Spring ligament tear decreases static stability of the ankle joint

Spring Ligament Reconstruction for Progressive Collapsing Foot Deformity: Contemporary Review

The spring ligament is one of the main stabilizers of the medial arch of the foot and the primary static supporter of the talonavicular joint. Attenuation or rupture of this ligament is thought to play a central role in the pathophysiology of progressive collapsing foot deformity. Traditional correction of flexible flatfoot consists of posterior tibial tendon augmentation along with various osteotomies or hindfoot fusions. Repair or reconstruction of the spring ligament has not been as widely pursued. In recent years, newer techniques have been explored and may improve outcomes of traditional procedures, or possibly entirely replace some osteotomies. Combined spring-deltoid ligament reconstruction is also gaining traction as a viable technique, particularly as the ankle begins to deform into valgus. This review summarizes the variety of nonanatomic and anatomic reconstruction techniques that have been described, including autologous tendon transfers, allografts, and synthetic augmentation. Although many have only been characterized in biomechanical cadaver studies, this article reviews preliminary clinical studies that have shown promising results. There is a need for more high-quality studies evaluating the clinical, radiographic, and patient-reported outcomes following spring ligament reconstruction.

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.

Evaluation of the heel external rotation test in soft tissue deficiencies associated with adult acquired flatfoot deformity (AAFD). A cadaver sectioning analysis

BACKGROUND

To date, evaluation of the heel external rotation test has not been taken with respect to AAFD. Traditional 'gold standard' tests do not account for the contribution of the midfoot ligaments towards instability. These tests would be flawed as any midfoot instability may produce a false positive result.

AIMS

To evaluate the differential contribution of the spring, deltoid and other local ligaments in external rotation generated at the heel.

METHODS

Serial ligament sectioning was performed on 16 cadaveric specimens, with a 40 N-external rotation force applied to the heel. These were divided into four groups with different sequences of ligament sectioning. Measurements of the total amount/range of external, tibiotalar and subtalar rotation were made.

RESULTS

The deep component of the deltoid ligament (DD) was the main ligament influencing heel external rotation (P < 0.05, in all cases), and acted primarily at the tibiotalar joint (87.9 %). The spring ligament (SL) influenced heel external rotation predominantly (91.2 %) at the subtalar joint (STJ). Greater than 20 degrees external rotation could only be achieved with DD sectioning. The interosseous (IO) and cervical (CL) ligaments did not significantly contribute to external rotation at either joint (P > 0.05).

CONCLUSION

Clinically relevant external rotation (>20 degrees) is solely attributable to DD failure in the presence of intact lateral ligaments (LL). This test may improve detection of DD instability and allow clinicians to subclassify patients with Stage 2 AAFD into those where DD may or may not be compromised.

Fibrocartilaginous Tissue: Why Does It Fail to Heal?

Tendons and ligaments are critical components in the function of the musculoskeletal system, as they provide stability and guide motion for the biomechanical transmission of forces into bone. Several common injuries in the foot and ankle require the repair of ruptured or attenuated tendon or ligament to its osseous insertion. Understanding the structure and function of injured ligaments and tendons is complicated by the variability and unpredictable nature of their healing. The healing process at the tendon/ligament to bone interface is challenging and often frustrating to foot and ankle surgeons, as they have a high failure rate necessitating the need for revision.

A Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.

The Role of Diffusion Weighted MR Imaging in the Diagnosis of Tendon Injuries of the Ankle and Foot

Background and objectives: Our aim is to determine the diagnostic performance and utility of Diffusion Weighted MR Imaging (DWI) against the routine Magnetic Resonance Imaging (MRI) for the evaluation of patients with tendon injuries of the ankle and foot. Materials and Method: After institutional review board approval and informed consent taken from all the patients, ankle and foot MR imaging and DWI-Apparent Diffusion Coefficient (ADC) mapping were performed on the 81 injured tendons of 50 patients. All tendon injuries were named as Rupture (R), Partial tear (PT), and Tenosynovitis (T). Diagnostic interpretation was based on the MRI-DWI and ADC mapping, verified by either open surgery, diagnostic arthroscopy, or conservative procedures-splint application. Statistical analysis of this research was assessed by Fischer’s exact test, variance analysis test between dependent groups, Receiver Operating Characteristics (ROC) curve, and Pearson chi square statistics. Results: MRI depicted all tendon injuries with 70% sensitivity and 100% specificity, and showed a significant statistical relationship to surgical and arthroscopic references with high agreement (p < 0.05, k: 0.609). DWI had 100% sensitivity and 83–90% specificity for the visualization of tendon injuries with certain agreement and a significant statistical relationship to the gold standard (p < 0.05, k: 0.890–0.899). For all those injured tendons, DWI had 100% sensitivity for the diagnosis of R, and 92–97% sensitivity corresponding to PT and T over routine ankle MR imaging. The specificity of DWI to MRI ranged from 75 to 44% for all the injured tendons. DWI had significant statistical superiority over MRI for the visualization of R, PT, and T of all tendons included in this research (p < 0.05). Conclusions: DWI is a good imaging modality for the visualization of ankles with tendon injuries, possibly further improving the sensitivity of the classical ankle and foot MRI, and supplying more beneficial and diagnostic information than routine MR imaging on the basis of R, PT, and T of tendons at the ankle and foot.

Biomechanics of Medial Ankle and Peritalar Instability

The deltoid and spring ligaments are the primary restraints against pronation and valgus deformity of the foot, and in preserving the medial arch. The posterior tibial tendon has a secondary role in plantar arch maintenance, and its biomechanical stress increases considerably when other tissues fail. A thorough understanding of the anatomy and biomechanics of the deltoid-spring ligament is crucial for successful reconstruction of the tibiocalcanealnavicular ligament, hence, to restore ankle and medial peritalar stability. Although effective in correcting the deformity, tibionavicular tenodesis might be critical, as it blocks physiologic pronation of the hindfoot, which may result in dysfunction and pain.

Association between anterior talofibular ligament injury and ankle tendon, ligament, and joint conditions revealed by magnetic resonance imaging

Background

The lateral ankle ligament complex is the most frequently injured ligament secondary to strong ankle inversion movement during lateral ankle sprains (LAS). Among these injuries, anterior talofibular ligament (ATFL) injury is the most frequent condition (present in 66-85% of such injuries). The purpose of this research was to use magnetic resonance imaging (MRI) to determine the association between ankle tendon, ligament, and joint conditions and ATFL injuries.

Methods

A case-control MRI study was carried out to compare the presence of ankle muscle, tendon, ligament, and joint conditions in patients with injured ATFLs (case group; n=25) and non-injured ATFLs (control group; n=25).

Results

Achilles tendinopathy was present in 1/25 (4%) patients with injured ATFLs and 7/25 (28%) non-injured ATFL subjects (P=0.048). Injured calcaneofibular ligaments (CFLs) were present in 19/25 (76%) patients with injured ATFLs and 1/25 (4%) non-injured ATFL subjects (P<0.001). Finally, injured tibiotalar joints were present in 16/25 (64%) patients with injured ATFLs and 5/25 (20%) non-injured ATFL subjects (P=0.002). Other musculoskeletal structure injuries occurred at similar rates between patients with injured ATFLs and those with non-injured ATLFs (P≥0.05).

Conclusions

Patients with ATFL injuries showed a greater presence of CFL and tibiotalar joint injuries than subjects with non-injured ATFLs.

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.

Peritalar Kinematics With Combined Deltoid-Spring Ligament Reconstruction in Simulated Advanced Adult Acquired Flatfoot Deformity

BACKGROUND

Adult acquired flatfoot deformity (AAFD) is a complex and progressive deformity involving the ligamentous structures of the medial peritalar joints. Recent anatomic studies demonstrated that the spring and deltoid ligaments form a greater medial ligament complex, the tibiocalcaneonavicular ligament (TCNL), which provides medial stability to the talonavicular, subtalar, and tibiotalar joints. The aim of this study was to assess the biomechanical effect of a spring ligament tear on the peritalar stability. The secondary aim was to assess the effect of TCNL reconstruction in restoration of peritalar stability in comparison with other medial stabilization procedures, anatomic spring or deltoid ligament reconstructions, in a cadaveric flatfoot model.

METHODS

Ten fresh-frozen cadaveric foot specimens were used. Reflective markers were mounted on the tibia, talus, navicular, calcaneus, and first metatarsal. Peritalar joint kinematics were captured by a multiple-camera motion capture system. Mild, moderate, and severe flatfoot models were created by sequential sectioning of medial capsuloligament complex followed by cyclic axial loading. Spring only, deltoid only, and combined deltoid-spring ligament (TCNL) reconstructions were performed. The relative kinematic changes were compared using 2-way analysis of variance (ANOVA).

RESULTS

Compared with the initial condition, we noted significantly increased valgus alignment of the subtalar joint of 5.1 ± 2.3 degrees (P = .031) and 5.8 ± 2.7 degrees (P < .01) with increased size of the spring ligament tear to create moderate to severe flatfoot, respectively. We noted an increased tibiotalar valgus angle of 5.1 ± 2.0 degrees (P = .03) in the severe model. Although all medial ligament reconstruction methods were able to correct forefoot abduction, the TCNL reconstruction was able to correct both the subtalar and tibiotalar valgus deformity (P = .04 and P = .02, respectively).

CONCLUSION

The TCNL complex provided stability to the talonavicular, subtalar, and tibiotalar joints. The combined deltoid-spring ligament (TCNL) reconstructions restored peritalar kinematics better than isolated spring or deltoid ligament reconstruction in the severe AAFD model.

CLINICAL RELEVANCE

The combined deltoid-spring ligament (TCNL) reconstruction maybe considered in advanced AAFD with medial peritalar instability: stage IIB with a large spring ligament tear or stage IV.

Biomechanics and Orthotic Treatment of the Adult Acquired Flatfoot

The adult acquired flatfoot deformity resulting from posterior tibial tendon dysfunction is the result of rupture of the posterior tibial tendon as well as key ligaments of the ankle and hindfoot. Kinematic studies have verified certain levels of deformity causing hindfoot eversion, lowering of the medial longitudinal arch and forefoot abduction. The condition is progressive and left untreated will cause significant disability. Bracing with ankle-foot orthoses has shown promising results in arresting progression of deformity and avoiding debilitating surgery. Various types of ankle-foot orthoses have been studied in terms of effects on gait as well as efficacy in treatment.

Alterations in tibiotalar joint reaction force following syndesmotic injury are restored with static syndesmotic fixation

INTRODUCTION

Syndesmotic injury alters joint mechanics, which may fail to be restored unless an anatomic reduction is obtained.

METHODS

A minimally invasive method of measuring joint forces was utilized that does not require significant dissection or intraarticular placement of sensory instruments. Steinmann pins were placed in the tibia and talus of eight fresh-frozen human cadaveric lower extremities and a baseline joint reaction force was determined. A syndesmotic injury was created and reduction (anatomic and anterior malreduction) performed with one or two quadricortical screws and joint reaction forces were measured after the injury and subsequent repairs.

FINDINGS

Baseline mean tibiotalar joint reaction force was 31.4 (SD 7.3 N) and syndesmotic injury resulted in a 35% decrease (mean 20.3, SD 8.4 N, p < 0.01). Fixation of the injury using one or two syndesmotic screws resulted in significant increase compared to the injury state (mean 28.7, SD3.9 N, and mean 28.3, SD 6.4 N, p < 0.05), however there was no significant difference between the two methods of fixation. Malreduction of the fibula also increased joint reaction force compared to the injury state (mean 31.5, SD 5.2 N, p < 0.01), however a significant difference was not detected between malreduction and anatomic reduction.

INTERPRETATION

The present study demonstrates that syndesmotic injury decreases joint reaction force within the tibiotalar joint, suggesting ankle joint instability. Tibiotalar force was restored with anatomic reduction with either a 1 or 2 quadricortical syndesmotic screws. Furthermore, anterior malreduction restored joint reaction force to levels similar to those observed at baseline and with anatomic reduction.

LEVEL OF EVIDENCE

Level V: biomechanical/cadaver study.