1
|
Rigby RB, Ptak NA. Incidence of Medial Deltoid Ligament Instability in 226 Patients With Chronic Ankle Instability. J Foot Ankle Surg 2024; 63:245-249. [PMID: 38043601 DOI: 10.1053/j.jfas.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 12/05/2023]
Abstract
The deltoid ligament is vitally important in the stability of the ankle and preventing excessive medial ankle movement. Historically, the impact of medial ankle instability has not been well understood in the setting of chronic ankle instability. A retrospective review of 226 patients treated for ankle instability between 2017 and 2022 identified 40 patients who required both medial and lateral repair. Decision for medial deltoid repair was based upon patient presentation, MRI findings, intraoperative fluoroscopy and final confirmation via arthroscopic positive "drive-through sign". Preoperative and postoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle scores, Patient-Recorded Outcomes Measurement Information System (PROMIS) scores, and Karlsson-Peterson Ankle Function (K&P) scores were obtained and compared. There were statistically significant improvements found in all 3 scoring systems at a mean follow-up time of 11.7 months postoperatively. In the setting of chronic ankle instability, consideration should be given to the evaluation and potential repair of the deltoid ligament in order to provide sufficient stability to the medial ankle.
Collapse
Affiliation(s)
- Ryan B Rigby
- Logan Regional Orthopedics, Intermountain Healthcare, Logan, UT.
| | | |
Collapse
|
2
|
Omar IM, Weaver JS, Altbach MI, Herynk BA, McCurdy WE, Kadakia AR, Taljanovic MS. Imaging of osteoarthritis from the ankle through the midfoot. Skeletal Radiol 2023; 52:2239-2257. [PMID: 36737484 PMCID: PMC10400729 DOI: 10.1007/s00256-023-04287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
Ankle, hindfoot, and midfoot osteoarthritis (OA) is most commonly posttraumatic and tends to become symptomatic in younger patients. It often results from instability due to insufficiency of supportive soft tissue structures, such as ligaments and tendons. Diagnostic imaging can be helpful to detect and characterize the distribution of OA, and to assess the integrity of these supportive structures, which helps determine prognosis and guide treatment. However, the imaging findings associated with OA and instability may be subtle and unrecognized until the process is advanced, which may ultimately limit therapeutic options to salvage procedures. It is important to understand the abilities and limitations of various imaging modalities used to assess ankle, hindfoot, and midfoot OA, and to be familiar with the imaging findings of OA and instability patterns.
Collapse
Affiliation(s)
- Imran M Omar
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 800, Chicago, IL, 60611, USA.
| | - Jennifer S Weaver
- Department of Radiology, Medical Center North, Vanderbilt University Medical Center, 1161 21St Ave. South, Nashville, TN, 37232, USA
| | - Maria I Altbach
- Department of Medical Imaging, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
| | - Bradley A Herynk
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 800, Chicago, IL, 60611, USA
| | - Wendy E McCurdy
- Department of Medical Imaging, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
| | - Anish R Kadakia
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 1350, Chicago, IL, 60611, USA
| | - Mihra S Taljanovic
- Department of Medical Imaging, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
- Department of Orthopaedic Surgery, University of Arizona College of Medicine Tucson, 1501 North Campbell, P.O. Box 245067, Tucson, AZ, 85724, USA
- Department of Radiology, University of New Mexico School of Medicine, 2211 Lomas Boulevard NE, Albuquerque, NM, 87106, USA
| |
Collapse
|
3
|
Ji X, Li H, Li H, Tong J, Hua Y. Safe Talar Tunnel Placement During Reconstruction of the Deep Layer of the Deltoid Ligament: A Comparison of 4 Different Anatomic Landmarks on the Lateral Malleolus. Orthop J Sports Med 2023; 11:23259671231211560. [PMID: 38035217 PMCID: PMC10687947 DOI: 10.1177/23259671231211560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/06/2023] [Indexed: 12/02/2023] Open
Abstract
Background Deltoid ligament reconstruction of the ankle can be considered when the ruptured ligament is insufficient for direct repair. Purpose To compare the safety of talar tunnels oriented toward 4 different anatomic landmarks on the lateral malleolus during reconstruction of the deep layer of the deltoid ligament (DDL). Study Design Descriptive laboratory study. Methods A total of 30 computed tomography scans of the ankle joint in healthy adults were collected to generate 3-dimensional models. Virtual talar tunnels with a diameter of 5 mm and with different lengths (20.0, 25.0, and 30.0 mm) were created from the talar insertion of the DDL and were oriented toward the talar neck as well as the most anterior, the most distal, and the most posterior points of the distal fibula. The minimal safe distance (MSD) of a drilling route was calculated for the tunnels, and the safe distance from the end of the tunnel to the bone surface was measured for each tunnel. The nonpaired Student t test was used to detect differences among the safe distances of the 4 different bone tunnels. Results For the 20.0-mm tunnels, the safe distance of the tunnel oriented toward the talar neck (5.90 ± 1.16 mm) did not meet the MSD (6.0 mm). For the 25.0-mm tunnels, the safe distances of the tunnels oriented toward the talar neck (4.53 ± 1.13 mm) and the anterior point of the fibula (5.91 ± 1.52 mm) did not meet the MSD (6.9 mm). Conclusion Tunnels that were 5 mm in diameter and 20.0 and 25.0 mm in length, oriented toward the most distal or most posterior point of the distal fibula, were safe for DDL reconstruction. Clinical Relevance Knowledge of safe talar tunnel placement is important, especially to avoid bone surface penetration during DDL reconstruction.
Collapse
Affiliation(s)
- Xiaoxi Ji
- Sports Medicine Center, Department of Sports Medicine and Arthroscopy Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongyun Li
- Sports Medicine Center, Department of Sports Medicine and Arthroscopy Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong Li
- Sports Medicine Center, Department of Sports Medicine and Arthroscopy Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahui Tong
- Sports Medicine Center, Department of Sports Medicine and Arthroscopy Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yinghui Hua
- Sports Medicine Center, Department of Sports Medicine and Arthroscopy Surgery, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
4
|
Brady AW, Bryniarski A, Brown JR, Waltz R, Stake IK, Kreulen CD, Haytmanek CT, Clanton TO. The Biomechanical Role of the Deltoid Ligament on Ankle Stability: Injury, Repair, and Augmentation. Am J Sports Med 2023; 51:2617-2624. [PMID: 37449714 DOI: 10.1177/03635465231181082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Deltoid ligament injuries occur in isolation as well as with ankle fractures and other ligament injuries. Both operative treatment and nonoperative treatment are used, but debate on optimal treatment continues. Likewise, the best method of surgical repair of the deltoid ligament remains unclear. PURPOSE To determine the biomechanical role of native anterior and posterior components of the deltoid ligament in ankle stability and to determine the efficacy of simple suture versus augmented repair. STUDY DESIGN Controlled laboratory study. METHODS Ten cadaveric ankles (mean age, 51 years; age range, 34-64 years; all male specimens) were mounted on a 6 degrees of freedom robotic arm. Each specimen underwent biomechanical testing in 8 states: (1) intact, (2) anterior deltoid cut, (3) anterior repair, (4) tibiocalcaneal augmentation, (5) deep anterior tibiotalar augmentation, (6) posterior deltoid cut, (7) posterior repair, and (8) complete deltoid cut. Testing consisted of anterior drawer, eversion, and external rotation (ER), each performed at neutral and 25° of plantarflexion. A 1-factor, random-intercepts, linear mixed-effect model was created, and all pairwise comparisons were made between testing states. RESULTS Cutting the anterior deltoid introduced ER (+2.1°; P = .009) and eversion laxity (+6.2° of eversion; P < .001) at 25 degrees of plantarflexion. Anterior deltoid repair restored native ER but not eversion. Tibiocalcaneal augmentation reduced eversion laxity, but tibiotalar augmentation provided no additional benefit. The posterior deltoid tear showed no increase in laxity. Complete tear introduced significant anterior translation, ER, and eversion laxity (+7.6 mm of anterior translation, +13.8° ER and +33.6° of eversion; P < .001). CONCLUSION A complete deltoid tear caused severe instability of the ankle joint. Augmented anterior repair was sufficient to stabilize the complete tear, and no additional benefit was provided by posterior repair. For isolated anterior tear, repair with tibiocalcaneal augmentation was the optimal treatment. CLINICAL RELEVANCE Deltoid repair with augmentation may reduce or avoid the need for prolonged postoperative immobilization and encourage accelerated rehabilitation, preventing stiffness and promoting earlier return to preinjury activity.
Collapse
Affiliation(s)
- Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Justin R Brown
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Ingrid K Stake
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | | |
Collapse
|
5
|
Pflüger P, Valderrabano V. Sprain of the Medial Ankle Ligament Complex. Foot Ankle Clin 2023; 28:355-367. [PMID: 37137629 DOI: 10.1016/j.fcl.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Injuries of the medial ankle ligament complex (MALC; deltoid and spring ligament) are more common following ankle sprains than expected, especially in eversion-external rotation mechanisms. Often these injuries are associated with concomitant osteochondral lesions, syndesmotic lesions, or fractures of the ankle joint. The clinical assessment of the medial ankle instability together with a conventional radiological and MR imaging is the basis for the definition of the diagnosis and therefore the optimal treatment. This review aims to provide an overview as well as a basis to successfully manage MALC sprains.
Collapse
Affiliation(s)
- Patrick Pflüger
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Victor Valderrabano
- SWISS ORTHO CENTER, Swiss Medical Network, Schmerzklinik Basel, University of Basel, Hirschgässlein 15, Basel 4010, Switzerland.
| |
Collapse
|
6
|
Abstract
Ankle sprains are extremely common. It is important to have a clear insight of the course of recovery after such injury to evaluate the effective strategies to guide management decisions, and understand the potential risk factors involved in the development of chronic problems and recurrent ankle sprains. When a prompt diagnosis is not formulated, ligament tears can remain untreated, and chronic ankle instability can result after acute lateral or medial ankle sprain. When the medial ligament complex (MLC), in particular the anterior fascicle of the deltoid ligament, is involved, rotational ankle instability (RAI) can develop. Generally, a tear of the anterior fibres of the MCL accompanied by anterior talofibular ligament (ATFL) insufficiency has been associated with RAI, while injury of the intermediate fibres of the MLC has been associated with medial ankle instability (MAI). Conservative management is the first line of treatment, with surgery reserved for special cases or if rehabilitation has failed. Regarding surgery, several options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Ankle arthroscopy is increasingly used to address ligament insufficiency and to identify and treat intra-articular pathologies. Repair of MLC tears by an arthroscopic all-inside procedure is effective in both MAI and RAI.
Collapse
Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Fisciano, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Fisciano, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Italy
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
- Keele University, Faculty of Medicine, School of Pharmacology and Bioengineering, Guy Hilton Research Centre, Hartshill, Stoke-on-Trent, UK
| |
Collapse
|
7
|
Robberecht J, Shah DS, Taylan O, Natsakis T, Vandeputte G, Vander Sloten J, Jonkers I. The role of medial ligaments and tibialis posterior in stabilising the medial longitudinal foot arch: a cadaveric gait simulator study. Foot Ankle Surg 2022; 28:906-911. [PMID: 34955405 DOI: 10.1016/j.fas.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/28/2021] [Accepted: 12/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Debate exists whether adult acquired flatfoot deformity develops secondary to tibialis posterior (TibPost) tendon insufficiency, failure of the ligamentous structures, or a combination of both. AIM The aim of this study is to determine the contribution of the different medial ligaments in the development of acquired flatfoot pathology. Also to standardise cadaveric flatfoot models for biomechanical research and orthopaedic training. METHODS Five cadaveric feet were tested on a dynamic gait simulator. Following tests on the intact foot, the medial ligaments - fascia plantaris (FP), the spring ligament complex (SLC) and interosseous talocalcaneal ligament (ITCL) - were sectioned sequentially. Joint kinematics were analysed for each condition, with and without force applied to TibPost. RESULTS Eliminating TibPost resulted in higher internal rotation of the calcaneus following the sectioning of FP and SLC (d>1.28, p = 0.08), while sectioning ITCL resulted in higher external rotation without TibPost (d = 1.24, p = 0.07). Sequential ligament sectioning induced increased flattening of Meary's angle. CONCLUSION Function of TibPost and medial ligaments is not mutually distinctive. The role of ITCL should not be neglected in flatfoot pathology; it is vital to section this ligament to develop flatfoot in cadaveric models.
Collapse
Affiliation(s)
- Joris Robberecht
- Department of Orthopedic Surgery, AZ Turnhout, Turnhout, Belgium.
| | - Darshan S Shah
- Institute for Orthopedic Research and Training (IORT), KU Leuven, Leuven, Belgium; Department of Mechanical Engineering, Indian Institute of Technology Bombay, Mumbai, India.
| | - Orçun Taylan
- Institute for Orthopedic Research and Training (IORT), KU Leuven, Leuven, Belgium.
| | - Tassos Natsakis
- Department of Automation, Technical University of Cluj-Napoca, Romania
| | | | - Jos Vander Sloten
- Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium.
| | - Ilse Jonkers
- Department of Human Movement Sciences, KU Leuven, Leuven, Belgium.
| |
Collapse
|
8
|
Malakoutikhah H, Madenci E, Latt LD. The impact of ligament tears on joint contact mechanics in progressive collapsing foot deformity: A finite element study. Clin Biomech (Bristol, Avon) 2022; 94:105630. [PMID: 35334403 DOI: 10.1016/j.clinbiomech.2022.105630] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with longstanding progressive collapsing foot deformity often develop osteoarthritis of the ankle, midfoot, or hindfoot joints, which can be symptomatic or lead to fixed deformities that complicate treatment. The development of deformity is likely caused by ligament degeneration and tears. However, the effect of individual ligament tears on changes in joint contact mechanics has not been investigated. METHODS A validated finite element model of the foot was used to compare joint contact areas, forces, and pressures between the intact and collapsed foot, and to evaluate the effect of individual ligament tears on joint contact mechanics. FINDINGS Collapsing the foot resulted in an increase in contact pressure in the subtalar, calcaneocuboid, tibiotalar, medial naviculocuneiform, and first tarsometatarsal joints but a decrease in contact pressure in the talonavicular joint. Rupture of the spring ligament was the main contributor to increased calcaneocuboid and subtalar joint contact pressures and decreased medial naviculocuneiform and first tarsometatarsal joint contact pressures, as well as talonavicular subluxation. Deltoid ligament rupture was the primary source of increased contact pressure in the medial naviculocuneiform, first tarsometatarsal, and tibiotalar joints. INTERPRETATION Degenerative tearing of the ligaments in flatfoot deformity leads to increased joint contact pressures, primarily in the calcaneocuboid, subtalar, and tibiotalar joints, which has been implicated in the development of osteoarthritis in these joints. An improved understanding of the relationship between ligament tears and joint contact pressures could provide support for the use of ligament reconstructions to prevent the development of arthrosis.
Collapse
Affiliation(s)
- Hamed Malakoutikhah
- Department of Aerospace and Mechanical Engineering, University of Arizona, Tucson, AZ, USA.
| | - Erdogan Madenci
- Department of Aerospace and Mechanical Engineering, University of Arizona, Tucson, AZ, USA.
| | | |
Collapse
|
9
|
Gregersen MG, Fagerhaug Dalen A, Nilsen F, Molund M. The Anatomy and Function of the Individual Bands of the Deltoid Ligament—and Implications for Stability Assessment of SER Ankle Fractures. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221104078. [PMID: 35722175 PMCID: PMC9201323 DOI: 10.1177/24730114221104078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Deltoid ligament injury occurs often with supination-external rotation (SER)
ankle trauma. SER fibula fractures with concomitant deltoid ligament injury
are considered unstable—requiring operative fixation. Recent studies have
questioned this general practice with emphasis on better defining the medial
side ankle ligamentous injury. The function of the individual bands of the
deltoid ligament, and the interplay between them, are not fully understood.
We undertook this study to develop a better understanding of these complex
ligamentous structures and ultimately aid assessment and treatment choice of
SER ankle fractures with concomitant deltoid ligament injuries. Methods: Ten fresh-frozen cadaveric foot and ankle specimens were studied. We
identified the various ligament bands and did a functional analysis by
assessment of ligament length and tension at predefined angles of ankle
dorsi-plantarflexion combined with valgus/varus and rotation. The results
were determined by manual evaluation with calipers and goniometers, manual
stress, and direct visualization. Results: We recorded primarily 5 different bands of the deltoid ligament: the
tibionavicular (TNL; 10/10) tibiospring (TSL; 9/10), tibiocalcaneal (TCL;
10/10), deep anterior tibiotalar (dATTL; 9/10), and deep posterior
tibiotalar (dPTTL; 10/10) ligaments. The tibiospring ligament was tense in
plantarflexion, while the tibiocalcaneal and deep posterior tibiotalar
ligaments were tense in dorsiflexion. The superficial layer ligaments and
the deep anterior tibiotalar ligament length and tension were largely
affected by changes in varus/valgus and rotation. The deep posterior
tibiotalar ligament length and tension was altered predominantly by changes
in dorsi-plantarflexion; varus/valgus positioning had a minor effect on this
band. Conclusions: We confirmed the finding of previous studies that dorsi-plantarflexion
affects the tensile engagement of the separate ligament bands differently.
Likewise, combined movements with varus/valgus and rotation seem to affect
the separate ligament bands differently. Our results suggest that the TNL,
TSL, and dATTL are at risk of injury, whereas the TCL and particularly the
dPTTL are protected in the event of an SER-type ankle fracture mechanism of
injury. Level of Evidence Level V, cadaveric study.
Collapse
Affiliation(s)
- Martin G. Gregersen
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Grålum, Norway
| | | | - Fredrik Nilsen
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Marius Molund
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| |
Collapse
|
10
|
Gross CE, Jackson JB. The Importance of the Medial Column in Progressive Collapsing Foot Deformity: Osteotomies and Stabilization. Foot Ankle Clin 2021; 26:507-521. [PMID: 34332732 DOI: 10.1016/j.fcl.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Adult acquired flatfoot deformity is a complex pathologic condition that requires considerate and thoughtful surgical solutions. Medial column procedures are often supplemented by a medializing calcaneal osteotomy and/or a lateral column lengthening because of the complex nature of progressive collapsing foot deformity and its resultant peritalar instability. Other osteotomies and fusions include a Cotton osteotomy and first tarsometatarsal fusion.
Collapse
Affiliation(s)
- Christopher E Gross
- Medical University of South Carolina, 96 Jonathon Lucas Drive, Charleston, SC 209403, USA.
| | - J Benjamin Jackson
- University of South Carolina, Prisma Orthopaedics, 2 medical park, Suite 404, Columbia, SC 29203, USA
| |
Collapse
|