Supination-external rotation (SER) stage 4 injuries represent a significant portion of lower limb trauma cases. Consequently, the development of the All-Inside Deltoid Repair technique provides a valuable tool for managing these bimalleolar-equivalent fractures. While surgeons often debate the necessity of medial-side surgical intervention, achieving anatomical stability is vital for long-term joint health. This approach aims to restore ligamentous integrity without the morbidity associated with larger open incisions.

The Clinical Advantage of All-Inside Deltoid Repair

Recent evidence highlights the effectiveness of this minimally invasive method. A prospective study involving 12 patients demonstrated favorable short-term results. Specifically, the participants reported a mean Visual Analog Scale (VAS) score of 1.5 at the six-month follow-up. Additionally, the mean AOFAS score reached 87, reflecting strong functional recovery. Importantly, no complications occurred during the study period, suggesting a high safety profile for the procedure.

Radiographic stability remains a primary concern for orthopedic surgeons. Furthermore, the All-Inside Deltoid Repair technique successfully maintained joint alignment under various conditions. The medial clear space (MCS) showed no significant widening during weight-bearing or stress radiographs. Similarly, the talar tilt (TT) remained consistent across all measurements. Therefore, these findings confirm that the repair effectively preserves joint integrity and prevents undesirable displacement.

Why Stability Matters in Bimalleolar-Equivalent Fractures

In bimalleolar-equivalent injuries, the lateral malleolus is fractured and the deltoid ligament is torn. However, this combination often creates significant instability that mimics a traditional two-bone fracture. Traditional management sometimes overlooks the medial ligamentous injury, focusing only on the fibular fixation. Consequently, patients may experience persistent medial-sided pain if the deltoid is not addressed. By utilizing the All-Inside Deltoid Repair, surgeons can secure both sides of the joint more effectively.

Conclusion

The use of arthroscopic techniques in trauma care continues to evolve. In SER IV bimalleolar-equivalent ankle fractures, this repair method maintains radiographic reduction and yields excellent functional outcomes. Moreover, it offers a reliable solution for surgeons seeking to optimize joint mechanics while minimizing surgical trauma.

What defines an SER IV bimalleolar-equivalent ankle fracture?

This injury involves a fibular fracture combined with a complete rupture of the medial deltoid ligament. It is termed "equivalent" because the resulting instability is similar to having both the medial and lateral malleoli fractured.

How does All-Inside Deltoid Repair improve patient recovery?

The All-Inside Deltoid Repair uses arthroscopic assistance to fix the ligament with minimal tissue disruption. This technique allows for stable joint alignment and early mobilization, which often leads to better functional scores and lower pain levels.

Disclaimer: This content is for informational and educational purposes only. It does not constitute medical advice or establish a doctor-patient relationship. Always seek the advice of a qualified healthcare provider for any questions regarding a medical condition or treatment. Refer to the latest local and national guidelines for clinical practice.

References

Baumfeld TS et al. Deltoid All-Inside Repair in SER IV Bimalleolar-Equivalent Ankle Fractures. Foot Ankle Spec. 2026 Apr 12. doi: 10.1177/19386400261427776. PMID: 41966839.

Orthobullets. Ankle Fractures - Trauma. Accessed April 13, 2026. Available at: https://www.orthobullets.com/trauma/1047/ankle-fractures

Del Balso C, et al. Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures. J Foot Ankle Surg. 2022;28(6):851-855. doi:10.1016/j.fas.2021.08.007