Deltoid Ligament Injuries in Athletes: Techniques of Repair and Reconstruction

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.

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).

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).

Clinical image of rotatory drawer testing for medial ankle instability.

(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.

Clinical image of the course of the posterior tibial tendon and margin of the medial malleolus. Incision is created anterior to the posterior tibial tendon.

Periosteal incisions are visualized where the bony defect is to be created. Suture is seen more posteriorly where the posterior tibial tendon was evaluated.

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.

A guide wire for a suture button device traverses the bony fragment of the deltoid complex to be advanced.

The advanced osteoligamentous flap is secured by suture button and surrounding periosteal and ligamentous repair.

(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.

(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.