Endoscopic Repair of the Superficial Deltoid Ligament and Spring Ligament

Arthroscopic Deltoid Ligament Reconstruction in Rotational Ankle Instability

Chronic lateral ankle instability is a common orthopaedic problem. The continuous stress applied by the lateral instability may affect the superficial deltoid ligament. The combination of lateral ankle instability and injury to the most anterior fascicles of the deltoid ligament contributes to rotational ankle instability. The purpose of this Technical Note is to describe the details of arthroscopic deltoid ligament reconstruction in rotational ankle instability. This minimally invasive approach allows other associated lesions to be detected and managed arthroscopically.

Ligament Insufficiency with Flatfoot: Spring Ligament and Deltoid Ligament

The objective of this article was to review the deltoid ligament and spring ligament specifically as they pertain to ligament insufficiency and adult-acquired flatfoot deformity. Discussion includes the normal and abnormal biomechanical forces that extend through these ligaments in normal and flatfoot deformity. Current literature related to spring ligament repair as part of the flatfoot deformity reconstruction is also reviewed.

The Potential of Endoscopic Spring Ligament Repair in Flatfoot Reconstruction

BACKGROUND

Spring ligament fulfills 2 main important functions: one, supporting the head of the talus and stabilizing the talonavicular joint, and the other, maintaining the longitudinal arch by acting as a static support. In this preliminary report, we describe an endoscopic repair for spring ligament injuries with modified portals.

METHODS

We performed a retrospective case series study from February 2019 to January 2022. Posterior tibial tendon and/or associated bone deformities were assessed at the same surgical procedure. All patients were ≥18 years old and they had more than 6 months of follow-up. The procedure was performed in 11 patients. Mean age was 46 years (range 18-63). Ten had concomitant bony realignment surgery, and 8 had posterior tibial tendon surgery.

RESULTS

In all patients, endoscopic spring ligament repair could be technically done. The modified portals were used in all procedures as described in the surgical technique. Three patients had a superficial lesion, 1 had a rupture <5 mm, 7 had a rupture >5 mm but not a complete rupture through the entire spring ligament. Most of the patients had good clinical results from the surgery that included endoscopic spring ligament debridement and/or repair at 2 years follow up.

CONCLUSION

In this small series we found that endoscopy may be an effective technique to diagnose and treat incomplete spring ligament injuries.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Seguridad de los portales para la reparación endoscópica del ligamento calcaneonavicular: estudio cadavérico

Introducción: La lesión del ligamento calcaneonavicular ha sido descrita como una de las causas de la deformidad en el pie plano del adulto. El objetivo de este artículo es describir portales modificados para el diagnóstico y la reparación endoscópica de las lesiones del fascículo superomedial del ligamento calcaneonavicular y evaluar la seguridad de los portales utilizados. Materiales y Métodos: Se llevó a cabo un estudio cadavérico con seis preparados reproduciendo una lesión del fascículo superomedial del ligamento calcaneonavicular con una punta de corte de radiofrecuencia y la posterior reparación endoscópica. Se crearon dos portales modificados para el abordaje. Luego se procedió a la disección anatómica para evaluar la seguridad de los portales en relación con las estructuras anatómicas. El primer portal se realiza inmediatamente proximal a una línea trazada desde la punta del maléolo medial dirigida al centro del talón, el segundo portal se emplaza 0,5 cm proximal a la inserción del tendón tibial posterior en el escafoides por transiluminación. Si es necesario, se coloca un portal accesorio inmediatamente dorsal al tendón tibial posterior a mitad de camino entre los dos portales antes descritos. Resultados: En todos los casos, fue posible la reparación del ligamento con el procedimiento endoscópico. En la disección anatómica de los portales, se observó una distancia promedio a las estructuras vasculonerviosas de 11,83 mm del portal proximal y de 9,66 mm del portal distal. Conclusión: Los portales modificados son seguros y permiten la visualización directa del haz superomedial del ligamento calcaneonavicular y su reparación endoscópica.

Arthroscopically Assisted Reduction and Fixation of Deltoid Ligament Avulsion Fracture From Medial Malleolus

Ankle fractures are one of the most common orthopaedic injuries. The surgical principle is to restore anatomy and stability of the ankle mortise. Repositioning of the talus under the tibia with normalization of the medial clear space is mandatory for a good outcome. Deltoid ligament injuries can present as an avulsion fracture of the medial malleolus. The purpose of this Technical Note is to describe the details of arthroscopically assisted reduction and fixation of deltoid ligament avulsion fracture from medial malleolus. This can restore the medial stability of the ankle.

Current Trends in Treatment of Injuries to Spring Ligament

The spring ligament is the main static supporter of the medial longitudinal arch. Identifying every detail of the pathophysiology of each condition in which these structures are involved is the key to an appropriate approach and treatment. Isolated reconstruction of the posterior tibial tendon present long-term results with a high failure rate. It is important to diagnose spring ligament injuries because of the probable consequences if not treated, such as acquired flatfoot deformity and loss of correction of treated flatfoot. The option of surgical treatment is discussed in this article.

Validity and reproducibility of foot motion analysis using a stretch strain sensor

BACKGROUND

Multi-segment foot analysis is traditionally challenging to perform while subjects are wearing footwear or a foot orthosis and is difficult to apply in the clinical setting. A recently developed stretch strain sensor (STR), that is thin and highly flexible, may solve this limitation because it does not require observation using a camera and is highly portable.

RESEARCH QUESTION

This study aimed to examine the reproducibility and validity of foot motion analysis using the STR during walking and running by comparing it with a conventional motion capture system.

METHODS

Twenty-one healthy participants were examined in this study. The STR was placed on the participant's foot in one of two locations in separate experiments (spring ligament; SL and navicular drop; ND methods). Foot kinematic data during walking and running were simultaneously recorded using the STR and a three-dimensional motion capture system. Intra-class correlation (ICC) was used to assess test-retest reproducibility of the STR method. Cross-correlation coefficient evaluated the similarity of the pattern of the signals between the two systems. Pearson and Spearman correlation analysis was used to evaluate the relationships between the STR measurement and angular excursion of the forefoot or hindfoot.

RESULTS

The ICCs of the SL method were 0.95 and 0.96, and those of the ND method were 0.93 and 0.71 during walking and running, respectively. In the SL method, the pattern of the signals between the STR and forefoot frontal motion was strongly correlated. The STR measurement was significantly correlated with forefoot eversion excursion (walking: r=-0.67, running: r=-0.64, p < 0.01 each). In the ND method, the STR signal was not associated with forefoot and hindfoot kinematics.

SIGNIFICANCE

Our results showed that the STR has acceptable reproducibility and validity of foot motion analysis. This system may enable measurement of foot motion while subjects are wearing shoes and outside the laboratory.

Flatfoot Deformity Due to Isolated Spring Ligament Injury

Patients with acquired flatfoot deformity due to isolated injury of the spring ligament, with healthy posterior tibialis tendon, are rarely identified. Between December 2004 and September 2011 (6 years and 9 months), we treated 10 patients with acquired flatfoot deformity due to spring ligament injury without tibialis posterior tendon tear. One patient (10%) was lost to follow-up. The mean age of the patients was 44.33 ± 12.91 years; 4 (44.4%) were female, and 5 (55.56%) were male. Clinical presentation included mild to moderate hindfoot valgus and pain extending from the inferior part of the medial malleolus to the navicular, inferior to tibialis posterior. Forefoot abduction was not always present. Weightbearing radiographs and magnetic resonance imaging (MRI) scans were obtained in all cases. Six patients (66.66%) of the patients had a history of minor trauma. Spring ligament repair was performed in all cases, and 4 patients (44.44%) underwent adjunct procedures. After surgery, a cast was applied, and weightbearing was avoided for 6 weeks. The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 39.66 ± 18.55, and this improved to 84.88 ± 12.41 after surgery (p = .023). No statistically significant differences were found between males and females or between isolated repairs and adjunct procedures. The mean duration of follow-up was 45.33 ± 37.11 months (range 15 to 120), and no complications were identified. Isolated injuries of the spring ligament with normal posterior tibialis tendon are rarely described and may be more prevalent than generally appreciated.

Acute Deltoid Ligament Repair in Ankle Fractures

There is no consensus on whether the deltoid ligament must be repaired in ankle fractures. Recent studies have shown better early radiologic results when the deltoid ligament is repaired, but no differences in long term functional outcomes. However, there is evidence suggesting that patients with high fibular fractures or injuries with concomitant syndesmotic instability may benefit from repair. The authors recommend repairing the deltoid ligament complex in bimalleolar equivalent fractures associated with syndesmotic or gross multiligamentous instability as well as in heavier patients with greater mechanical requirements.

Indications for Deltoid and Spring Ligament Reconstruction in Progressive Collapsing Foot Deformity

RECOMMENDATION

There is evidence supporting medial soft tissue reconstruction, such as spring and deltoid ligament reconstructions, in the treatment of severe progressive collapsing foot deformity (PCFD). We recommend spring ligament reconstruction to be considered in addition to lateral column lengthening or subtalar fusion at the initial operation when those procedures have given at least 50% correction but inadequate correction of the severe flexible subluxation of the talonavicular and subtalar joints. We also recommend combined flatfoot reconstruction and deltoid reconstruction be considered as a joint sparing alternative in the presence of PCFD with valgus deformity of the ankle joint if there is 50% or more of the lateral joint space remaining.

LEVEL OF EVIDENCE

Level V, expert opinion.

Role of Minimally Invasive Surgery in Adult Flatfoot Deformity

Adult acquired flatfoot deformity (AAFD) as a consequence of posterior tibial tendon dysfunction is commonly divided in flexible (stages I and II) and fixed (stages III and IV) deformities. The aim of this article is to summarize the evidence available for minimally invasive surgical techniques that can be used in the treatment of flexible AAFD, including tibialis posterior tendoscopy, subtalar arthroereisis, minimally invasive calcaneal osteotomy, and medial proximal gastrocnemius recession. A treatment algorithm and technical tips have also been provided.

Diagnostic value of intraoperative tap test for acute deltoid ligament injury

PURPOSE

Deltoid ligament injuries appear with isolated or even no displacement of the lateral malleolus fracture which could easily lead to misdiagnosis, which frequently brings about ankle medial instability and talus shift that eventually lead to the occurrence of ankle osteoarthritis. This study is aimed to investigate the value of the tap test for assessing the integrity of the deltoid ligament intraoperatively.

METHODS

Ninety-two patients with malleolar fractures and possible acute deltoid ligament injury treated in our hospital from March 2013 to May 2016 were enrolled in this prospective study. The gravity stress test and tap test were performed preoperatively by three physicians independently before and after fixation of the fibula. The sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates of both tests were determined based on medial malleolus exploration for the integrity of the deltoid ligament. The inter-observer consistency was also analyzed.

RESULTS

Forty seven (51.1%) versus fifty two (56.5%) of the 92 patients tested positive for deltoid ligament injury according to the preoperative gravity stress test or the subsequent tap test. Forty-eight cases (52.2%) were confirmed during surgery. The sensitivity of gravity stress test was lower than that of tap test (95.8% vs 100%), and specificity of gravity stress test was the same as tap test (97.7% vs 97.7%). Between gravity stress test and tap test, the positive and negative predictive values were 97.9% vs 92.3% and 95.6% vs 100%, and the false-positive and false-negative rates were 2.3% vs 9.09% and 4.2% vs 0%, respectively. Between the two tests results, the percentage of inter-observer agreement was > 90% (kappa coefficient > 0.80).

CONCLUSION

The tap test has the advantages of high sensitivity, simple operation, and less radiation exposure, suggesting that it is of high diagnostic value for assessing the integrity of the acute deltoid ligament.

Endoscopically Assisted Reconstruction of Posterior Tibial Tendon for Stage 2 Posterior Tibial Tendon Dysfunction

The posterior tibial tendon functions as a primary stabilizer of the medial longitudinal arch of the foot. Posterior tibial tendon dysfunction accounts for 80% of cases of adult-acquired flatfoot deformity. It is classified into 4 stages based on the function of the tibialis posterior tendon, the reducibility of the deformity, and the condition of the ankle joint. The purpose of this Technical Note is to describe the technical details of endoscopically assisted reconstruction of theposterior tibial tendon for stage 2 posterior tibial tendon dysfunction. It consists of using the medial half of the anterior tibialis tendon as a primary transfer and augmentation by the flexor digitorum longus. This construct is then protected with a subtalar arthroereisis.

Arthroscopic Management of Osteochondral Lesion of Plantar Medial Talar Head

Osteochondral lesions of the talar head can be classified into 4 types: type 1 is located at the anterior part of the talar head, type 2 is at the plantar side of the talar head, type 3 is at the plantar lateral side of the talar head, and type 4 is at the plantar medial aspect of the talar head. The purpose of this Technical Note is to describe the details of arthroscopic management of an osteochondral lesion of the plantar medial talar head. It includes arthroscopic synovectomy of the medial recess of the anterior subtalar joint, debridement, and microfracture of the osteochondral lesion.

Spring Ligament Instability

The crucial role of the spring ligament complex within the pathologic process that leads to flatfoot deformity has evolved recently. There has been improvement in the anatomic knowledge of the spring ligament and understanding of its complex relationship to the deltoid complex and outstanding advances in biomechanics concepts related to the spring ligament. Optimization of flatfoot treatment strategies are focused on a renewed interest in the spring ligament and medial soft tissue reconstruction in concert with bony correction to obtain an adequate reduction of the talonavicular deformity and restoration of the medial longitudinal arch.

Arthroscopic approach to the spring (calcaneonavicular) ligament

BACKGROUND

This research studied the safety and efficacy of a new portal to the spring ligament. This portal is located just plantar to the insertion of the posterior tibial tendon and above the fibrous septum between the posterior tibial and the flexor digitorum longus tendons.

METHODS

Twelve fresh frozen foot and ankle specimens were used. The distance between the accessory medial portal and the medial plantar nerve was measured. The relation between the medial plantar nerve and the spring ligament was studied. The depth that can be reached through the portal was also assessed.

RESULTS

The average distance between the insertion point of the 3mm diameter metal rod and the medial plantar nerve was 20(6-27)mm. The medial plantar nerve located at lateral third of the ligament in 8 specimens (67%), middle third in 2 specimens (17%) and medial third in 2 specimens (17%). The tip of rod can reach Zone A in all specimens.

CONCLUSION

This study demonstrated that arthroscopic approach and repair of the spring ligament can injure the medial plantar nerve.

CLINICAL RELEVANCE

The clinical relevance of this cadaver study is that it confirmed the feasibility of arthroscopic approach to the whole span of the spring ligament and alerted the potential risk of injury to the medial plantar nerve during arthroscopic assisted repair of the ligament.

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

BACKGROUND

Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data.

METHODS

We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated.

RESULTS

At a mean of 25.6 months' follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament.

CONCLUSIONS

Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series.

The role of arthroereisis of the subtalar joint for flatfoot in children and adults

Subtalar arthroereisis has been reported as a minimally-invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults.It has been described as a standalone or adjunctive procedure, and is indicated in the treatment of flexible flatfoot, tibialis posterior tendon dysfunction, tarsal coalition and accessory navicular syndrome.Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols.Sinus tarsi pain is the most frequent complication, often requiring removal of the implant.To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear. Cite this article: EFORT Open Rev 2017;2:438-446. DOI: 10.1302/2058-5241.2.170009.

Arthroscopic Repair of Superomedial Spring Ligament by Talonavicular Arthroscopy

A spring ligament tear can occur because of failure of the tibialis posterior tendon in adult-acquired flatfoot deformity or as an isolated injury with a normal tibialis posterior tendon. The superomedial spring ligament is the most common site of rupture. Compromise of this ligament is a primary causative factor of peritalar subluxation, and a functioning tibialis posterior tendon cannot prevent or correct a planovalgus foot deformity. Therefore, the spring ligament should be repaired in addition to treatment of tibialis posterior tendon abnormalities. The purpose of this technical note is to describe a minimally invasive approach for repair of the superomedial spring ligament by talonavicular arthroscopy.