Fibular Malreduction: The Real Reason for Deltoid Repair

by Vince Vacketta, DPM

Yes, I’m back on this topic again. 

Study questions need for deltoid repair

A study published early this month provides compelling evidence that omitting deltoid repair does not worsen short-term outcomes. Researchers analyzed 132 SER-IV (AO/OTA 44-B2) ankle fractures:

• 89 bimalleolar fractures.

• 43 deltoid-variant.

• No deltoid ligament repairs were performed.

• Patients requiring posterior malleolar fixation or syndesmotic fixation were excluded. 

After a mean follow-up of 11.8 months, both groups maintained equivalent mortise reduction and radiographic alignment, with no differences in complications, secondary surgery, or short-term clinical outcomes.

Why this study stands out

Previous studies have often compared deltoid repair to syndesmotic fixation, making it difficult to determine whether stability came from the deltoid repair or the syndesmotic implant. 

This study is unique because patients achieved equivalent outcomes without routine syndesmotic fixation or deltoid repair, suggesting that anatomic fibular reduction and restoration of a stable mortise alone may be sufficient in many SER-IV injuries. It adds to growing evidence that routine deltoid repair may not be necessary after anatomic fibular fixation. If the deltoid ligament is unstable after fibular reduction, look critically at fibular length and rotation. The deltoid isn’t out; the fibula is malreduced.