Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Nov;45(11):1239-1246.
doi: 10.1177/10711007241274712. Epub 2024 Sep 23.

Syndesmotic and Deltoid Injuries: Companions or Coincidences

Federico Paolo Gaube  1 , Felix Maßen  1 , Hans Polzer  1 , Wolfgang Böcker  1 , Paul Reidler  2 , Maximilian Michael Saller  1 , Sebastian Felix Baumbach  1 , Nina Hesse  2
Affiliations

Syndesmotic and Deltoid Injuries: Companions or Coincidences

Federico Paolo Gaube et al. Foot Ankle Int. 2024 Nov.

Abstract

Background: Syndesmotic complex injuries are supposedly associated with injuries to the deltoid ligament (DL) complex. Several syndesmosis classifications take DL injuries into account when rating the stability of the syndesmotic injury. Still, no study has yet assessed the frequency and severity of DL injuries in unstable syndesmotic injuries. The aim of this retrospective cohort study was to assess both the severity of the syndesmotic and DL injury in patients undergoing surgery for an unstable syndesmotic injury.

Methods: The integrity of the syndesmotic and DL complex of 37 patients were assessed on MRI by 2 musculoskeletal radiologists. Eligible were adult patients with an acute, isolated, unstable syndesmotic injury (ligamentous or bony avulsions) who underwent surgery. The DL complex was classified as having 3 superficial (TNL/TSL/TCL) and 2 deep (aTTL/pTTL) components. Grade 0 indicated an intact ligament; grade I showed a periligamentous edema; grade II a partial tear presenting as laxity, irregular contour, or partial discontinuity with concomitant hyperintense signaling; grade III a complete tear; or grade IV in case of an avulsion fracture. Frequency and severity of DL injuries were assessed, and possible injury combinations analyzed using an h-cluster analysis and Mann-Whitney U test.

Results: Mean severity (grade 0-3) was 2.6 ± 0.8 for the syndesmotic complex and 1.6 ± 1.1 for the DL (superficial 1.5 ± 1.1, deep 1.6 ± 1.1). Seven patients (19%) had no (n = 3; 8%) or minor (grade 1: n = 4; 11%) DL injuries. Overall, 2 different patient clusters and 4 separate ligament clusters were identified.

Conclusion: Unstable syndesmotic injuries can occur isolated or with an accompanying DL injury. There appears to be a great heterogeneity between the severity of syndesmotic and deltoid ligament injuries.

Keywords: MRI; coinjury; deltoid ligament; instability; syndesmosis; trauma.

PubMed Disclaimer

Conflict of interest statement

Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Hans Polzer, MD, reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthrex GmbH. Sebastian F. Baumbach, MD, reports collaborative research, paid lectures, and support for attending meetings and/or travel from Arthrex. Disclosure forms for all authors are available online.

Figures

Figure 1.
Figure 1.
Flowchart illustrating the applied diagnostic algorithm. AiTFL, anterior inferior tibiofibular ligament; ERST, external rotation stress test; MCSc, medial clear space contralateral ankle; MCSi, medial clear space injured ankle; MRI, magnetic resonance imaging; PiTFL, posterior inferior tibiofibular ligament.
Figure 2.
Figure 2.
Illustration of the anatomical structures assessed during MRI reading: Syndesmosis and Deltoid ligament complex. AiTFL, anterior inferior tibiofibular ligament; aTTL, deep anterior tibiotalar ligament; IOL, interosseous ligament; IOM, interosseous membrane; PiTFL, posterior inferior tibiofibular ligament; pTTL, deep posterior tibiotalar ligament; SL, spring ligament; TCL, tibiocalcaneal ligament; TNL, tibionavicular ligament; TSL, tibiospring ligament.
Figure 3.
Figure 3.
Patient selection flow chart. MRI, magnetic resonance imaging.
Figure 4.
Figure 4.
Results of the cluster analysis. Left: Heat map illustrating the grade of ligament injury for each patient. The heat map is divided per the results of the cluster analysis. There are 2 specific patient and 4 specific ligament clusters. Right: Bubble Graph illustrating the cumulative results (mean ± SD injury severity) for each cluster. AiTFL, anterior inferior tibiofibular ligament; aTTL, deep anterior tibiotalar ligament; DL, deltoid ligament; IOL, interosseous ligament; PiTFL, posterior inferior tibiofibular ligament; PMF, posterior malleolar fracture; pTTL, deep posterior tibiotalar ligament; TCL, tibiocalcaneal ligament; TNL, tibionavicular ligament; TSL, tibiospring ligament. [See online article for color figure.]
See this image and copyright information in PMC

References

    1. Baltes TPA, Al Sayrafi O, Arnáiz J, et al.. Acute clinical evaluation for syndesmosis injury has high diagnostic value. Knee Surg Sports Traumatol Arthrosc. 2022;30(11):3871-3880. doi:10.1007/s00167-022-06989-2 - DOI - PMC - PubMed
    1. Baltes TPA, Arnaiz J, Al-Naimi MR, et al.. Limited intrarater and interrater reliability of acute ligamentous ankle injuries on 3 T MRI. J ISAKOS. 2021;6(3):153-160. doi:10.1136/jisakos-2020-000503 - DOI - PubMed
    1. Brady AW, Bryniarski A, Brown JR, et al.. The biomechanical role of the deltoid ligament on ankle stability: injury, repair, and augmentation. Am J Sports Med. 2023;51(10):2617-2624. doi:10.1177/03635465231181082 - DOI - PubMed
    1. Butler BA, Hempen EC, Barbosa M, et al.. Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures. J Orthop. 2020;17:87-90. doi:10.1016/j.jor.2019.06.005 - DOI - PMC - PubMed
    1. Calder JD, Bamford R, Petrie A, McCollum GA. Stable versus unstable grade II high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports. Arthroscopy. 2016;32(4):634-642. doi:10.1016/j.arthro.2015.10.003 - DOI - PubMed

LinkOut - more resources