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Deltoid Ligament Reconstruction

Article written by: ANDREI BOGDAN, MD, Orthopedics-traumatology doctor

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For all traumatic or chronic diseases of the musculoskeletal system, the Centrokinetic private clinic in Bucharest is prepared with an integrated Orthopedic Department, which offers all the necessary services to the patient, from diagnosis to complete recovery.
The Department of Orthopedic Surgery of the Centrokinetic Clinic is dedicated to providing excellent patient care and exceptional education for young physicians in the fields of orthopedic surgery and musculoskeletal medicine.
 

Discover the open MRI imaging center in our clinic. Centrokinetic has a state-of-the-art MRI machine, dedicated to musculoskeletal conditions, in the upper and lower limbs. The MRI machine is open so that people suffering from claustrophobia can do this investigation. The examination duration is, on average, 20 minutes.

Centrokinetic attaches great importance to the entire medical act: investigations necessary for correct diagnosis (ultrasound, MRI), surgery, and postoperative recovery.

The talocrural joint (ankle) is a joint complex that allows the orientation of the foot in all directions of space, shock absorption, and weight transmission to the support in static and locomotion. To withstand the action of high stresses, the ankle joint must be stable in both joint statics and dynamics. The stability of the ankle is mixed, resulting from the combined action of bone and ligament elements. The geometric conformation of the articular surfaces is mainly responsible for bone stability.

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The deltoid ligament is the primary stabilizing ligament of the ankle joint. Located both superficially and deeply, the components of the ligament can be affected in case of an ankle fracture with rotational mechanism, of recurrent ankle sprains by eversion mechanism, or if the patient has a chronic flat valgus leg. The benefits of deltoid ligament reconstruction in these conditions are quite limited. Neglect of the deltoid ligament in the treatment of complex ankle injuries can lead to chronic ankle instabilities.

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Surgery of deltoid ligament injuries may be indicated in unstable bimalleolar fracture of the ankle, especially if the reduction is not perfect after fixation of the fibula.  

Most reconstructions of the deltoid ligament involve suturing "end to end" the superficial fibers of the deltoid ligament or bone reinsertion, using dedicated anchors. Deep fiber reconstructions can be performed by direct sutures or with autografts or allografts, fixed by different methods.

We will describe a technique that ensures the anatomical repair of both superficial and deep fibers while reducing the talus to the medial malleolar face of the tibiotalar joint. This technique can protect the horizontal fibers of the deep deltoid ligament, heal with the appropriate length while ensuring the stability of reconstruction.

Surgical technique

Under spinal anesthesia, a longitudinal incision of 6 cm is made, centered over the medial ankle and oriented slightly obliquely from proximal-posterior to distal-anterior, ending terminally distal over the neck of the talus. The dissection is carefully performed to identify and protect the saphenous nerve and veins. The sheath of the tendon of the posterior tibialis muscle is incised and the tendon is dislocated, to have a direct approach on the deltoid ligament. At the anterior edge of the deltoid ligament, a capsulotomy is performed, which inspects the ankle joint. 

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Subsequently, the anatomical location of the deltoid ligament injury is identified: a rupture in the middle of the ligament or bone disinsertion, most commonly on the tibial ankle. Bone disinsertion can also be at the level of the talus for deep fibers or the calcaneus for the superficial ones. In any of these situations, the reconstruction is performed with 2.8mm anchors, 1 to 3 anchors can be used, depending on the severity of the injury.

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In case of chronic ligament damage, in which the quality of the tissue is poor, we prefer the reconstruction of the deltoid ligament with autograft harvested from the tendon of the gracilis or long peroneal muscle. After harvesting and preparing the graft, a 4.5 mm canal is made at the level of the tibial malleolus, along the entire tibia, then a 4.5mm thick channel at the level of the talar neck, and a 4.5mm channel at the level of the heel. The graft is fixed with TightRope at the tibia and 2 4.75mm SwiveLock anchors at the talus and heel.


At home

Although recovery after this operation is much faster than a classic intervention, it will still take a few weeks for you to fully recover the operated joint. You should expect pain and discomfort for at least a week postoperatively. You can use a special ice pack, which will reduce the pain and inflammation. You must be careful not to lean on the operated area in the first weeks because the pain and discomfort can worsen. You can take a bath, but without wetting the bandage and incisions. The threads are suppressed at 14 days postoperatively.

At 3 months postoperatively, an MRI is necessary to see how the tendon suture heals. Driving is allowed after 8 weeks and hard physical work after 10 weeks.

Physical therapy plays a very important role in the rehabilitation program, and the exercises must be followed by a physical therapist until the end of the recovery period.

It is very important to follow the recovery program strictly and seriously for the surgery to be a success. Our medical team works on average with the patient after this intervention, 12-16 weeks until complete recovery of the operated area.

Following any surgery, medical recovery plays an essential role in the social, professional, and family reintegration of the patient. Because we pursue the optimal outcome for each patient entering the clinic, recovery medicine from Centrokinetic is based on a team of experienced physicians and physical therapists and standardized medical protocols.