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Chronic medial ankle instability medial drive through sign and surgical repair technique

Open AccessPublished:July 06, 2022DOI:https://doi.org/10.1016/j.fastrc.2022.100225

      Abstract

      It has been estimated that the deltoid ligament complex is injured in 5-15% of acute inversion ankle injuries. This injury can result in clinically significant pain and instability. Accurate diagnosis is a combination of positive clinical findings and advanced imaging. However, arthroscopy can be a valuable tool in the diagnosis of deltoid ligament (medial ankle) instability. The authors describe the medial drive-through sign, an arthroscopic finding indicative of clinically significant deltoid ligament instability in which the ability to pass a 4mm shaver between the medial malleolus and talus is indicative of a positive medial drive through sign. The authors further introduce an anchor assisted surgical repair technique for direct repair of the deltoid ligament complex that is currently being studied for later reporting and publication.

      Introduction

      Ankle ligament injuries are the most common injuries in sport and recreational activity.
      • Haddad S.L.
      • Dedhia S.
      • Ren Y.
      • Rotstein J.
      • Zhang L.Q.
      Deltoid ligament reconstruction: a novel technique with biomechanical analysis.
      ,
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      Most of these are inversion type injuries involving the lateral ligaments of the ankle with the medial ankle ligaments, most importantly the deltoid ligament, injured in an estimated 5–15% of injuries. With improved imaging and with the increased use of arthroscopy for diagnostic purposes it is believed that medial ligament injuries require repair more often than previously believed.
      • Savage-Elliott I.
      • Murawski C.D.
      • Smyth N.A.
      • Golanó P.
      • Kennedy J.G.
      The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies.
      ,
      • Mengiardi B.
      • Pinto C.
      • Zanetti M.
      Medial collateral ligament complex of the ankle: MR imaging anatomy and findings in medial instability.
      Unrecognized medial sided injury in conjunction with loss of lateral stability could potentially lead to unconstrained tibiotalar motion and secondary arthritis.
      In an acute injury the deltoid ligament is typically injured with eversion and external rotation of the ankle. This can occur with or without a concomitant lateral malleolar fracture. However, Hintermann et al reported that 42% of their patients studied reported a supination mechanism of injury. Based on the frequent observation of a consistent injury pattern to the anterior talofibular and calcanealfibular ligaments and the presence of medial talar osteochondral lesions (OCL). Hintermann et al. speculated that a persistent instability of the lateral ligaments resulted in chronic stress on the anterior fibers of the deltoid ligament.
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      The deltoid ligament can also be chronically injured in posterior tibial tendon dysfunction where the ligament is subjected to chronic stress and loses competency overtime.
      • Savage-Elliott I.
      • Murawski C.D.
      • Smyth N.A.
      • Golanó P.
      • Kennedy J.G.
      The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies.
      The deltoid ligament is the primary medial stabilizer of the tibiotalar joint. Deltoid insufficiency may manifest as a symptom complex characterized by persistent medial joint line tenderness and pain, as well as complaints of “giving way”. The latter most commonly while on uneven ground or going downhill or downstairs. In more severe cases of instability, there may be an increased valgus position of the hindfoot.
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      There remains some controversy over the surgical indications for repair and how best to repair the deltoid ligament complex. There have been multiple techniques published previously with no technique shown to have superior outcomes.
      • Haddad S.L.
      • Dedhia S.
      • Ren Y.
      • Rotstein J.
      • Zhang L.Q.
      Deltoid ligament reconstruction: a novel technique with biomechanical analysis.
      ,
      • Pellegrini M.J.
      • Torres N.
      • Cuchacovich N.R.
      • Huertas P.
      • Muñoz G.
      • Carcuro G.M.
      Foot and ankle surgery chronic deltoid ligament insufficiency repair with internal brace TM.
      • Jeng C.L.
      • Bluman E.M.
      • Myerson M.S.
      Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity.
      • Jung H.G.
      • Park J.T.
      • Eom J.S.
      • Jung M.G.
      • Lee D.O.
      Reconstruction of superficial deltoid ligaments with allograft tendons in medial ankle instability: a technical report.
      • Deland J.T.
      • De Asla R.J.
      • Segal A.
      Reconstruction of the chronically failed deltoid ligament: a new technique.
      The available data suggests that in cases where the native deltoid ligament tissue is of good quality that a primary repair, with or without augmentation, is reasonable.
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      ,
      • Pellegrini M.J.
      • Torres N.
      • Cuchacovich N.R.
      • Huertas P.
      • Muñoz G.
      • Carcuro G.M.
      Foot and ankle surgery chronic deltoid ligament insufficiency repair with internal brace TM.
      In cases where this tissue is of poor quality or insufficient, reconstruction may provide more reliable results.
      • Haddad S.L.
      • Dedhia S.
      • Ren Y.
      • Rotstein J.
      • Zhang L.Q.
      Deltoid ligament reconstruction: a novel technique with biomechanical analysis.
      ,
      • Jeng C.L.
      • Bluman E.M.
      • Myerson M.S.
      Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity.
      • Jung H.G.
      • Park J.T.
      • Eom J.S.
      • Jung M.G.
      • Lee D.O.
      Reconstruction of superficial deltoid ligaments with allograft tendons in medial ankle instability: a technical report.
      • Deland J.T.
      • De Asla R.J.
      • Segal A.
      Reconstruction of the chronically failed deltoid ligament: a new technique.
      Arthroscopy has been shown to be a useful tool in assessing medial ankle instability.
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      ,
      • Schairer W.W.
      • Nwachukwu B.U.
      • Dare D.M.
      • Drakos M.C.
      Arthroscopically assisted open reduction-internal fixation of ankle fractures: significance of the arthroscopic ankle drive-through sign.
      ,
      • Pellegrini M.J.
      • Torres N.
      • Cuchacovich N.R.
      • Huertas P.
      • Muñoz G.
      • Carcuro G.M.
      Foot and ankle surgery chronic deltoid ligament insufficiency repair with internal brace TM.
      A medial drive through sign has been described to assess for deltoid instability in which an arthroscopic shaver or probe of at least 2.9 mm is able to be passed from anterior to posterior between the medial malleolus and talus.
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      ,
      • Schairer W.W.
      • Nwachukwu B.U.
      • Dare D.M.
      • Drakos M.C.
      Arthroscopically assisted open reduction-internal fixation of ankle fractures: significance of the arthroscopic ankle drive-through sign.
      ,
      • Pellegrini M.J.
      • Torres N.
      • Cuchacovich N.R.
      • Huertas P.
      • Muñoz G.
      • Carcuro G.M.
      Foot and ankle surgery chronic deltoid ligament insufficiency repair with internal brace TM.
      This has been described in the setting of deltoid instability with or without a concomitant malleolar fracture. Hintermann et al have suggested an instability grading scale. Grade 1 is stable with some translation of the talus, but less than 2mm; Grade 2 is moderately unstable which allows introduction of a 5mm probe between the medial talus and medial malleolus, and Grade 3 is severely unstable where the talus can easily be moved out of the ankle mortise.
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      The authors suggest that the ability to introduce a 4 mm shaver can be considered a positive drive through sign and indicative of deltoid instability. The authors of this paper are advocating for the use of the medial drive through sign in the setting of chronic ankle instability, as well describe our repair technique of the deltoid ligament utilized in the setting of chronic ankle instability. The findings described were encountered as part of routine diagnostic work-up and surgical intervention and not as part of this report. An IRB approved study will be reported at a later date.

      Surgical technique

      The patient's limb is positioned supine to allow access for arthroscopy. Stress fluoroscopy is performed after general anesthesia to evaluate both the medial and lateral ankle ligament complex. Ankle arthroscopy is then performed using standard techniques. Non-invasive distraction is used. With the camera in the anterior lateral portal, the medial ankle compartment and deltoid complex are evaluated. A “drive through” test is performed using a 4.0 mm shaver. The ability to insert this shaver into the medial gutter between the talus and tibia is suggestive of deltoid insufficiency (Fig. 1). Following this, any abnormal tissue is debrided from the medial gutter. The medial malleolus is also inspected. The distal rim of cartilage on the medial malleolus may be frayed. Further, the anterior colliculus may show partial or complete loss of the deltoid attachment consistent with a sleeve type avulsion. After all other concomitant intra-articular pathology is appropriately addressed the arthroscopic instrumentation is removed along with the ankle joint distractor.
      Fig 1
      Fig. 1Demonstration of a positive drive through sign with a 4.0mm shaver.
      A medial incision is made along the anterior edge of the medial malleolus and is curved posteriorly at the tip of the medial malleolus. The greater saphenous vein and saphenous nerve are retracted and a medial arthrotomy is performed directly anterior to the medial malleolus (Fig. 2). A periosteal flap is created revealing the anterior face of the medial malleolus. A rongeur may be used to decorticate this area to enhance soft tissue adhesion. Two suture anchors are placed into the distal anterior face of the medial malleolus (one at the anterior face and the second near the anterior colliculus). With the foot held in neutral dorsiflexion and slight inversion, the sutures are hand tied advancing the ligament further upon the medial malleolus. The remaining suture may then be advanced from deep to superficial through the periosteal flap and then again through the capsular-ligamentous flap, creating a double row repair. The sutures are then tied off (Fig. 3).
      Fig 2
      Fig. 2Initial arthrotomy through anterior superficial deltoid complex into medial tibiotalar joint. The capsuloligamentous flap is held in the forceps. The anterior face of the medial malleolus at the tip of the scissor.
      Fig 3
      Fig. 3Advancement using suture and bone anchors of the anterior superficial deltoid complex upon anterior face of medial malleolus.
      The ankle is then assessed for range of motion and medial stability defined by valgus and external rotation stress test and lateral translation test. After irrigation the incision is closed in standard fashion. Other additional procedures such as lateral ankle ligament repair may then be performed if necessary. The patient is then placed into a well-padded below-knee fiberglass splint for three weeks. The patient may advance to weight-bearing as tolerated in a tall immobilization boot at three weeks. At six weeks post-operative the patient returns to regular shoes, wears a lace up ankle brace and begins formal physical therapy. The patient avoids any side-to-side exercise, and the brace is worn until twelve weeks post-operative. Return to sports begins between three to four months and the patient advances as tolerated.

      Discussion

      It is well understood that there are 2 layers of the deltoid ligament, the superficial and deep layers, separated by a fat pad.
      • Savage-Elliott I.
      • Murawski C.D.
      • Smyth N.A.
      • Golanó P.
      • Kennedy J.G.
      The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies.
      The superficial layer contains the tibionavicular, tibiospring, tibiocalcaneal, and superficial tibiotalar with the deep layer containing the deep anterior and deep posterior tibiotalar ligaments.
      • Savage-Elliott I.
      • Murawski C.D.
      • Smyth N.A.
      • Golanó P.
      • Kennedy J.G.
      The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies.
      The superficial ligaments cross both the tibiotalar and subtalar joints with the deep layer only crossing the tibiotalar joint.
      • Boss A.P.
      • Hintermann B.
      Anatomical study of the medial ankle ligament complex.
      The superficial layer specifically prevents talar abduction and talar tilt while the deep portion limits external rotation.
      • Hintermann B.
      Medial ankle instability.
      Both the superficial and deep portions are equally effective in limiting pronation of the talus.
      • Hintermann B.
      Medial ankle instability.
      The deltoid ligament also is significantly involved in the coupling mechanism of the leg and the foot. Studies have shown that sectioning of the deltoid ligament impacts tibial rotation as well as foot inversion and eversion, so insufficiency of the deltoid ligament will alter a patient's gait pattern.
      • Knupp M.
      • Lang T.H.
      • Zwicky L.
      • Lötscher P.
      • Hintermann B.
      Chronic ankle instability (medial and lateral).
      Stress examinations of the ankle are an important aspect of the physical exam and best performed with the patient in a seated position with their legs hanging off the exam table.
      • Hintermann B.
      Medial ankle instability.
      Complete stress examination of the medial and lateral collateral ligaments includes eversion, valgus, external rotation, talar tilt testing, anterior, and anterior lateral drawer. Studies have shown that these physical exam maneuvers may not be sufficient with sensitivity and specificity of 50.9% and 90.9%. This may be because medial ankle injuries rarely happen in isolation and many patients have other ligamentous injuries or other injuries about the ankle that may hamper the ability to detect injuries to the deltoid ligament.
      • Crim J.
      • Longenecker L.G.
      MRI and surgical findings in deltoid ligament tears.
      MRI is the usual imaging modality of choice for evaluation of deltoid ligament injuries. MRI can show edema, discontinuity, or delamination of the ligaments as well as complete tears. It is difficult however to distinguish laxity or insufficient ligaments on MRI especially in the setting of chronic instability.
      • Mengiardi B.
      • Pinto C.
      • Zanetti M.
      Medial collateral ligament complex of the ankle: MR imaging anatomy and findings in medial instability.
      Sensitivity and specificity in identifying injuries to the superficial layer is 83.3% and 93.9% while for the deep layer it is 96.3% and 97.9%.
      • Crim J.
      • Longenecker L.G.
      MRI and surgical findings in deltoid ligament tears.
      Therefore, arthroscopy is utilized by the authors as the final determinant of deltoid instability.
      Surgical management of medial ankle instability continues to be a controversial subject in the literature. It is still only recently that the importance of the medial ankle ligament complex has been a focus of the literature and the evidence that we currently have in surgical management are mostly case reports and are in small numbers of patients. Pellegrini et al reported their results on chronic deltoid insufficiency repair with a fixed tension anchor augmentation and found a significant improvement in the SF-36 (60.2 to 84.4) and FAAM (58.7 to 75.3) scores. Just as importantly they found 100% patients stated they would do the procedure again.
      • Pellegrini M.J.
      • Torres N.
      • Cuchacovich N.R.
      • Huertas P.
      • Muñoz G.
      • Carcuro G.M.
      Foot and ankle surgery chronic deltoid ligament insufficiency repair with internal brace TM.
      Hintermann et al published a case series of 52 patients with documented medial ankle instability. Forty-nine of these patients underwent deltoid repair and 14 patients had additional bony procedures done such as a calcaneal lengthening osteotomy. Overall patients had significantly improved AOFAS hindfoot scores (42.9 to 91.6), but they did find that they obtained better correction of the deformity and realignment in cases where there were bony procedures in addition to the soft tissue procedures.
      • Hintermann B.
      • Valderrabano V.
      • Boss A.
      • Trouillier H.H.
      • Dick W.W.
      Medial ankle instability: an exploratory, prospective study of fifty-two cases.
      Some surgeons may oppose direct repair of the deltoid ligament in a chronic scenario because of compromised tissue quality. Deltoid ligament reconstruction techniques have been described using the peroneal longus or allograft tendons.
      • Jung H.G.
      • Park J.T.
      • Eom J.S.
      • Jung M.G.
      • Lee D.O.
      Reconstruction of superficial deltoid ligaments with allograft tendons in medial ankle instability: a technical report.
      ,
      • Deland J.T.
      • De Asla R.J.
      • Segal A.
      Reconstruction of the chronically failed deltoid ligament: a new technique.
      Deland et al describe deltoid ligament reconstruction with peroneus longus tendon. They report on 5 patients with a minimum of 2 year follow up, reporting 1 failure with talar tilt of 9 degrees post op.
      • Deland J.T.
      • De Asla R.J.
      • Segal A.
      Reconstruction of the chronically failed deltoid ligament: a new technique.
      There have been other techniques reported in the literature, but there continues to be a need for more objective data with no technique proven to be superior to others at this time.
      The technique that we have described in our paper has certain advantages. First, is the low technical demand as it is a direct repair and does not rely upon the use of tendon allograft. Also the suture anchor augmented double row capsuloligamentous technique results in a robust repair that we believe will provide reliable improvement in pain and functional measures. We are currently collecting data for a retrospective review of patients that have undergone our medial deltoid repair technique. This data will soon be reported.

      Conclusion

      The authors present the use of the medial drive-through sign and deltoid ligament repair in the setting of chronic deltoid ligament instability. These patients present with ankle pain and clinical symptoms of ankle instability. Patients report pain medially over the deltoids. Patients may have positive medial and/or anteromedial drawer (external rotation) stress exams, with changes on MRI suggestive of deltoid injury. When arthroscopy is done, the medial drive through sign is part of the routine arthroscopic examination of the ankle. When a positive medial drive through sign is found, repair of the deltoid ligament is indicated in the setting of chronic ankle instability.

      Declaration of competing interests

      The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
      Justin Fleming: Consultant, advisor, speaker, and intellectual property rights Arthrex.
      Ryan Rigby: Consultant, advisor, speaker Arthrex.

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