Isolated spring ligament rupture causing acute flatfoot deformity: case report

Injuries to the Spring Ligament: Nonoperative Treatment

The fibrocartilage within the superomedial calcaneonavicular (spring) ligament is part of an interwoven complex of ligaments that span the ankle, subtalar, and talonavicular joints. Acute isolated rupture of the spring ligament has been reported in association with an eversion ankle sprain. Attenuation and failure of the spring ligament causes complex 3D changes called the progressive collapsing foot deformity (PCFD). This deformity is characterized by hindfoot eversion, forefoot supination, collapse of the medial longitudinal arch, and forefoot abduction. Nonoperative treatment of an isolated spring ligament rupture and PCFD using various designs of orthoses have shown promising results.

Outcomes of 2B Adult Acquired Flatfoot Deformity Correction in Patients With and Without Spring Ligament Tear

BACKGROUND

It is currently unclear how injury to the spring ligament (SL) affects the preoperative presentation of adult acquired flatfoot deformity (AAFD) or the outcome of operative reconstruction. The purposes of this study were to assess the preoperative features and pre- or postoperative function of patients who underwent direct operative repair of an SL tear compared to those without a tear.

METHODS

86 patients undergoing operative correction of grade 2B AAFD by a single fellowship-trained foot and ankle orthopaedic surgeon were reviewed at an average follow-up of 45.9 months. There were 35 feet found to have an SL tear that underwent concomitant debridement and direct repair of the SL. Patient charts were reviewed for demographic information, preoperative visual analog scale (VAS) pain level, and their Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales. Preoperative radiographic parameters were assessed. Patient outcomes of VAS pain, FAAM-ADL, and FAAM-Sports were collected and compared between groups.

RESULTS

Those with an SL tear had significantly lower FAAM-ADL and sports scores, with higher VAS pain scores preoperatively. Patient age, talonavicular uncoverage percentage, and talonavicular angle were found to be associated with spring ligament degeneration. At final follow-up, patients demonstrated a significant improvement in all outcome parameters, with no statistical difference found with patient satisfaction, final postoperative VAS pain, FAAM-ADL, or FAAM-Sports in those requiring a repair of their SL as compared to the control group.

CONCLUSION

Increasing patient age, increasing talonavicular uncoverage percentage, and decreasing talonavicular angle are all independently associated with increased likelihood of patients with AAFD having an SL tear. At follow-up for operative treatment of grade 2B AAFD flatfoot with our approach, we found no clinical outcomes difference between those without SL tears and those with SL tears treated with concomitant SL debridement and repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

An unusual presentation of acute isolated spring ligament injury in an adolescent: A case report

Spring ligament is an important stabilizing soft tissue structure on the plantar aspect of calcaneo-navicular joint. It is principal stabilizing structure to maintain the medial longitudinal arch during weight bearing. Attenuation of spring ligament along with tibialis posterior tendon deficiency usually results in adult acquired flat foot. However, cases of isolated injury to spring ligament are rare in the literature. A case of neglected spring ligament injury in a 15 years old girl with an unusual and dramatic presentation is described. Head of talus used to dislocate medially and plantarwards on every step of walking. This was treated successfully with talonavicular fusion. Level of clinical evidence: Level IV.

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.

Morphology of Spring Ligament Fibrocartilage Complex Lesions

BACKGROUND

The spring ligament fibrocartilage complex (SLFC) is an important static foot stabilizer comprising the superomedial ligament (SML) and the inferior ligament, with anatomical variations (third ligament). The aim of this study was to describe the patterns of the lesions found during SLFC surgery, to allow direct comparison between the results with various surgical techniques.

METHODS

Fourteen consecutive patients with SLFC lesions were analyzed during surgical treatment. The mean patient age was 37.3 years, and the mean time from injury was 6.9 months. Intraoperative assessments and anatomical descriptions of the lesions were collected.

RESULTS

Three types of lesion were found. In 13 of 14 cases, only the superomedial ligament was involved: five superomedial ligament distentions and eight superomedial ligament ruptures. In one case, total SLFC (superomedial and inferior ligaments) rupture was observed.

CONCLUSIONS

The first classification of SLFC lesions is presented, which is simple, consistent, and based on anatomical description.

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.

What to Do with the Spring Ligament

The spring ligament complex is an important static restraint of the medial longitudinal arch of the foot and its failure has been associated with progressive flatfoot deformity. Reconstruction of the spring ligament complex is most appropriate in stage II posterior tibial tendon dysfunction, before severe peritalar subluxation and rigid deformity develops. Although an understanding of the spring ligament complex and its contribution to medial arch stability has grown, there is no unanimously accepted surgical technique that has consistently demonstrated satisfactory outcomes. This article reviews the pathoanatomy of the spring ligament complex and the role of spring ligament reconstruction in acquired flatfoot deformity, and highlights current research.

Novel reconstruction technique for an isolated plantar calcaneonavicular (SPRING) ligament tear: A 5 case series report

BACKGROUND

It is usually accepted that acquired flatfoot deformity after injury is usually due to partial or complete tear of the posterior tibial tendon (PTT), with secondary failure of the other structures which maintain the medial longitudinal arch, such as the plantar calcaneo-navicular (SPRING) ligament. It is unusual to find an isolated Spring Ligament (SL) tear, with an intact TP tendon.

METHODS

The medial arch reconstruction technique of an isolated SL tear in 5 patients is presented discussed in this paper. In these 5 cases the clinical presentation mimicked PTT dysfunction. The operative regimen consisted of three steps: direct repair of the ligament, primary reconstruction of the SL by using FiberWire^® (Arthrex, Inc) and a medial calcaneal osteotomy.

RESULTS

American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score improved from 55.8 (range, 34-74) before surgery to 97.6 (range, 91-100) at more than one year follow-up. No recurrence of the flatfoot deformity was observed at 10 years follow-up.

CONCLUSION

SL tear should be suspected in cases of clinical presentation of medial arc collapse even when PTT is intact. In such cases of isolated SL tear reconstruction of the torn ligament using the method described is recommended.

Anatomic Reconstruction Technique for a Plantar Calcaneonavicular (Spring) Ligament Tear

Acquired flatfoot deformity in adults is usually due to partial or complete tearing of the posterior tibial tendon, with secondary failure of other structures such as the plantar calcaneonavicular (spring) ligament (SL), which maintain the medial longitudinal arch. In flexible cases, the tibialis posterior can be replaced with the flexor digitorum longus. It is common practice to suture the SL directly in the case of a tear; however, if the tear is complete, suturing directly to the ligament alone will not be possible. Reconstruction of the ligament is needed; however, no validated methods are available to reconstruct this ligament. The operative technique of SL reconstruction described in this report as a part of acquired flatfoot deformity reconstruction consists of augmenting remnants of the spring from the navicularis to the sustentaculum tali and suspending it to the medial malleolus using 2-mm-wide, long-chain polyethylene suture tape. This technique results in the firm anatomic reconstruction of the SL, in addition to "classic" medial arch reconstruction. We recommend SL reconstruction for medial arch reconstruction when the SL is torn.

Imaging of adult flatfoot: correlation of radiographic measurements with MRI

OBJECTIVE. The purpose of this study is to determine whether radiographic foot measurements can predict injury of the posterior tibial tendon (PTT) and the supporting structures of the medial longitudinal arch as diagnosed on MRI. MATERIALS AND METHODS. After institutional review board approval, 100 consecutive patients with radiographic and MRI examinations performed within a 2-month period were enrolled. Thirty-one patients had PTT dysfunction clinically, and 69 patients had other causes of ankle pain. Talonavicular uncoverage angle, incongruency angle, calcaneal pitch angle, Meary angle, cuneiform-to-fifth metatarsal height, and talar tilt were calculated on standing foot or ankle radiographs. MRI was used to assess for abnormalities of the PTT (tenosynovitis, tendinosis, and tear) and supporting structures of the medial longitudinal arch (spring ligament, deltoid ligament, and sinus tarsi). Statistical analysis was performed using the chi-square and Fisher exact tests for categoric variables; the Student t test was used for continuous variables. RESULTS. There was a statistically significant association of PTT tear with abnormal talonavicular uncoverage angle, calcaneal pitch angle, Meary angle, and cuneiform-to-fifth metatarsal height. PTT tendinosis and isolated tenosynovitis had a poor association with most radiologic measurements. If both calcaneal pitch and Meary angles were normal, no PTT tear was present. An abnormal calcaneal pitch angle had the best association with injury to the supporting medial longitudinal arch structures. CONCLUSION. Radiographic measurements, especially calcaneal pitch and Meary angles, can be useful in detecting PTT tears. Calcaneal pitch angle provides the best assessment of injury to the supporting structures of the medial longitudinal arch.