Is systematic deltoid ligament repair necessary in bimalleolar equivalent ankle fractures? A bi-centric case-control study.

BACKGROUND

Bimalleolar equivalent fractures (BEF) represent a particularly challenging subset of ankle fractures, with ongoing debate among ankle surgeons about the necessity of systematic deltoid ligament repair. The present study aims to address this controversy by investigating the radiological and clinical outcomes of deltoid ligament repair in BEF compared to conservative management.

HYPOTHESIS

Systematic deltoid ligament repair in BEF is not necessary.

PATIENTS AND METHODS

This bi-centric case-control study included 67 patients from two university hospitals. Patients were divided into two groups: the conservative group (n = 38), and the suture group (n = 29). Inclusion criteria were lateral malleolus fracture with Medial Clear Space (MCS) ≥4 mm, and age ≥18 years. Primary radiological outcomes were MCS and tibio-fibular clear space (TFCS) postoperatively and at 3 months. Clinical outcomes included weight-bearing capacity, time to return to pre-injury activity levels, and subjective sensation of ankle instability.

RESULTS

Radiologically, both groups showed significant reduction in MCS and TFCS postoperatively, with no significant difference at the three-month follow-up. Clinically, the conservative group demonstrated significantly higher weight-bearing capacity at 45 days (p = 0.005) and earlier return to pre-injury activity levels (p = 0.0049). Subjective instability was reported less frequently in the conservative group (p = 0.0038). In patients with syndesmotic injuries, no significant differences were observed in radiological or clinical outcomes between the two groups.

CONCLUSION

This study suggests that conservative management of the deltoid ligament in BEF provides comparable radiological outcomes and superior early clinical outcomes compared to surgical repair. The findings support the consideration of conservative treatment for BEF. Further research with larger sample sizes and longer follow-up are necessary to validate these results.

LEVEL OF EVIDENCE

III; retrospective bi-centric case-control study.