Weber C Ankle Fracture — Should the Deltoid Ligament Be Repaired?

A randomized trial in patients with Weber C ankle fractures and deltoid ligament injury found an important difference between early mechanical stability and later clinical outcome. Direct deltoid repair improved early talar stability on weight-bearing or stress imaging, but at 12 months it did not provide an advantage in the radiographic outcomes assessed or in ankle function.

Polish version: Złamanie Weber C — czy naprawiać więzadło trójgraniaste?

Why is this study clinically relevant?

In unstable ankle fractures with injury to the medial ligament complex, a practical question remains after fracture anatomy has been restored: should the deltoid ligament be repaired routinely? In theory, direct repair may improve stability of the medial column, but it also adds another surgical step. Choi and colleagues evaluated this question in a randomized controlled trial.

Study question and methodology

The study included patients with Weber C fractures corresponding to OTA/AO type 44C, produced by a pronation-external rotation mechanism and associated with deltoid ligament injury. After the fracture fixation strategy had been established, patients were randomized to direct repair of the deltoid ligament or to no ligament repair.

Medial clear space and talar tilt were assessed on standing and stress radiographs at 3, 6 and 12 months. Functional outcome was measured with the FAAM. Seventy-one patients completed the 12-month follow-up: 35 in the repair group and 36 in the no-repair group.

Key results

• Medial clear space was comparable between groups across the imaging views and time points assessed.
• At 3 months, the group without deltoid repair showed greater valgus talar tilt on stress imaging. This was a signal of better early stability after direct repair.
• At 12 months, the difference in talar tilt was no longer statistically significant.
• FAAM scores improved in both groups. At 12 months, the activities-of-daily-living component was approximately 89–90% in both groups.

Clinical interpretation for an orthopaedic surgeon

The most useful conclusion is not that the deltoid ligament should never be repaired. Rather, in this specific fracture group, routinely adding medial ligament repair did not translate into better function at one year despite an early improvement in talar stability.

This distinction matters. A better postoperative radiographic parameter is most clinically important when it translates into better function, less late instability, fewer reoperations or lower risk of post-traumatic degeneration. A 12-month follow-up cannot resolve all of those questions.

Limitations

• The trial was conducted at a single centre and included 71 patients with complete one-year follow-up.
• It addressed a narrowly defined group of Weber C fractures with deltoid ligament injury; the findings should not automatically be applied to every unstable ankle fracture.
• One year is adequate for assessing early function but too short for reliable evaluation of late instability, post-traumatic osteoarthritis or revision risk.
• The absence of a statistically significant difference at 12 months is not formal proof that the two strategies are equivalent.
• The publicly available abstract does not answer every subgroup question, including whether particular patterns of medial injury may benefit more from repair.

What might change in practice — and what does the study not prove?

The trial provides an argument against treating direct deltoid ligament repair as an automatic component of every Weber C fracture fixation when the ligament is injured. The decision may still depend on the quality of fracture reduction, residual ankle stability after fixation, the character of the medial injury and the overall fracture pattern.

The study does not prove that repair is unnecessary in every patient, nor does it prove that a transient early difference in stability has no longer-term significance. Larger cohorts and longer follow-up are needed to answer those questions.

Reference

Choi JY, Yu OJ, Jung YH, Suh JS. Deltoid Ligament Repair Does Not Improve Radiographic or Clinical Outcomes in Weber Type C Pronation-External Rotation Ankle Fractures: A Randomized Controlled Trial. Journal of Orthopaedic Trauma. 2026;40(8):399–407. DOI: 10.1097/BOT.0000000000003189. Issue date: 1 August 2026.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.