title: Repair of Acute Superficial Deltoid Complex Avulsion During Ankle Fracture Fixation in National Football League Players.
abstract: BACKGROUND
  Infolding and retraction of an avulsed deltoid complex after ankle fracture can be a source of persistent increased medial clear space, malreduction, and postoperative pain and medial instability. The purpose of this descriptive case series was to analyze the preliminary outcomes of acute superficial deltoid complex avulsion repair during ankle fracture fixation in a cohort of National Football League (NFL) players. We found that there is often complete avulsion of the superficial deltoid complex off the proximal aspect of the medial malleolus during high-energy ankle fractures in athletes.
  
  
  METHODS
  Between 2004 and 2014, the cases of 14 NFL players who underwent ankle fracture fixation with open deltoid complex repair were reviewed. Patients with chronic deltoid ligament injuries or ankle fractures more than 2 months old were excluded. Average age for all patients was 25 years and body mass index 34.4. Player positions included 1 wide receiver, 1 tight end, 1 safety, 1 running back, 1 linebacker, and 9 offensive linemen. Average time from injury to surgery was 7.5 days. Surgical treatment for all patients consisted of ankle arthroscopy and debridement, followed by fibula fixation with plate and screws, syndesmotic fixation with suture-button devices, and open deltoid complex repair with suture anchors. Patient demographics were recorded with position played, time from injury to surgery, games played before and after surgery, ability to return to play, and postoperative complications. Return to play was defined as the ability to successfully participate in at least 1 full regular-season NFL game after surgery.
  
  
  RESULTS
  All NFL players were able to return to running and cutting maneuvers by 6 months after surgery. There were no significant differences in playing experience before surgery versus after surgery. Average playing experience before surgery was 3.3 seasons, 39 games played, and 22 games started. Average playing experience after surgery was 1.6 seasons, 16 games played, and 15 games started. Return to play was 86% for all players. There were no intraoperative or postoperative complications noted, and no players had clinical evidence of medial pain or instability at final follow-up with radiographic maintenance of anatomic mortise alignment.
  
  
  CONCLUSIONS
  Superficial deltoid complex avulsion during high-energy ankle fractures in athletes is a distinct injury pattern that should be recognized and may benefit from primary open repair. The majority of NFL players treated surgically for this injury pattern are able to return to play after surgery with no reported complications or persistent medial ankle pain or instability.
  
  
  METHODS
  Level IV, retrospective case series.
authors.affiliation: OrthoCarolina Foot & Ankle Institute, Charlotte, NC, USA andyhsu1@gmail.com.
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Hsu
authors.affiliation: OrthoCarolina Foot & Ankle Institute, Charlotte, NC, USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Lareau
authors.affiliation: OrthoCarolina Foot & Ankle Institute, Charlotte, NC, USA.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Anderson
mesh_terms: D000328:Adult; D016512:Ankle Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D005538:Football / Q000293:injuries*; D005593:Fracture Fixation, Internal / Q000379:methods*; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008023:Ligaments, Articular / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery*; D008297:Male; D011859:Radiography; D020127:Recovery of Function; D016896:Treatment Outcome; D014481:United States
keywords: National Football League; ankle fracture; athlete; deltoid ligament; football; instability; return to play; syndesmosis