Reconstruction of the Deltoid-Spring Ligament: Tibiocalcaneonavicular Ligament Complex

Combined Deltoid and Spring Ligament Reconstruction Using the Quadrangular Construct: Our Experience and Review of the Literature

Background A combined reconstruction of chronic deltoid and spring ligament insufficiency is uncommon. Our study aims to share our experience in treating post-traumatic, chronic deltoid, and spring ligament insufficiency using the "quadrangular construct" technique. Material and methods Five patients who had post-traumatic combined deltoid and spring ligament insufficiency were included in the study. All patients reported a "giving-way" sensation. Preoperatively, each patient underwent weight-bearing radiographs of the ankle and foot. The talo-first metatarsal angle and hindfoot alignment angle were noted. The superficial deltoid ligament was repaired using a suture anchor augmented with Internal BraceTM (Arthrex, Naples, USA) FiberTape® to form a quadrangular construct that anatomically mimics various components of the deltoid-spring ligament complex. Due to the associated excessive heel valgus, three patients also underwent medial displacement calcaneum osteotomy. Additionally, one patient required lateral ligament repair, and another patient required syndesmotic stabilization. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to evaluate preoperative and postoperative ankle function. Results All five patients were followed up for a mean of 20 months (range: 12-24 months). The mean preoperative talo-first metatarsal angle improved from 8.46 degrees to 4.84 degrees. The preoperative mean hindfoot alignment angle was reduced from 10.9 to 5.76 degrees postoperatively. One patient had irritation due to the anchor, which needed removal after one year. Postoperatively, no patients re-experienced the feeling of "giving way". The AOFAS scores postoperatively showed two patients as excellent, two as good, and one as fair. All the patients returned to their pre-injury work. Conclusion  We have developed a technique for combined deltoid and spring ligament reconstruction using a quadrangular construct. This technique helps to restore anatomical stability, is safe, easily reproducible, and has shown positive short-term results in follow-up. The level of evidence is one of the methods used to categorize the quality and reliability of research, and our study falls under the category of level IV evidence.

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.

Medium- to Long-term Results of Nonanatomic Spring Ligament Reconstruction Using an Allograft Tendon in Progressive Collapsing Foot Deformity With Severe Abduction Deformity

BACKGROUND

Spring ligament reconstruction (SLR) has been suggested as an adjunct to other reconstructive procedures to potentially avoid talonavicular joint fusion in progressive collapsing foot deformity (PCFD) with severe abduction deformity. Most clinical reports present short-term follow-up data and a small number of patients. The purpose of this study was to examine the medium- to long-term outcomes of an SLR using allograft tendon augmentation as part of PCFD surgical reconstruction. This study to our knowledge represents the largest number of patients and the longest follow-up to date.

METHODS

This study retrospectively reviewed 26 patients (27 feet, mean age of 61.4 years) who underwent SLR with allograft tendon as part of PCFD reconstruction. The mean follow-up of the cohort was 8 years (range, 5-13.4). Radiographic evaluation consisted of 5 parameters including talonavicular coverage angle (TNC), with the maintenance of correction being evaluated by comparing parameters from the early postoperative period (mean: 11.6 months, range, 8-17) to final follow-up. Foot and Ankle Outcome Score (FAOS) and patient satisfaction questionnaires were collected at final follow-up. Conversion to talonavicular or subtalar fusion was considered as a failure.

RESULTS

Final radiographs demonstrated successful abduction correction, with the mean TNC improving from 43.7 degrees preoperatively to 14.1 degrees postoperatively (P < .0001). All other radiographic parameters improved significantly and exhibited maintenance of the correction. All FAOS subscales showed significant improvement. Responses to the satisfaction questionnaire were received from all except 1 patient, of whom 88.5% (23/26) were satisfied with the results, 96.2% (25/26) would undergo the surgery again, and 88.5% (23/26) would recommend the surgery. Eight feet (29.6%) required painful hardware removal and 1 (3.7%) developed nonunion of the lateral column lengthening osteotomy. No patient required conversion to talonavicular or subtalar fusion.

CONCLUSION

This study demonstrates favorable medium- to long-term outcomes following PCFD reconstruction including an SLR with allograft tendon augmentation.

LEVEL OF EVIDENCE

Level IV, case series.

Adult Acquired Flatfoot Deformity

Adult acquired flatfoot deformity (AAFD) is a condition commonly seen by orthopaedic surgeons. Posterior tibial tendon dysfunction is thought to be the initial pathoanatomic etiology that leads to this deformity. Successful resolution of the pain associated with AAFD can be achievable with nonsurgical methods. Patients who continue to have pain or functional limitations despite nonsurgical treatment can find improvement with appropriately selected surgical interventions. This article addresses new advances in treatment based on the stage of AAFD and will identify areas of continued development with a focus on surgical management. The literature continues to evolve as demonstrated by a recent update regarding the nomenclature and treatment of this condition to progressive collapsing flatfoot deformity. Future goals of research include understanding the natural history of the disease, from asymptomatic to symptomatic, and studying a wide array of newer treatments and implants that have not been prospectively evaluated.

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.

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.

Current Concepts in Treatment of Ligament Incompetence in the Acquired Flatfoot

Flatfoot deformity consists of a loss of medial arch, hindfoot valgus, and forefoot abduction. Historically considered a posterior tendon insufficiency, multiple ligament damage and subsequent incompetence explain the different clinical presentations with varying degrees of deformity. When surgery is deemed necessary, depending on the apex of the deformity, skeletal and soft tissue procedures are considered to keep motion and restore function. Osteotomies are considered at every level where an apex of deformity is found. The recently designated tibiocalcaneonavicular ligament comprises the older superficial and deep deltoid and spring ligaments; its repair or reconstruction should be considered in most flatfoot cases.

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.

Strain pattern of each ligamentous band of the superficial deltoid ligament: a cadaver study

BACKGROUND

There are few reports on the detailed biomechanics of the deltoid ligament, and no studies have measured the biomechanics of each ligamentous band because of the difficulty in inserting sensors into the narrow ligaments. This study aimed to measure the strain pattern of the deltoid ligament bands directly using a Miniaturization Ligament Performance Probe (MLPP) system.

METHODS

The MLPP was sutured into the ligamentous bands of the deltoid ligament in 6 fresh-frozen lower extremity cadaveric specimens. The strain was measured using a round metal disk (clock) fixed on the plantar aspect of the foot. The ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N-m force was applied to the ankle and subtalar joint complex. Then the clock was rotated every 30° to measure the strain of each ligamentous band at each endpoint.

RESULTS

The tibionavicular ligament (TNL) began to tense at 10° plantar flexion, and the tension becomes stronger as the angle increased; the TNL worked most effectively in plantar flex-abduction. The tibiospring ligament (TSL) began to tense gradually at 15° plantar flexion, and the tension became stronger as the angle increased. The TSL worked most effectively in abduction. The tibiocalcaneal ligament (TCL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased. The TCL worked most effectively in pronation (dorsiflexion-abduction). The superficial posterior tibiotalar ligament (SPTTL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased, with the SPTTL working most effectively in dorsiflexion.

CONCLUSION

Our results show the biomechanical function of the superficial deltoid ligament and may contribute to determining which ligament is damaged during assessment in the clinical setting.

Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review

BACKGROUND

Deltoid ligament injuries are typically caused by supination-external rotation or pronation injury. Numerous ligament reconstruction techniques have been proposed; however, clear indications for operative repair have not yet been well established in the literature.

METHODS

We reviewed primary research articles comparing ORIF treatment for ankle fracture with versus without deltoid ligament repair.

RESULTS

Five studies were identified with a total of 281 patients. 137 patients underwent ORIF with deltoid repair, while 144 patients underwent ORIF without deltoid ligament repair. Clinical, radiographic, and functional outcomes, as well as complications were considered. The average follow-up was 31 months (range, 5-120).

CONCLUSIONS

Current literature does not provide clear indication for repair of the deltoid ligament at the time of ankle fracture repair. There may be some advantages of adding deltoid ligament repair for patients with high fibular fractures or in patients with concomitant syndesmotic fixation.

LEVEL OF CLINICAL EVIDENCE

III.

Deltoid-Spring Ligament Reconstruction in Adult Acquired Flatfoot Deformity With Medial Peritalar Instability

BACKGROUND

A spring ligament tear is commonly present in advanced stages of adult acquired flatfoot deformity (AAFD). Previous anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament, forming the tibiocalcaneonavicular ligament (TCNL). Adding allograft TCNL reconstruction to osseous correction has been suggested to augment medial peritalar stability in advanced AAFD with large spring ligament tears. We aimed to investigate the clinical and radiographic outcomes of TCNL reconstruction for flexible AAFD with medial peritalar instability.

METHODS

Fourteen feet in 12 patients who underwent osseous and TCNL reconstructions for advanced AAFD (stage IIB with large spring ligament tears or stage IV) were recruited for the study. The mean postoperative follow-up was 24 (range, 12-33) months. Pre- and postoperative clinical outcomes were assessed by the Foot and Ankle Ability Measure (FAAM), SF-36, and Patient-Reported Outcomes Measurement Information System (PROMIS). Correction of forefoot abduction and the sagittal arch were measured from pre- and postoperative weightbearing radiographs.

RESULTS

The FAAM Activities of Daily Living improved from 69.3 to 90.1 (P = .001). The SF-36 Physical Function (PF) and Pain subscales both improved significantly (39.4 to 87.8 and 44.6 to 93.1, respectively, P < .001 for each). The PROMIS PF improved from 38.2 to 46.8 (P = .002) and the PROMIS Pain Interference (PI) from 62.6 to 50.1 (P = .003). Radiographic measures showed an improved anterior-posterior (AP) talo-first metatarsal angle of 24.7 to 11.8 degrees (P < .001) and talonavicular coverage angle of 47.4 to 23.1 degrees (P < .01). An improved Meary's angle of 29.7 to 12.5 degrees (P < .001) and a calcaneal pitch angle of 11.7 to 16.9 degrees (P = .14) were noted in the lateral view.

CONCLUSION

Considering the anatomic characteristics of the deltoid-spring ligament complex, TCNL reconstruction may play a significant role in maintaining peritalar stability when performed with osseous correction. Deltoid-spring ligament (TCNL) reconstruction is a viable surgical option for those with advanced stage AAFD with medial peritalar instability that leads to improved functional and radiographic outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Spring ligament tear decreases static stability of the ankle joint

BACKGROUND

Spring ligament tear is often found in advanced adult acquired flatfoot deformity and its reconstruction in conjunction with the deltoid ligament has been proposed to restore the tibiotalar and talonavicular joint stability. The aim of the present study is to determine the effect of spring ligament injury and subsequent reconstruction on static joint reactive force using a non-invasive method of measurement.

METHODS

Ten fresh-frozen human cadaveric lower legs were disarticulated at the knee joint. Static joint reactive force of the tibiotalar and talonavicular joint were measured at baseline, after spring ligament injury, and after ligament reconstruction. Reconstruction consisted of a forked semitendinosis allograft with dual limbs to reconstruct the tibionavicular and tibiocalcaneal ligaments.

FINDINGS

The mean baseline joint reactive force of the tibiotalar and talonavicular joints were 37.2 N + 8.1 N and 13.4 N + 4.2 N, respectively. The spring ligament injury model resulted in a significant 29% decrease in tibiotalar joint reactive force. Reconstruction of the tibionavicular limb resulted in a significant increase in tibiotalar and talonavicular joint reactive force compared to those seen in the injury state. Furthermore, the addition of the tibiocalcaneal limb significantly increased tibiotalar joint reactive force compared to those results obtained from the injury state and the tibionavicular limb alone.

INTERPRETATION

This is the first study to demonstrate diminished tibiotalar static joint reactive force in a spring ligament injury model with subsequent joint reactive force restoration using two-limbed reconstruction of the deltoid and spring ligament.

LEVEL OF EVIDENCE

Biomechanical Study.