Deltoid Ligament Repair
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
- 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.
3. Examine for Instability
- The ankle was put through a range of motion to test for stability and demonstrate laxity of the incompetent ligament.
4. Rasp and Irrigate
- A rasp was used to prepare the bone prior to drilling and the resulting debris was irrigated out of the wound.
5. Repair Ligament
- 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.
6. Test Repair
- 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.
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
So basically now we've shown through our arthroscopic evaluation of the joint that there's a deltoid deficiency. Superficial deltoid ligaments 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 do an open repair now. And what I'll do is use that medial portal. We're going to make a an incision over the anterior portion of the medial malleolus, and I'm going to use some surface anatomy palpate that area. And I'm going to just extend this right like that and will 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 saphenous vein and nerve. This could 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 going to give me some Bovie. Great. Thank you. I'm going to need to extend this little more.
I can 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 Mets and Bones. We're going to enter the joint here. Come come down this way a little bit more. Yup. 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 will 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. Switchback in a little. Better. There we go; that’s nice. Right over here.
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 as nice thick capsulary tissue. 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 ronjure. Take this whole area confluent capsule and deltoid ligament. Can 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 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 anterior deltoid ligament fibers back to back to the to the medial malleolus.
There you go. That's really popping out there.
So we're going to take a rasp and a freshen up the front edge here, will irrigate out the joint a little bit to make sure that we don't take any of this slurry into the joint. Good. Alright let's irrigate a little bit here. Just cleaning out any debris from the joint. Things are looking pretty good.
So again will find that slip of tissue that we're going to grab. and this is this...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 axle here. I'm not going to put it in the joint. I don't want to put a 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. I 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 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 say this is going to slip right up into this area here. They don’t need to be any any massive uhh. Anchor that up there, and then before we let it go. Hold that up there. Got vicryl?
And I'm going to it’s deep enough so that we can see you can see that that has play and now we just going to reinforce it with some of these fibers here and some of these fibers there. 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. Cut you. Needle back.
Let’s test this out now. So I feel just make sure that you got good range of motion. I don't feel any crepitance and then I'm going to oh yeah. Oh yeah. We are much more stable on the medial side. We saw some lateral instability we're going to take care of that right now so why don't we do this - close this up right now.
Three or four is fine.
I’ll take scissors please.
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