Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 11-17, March 2010

Deltoid Ligament Injuries in Athletes: Techniques of Repair and Reconstruction

  • Timothy C. Beals, MD

      Affiliations

    • Deparment of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT
    • Corresponding Author InformationAddress reprint requests to Timothy C. Beals, MD, Department of Orthopaedics, University Orthopaedic Center, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108
    • ,
  • Julia Crim, MD

      Affiliations

    • Department of Radiology, University of Utah School of Medicine, Salt Lake City, UT
    • ,
  • Florian Nickisch, MD

      Affiliations

    • Deparment of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT

Article Outline

Deltoid ligament injuries are a source of valgus and rotational ankle instability and often occur as a result of athletic injury. The anatomy of the medial ankle ligament complex is reviewed and pertinent radiological findings are emphasized. The clinical evaluation of athletes with medial ankle instability as well as methods of repair and reconstruction of the deltoid ligament complex in those patients requiring surgical care are described.

Keywords: deltoid, ligament, ankle, reconstruction, instability

 

Although ligamentous injuries of the ankle are common, the majority of focus is upon lateral sided injuries.1, 2 Injuries of the medial complex of ligaments of the hindfoot are less common, but they are observed after sporting injury and ankle fractures.3, 4, 5 The purpose of this article is to describe the evaluation of athletes with medial-sided ankle pain, with emphasis on the assessment of the medial ankle ligamentous complex. The anatomy and radiological findings associated with injury to the deltoid complex are reviewed. Finally, techniques that can be used for surgical repair or reconstruction of this ligamentous complex, where mechanical failure creates functional impairment are demonstrated.

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Anatomy and Radiographic Findings 

Many authors have described the anatomic delineation of the ligaments of the medial ankle. Sarrafian6 provided the most thorough review of the several existing descriptions. Experienced surgeons recognize that the actual distinction between the formally described anatomic structures is often less clear during surgery than images in texts as sheets of tissue meld together, particularly in those patients with subacute or chronic injuries who come to surgical repair or reconstruction. The singular point of agreement emphasized by each author is the presence of a superficial layer and a deep layer. The superficial layer primarily originates from the superficial margin of the anterior colliculus and attaches to the dorsal talus, navicular, and sustentaculum (anterior superficial tibiotalar and tibionavicular fascicles, tibioligamentous fascicle, tibiocalcaneal ligament, and superficial posterior tibiotalar ligament). The deep deltoid (deep anterior and deep posterior tibiotalar ligaments) arises from the deep margin of the posterior colliculus and attaches on the medial talus. Boss and Hintermann7 have emphasized the variability observed in a cadaveric study of deltoid ligaments.

The best imaging modality to define injury to the medial ankle ligament complex is magnetic resonance imaging (MRI). Deltoid anatomy appears fairly constant on MRI. The deep deltoid ligament can be divided into 2 portions, posterior and anterior. The posterior portion is what is usually identified as the deep deltoid ligament surgically. This structure is broad, and contains multiple discrete fibers resulting in a striated appearance on MRI. There is often a small amount of fluid separating the fiber bundles. Fibers extend horizontally from the posterior colliculus and posterior margin of anterior colliculus of the medial malleolus to a broad attachment on a medial concavity of the talar body (Fig. 1). The anterior deep fibers of the deltoid ligament extend from the anterior margin of the medial malleolus to a tubercle on the medial talar neck (Fig. 2).

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  • Figure 1. 

    Coronal fast spin-echo (FSE) T2-weighted with fat saturation MRI image showing posterior deep deltoid ligament (arrowhead), a broad, fan shaped ligament extending horizontally from the posterior colliculus of the medial malleolus to the deltoid fovea at the medial margin of the talus.

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  • Figure 2. 

    Coronal FSE T2-weighted with fat saturation MRI image showing the thin anterior deep deltoid ligament (arrowhead), extending from the anterior colliculus to the antero-medial margin of the talar body. The anterior deep deltoid ligament is difficult to identify at arthroscopy. Much more prominent on this image is the robust and constant tibiosustentacular (ie, tibiocalcaneal) component of the superficial deltoid (arrow).

The superficial fibers of the deltoid ligament have a common origin on the medial and anteromedial surface of the medial malleolus. Posteriorly, the common origin merges with the flexor retinaculum. Distinct bands can be seen inserting on the talar neck, navicular, spring ligament, sustentaculum tali, and posteriorly on the body of the talus. The bands are named according to their proximal and distal attachments (Fig. 3). Some confusion exists in the literature about the tibiospring ligament, which is sometimes considered to be the superomedial calcaneonavicular ligament. The inferior calcaneonavicular ligament is formally described as the spring ligament.8, 9

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  • Figure 3. 

    Axial FSE T2-weighted with fat saturation MRI image showing the origin of the superficial deltoid ligament from the anteromedial margin of the medial malleolus (arrow). A thin sheet of fibers extends posteriorly, merging with the periosteum of the tibia and with fibers of the flexor retinaculum (arrowhead).

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Function of the Deltoid Ligament 

It is critically important to recognize that the deltoid ligament complex is a condensation of discrete components that have different functions. The deep deltoid resists posterior translation of the talus, as well as valgus angulation and lateral translation of the talus away from the medial malleolus. It does not prevent moderate rotation of the talus relative to the tibia in the ankle mortise. The superficial structures of the deltoid complex resist external rotation of the talus relative to the tibia and valgus stress. In addition to the constraints provided by the superficial deltoid ligament fibers, the flexor retinaculum and even the posterior tibial tendon sheath contribute to medial ligament complex stability.10, 11

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Clinical Examination 

Examination of the lateral ligaments of the ankle is well described, with recognized tests that identify the relative stability of the anterior talofibular and calcaneofibular ligaments, namely the anterior drawer and varus tilt tests, respectively. Hintermann et al have suggested that arthroscopic findings offer the best way to define medial ligamentous instability,12, 13 however there is no established standard for clinical examination of the deltoid ligament. We have found the clinical examination to be fairly reliable when the anatomy is thoroughly understood and the examination of the superficial and the deep deltoid ligaments are performed separately. The following are the methods we use to assess deltoid stability at our institution.

Examination of the superficial deltoid is performed with the patient seated on a table and relaxed in a position of mild ankle plantarflexion. The heel is cupped in the examiner's hand and brought forward while stabilizing the tibia with the opposite hand. In the case of superficial deltoid insufficiency, enhanced external rotation of the talus is observed in comparison with the contralateral side (Fig. 4). Stated another way, with increasing anterior translation, a normal foot will internally rotate around the intact superficial deltoid but will fail to do so if the ligament is impaired. Increased rotational instability also can be due to lateral collateral ligament injury, increasing the difficulty of assessing the contribution of medial ligament injury. The anterior portion of the medial malleolus is painful to palpation in patients who have acute superficial deltoid injuries but this finding may be absent in athletes with chronic instability.

The deep deltoid ligament is evaluated by assessing posterior translation of the talus relative to a stabilized tibia. To examine for abnormal posterior translation, the patient must be completely relaxed. This is often best achieved by having the patient lie prone on a table with the foot hanging over the edge. The degree of posterior translation of the foot is assessed in comparison with the contralateral side. Fluoroscopic evaluation of anesthetized patients with deep deltoid ligament functional incompetence may show apparent increase in the joint space between the tibial plafond and the talar trochlea as a result of translation of the talus along the posterior plafond.

Valgus tilt is also evaluated. Valgus tilt of the ankle is partly controlled by the deltoid ligament complex, with both the deep deltoid and the tibiocalcaneal portion of the superficial deltoid acting to limit this motion. Unfortunately, the findings from this test are less clear. It is difficult for the examiner to determine the contribution of the ankle to this motion in contrast to the subtalar complex. Radiographic stress images have not been found to be routinely helpful beyond a simple standing ankle view or an axial hindfoot alignment view with the observation of valgus tilt through the joint space. Widening of the medial clear space to more than 6 mm is a specific but not sensitive radiographic sign of deep deltoid insufficiency.

In the case of suspected deltoid ligament insufficiency, it is imperative that the examiner makes a complete assessment of the limb in terms of alignment, standing posture, and gait pattern. One must determine changes in the alignment of the hindfoot relative to the tibia with provocative testing, such as bilateral and single leg heel rise tests. The possible contribution of abnormalities of the posterior tibial tendon and the spring ligament complex to the rotational or valgus instability of the hindfoot must also be assessed.

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Functional Classification of Deltoid Complex Injuries 

For identifying which components of the deltoid complex are functionally deficient, we have defined 2 groups of patients, those with failure to limit rotational stress (type I) and those with enhanced talar coronal angulation or translation (type II). In type I deltoid insufficiency, the superficial ligament is incompetent, which yields an increase in rotational instability without evidence of instability of the tibiotalar joint with valgus stress or posterior translation. In type II insufficiency, both the superficial and deep components of the deltoid are functionally incompetent, which results in an increase in rotational instability and coronal tibiotalar instability to valgus stress. We recognize that this functional assessment is an arbitrary distinction imposed on a continuum of injuries. However, we have found it meaningful when surgical treatment is considered as “repair” in contrast to “reconstruction.” For this discussion, the term “repair” is used to describe a surgical circumstance where tissue can be directly replaced to its anatomic origin in contrast to “reconstruction,” which refers to procedures where a modification of tissue arrangement is performed to remedy functionally important mechanical instability.

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Technique of Repair 

For direct repair of the superficial deltoid ligament to be successful, the tissue that is to be advanced back to the medial malleolus must be of adequate integrity to have confidence that the structural repair will be maintained after healing. A longitudinal incision is created over the anterior portion of the medial malleolus and the superficial deltoid complex is identified. A 3-5 cm incision allows evaluation of the posterior tibial tendon if that is deemed necessary. To identify possible midsubstance tears, it is important to clean subcutaneous adipose tissue off the ligamentous structure. Damp gauze is well suited for this purpose. If no midsubstance tear is identified a deeper longitudinal incision that curves posteriorly is created in front of the medial malleolus through the ligamentous tissue and the anterior portion of the superficial deltoid complex is defined. This ligamentous tissue may be avulsed from the malleolus and can be reapproximated to the bone or advanced using a suture anchor and imbrication of the surround tissue layer once the anchor tensions the deep tissue (Fig. 5). It is important to create a proper environment for healing by roughening the exposed area of the anterior medial malleolus. The portions of the superficial deltoid affected in this repair technique include the anterior superficial tibiotalar, and the tibionavicular and tibioligamentous fascicles. This repair does not directly affect the tibiocalcaneal ligament. It should be noted that the literature is confusing as it describes this anatomy. Hintermann et al13 refers to the “tibial spring ligament,” which corresponds to the tibionavicular and tibioligamentous fascicles of the superficial deltoid complex as defined by Sarafian.6

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  • Figure 5. 

    (A) Operative image showing a superficial deltoid ligament avulsed from the medial malleolus. (B) Fluoroscopic image showing the location of a metallic anchor used for the direct repair of an avulsed superficial deltoid ligament.

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Technique of Reconstruction 

The goal of reconstruction is to reconstitute the medial ligamentous structural integrity. Patients requiring a reconstructive operation typically exhibit both rotatory instability as well as enhanced talar translation or valgus angulation in the coronal plane. One must thoroughly assess the patient to appreciate whether there is concomitant posterior tibial tendon dysfunction and/or lateral ligamentous instability. It is imperative to identify preoperatively whether the observed clinical alignment demands concomitant osteotomy or other corrective surgery.

Because of the relatively uncommon circumstance of functional deltoid insufficiency, there are few described techniques for reconstruction. Deland et al have described a technique for reconstruction in the setting of stage IV posterior tibial tendon insufficiency when combined with appropriate reconstruction of the foot deformity. Their technique involves passing a peroneus longus tendon graft through a bone tunnel in the talus from lateral to medial and then through a second tunnel from the tip of the medial malleolus to the lateral tibia.14 Bohay and Anderson15 have described the use of an autograft flexor hallucis longus tendon transfer technique in patients with stage 4 posterior tibial tendon insufficiency. Bluman and Myerson16 described the use of an allograft technique for this same population. Both authors acknowledge the contribution of Manoli in the advancement of techniques of deltoid reconstruction. The authors have favorable experience with an alternative technique tightening the incompetent superficial deltoid complex by translating the bony origin of the anterior portion of the deltoid proximally on the tibia and securing it with a tensioned suture device. This technique may be most appropriate for athletes with rotational (type I) problems when the tissues for repair are particularly damaged but it can also be used for those with more severe ligamentous insufficiency (type II).

An incision is made over the medial malleolus that is parallel to the course of the posterior tibial tendon but slightly anterior to its course (Fig. 6). The superficial deltoid ligament is defined anteriorly at the margin of the medial malleolus and the region of the tibiocalcaneal ligament is defined by palpation more posteriorly on the anterior colliculus. This is the region of tissue that is to be advanced proximally. Parallel incisions are made in the periosteum (Fig. 7) and then an osteotome is used to create a bony defect in the region of origin of the superficial deltoid complex in a rectangular shape. This piece of bone and its associated ligamentous attachment is liberated from the medial malleolus (Fig. 8). Then, the osteotome is used to create a more proximal defect in the tibia in line with this defect and that bone is removed to allow the bone fragment attached to the ligamentous origin of the superficial deltoid to be advanced up into the area of defect. A guide wire is used to create a hole from the proximal end of the bony defect in the medial malleolus through to the lateral cortex of the tibia more proximally. Dissection through a small incision laterally is performed onto the guide wire that exits the tibia and then a cannulated drill is passed over the wire. A suture-button device is passed from lateral to medial out of the area of bony defect and then passed through the substance of the ligamentous tissue just beneath the bone fragment to be advanced (Fig. 9). The device is tightened on the lateral tibia, advancing the superficial deltoid ligament complex proximally in the tibial trough and increasing the stability to rotational and valgus forces to the ankle. The surrounding periosteal and ligamentous tissues of the deltoid complex are repaired to support the reconstruction (Fig. 10). It should be acknowledged that intraoperative fluoroscopy is helpful to ensure proper tunnel and device placement (Fig. 11). Perioperative treatment has been to limit weight bearing for 6 weeks with casting or boot immobilization and allow subsequent activities to tolerance.

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  • Figure 8. 

    A clamp everts the osteoligamentous flap that is to be advanced proximally on the medial malleolus. The origin of the tibiocalcaneal ligament is attached to the bony fragment but the deep deltoid origin is undisturbed.

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  • Figure 11. 

    (A) Intraoperative fluoroscopy image of rock climber 9 months after fall with resultant medial ankle instability. Note the medial joint gapping with stress and bone fragments consistent with deltoid ligament disruption. (B) Arthroscopic image demonstrating a hook around an avulsed superficial deltoid ligament. (C) Same patient after deltoid reconstruction with advancement of an osteoligamentous flap. Mortise is restored.

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Realignment and Reconstruction 

One fundamental principle embraced by foot and ankle orthopedists is that for a limb to be optimally managed it must end up in proper alignment after reconstructive surgery. Deltoid reconstruction done in the absence of an assessment of limb alignment and without proper combined procedures to address abnormal mechanics will be less likely to succeed, particularly in the longer term. One would assume that excessive valgus alignment is the primary deformity in athletes with a deficient functional deltoid complex but those with medial and lateral chronic ligamentous instability encompasses the spectrum of patients in terms of deformity. The key to optimal treatment is to ensure a proper assessment of both the ligamentous stability of the ankle and to characterize the alignment of the limb both above and below the level of the ankle. Figure 12A illustrates the alignment of a patient with a type II medial ankle ligamentous insufficiency in concert with a flatfoot deformity. The patient was treated with a deltoid ligament reconstruction procedure and an osteotomy of the calcaneus and fusion to address the static deformity as well as the dynamic instability (Fig. 12B). Note that the valgus tilt of the talus seen on the preoperative image is corrected to anatomic alignment in the postoperative weight bearing view 2 years later.

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  • Figure 12. 

    (A) Preoperative weight bearing ankle view showing valgus tilt consistent with incompetence to the deltoid ligament complex. Excessive valgus is present. (B) Same patient after deltoid ligamentous reconstruction as described and concomitant realignment.

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Conclusions 

Deltoid ligament injuries, particularly in athletes, can lead to medial ankle pain and instability. Proper assessment of the mechanical alignment of the limb and the ligamentous stability of both the medial and lateral ligaments allows the treating physician to properly diagnose deltoid ligamentous insufficiency. MRI imaging is key to identifying the components of the ligament that are injured and helps in planning the appropriate operative plan and repair strategy. Options for repair and reconstruction are available to address the degree of insufficiency identified and proper assessment of the need for concomitant procedures is emphasized. Techniques for repair and reconstruction of the deltoid complex are described. Deltoid ligament reconstruction is an unusual procedure in foot and ankle reconstruction but one that is necessary to address incompetence of the medial ankle ligamentous complex.

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References 

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PII: S1060-1872(09)00123-3

doi:10.1053/j.otsm.2009.10.001

Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 11-17, March 2010

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