After a failed functional test and an arthroscopic evaluation of the patient’s joint that revealed both a deltoid deficiency and avulsed superficial ligaments, Dr. Eric Bluman proceeds to perform an open repair of the deltoid ligament using a medial portal.
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This article is the companion to the JoMI articles:
- Brostrom-Gould Procedure for Lateral Ankle Instability
by Eric Bluman, MD, PhD
- Peroneal Tendon Debridement
by Eric Bluman, MD, PhD
- Five-Month Patient Follow-Up following Ankle Ligament Reconstruction
by Eric Bluman, MD, PhD
Table of Contents
- An incision was made over the medial gutter of the ankle.
- Dissection was carried down to find the anterior fibers of the deltoid ligament.
- Careful dissection was performed and great care was taken to protect the saphenous nerve and vein.
- It was clear from the arthroscopy that had been done previously that the anterior fibers of the deltoid had been avulsed off the anterior portion of the medial malleolus.
- This area was further cleaned of fibrous tissue.
- The ankle was put through a range of motion to test for stability and demonstrate laxity of the incompetent ligament.
- A rasp was used to prepare the bone prior to drilling and the resulting debris was irrigated out of the wound.
- Drill holes were made and a suture anchor was placed.
- The sutures were then passed through the proximal portion of the anterior fibers of the deltoid ligament, and these were tied down to their origin.
- The ankle was put through a range of motion to test for stability and ensure that the repair remained intact under stress.
- After this had been done, the wound was thoroughly irrigated and closed in a layered fashion.
So basically now, we - we’ve - we've shown through our arthroscopic evaluation of the joint that there's a deltoid deficiency. Superficial deltoid ligaments are - are shown to be avulsed. We did a functional test showing that they're - they're not working properly, so we're going to go ahead and do an open repair now. And what I'll do is - using that medial portal, we're going to make a - an incision over the anterior portion of the medial malleolus, and I'm gonna use some surface anatomy, palpate that area, and I'm gonna just extend this right like that - and we’ll probably have to adjust that as we go. Alright.
So we're going to just make a incision. Structures we need to watch out for in this area are the s - saphenous vein and nerve. This can be a fairly linear incision - a little bit of - a little bit of curve to it is okay. Forceps please. And we're just going to deepen this straight down, watching out for any neurovascular structures that we can avoid. So we're - we’re again - give me some Bovie. Great. Thank you.
I'm going to need to extend this a little more, and get through this fibro-fatty tissue over the anterior portion of the joint. Little bit of distension because of the arthroscopy but not - not too bad. Can we have a 2-3 self retainer please? Yeah. Little stretch on the tissues, and basically, continue with a sharp dissection straight down.
And this is basically our capsule right here. We convert to Metzenbaum. We're going to enter the joint here. Alright, come - come down this way a little bit more - yeah, yeah. Yep. And now we're in the joint.
Let me have a knife please? Just what we saw - there’s that little bit of scar tissue. That's a pretty good view. There's that scar tissue that we didn't clean out that we’ll clean out right now, and there is your stump. There’s your stump of deltoid right there. Clean out this. We may be able to use some of the stump to sew to, so I'm not going to - not going to totally get rid of it. I'm going to take a knife. And switch back in a little. Better. There we go - that’s nice.
I think right there is the saphenous nerve. Right over here? Yeah. Yep. So we got that well protected, and there you can see this area here where it's a avulsed from the bone. I’m peeling back some tissue. Yeah. This is his nice thick capsular tissue, and we're going to put it right back in there - close it right down to that raw area, which I'm going to freshen up with a rongeur. Take this whole area - confluent capsule and deltoid ligament - and put it in there. I'm going to - I thought I was going to be able to use that. I think that we may need to just remove that. Let me have a knife please.
Guys, how's it looking? Yours looks great. I just - at back - I need to move it to my right. Yeah. Not too deep, but it's - you know, it's not the - not the biggest incision in the world.
Okay so now, we've got the front of the medial malleolus cleared off pretty well, and I'm going to expose some raw bone to facilitate healing of the - of the - of the anterior deltoid ligament fibers back to - back to the - to the medial malleolus.
There you go. Yep. Look at that - wow. That's really popping out there.
So we're going to take a rasp, and I’m going to freshen up the front edge here. We’ll irrigate out the joint a little bit and make sure that we don't take any of this slurry into the joint. Good. Alright, let's irrigate a little bit here. And just cleaning out any debris from the joint. Things are looking - looking pretty good. Yeah. Okay.
So again, we’ll find that slip - we’ll see this slip of tissue that we're going to grab. And this is this - avulsed. Yeah. This is just a drill - drill guide - self stop. We're going to create a pilot hole for the - for the suture anchor, and I'm going to put it right up in the axilla here. I'm not going to put it in the joint. I don't want to put it too far from the joint. I'm going to put it right up here. I'm going to cant it a little bit superior and medial - make sure it's in really good bone within the medial malleolus and drill. And just create that pilot hole. You can see it right there.
This is the suture anchor we're going to use. You don't need a huge suture anchor. We're just going to use it to hike up the tissue, hold it in place, anchor at there until - until we get healing. So here it goes - right into the pilot hole. I'm going to orient the tines parallel with the middle malleolus. Give me something to grab this with ‘cause these are always problematic, and then release the sutures. I get a big, big bite of it. Nice and mobile. And I'm going to show you - this is gonna slip right up into this area here. It doesn’t need to be any - any massive… So you can… Anchor that up there, and then - and before we let it go, hold that up there. Let go. Vicryl.
And I'm gonna - it’s deep enough so that we can see - you can see that that has play, and now we’re just going to reinforce it with some of these fibers here and some of these fibers here. We're just going to repair it. Can I take it in one? I will take it in two. Would you consider doing bone holes? Yes, to reinforce what we… Scissors please. K - cut here. Needle back.
Let’s test this out now. So, I’m going to feel just to make sure that she’s got good range of motion now, I don't feel any crepitance, and then I'm going to - oh yeah. Oh yeah. So we’re - we’re much more stable - oh yeah - on the medial side. We still have some lateral instability, but we're going to take care of that right now. So why don't we do this - why don’t we close this up right now.
Can I have a 3-0 vicy - monocryl? Do you want a four? Three or four is fine.
I’ll take scissors please.