et al (2019) Impact of torque on assessment of syndesmotic injuries using weightbearing computed tomography scans. Foot Ankle Int 40:710–719

    PubMed  Google Scholar 

  20. 20.

    Lauge-Hansen N (1950) Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60:957–985

    CAS  PubMed  Google Scholar 

  21. 21.

    Lawlor MC, Kluczynski MA, Marzo JM (2018) Weight-bearing cone-beam CT scan assessment of stability of supination external rotation ankle fractures in a cadaver model. Foot Ankle Int 39:850–857

    PubMed  Google Scholar 

  22. 22.

    Lee S, Lin J, Hamid KS, Bohl DD (2019) Deltoid ligament rupture in ankle fracture: diagnosis and management. J Am Acad Orthop Surg 27:e648–e58

    PubMed  Google Scholar 

  23. 23.

    Linklater JM, Read JW, Hayter CL (2014) Imaging of the foot and ankle. In: Coughlin MJ, Saltzman CL, Anderson RB (Hrsg) Mann’s surgery of the foot and ankle. Elsevier Saunders, Philadelphia

    Google Scholar 

  24. 24.

    Metitiri O, Ghorbanhoseini M, Zurakowski D, Hochman MG, Nazarian A, Kwon JY (2017) Accuracy and measurement error of the medial clear space of the ankle. Foot Ankle Int 38:443–451

    PubMed  Google Scholar 

  25. 25.

    Michelson JD, Varner KE, Checcone M (2001) Diagnosing deltoid injury in ankle fractures: the gravity stress view. Clin Orthop Relat Res 387:178–182. https://doi.org/10.1097/00003086-200106000-00024

    Article  Google Scholar 

  26. 26.

    Murphy JM, Kadakia AR, Irwin TA (2012) Variability in radiographic medial clear space measurement of the normal weight-bearing ankle. Foot Ankle Int 33:956–963

    PubMed  Google Scholar 

  27. 27.

    Nortunen S, Flinkkilä T, Lantto I, Kortekangas T, Niinimäki J, Ohtonen P et al (2015) Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination-external rotation-type lateral malleolar fractures. Bone Joint J 97-b:1126–1131

    CAS  PubMed  Google Scholar 

  28. 28.

    Nortunen S, Lepojärvi S, Savola O, Niinimäki J, Ohtonen P, Flinkkilä T et al (2014) Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI. J Bone Joint Surg Am 96:1855–1862

    PubMed  Google Scholar 

  29. 29.

    Park SS, Kubiak EN, Egol KA, Kummer F, Koval KJ (2006) Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma 20:11–18

    PubMed  Google Scholar 

  30. 30.

    Pitakveerakul A, Kungwan S, Arunakul P, Arunakul M (2019) Radiographic parameters in gravity stress view of the ankle: normative data. Foot Ankle Surg 25:819–825

    PubMed  Google Scholar 

  31. 31.

    Rammelt S, Amlang M, Zwipp H (2010) Standardröntgendiagnostik an Fuß und Sprunggelenk. Fuss Sprungg 7:80–91

    Google Scholar 

  32. 32.

    Rammelt S, Boszczyk A (2018) Computed tomography in the diagnosis and treatment of ankle fractures: a critical analysis review. JBJS Rev 6:e7

    PubMed  Google Scholar 

  33. 33.

    Rammelt S, Obruba P (2015) An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg 41:601–614

    CAS  PubMed  Google Scholar 

  34. 34.

    Rammelt S, Schneiders W, Grass R, Rein S, Zwipp H (2011) Ligamentous injuries to the ankle joint. Z Orthop Unfall 149:e45–e67

    CAS  PubMed  Google Scholar 

  35. 35.

    Ramsey PL, Hamilton W (1976) Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 58:356–357

    CAS  PubMed  Google Scholar 

  36. 36.

    Richter J, Schulze W, Clasbrummel B, Muhr G (2003) The role of the tibiofibular syndesmotic and the deltoid ligaments in stabilizing Weber B type ankle joint fractures—an experimental investigation. Unfallchirurg 106:359–366

    CAS  PubMed  Google Scholar 

  37. 37.

    Rosa I, Rodeia J, Fernandes PX, Teixeira R, Saldanha T, Consciência JG (2020) Ultrasonographic assessment of deltoid ligament integrity in ankle fractures. Foot Ankle Int 41:147–153

    PubMed  Google Scholar 

  38. 38.

    Savage-Elliott I, Murawski CD, Smyth NA, Golano P, Kennedy JG (2013) The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies. Knee Surg Sports Traumatol Arthrosc 21:1316–1327

    PubMed  Google Scholar 

  39. 39.

    Seidel A, Krause F, Weber M (2017) Weightbearing vs gravity stress radiographs for stability evaluation of supination-external rotation fractures of the ankle. Foot Ankle Int 38:736–744

    PubMed  Google Scholar 

  40. 40.

    Sripanich Y, Weinberg MW, Krähenbühl N, Rungprai C, Saltzman CL, Barg A (2020) Reliability of measurements assessing the Lisfranc joint using weightbearing computed tomography imaging. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03477-5. https://pubmed.ncbi.nlm.nih.gov/32415387/

    Article  PubMed  Google Scholar 

  41. 41.

    Stenquist DS, Miller C, Velasco B, Cronin P, Kwon JY (2020) Medial tenderness revisited: is medial ankle tenderness predictive of instability in isolated lateral malleolus fractures? Injury 51:1392–1396

    PubMed  Google Scholar 

  42. 42.

    Strömsöe K, Höqevold HE, Skjeldal S, Alho A (1995) The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg Br 77:920–921

    PubMed  Google Scholar 

  43. 43.

    Stufkens SA, Knupp M, Lampert C, van Dijk CN, Hintermann B (2009) Long-term outcome after supination-external rotation type‑4 fractures of the ankle. J Bone Joint Surg Br 91:1607–1611

    CAS  PubMed  Google Scholar 

  44. 44.

    Sun X, Li T, Sun Z, Li Y, Yang M, Li S et al (2018) Does routinely repairing deltoid ligament injuries in type B ankle joint fractures influence long term outcomes? Injury 49:2312–2317

    PubMed  Google Scholar 

  45. 45.

    Taniguchi A, Tanaka Y, Takakura Y, Kadono K, Maeda M, Yamamoto H (2003) Anatomy of the spring ligament. J Bone Joint Surg Am 85-a:2174–2178

    Google Scholar 

  46. 46.

    Tornetta P 3rd (2000) Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am 82:843–848

    PubMed  Google Scholar 

  47. 47.

    Valderrabano V, Hintermann B (2005) Diagnostik und Therapie der medialen Sprunggelenkinstabilität. Arthroskopie 18:112–118

    Google Scholar 

  48. 48.

    Valderrabano V, Hintermann B, Horisberger M, Fung TS (2006) Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med 34:612–620

    PubMed  Google Scholar 

  49. 49.

    Valderrabano V, Wiewiorski M, Frigg A, Hintermann B, Leumann A (2007) Chronic ankle instability. Unfallchirurg 110:691–699 (quiz 700)

    CAS  PubMed  Google Scholar 

  50. 50.

    Valderrabano V, Wiewiorski M, Frigg A, Hintermann B, Leumann A (2007) Direct anatomic repair of the lateral ankle ligaments in chronic lateral ankle instability. Unfallchirurg 110:701–704

    CAS  PubMed  Google Scholar 

  51. 51.

    van den Bekerom MP, Mutsaerts EL, van Dijk CN (2009) Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg 129:227–235

    PubMed  Google Scholar 

  52. 52.

    van Leeuwen C, Haak T, Kop M, Weil N, Zijta F, Hoogendoorn J (2019) The additional value of gravity stress radiographs in predicting deep deltoid ligament integrity in supination external rotation ankle fractures. Eur J Trauma Emerg Surg 45:727–735

    PubMed  Google Scholar 

  53. 53.

    Vega J, Golano P, Pena F (2016) Iatrogenic articular cartilage injuries during ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 24:1304–1310

    PubMed  Google Scholar 

  54. 54.

    Walker RH, Farris C (1981) Irreducible fracture-dislocations of the ankle associated with interposition of the tibialis posterior tendon: case report and review of the literature of a specific ankle fracture syndrome. Clin Orthop Relat Res 160:212–216. https://pubmed.ncbi.nlm.nih.gov/7285426/

    Google Scholar 

  55. 55.

    Weber M, Burmeister H, Flueckiger G, Krause FG (2010) The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle. Arch Orthop Trauma Surg 130:693–698

    PubMed  Google Scholar 

  56. 56.

    Won HJ, Koh IJ, Won HS (2016) Morphologic variations of the deltoid ligament of the medial ankle. Clin Anat 29(8):1059–1065. https://doi.org/10.1002/ca.22793. https://pubmed.ncbi.nlm.nih.gov/27618430/

    Article  PubMed  Google Scholar 

  57. 57.

    Woo SH, Bae SY, Chung HJ (2018) Short-term results of a ruptured deltoid ligament repair during an acute ankle fracture fixation. Foot Ankle Int 39:35–45

    PubMed  Google Scholar 

  58. 58.

    Wu K, Lin J, Huang J, Wang Q (2018) Evaluation of transsyndesmotic fixation and primary deltoid ligament repair in ankle fractures with suspected combined deltoid ligament injury. J Foot Ankle Surg 57:694–700

    PubMed  Google Scholar 

  59. 59.

    Yu GR, Zhang MZ, Aiyer A, Tang X, Xie M, Zeng LR et al (2015) Repair of the acute deltoid ligament complex rupture associated with ankle fractures: a multicenter clinical study. J Foot Ankle Surg 54:198–202

    PubMed  Google Scholar 

  60. 60.

    Zhao HM, Lu J, Zhang F, Wen XD, Li Y, Hao DJ et al (2017) Surgical treatment of ankle fracture with or without deltoid ligament repair: a comparative study. BMC Musculoskelet Disord 18:543

    PubMed  PubMed Central  Google Scholar 

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Correspondence to Prof. Dr. Alexej Barg.

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C. Schlickewei, N. Krähenbühl, G.J. Dekeyser, M. Mills, M. Priemel, S. Rammelt, K.‑H. Frosch und A. Barg geben an, dass kein Interessenkonflikt besteht.

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Schlickewei, C., Krähenbühl, N., Dekeyser, G.J. et al. Instabile Verletzungen des Deltabandkomplexes bei Sprunggelenkfrakturen. Unfallchirurg 124, 190–199 (2021). https://doi.org/10.1007/s00113-021-00970-3

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Schlüsselwörter

  • Oberes Sprunggelenk
  • Gelenkinstabilität
  • Diagnostisches Assessment
  • Konservative Therapie
  • Rekonstruktive Chirurgie

Keywords

  • Ankle joint
  • Joint instability
  • Diagnostic assessment
  • Conservative therapy
  • Reconstructive surgery