Primary deltoid ligament repair versus trans-syndesmotic fixation for acute bimalleolar equivalent ankle fractures: A meta-analysis of comparative studies

Background: The indication for deltoid ligament repair in lateral malleolus fractures with associated deltoid ligament injury is controversial. The goal of this meta-analysis is to compare clinical outcomes after acute deltoid ligament repair and trans-syndesmotic screw fixation following fibula fixation for management of bimalleolar equivalent fractures. Methods: Five databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines until April 1, 2023. Primary outcomes included functional outcomes and symptomatic implant removal, while secondary outcomes included pain scores and complication rate. The Newcastle-Ottawa scale was used to check study quality. Results: A total of 123 in the deltoid ligament repair group and 180 in the trans-syndesmotic screw fixation group were included across 5 article. Patients receiving the deltoid ligament repair technique exhibited similar American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scale scores at mean 12 months (Mean Difference (MD), 0.33; 95 % Confidence Interval (CI), −0.4 - 0.70; I2 = 0 %; P = 0.09). The symptomatic implant removal rate was lower in these patients (RR, 0.23; 95 % CI, 0.09–0.63; I2 = 9 %; P = 0.01). They likewise reported comparable visual analog scale for pain (MD = −0.03; 95 % CI, −0.39-0.34; I2 = 0 %; P = 0.8), and lower complication rates (RR, 0.26; 95 % CI, 0.10–0.69; I2 = 0 %; P = 0.01). Conclusion: This study highlights that acute deltoid ligament repair could be a safe and demonstrated comparable functional outcomes and pain scores to trans-syndesmotic screw fixation, while also offering the advantage of a reduced incidence of symptomatic implant removal and other complications. However, further studies that carefully control for potential confounders are necessary to validate these findings and establish a more definitive consensus for the management of bimalleolar equivalent ankle fractures.