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Kwon et al
addressed the issue, one may ponder the difference between
the patient who presents with a wide MCS on nonstress
views as compared with the patient with equivalent MCS
widening on a stress view. Considering how a relative minimal change in ankle positioning (lateral decubitus positioning during gravity stress examination) can displace the
mortise and that a radiograph is a "snap shot in time," future
investigations may choose to focus attention on examining
the best treatment option for the patient who presents with a
clearly displaced mortise. Our assumptions may be challenged once again.

Is Deltoid Repair Necessary?
Multiple previously published reports stemming back from
the mid-1980s have supported the lack of additional utility
of deltoid repair. In 1987, Baird et al2 reported a cohort of
19 patients who underwent operative fixation without deltoid repair and noted good/excellent results without subsequent instability. In 1989, Zeegers et al69 reported on a
cohort of 28 patients who underwent similar fixation without deltoid repair and noted no subsequent clinical instability nor radiographic findings on stress radiography. Multiple
authors similarly demonstrated a lack of clinical benefit to
deltoid repair.35,60,62
Despite the previous literature, there has been renewed
interest and investigation in deltoid repair for this patient
cohort likely stemming from methodologic weaknesses of
previous investigations. Hsu et al24 examined deltoid repair
in a cohort of 14 National Football League players who
underwent fracture fixation. While all patients underwent
other concomitant procedures such as ankle arthroscopy
and syndesmotic fixation and heterogenous fracture patterns existed, all patients were able to return to full sporting
activities. Most recently, Woo et al66 retrospectively examined 78 consecutive cases of deltoid ligament injury with an
associated ankle fracture. All patients were treated operatively, with 41 patients undergoing deltoid ligament repair.
Average follow-up was 17 months with patients assessed
using Foot Function Index, AOFAS hindfoot score, and
VAS. Although clinical outcomes were not significantly different between the groups, those who underwent deltoid
repair were noted to have a smaller MCS on final follow-up.
Interestingly, those who had concomitant syndesmotic fixation showed a similar result but with improved outcomes
scores as compared with the non-deltoid repair cohort.
While previously reported literature has come under
recent challenge, it is clear that not all patients require deltoid repair, although a yet undefined cohort of patients may
demonstrate benefit. Higher-quality prospective studies are
required to determine which patients would benefit from
deltoid ligament repair as well as comparative investigations examining the best means of repair.

Conclusion
The optimal means of evaluating and treating the patient
with an apparent isolated Weber B fibula fracture continue
to evolve. Anatomic alignment of the ankle mortise leads to
more normal joint contact forces, pressures, and kinematics. While gravity/manual stress views can reveal mortise
instability, it is unclear whether surgery should be indicated
based solely on an increased MCS. Weight-bearing radiographs appear to correlate more closely with subsequent
mortise alignment, and reliance on gravity/manual stress
views may result in unnecessary surgery. While able to
detect ligamentous injury, MRI has a limited role given its
inability to predict instability. Repair of the deltoid ligament
may be warranted in certain cases, although higher-quality
studies are required to determine which patients would benefit from repair and which repair technique is ideal. While
equivalent short-term outcomes between operative and nonoperative treatment have been demonstrated in recent
series, longer-term follow-up of patients with a nonanatomic mortise is necessary.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
ICMJE forms for all authors are available online.

Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

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Table of Contents for the Digital Edition of Foot & Ankle International - July 2018