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Bilyy A, Win Mar WW, Al Abdeen Al Zuabi Z, Frimpong-Manso HB, Famure S, Solomou G, Brassett C, Pasapula C. The Deltoid-Spring Ligament Complex: A Scoping Review and New Segmental Classification. Cureus 2025; 17:e81715. [PMID: 40322447 PMCID: PMC12050096 DOI: 10.7759/cureus.81715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2025] [Indexed: 05/08/2025] Open
Abstract
The aim of this study is to review the variation in description of the individual bands comprising the deltoid and spring ligaments in anatomical dissection studies and to propose a novel approach to describe the structure. A literature search for cadaveric studies identifying anatomical variations in the deltoid and spring ligament complexes was conducted using PubMed and Medline databases. The inclusion criteria encompassed human cadaveric dissection studies with measurement of individual deltoid and spring ligament bands in the English language and with full-text availability. The following studies were excluded: animal studies, articles describing surgical repair approaches, and radiological assessment studies without cadaveric dissection. The demographic data, parameters of individual components, as well as the morphological structure of individual deltoid bands were summarised. Out of the 18,208 studies from the database search, 11 articles were included in this study. Thirteen additional studies were obtained from the bibliographies, resulting in a total of 24 studies with 528 ankles evaluated. Due to the complexity of their anatomical relationships, the deltoid and spring ligaments should be described as a single entity: the "deltoid-spring ligament complex". Its gross morphology can be described as triangular, trapezoidal, and rectangular. It can be differentiated into the deep deltoid and the superficial deltospring ligament, which are connected. The latter encompasses the superficial deltoid and superomedial part of the spring ligament. The deep plantar ligament and "the inferior spring ligament" are separate entities reflecting their discrete natures and histological differences. The superficial deltospring ligament can be divided into contiguous segments with variable bands (thickening but not true ligaments). Each segment can be clinically assessed en masse. This description can help to clarify the nomenclature.
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Affiliation(s)
- Andrey Bilyy
- Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital, London, GBR
| | - Wai Wai Win Mar
- Orthopaedics, Queen Elizabeth Hospital King's Lynn, King's Lynn, GBR
| | | | | | - Steven Famure
- Orthopaedics, Queen Elizabeth Hospital King's Lynn, King's Lynn, GBR
| | - Georgios Solomou
- Clinical Research, School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Cecilia Brassett
- Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, GBR
| | - Chandra Pasapula
- Trauma and Orthopaedics, Queen Elizabeth Hospital King's Lynn, King's Lynn, GBR
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Takahashi K, Teramoto A, Murahashi Y, Shiwaku K, Kamiya T, Emori M, Watanabe K, Fujie H. The In Situ Force and Contribution of Each Ligamentous Band of the Deltoid Ligament in Ankle Joint Stability: A Cadaveric Biomechanical Study. Orthop J Sports Med 2025; 13:23259671251327406. [PMID: 40182569 PMCID: PMC11963784 DOI: 10.1177/23259671251327406] [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: 10/21/2024] [Accepted: 11/18/2024] [Indexed: 04/05/2025] Open
Abstract
Background Each band of the deltoid ligament cooperatively contributes to stability of the medial side of the ankle joint. Investigating the function of each band of the deltoid ligament is essential to assess abnormalities and develop treatment options. Purpose To evaluate the changes in ankle kinematics when each band of the deltoid ligament is injured and to measure the in situ force of each ligamentous band in intact ankle kinematics. Study Design Descriptive laboratory study. Methods A total of 8 healthy fresh-frozen cadaveric legs were examined by applying forces through eversion and external rotation of the ankle joint using a 6 degrees of freedom robotic system. The deltoid ligament was separated into 6 discrete bands: tibionavicular ligament, tibiospring ligament, tibiocalcaneal ligament (TCL), anterior tibiotalar ligament, superficial posterior tibiotalar ligament (sPTTL), and deep posterior tibiotalar ligament; the bands were then sequentially transected. A loading test was performed in each model, and the changes in ankle motion and in situ force of each ligamentous band were measured using the robotic system. Results When an eversion force was applied to the intact ankle, the in situ force of the sPTTL was 21.6 N in dorsiflexion and that of the TCL was 19.4 N in plantarflexion, both of which were significantly greater than those of the other ligamentous bands. Additionally, the amount of eversion under eversion loading increased significantly by 3.3° with sPTTL resection in dorsiflexion and by 4.2° with TCL resection in plantarflexion. Conclusion The TCL and sPTTL play important roles among the ligamentous bands of the deltoid ligament. The sPTTL played a more significant role in ankle dorsiflexion, whereas the TCL played a more significant role in ankle plantarflexion. Clinical Relevance The TCL and sPTTL should receive attention in the treatment of deltoid ligamentous injuries.
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Affiliation(s)
- Katsunori Takahashi
- Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Yasutaka Murahashi
- Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Kousuke Shiwaku
- Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Tomoaki Kamiya
- Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Makoto Emori
- Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Kota Watanabe
- Department of Physical Therapy, School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Hiromichi Fujie
- Department of Mechanical Systems Engineering, Graduate School of Systems Design, Tokyo Metropolitan University, Tokyo, Japan
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Pirshahid AA, Brzozowski P, Sogbein O, Zdero R, Gee A, Halai M, Schemitsch E, Sanders DW, Lawendy AR, Del Balso C. Biomechanical Analysis of Ankle Stability Following Deltoid Ligament Repair and Reconstruction. BIOMED RESEARCH INTERNATIONAL 2025; 2025:6313005. [PMID: 40170794 PMCID: PMC11961274 DOI: 10.1155/bmri/6313005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Accepted: 01/13/2025] [Indexed: 04/03/2025]
Abstract
Background: The deltoid ligament has been shown to contribute to the stability of the ankle mortise, preventing valgus talar tilt, external rotation (ER), and translation. Research to date assessing the appropriateness of deltoid repair to reintroduce medial stability to a fractured ankle is unclear. Deltoid ligament reconstruction using autograft or allograft has been proposed in cases of chronic deltoid insufficiency. This biomechanical study sought to assess the stability offered by deltoid repair and reconstruction compared to the native deltoid ligament in its intact and defunctioned states. Materials and Methods: Twelve (six pairs) fresh frozen cadaveric lower extremities with intact deltoid ligaments underwent biomechanical assessment in a custom-made multiaxial testing apparatus. Each specimen was tested in plantarflexion/dorsiflexion (PF/DF), inversion/eversion (IV/EV), and internal rotation (IR)/ER and analyzed for angular range of motion (ROM) and stiffness. The specimens were tested with an intact deltoid ligament and following disruption via transection. Subsequently, paired specimens were randomized to either deltoid repair or reconstruction. A single double-loaded suture anchor was used to repair the deep and superficial deltoid ligaments. The tibialis anterior tendon was used as an autograft in the reconstruction group. Results: Normalized ROM and stiffness were significantly different in deficient specimens compared to all other groups during PF/DF. During IR/ER, the deficient ankle was significantly different from the intact and repair state. For IV/EV, deficient specimen ROM was significantly greater than the intact or repair states, while the stiffness for the deficient ankles was significantly less. Conclusion: Deltoid repair and reconstruction were comparable in returning the ankles to an intact state and conferring stability. These results suggest that in cases with insufficient or unstable deltoid ligament where repair is not possible, reconstruction has the potential to be a reliable alternative, but further studies are warranted to understand all advantages/disadvantages.
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Affiliation(s)
- Ali Ahmadi Pirshahid
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Olawale Sogbein
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Aaron Gee
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Mansur Halai
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Emil Schemitsch
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - David W. Sanders
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Abdel Rahman Lawendy
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
| | - Christopher Del Balso
- Division of Orthopaedic Surgery, Department of Surgery, Western University, London, Ontario, Canada
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Ontario, Canada
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Lim HSA, Koh JRD, Kumar SR, Moo IH, Kon KKC. Morphometric and Anatomical Analysis of the Deltoid Ligament Complex: A Cadaveric Study in the Southeast Asian Population. Cureus 2025; 17:e81442. [PMID: 40303538 PMCID: PMC12038298 DOI: 10.7759/cureus.81442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2025] [Indexed: 04/05/2025] Open
Abstract
Introduction The deltoid ligament complex (DLC) confers stability of the ankle joint. This study quantitatively analyzes the morphometry of the DLC in the Southeast Asian population, highlighting anatomical variations relevant to surgical procedures. Methodology Seven embalmed amputated limbs were dissected. The width and length of the superficial and deep layers with their corresponding bands were measured using a metric ruler. Results The mean width of the superficial layer of the DLC was 20.43 + 2.72 mm at the origin, 20.00 + 1.07 mm at midway, and 15.29 + 1.28 mm at insertion. The tibionavicular ligament (TNL), tibiocalcaneal ligament (TCL), deep posterior tibiotalar ligament (dPTTL), and the deep anterior tibiotalar ligament (dATTL) were present in all specimens. In the superficial layer, the mean length of the TNL and TCL was 38.57 + 3.58 mm and 34.29 + 6.47 mm, respectively. In the deep layer, the mean length of the dPTTL and dATTL was 18.71 + 1.83 mm and 20.29 + 2.31 mm, respectively. Conclusion While the prevalence of the components of the DLC varies widely across the literature, it was present in all specimens of our study. The longest and shortest bands of the DLC were the TNL and dPTTL, respectively, concurring with current literature. However, the mean length of TCL, dPTTL, and dATTL in the Southeast Asian population appeared to be longer than that reported in a meta-analysis of European cadaveric studies. Knowledge of the morphology and anatomical variations of each component of the DLC in the Southeast Asian population is crucial to improve surgical management of medial ankle instability.
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Affiliation(s)
| | - Jun Rui Don Koh
- Orthopaedic Surgery, Changi General Hospital, Singapore, SGP
| | | | - Ing How Moo
- Orthopaedic Surgery, Changi General Hospital, Singapore, SGP
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Liu K, Ji X, Su P. Advancements in minimally invasive treatment of deltoid ligament injuries combined with distal tibiofibular syndesmosis injuries. BMC Surg 2025; 25:50. [PMID: 39881270 PMCID: PMC11776317 DOI: 10.1186/s12893-025-02779-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Accepted: 01/13/2025] [Indexed: 01/31/2025] Open
Abstract
The deltoid ligament (medial collateral ligament) and the syndesmosis (a composite ligamentous structure at the distal tibiofibular junction) are critical for maintaining ankle stability. In cases of high-energy ankle fractures, these structures are often injured simultaneously, leading to instability and potential long-term complications such as post-traumatic arthritis. This review aims to explore advancements in minimally invasive techniques for the treatment of combined deltoid ligament and syndesmosis injuries, with a focus on optimizing surgical outcomes and reducing patient morbidity. Current treatment strategies primarily involve cortical screws for syndesmosis stabilization and anchor fixation for deltoid ligament repair. Recent innovations, such as bioabsorbable screws, suture-button devices with elastic micromotion, and syndesmotic plates, have demonstrated potential in improving biomechanical stability while minimizing complications. Furthermore, minimally invasive techniques, including arthroscopic repairs with suture anchors, as well as ligament reconstruction using autografts, allografts, or synthetic ligaments, are becoming increasingly popular. By incorporating these advancements, the field is moving toward more effective and patient-centered approaches to achieve anatomical and functional restoration under minimally invasive principles. Future research should focus on further validating these techniques and identifying the most effective strategies for complex injuries.
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Affiliation(s)
- Kun Liu
- Department of Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaoyan Ji
- Department of Hand and Foot Surgery, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China.
| | - Peng Su
- Department of Hand and Foot Surgery, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
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Fernandez MA, Lee J, Calder J, Katakura M, Jones M, Dalmau-Pastor M. The deltoid ligament complex is reliably visualised as four fascicles in two layers with 3D volumetric MRI in the ankles of 20 asymptomatic volunteers. Knee Surg Sports Traumatol Arthrosc 2024; 32:3076-3081. [PMID: 38961792 DOI: 10.1002/ksa.12345] [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: 03/13/2024] [Revised: 05/05/2024] [Accepted: 06/17/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE The anatomy of the deltoid ligament is complex. There is agreement on the presence of superficial and deep layers but the number and frequency of fascicles remains controversial. Identifying injuries to specific components of the deltoid ligament may inform decision-making on their management. The anatomy was reviewed to establish the number and dimension of fascicles visible with three-dimensional (3D) volumetric magnetic resonance images (MRI). METHODS Twenty ankles from asymptomatic healthy volunteers were imaged with 3D volumetric MRI. The presence of individual fascicles was recorded and measured in 3D. RESULTS The median age of participants was 26 years (range: 20-37) of which 13 (65%) were female. All 20 ankles had a deltoid ligament formed of four fascicles in two layers: three fascicles in the superficial layer; tibionavicular (mean dimensions 22.5 × 10.0 × 2.4 mm), tibiospring (16.6 × 6.7 × 1.9 mm) and tibiocalcaneal (23.8 × 4.6 × 1.8 mm) and a deep layer consisting of the tibiotalar fascicle, which could be divided into two parts: anterior tibiotalar (mean dimensions 10 × 5.6 × 4.1 mm) and the significantly larger posterior tibiotalar (14.2 × 13.8 × 17.5 mm, p < 0.01). There were no additional fascicles observed. CONCLUSIONS The deltoid ligament complex was consistently visualised as four fascicles (tibionavicular, tibiospring, tibiocalcaneal, tibiotalar) in two layers (superficial and deep) in all 20 ankles. The posterior part of the tibiotalar fascicle was the thickest of all the fascicles in the deltoid ligament. It is, therefore, possible to accurately identify the components of the deltoid ligament, and 3T MRI can be used to assess fascicle-specific injury, which will guide treatment and rehabilitation. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Miguel A Fernandez
- Fortius Clinic, FIFA Medical Centre of Excellence, London, UK
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Justin Lee
- Fortius Clinic, FIFA Medical Centre of Excellence, London, UK
- Department of Surgery and Interventional Science, University College London, London, UK
| | - James Calder
- Fortius Clinic, FIFA Medical Centre of Excellence, London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - Mai Katakura
- Fortius Clinic, FIFA Medical Centre of Excellence, London, UK
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mary Jones
- Fortius Clinic, FIFA Medical Centre of Excellence, London, UK
| | - Miki Dalmau-Pastor
- Department of Pathology and Experimental Therapeutics, Human Anatomy Unit, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- MIFAS By GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
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Dalmau-Pastor M, Malagelada F, Guelfi M, Kerkhoffs G, Karlsson J, Calder J, Vega J. The deltoid ligament is constantly formed by four fascicles reaching the navicular, spring ligament complex, calcaneus and talus. Knee Surg Sports Traumatol Arthrosc 2024; 32:3065-3075. [PMID: 38757967 PMCID: PMC11605026 DOI: 10.1002/ksa.12173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/11/2024] [Accepted: 03/17/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE The medial collateral ligament of the ankle, or deltoid ligament, can be injured in up to 40% of patients who sustain an ankle inversion sprain. Reporting injuries of the deltoid ligament is not easy due to confusion in the current anatomical descriptions, with up to 16 fascicles described, with variable frequencies. The purpose of this study was to clarify the anatomy of the deltoid ligament. METHODS Thirty-two fresh-frozen ankle specimens were used for this study. Careful dissection was undergone until full visualization of the deltoid ligament was achieved and measurements taken. RESULTS The deltoid ligament was found to have four constant fascicles in two layers. The superficial layer consists of the tibionavicular, tibiospring and tibiocalcaneal fascicles, while the deep layer consists of the tibiotalar fascicle. Measurements of these fascicles are given in detail. The tibiotalar fascicle and the anterior part of the tibionavicular fascicle were found to be intra-articular structures. CONCLUSION The deltoid ligament has a constant number of fascicles divided into a superficial and a deep layer. This clarification of the anatomy and terminology of the deltoid ligament and its fascicles will help clinical view, diagnosis and (interdoctor)communication and treatment. The ligamentous fibres of the deep layer, as well as the anterior fibres of the superficial layer (tibionavicular fascicle) are intra-articular, which could negatively impact its healing capacity, explaining chronicity of these types of injuries. LEVEL OF EVIDENCE Not applicable (cadaveric study).
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Affiliation(s)
- Miki Dalmau-Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
- MIFAS By GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
| | - Francesc Malagelada
- Foot and Ankle Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matteo Guelfi
- Foot and Ankle Unit, Casa di Cura Villa Montallegro, Genoa, Italy
- Department of Orthopaedic Surgery "Gruppo Policlinico Di Monza", Clinica Salus, Alessandria, Italy
| | - Gino Kerkhoffs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Amsterdam Collaboration for Health & Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center Amsterdam UMC, Amsterdam, The Netherlands
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jordi Vega
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
- MIFAS By GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
- iMove Traumatology Tres Torres, Barcelona, Spain
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Koris J, Calder JDF, Dalmau‐Pastor M, Fernandez MA, Ramasamy A. Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments. Knee Surg Sports Traumatol Arthrosc 2024; 32:3052-3064. [PMID: 38796726 PMCID: PMC11605033 DOI: 10.1002/ksa.12274] [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: 02/18/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. METHODS A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods. RESULTS A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available. CONCLUSION There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jacob Koris
- Trauma & Orthopaedic Specialty Registrar, John Radcliffe HospitalOxfordUK
| | - James D. F. Calder
- Department of BioengineeringImperial College LondonLondonUK
- Fortius ClinicLondonUK
| | - Miki Dalmau‐Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain
- MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society)MerignacFrance
| | | | - Arul Ramasamy
- Department of BioengineeringImperial College LondonLondonUK
- Academic Department of Military Trauma and OrthopaedicsRoyal Centre for Defence Medicine, EdgbastonBirminghamUK
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Vega J, Malagelada F, Guelfi M, Dalmau‐Pastor M. Arthroscopic repair is an effective treatment for dynamic medial ankle instability secondary to posttraumatic and partial injury of the deltoid ligament deep fascicle. Knee Surg Sports Traumatol Arthrosc 2024; 32:3112-3120. [PMID: 38690960 PMCID: PMC11605014 DOI: 10.1002/ksa.12197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique. METHODS Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique. RESULTS A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up. CONCLUSION Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jordi Vega
- Foot and Ankle UnitiMove TraumatologyBarcelonaSpain
- Foot and Ankle UnitOlympiaMadridSpain
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit)University of BarcelonaBarcelonaSpain
- MIFAS by GRECMIPMerignacFrance
| | - Francesc Malagelada
- Department of Trauma and Orthopedic Surgery, Royal London HospitalBarts Health NHS TrustLondonUK
| | - Matteo Guelfi
- Casa di Cura Villa MontallegroGenovaItaly
- Department of Orthopaedic Surgery “Gruppo Policlinico di Monza”Clinica SalusAlessandriaItaly
| | - Miki Dalmau‐Pastor
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit)University of BarcelonaBarcelonaSpain
- MIFAS by GRECMIPMerignacFrance
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David G, Hamel Q, Hubert L, Marc C, Steiger V, Rony L. Which type of supra-syndesmal fractures Weber C or Equivalent Weber C have the best reduction of the distal tibio-fibular syndesmosis? A prospective CT-scan investigation on 60 ankles. Orthop Traumatol Surg Res 2024:103980. [PMID: 39209257 DOI: 10.1016/j.otsr.2024.103980] [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: 03/30/2023] [Revised: 06/14/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION The reduction of the distal tibiofibular syndesmosis (SyTFd) is a crucial factor in the functional prognosis following a suprasyndesmotic ankle fracture. Few studies have compared, using computed tomography (CT), the quality of SyTFd reduction in Weber C ankle fractures (WebC) and Equivalent Weber C (EqWebC) fractures, where there is a medial ligament injury instead of a bony malleolar lesion. This CT-based study aimed to answer the following questions: (1) Do Weber C fractures allow for better reduction of the distal tibiofibular syndesmosis compared to Equivalent Weber C fractures? (2) Are the functional outcomes one year postoperatively better for Weber C fractures compared to Equivalent Weber C fractures? HYPOTHESIS The hypothesis was that WebC fractures would present better reduction of the SyTFd than EqWebC fractures due to the restoration of bone anatomy, considering the bony nature of the medial ligament involvement. MATERIALS AND METHODS Since December 2021, all patients presenting with an ankle fracture were included in a database. Suprasyndesmotic fractures were extracted, and between December 2021 and February 2022, 60 patients underwent surgery for a suprasyndesmotic fracture (28 WebC - 32 EqWebC). All patients were operated on using the same technique and underwent a postoperative bilateral CT scan in axial slices with both ankles in a neutral position (foot at 90 ° to the leg). An analysis of 8 measurements was performed under the same conditions. Each fractured ankle was compared to the healthy contralateral ankle, and a delta was obtained for each measurement. The follow-up was standardized. At one year, an AOFAS Score and a Maryland Foot Score (MFS) were recorded. Statistical differences between the two groups were measured using the Student's t-test and Chi-square test. RESULTS There was a significant difference between the WebC and EqWebC groups for clinical scores at one year postoperatively: AOFAS: 92.0 ± 6.3 [78-100] vs. 80.1 ± 5.4 [62-100], p < 0.05; MFS: 90.9 ± 6.4 [78-100] vs. 81.6 ± 5.2 [64-100], p < 0.05. CT scan analysis of the SyTFd reduction found significantly better reduction in the WebC group. DISCUSSION WebC fractures showed better clinical scores associated with better SyTFd reduction on postoperative CT scans. The anatomical reduction related to the bone reduction criteria during surgery could explain our findings. LEVEL OF EVIDENCE III; Case-Control Comparative Study.
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Affiliation(s)
- Guillaume David
- Department of Orthopedic Surgery, University Hospital of Angers, 49033 Angers Cedex, France
| | - Quentin Hamel
- Department of Orthopedic Surgery, University Hospital of Angers, 49033 Angers Cedex, France
| | - Laurent Hubert
- Department of Orthopedic Surgery, University Hospital of Angers, 49033 Angers Cedex, France
| | - Clément Marc
- Department of Orthopedic Surgery, University Hospital of Angers, 49033 Angers Cedex, France
| | - Vincent Steiger
- Department of Orthopedic Surgery, University Hospital of Angers, 49033 Angers Cedex, France
| | - Louis Rony
- Department of Orthopedic Surgery, University Hospital of Angers, 49033 Angers Cedex, France.
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11
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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.
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Affiliation(s)
- Ryan B Rigby
- Logan Regional Orthopedics, Intermountain Healthcare, Logan, UT.
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12
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Obionu K, Palm H, Astrup Y, Lange NB, Krogsgaard MR. A clinical guide to the medial ligaments of the ankle: Anatomy, function, diagnosis of injuries and treatment of instability-a narrative review. Foot Ankle Surg 2024; 30:85-91. [PMID: 37926624 DOI: 10.1016/j.fas.2023.10.010] [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: 10/11/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability. METHODS Literature search on PubMed. RESULTS Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse. CONCLUSION There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.
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Affiliation(s)
- Kenneth Obionu
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Henrik Palm
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Yvette Astrup
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Naja Bjørslev Lange
- Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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13
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Cerezal A, Ocampo R, Llopis E, Cerezal L. Ankle Instability Update. Semin Musculoskelet Radiol 2023; 27:231-244. [PMID: 37230124 DOI: 10.1055/s-0043-1767767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Sprains are the most frequent injuries of the ankle, especially in sports. Up to 85% of cases affect the lateral ligament complex. Multi-ligament injuries with associated lesions of the external complex, deltoid, syndesmosis, and sinus tarsi ligaments are also common. Most ankle sprains respond to conservative treatment. However, up to 20 to 30% of patients can develop chronic ankle pain and instability.New concepts have been recently developed, based on arthroscopic advances, such as microinstability and rotatory ankle instability. These entities could be precursors of mechanical ankle instability and at the origin of frequently associated ankle injuries, such as peroneus tendon lesions, impingement syndromes, or osteochondral lesions.Imaging methods, especially magnetic resonance (MR) imaging and MR arthrography, are key in precisely diagnosing ligament lesions and associated injuries, facilitating an adequate therapeutic approach.
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Affiliation(s)
- Alvaro Cerezal
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario La Paz, Madrid, Spain
| | - Ronald Ocampo
- Department of Radiology, Hospital de Trauma del Instituto Nacional de Seguros, San Jose, Costa Rica
| | - Eva Llopis
- Department of Radiology, Hospital IMSKE, Hospital de la Ribera, Valencia, Spain
| | - Luis Cerezal
- Department of Radiology, Diagnóstico Médico Cantabria (DMC), Santander, Spain
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14
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Gomes TM, Oliva XM, Viridiana Sanchez E, Soares S, Diaz T. Anatomy of the Ankle and Subtalar Joint Ligaments: What We Do Not Know About It? Foot Ankle Clin 2023; 28:201-216. [PMID: 37137619 DOI: 10.1016/j.fcl.2022.12.003] [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: 05/05/2023]
Abstract
Understanding of the ankle and subtalar joint ligaments is essential to recognize and manage foot and ankle disorders. The stability of both joints relies on the integrity of its ligaments. The ankle joint is stabilized by the lateral and medial ligamentous complexes while the subtalar joint is stabilized by its extrinsic and intrinsic ligaments. Most injuries to these ligaments are linked with ankle sprains. Inversion or eversion mechanics affect the ligamentous complexes. A profound knowledge of the ligament's anatomy allows orthopedic surgeons to further understand anatomic or nonanatomic reconstructions.
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Affiliation(s)
- Tiago Mota Gomes
- Foot and Ankle Unit, Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Xavier Martin Oliva
- Department of Orthopedics, Clinica Del Remei, Barcelona, Spain; Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain.
| | - Elsa Viridiana Sanchez
- Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Sérgio Soares
- Foot and Ankle Unit, Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Department of Orthopaedics, Hôpital Fribourgeois, Villars-sur-Glâne, Switzerland
| | - Tania Diaz
- Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain
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15
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Abstract
The deltoid ligament is the primary stabilizer of the medial side of the ankle joint. It is a complex structure with an origin at the medial malleolus from where it spreads fan shaped distally with an insertion into the medial side of the talus, calcaneus and navicular bone. This chapter gives an overview of the anatomy, function, and pathology of the deltoid ligament.The deltoid ligament can become insufficient as a result of an ankle injury or prolonged strain. In the acute setting, deltoid insufficiency often coincides with multi ligament injury the ankle joint; syndesmosis injury, or ankle fractures. Management in the acute phase remains a subject of debate. Some orthopedic surgeons have a tendency towards repair, whereas most trauma surgeons often treat the deltoid nonoperatively. In the chronic setting the ligament complex is often elongated as a result of prolonged strain. It often coexists with a hindfoot valgus, as is the case in planovalgus feet. In such a case a realignment procedure should be combined with the deltoid repair.
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Affiliation(s)
- Loek Loozen
- Footbridge Center for Integrated Foot and Ankle Care, Department of Orthopaedics, University of British Columbia, Vancouver, CA
| | - Andrea Veljkovic
- Footbridge Center for Integrated Foot and Ankle Care, Department of Orthopaedics, University of British Columbia, Vancouver, CA
| | - Alastair Younger
- Footbridge Center for Integrated Foot and Ankle Care, Department of Orthopaedics, University of British Columbia, Vancouver, CA
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16
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West C, Norrish A, Brassett C, Pasapula C. Evaluation of the heel external rotation test in soft tissue deficiencies associated with adult acquired flatfoot deformity (AAFD). A cadaver sectioning analysis. Foot (Edinb) 2023; 55:101984. [PMID: 36867947 DOI: 10.1016/j.foot.2023.101984] [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: 03/03/2022] [Revised: 02/15/2023] [Accepted: 02/18/2023] [Indexed: 03/05/2023]
Abstract
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.
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Affiliation(s)
- Cavan West
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Alan Norrish
- Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK; Academic Orthopaedics, Trauma and Sports Medicine, School of Medicine and Health Sciences, University of Nottingham, UK
| | - Cecilia Brassett
- Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Chandra Pasapula
- Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK
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17
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Presurgical Perspective and Postsurgical Evaluation of Instability and Microinstability Secondary to Ankle Ligaments Injury. Semin Musculoskelet Radiol 2022; 26:644-655. [PMID: 36791734 DOI: 10.1055/s-0042-1760245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Injuries of the ankle ligaments complexes are very common, and ∼ 20 to 40% of patients can develop chronic ankle instability (CAI). Current concepts in CAI allow a better understanding of the ankle biomechanics needed to repair it. The surgical treatment of CAI has evolved in the last decade, and ankle arthroscopy has become an essential tool in the treatment of instability with promising results. We review the different surgical techniques to treat CAI, both those frequently used and the new approaches, as well as the normal postsurgical appearance of ankle ligaments repair and the most common complications.
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18
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McCormack DJ, Solan M, Aziz S, Faroug R, Kirmani S, Wright G, Mangwani J. Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study. World J Orthop 2022; 13:969-977. [PMID: 36439368 PMCID: PMC9685633 DOI: 10.5312/wjo.v13.i11.969] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/01/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability.
AIM To investigate the anatomical basis for fracture instability in SER type ankle fractures.
METHODS Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt.
RESULTS All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt.
CONCLUSION If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise.
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Affiliation(s)
- Daniel James McCormack
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Matthew Solan
- Department of Trauma and Orthopaedic Surgery, Royal Surrey City Hospital NHS Trust, University of Surrey, Guilford GU2 7XX, United Kingdom
| | - Sheweidin Aziz
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Radwane Faroug
- Department of Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury HP21 8AL, Buckinghampshire, United Kingdom
| | - Sayyied Kirmani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Georgina Wright
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Jitendra Mangwani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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19
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Martinez‐Franco A, Gijon‐Nogueron G, Franco‐Romero A, Tejero S, Torrontegui‐Duarte M, Jiménez‐Díaz F. Ultrasound Examination of the Ligament Complex Within the Medial Aspect of the Ankle and Foot. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2897-2905. [PMID: 35170800 PMCID: PMC9790653 DOI: 10.1002/jum.15964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/18/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Abstract
To properly diagnose and treat injuries to the ankle or foot, the physician must have good anatomical knowledge of the ligaments involved. The bundles can be distinguished and identified by ultrasound examination of the medial aspect, but this may be a challenging task. In the present illustrated study, we discuss how a detailed ultrasound examination can be made of the different ligaments within the medial aspect of the ankle and foot.
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Affiliation(s)
| | - Gabriel Gijon‐Nogueron
- Instituto de Investigación Biomédica de Málaga (IBIMA)MalagaSpain
- Department of Nursing and PodiatryUniversidad de MálagaMalagaSpain
| | | | - Sergio Tejero
- Foot and Ankle Unit, Orthopedic Surgery and Traumatology Service, Hospital Universitario Virgen del RocíoSevilleSpain
- School of Medicine, Universidad de SevillaSevilleSpain
| | | | - Fernando Jiménez‐Díaz
- University of Castilla La ManchaToledoSpain
- International Chair of Ultrasound MSK, UCAMMurciaSpain
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20
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Cao S, Wang C, Zhang C, Huang J, Wang X, Ma X. Length change pattern of the ankle deltoid ligament during physiological ankle motion. Foot Ankle Surg 2022; 28:950-955. [PMID: 35074287 DOI: 10.1016/j.fas.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/29/2021] [Accepted: 01/12/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Length change pattern of the ankle deltoid ligament during physiological ankle motion is still confused currently and had not been studied in vivo. METHODS The deltoid ligaments from 7 cadaveric specimens were dissected. Lengths of each band during 30° plantarflexion to 20° dorsiflexion were measured. A dual fluoroscopy imaging system was utilized to capture the images of hindfoot joint of 7 healthy subjects during the stance phase of walking. 3D bone models were reconstructed from CT images. Lengths of each band were calculated after model-image registration utilizing a solid modeling software. Percentage of length variation and poses when the bands were in maximum extension were documented among each band. RESULTS The anterior border of tibiocalcaneal ligament (TCL) had only 1.7% length variation in vitro and 5.7% length variation in vivo. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension at 30° plantarflexion, however, superficial posterior tibiotalar ligament, deep posterior tibiotalar ligament, and the posterior border of TCL were in maximum extension at 20° dorsiflexion. The tibionavicular ligament, tibiospring ligament, and deep anterior tibiotalar ligament were in maximum extension during foot flat. The TCL was in maximum extension during midstance. The superficial posterior tibiotalar ligament and deep posterior tibiotalar ligament were in maximum extension during heel off and toe off. CONCLUSION The length of TCL did not change during ankle dorsiflexion and plantarflexion. The bands anterior to and posterior to the TCL showed different length change pattern during physiological ankle dorsiflexion and plantarflexion.
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Affiliation(s)
- Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China.
| | - Chao Zhang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiazhang Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
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21
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Shazadeh Safavi K, Rezvani A, Janney CF, Chen J, Cassis W, Darayan N, Panchbhavi VK, Jupiter DC. Assessing the Utility of Deltoid Ligament Repair in Ankle Fracture: A Systematic Review. Cureus 2022; 14:e27040. [PMID: 35989770 PMCID: PMC9388398 DOI: 10.7759/cureus.27040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/05/2022] Open
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22
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Rougereau G, Marty-Diloy T, Vigan M, Donadieu K, Hardy A, Vialle R, Langlais T. A Preliminary Study to Assess the Relevance of Shear-Wave Elastography in Characterizing Biomechanical Changes in the Deltoid Ligament Complex in Relation to Ankle Position. Foot Ankle Int 2022; 43:840-849. [PMID: 35373593 DOI: 10.1177/10711007221079829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was (1) to evaluate the biomechanical properties of the different bundles of the deltoid ligament in various ankle positions in a cohort of healthy adult volunteers; (2) describe the impact of demographic and hindfoot morphology characteristics on their stiffness; (3) to assess the reliability and reproducibility of these measurements. METHODS Deltoid ligament complex of both ankles were assessed by shear-wave elastography (SWE) in 20 healthy patients resting on hinge support. The propagation shear-wave speed (SWS) in ligaments was measured, which is related to the tissue's elastic modulus. The following ligaments were analyzed in a neutral position and then in varus, valgus, dorsal, and plantar flexions: tibionavicular ligament (TNL), tibiocalcaneal ligament (TCL), the superficial posterior tibiotalar ligament (SPTL), the anterior tibiotalar ligament (ATTL), and the deep posterior tibiotalar ligament (DPTTL). RESULTS The mean SWS increased between neutral and 20 degrees valgus position for TCL (4.08 ± 0.78 m/s vs 5.56 ± 0.62 m/s, respectively; P < .0001) and for DPTTL (2.58 ± 0.52 m/s vs 3.59 ± 0.87 m/s, respectively; P < .0001). The mean SWS increased between neutral and 30 degrees plantarflexion for ATTL (2.11 ± 0.44 m/s vs 3.1 ± 0.5 m/s, respectively; P < .0001) and TNL (2.96 ± 0.66 m/s vs 4.99 ± 0.69 m/s, respectively; P < .0001). The mean SWS increased between neutral and 20 degrees dorsal flexion for SPTL (4.2 ± 1 m/s vs 5.45 ± 0.65 m/s, respectively; P < .0001).Women had less DPTTL SWS than men in the neutral position (2.37 ± 0.35 m/s vs 2.71 ± 0.49 m/s, respectively; P = .007). Other demographics had no impact on the SWS value of other ligaments. All inter- and intraobserver agreements were good to excellent. CONCLUSION This study presents a reliable and reproducible SWE measurement protocol to describe the physiological function of all bundles of the medial collateral ligament in healthy adults. CLINICAL RELEVANCE This examination technique can be available to orthopaedic surgeons, allowing reliable and reproducible monitoring of the SWS of the various ligaments constituting the medial collateral plane. The biomechanical values described in this study may give insight into in what position medial ankle ligament reconstruction should be tensioned.
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Affiliation(s)
- Grégoire Rougereau
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Department of Adult Orthopedic surgery, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
| | - Thibault Marty-Diloy
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Marie Vigan
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Unité de Recherche Clinique Hôpitaux Universitaires Paris Ile-de-France Ouest, APHP, Boulogne-Billancourt, France
| | - Kalinka Donadieu
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Alexandre Hardy
- Clinique du sport, Department of Orthopedic surgery, Paris, France
| | - Raphaël Vialle
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Department for Innovative Therapies in Musculoskeletal Disease, The MAMUTH Hospital, Sorbonne University, Paris
| | - Tristan Langlais
- Department of Pediatric Orthopedic surgery, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
- Department of Pediatric Orthopedic surgery, Children's hospital, Purpan, Toulouse University, Toulouse, France
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23
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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.
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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
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Ismail EE, Al Saffar RA, Motawei K, Hiware SD, Moizuddin K, Shaikh SA, Bayer SB, Al Harbi Y, Aldahhan RA, Daimi SR. Defining the Components of the Deltoid Ligament (DL): A Cadaveric Study. Cureus 2022; 14:e23051. [PMID: 35464563 PMCID: PMC9001815 DOI: 10.7759/cureus.23051] [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] [Received: 02/15/2022] [Accepted: 03/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background: The deltoid ligament (DL) is a strong triangle-shaped ligament with a complex fascicular arrangement. Understanding the morphological and/or functional typing of the DL structure is hindered by a paucity of clear, quantitative, and reproducible data and is further complicated by inconsistent terminology use. The aim of this work was to describe different components of the DL using strict identification criteria. Methods: Thirty embalmed cadaveric ankles of both sides were dissected on all sides and studied by using gross examination, micro-dissection, and light microscopy by tracing the fascicular pattern of each under 6X magnification. Results: Six ligamentous bands were identified. The tibiotalocalcaneal ligament (TTC) and the superficial posterior tibiotalar ligament (sPTT) were two superficial variants and the anterior tibiotalar ligament (ATT), the anterior tibiotalonavicular ligament (ATTN), the intermediate tibiotalar ligament (ITT), and the deep posterior tibiotalar ligament (dPTT) were four deep variants. The TTC was identified in all 30 embalmed cadaveric specimens. Five additional ligamentous bands (ITT, sPTT, dPTT, ATT, and ATTN) were variable findings in the current cohort. Conclusion: This study presents six ligamentous bands as a regular finding and five additional ligamentous bands as variable findings in the dissected specimen. This data could assist in the radiological diagnosis of DL injuries and advanced procedures related to its surgical repair and reconstruction.
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Chiang CC, Lin CFJ, Tzeng YH, Teng MH, Yang TC. Arthroscopic Quantitative Measurement of Medial Clear Space for Deltoid Injury of the Ankle: A Cadaveric Comparative Study With Stress Radiography. Am J Sports Med 2022; 50:778-787. [PMID: 35289224 DOI: 10.1177/03635465211067806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The deltoid ligament (DL) is an important stabilizer of the ankle. DL injury of varying severity can occur alone or with syndesmotic injury and fibular fracture. Limited diagnostic tools are available to assess DL injury quantitatively. PURPOSE To establish an arthroscopic quantitative assessment of DL injury and to compare its performance with that of external rotation stress (ERS) and gravity stress (GS) radiography. STUDY DESIGN Controlled laboratory study. METHODS In total, 24 cadaveric lower extremities were divided into 4 groups: group 1 consisted of intact DL, group 2 of superficial DL disruption, group 3 of deep DL disruption, and group 4 of complete DL (superficial and deep) disruption. All specimens underwent sequential sectioning of syndesmotic ligaments, and medial clear space (MCS) was measured with ankle arthroscopy, ERS radiography, and GS radiography at different stages of syndesmotic sectioning. RESULTS For noninjured deltoid (group 1) and injured deltoid (groups 2-4), area under the receiver operating characteristic curve (AUC) of measurement of MCS was 0.939 for arthroscopy, 0.932 for ERS radiography, and 0.874 for GS radiography, with a significant difference between arthroscopy and GS radiography (P = .014). For incomplete deltoid injury (groups 1-3) and complete deltoid injury (group 4), the AUC of MCS was 0.811 for arthroscopy, 0.656 for ERS radiography, and 0.721 for GS radiography, with a significant difference between arthroscopy and ERS radiography (P < .001) and between arthroscopy and GS radiography (P = .035). For all stages of syndesmotic sectioning, cutoff values of arthroscopic MCS with intact fibula were ≤2.5 mm for intact DL, between 2.5 and 3.5 mm for partial DL injury (superficial or deep), and ≥3.5 mm for complete DL injury. Arthroscopy was unable to detect a difference between superficial deltoid injury (group 2) and deep deltoid injury (group 3) in partial DL injury, with a measured MCS between 2.5 and 3.5 mm. The intraclass correlation coefficient of interrater reliability was 0.975 for arthroscopy, 0.917 for ERS radiography, and 0.811 for GS radiography. CONCLUSION Arthroscopic MCS measurement can differentiate intact DL, partial DL injury, and complete DL injury. Compared with ERS and GS radiography, arthroscopic MCS measurement has greater accuracy with excellent interrater reliability. CLINICAL RELEVANCE For patients with suspected DL injury, arthroscopic MCS is useful for determining deltoid lesion severity based on defined cutoff values for consideration in preoperative planning to improve surgical outcomes.
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Affiliation(s)
- Chao-Ching Chiang
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Fu Jeff Lin
- Department of Statistics, National Taipei University, Taipei, Taiwan.,Department of Orthopedic Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yun-Hsuan Tzeng
- Division of Medical Imaging for Health Management, Cheng-Hsin General Hospital, Taipei, Taiwan.,Department of Radiology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Hung Teng
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopedics, Taipei Veterans General Hospital, Yuli Branch, Hualien, Taiwan
| | - Tzu-Cheng Yang
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Orthopaedics, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
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The Role of Diffusion Weighted MR Imaging in the Diagnosis of Tendon Injuries of the Ankle and Foot. Medicina (B Aires) 2022; 58:medicina58020321. [PMID: 35208644 PMCID: PMC8879388 DOI: 10.3390/medicina58020321] [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] [Received: 12/30/2021] [Revised: 01/27/2022] [Accepted: 02/03/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Daniels TR. Ankle Stability: Commentary on an article by Joon Jo, MD, et al.: "Arthroscopic All-Inside Anterior Talofibular Ligament Repair with and without Inferior Extensor Retinacular Reinforcement. A Prospective Randomized Study". J Bone Joint Surg Am 2021; 103:e71. [PMID: 34468418 DOI: 10.2106/jbjs.21.00726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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Medial Ankle Stability Evaluation With Dynamic Ultrasound: Establishing Natural Variations in the Healthy Cohort. J Am Acad Orthop Surg 2021; 29:703-713. [PMID: 34270497 DOI: 10.5435/jaaos-d-20-00597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/02/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Destabilizing injuries to the deltoid ligament have relied on radiographic stress examination for diagnosis, with a focus on medial clear space (MCS) widening. Recently, studies have demonstrated the use of ultrasonography to assess deltoid ligament injury, but not the medial ankle stability. The purpose of this study was to assess the MCS via ultrasonography while weight-bearing and with a gravity stress test (GST) in the uninjured ankle as a means of establishing normative values for future comparison. METHODS Twenty-six participants with no reported ankle injury in their premedical history were included. The MCS was examined using ultrasonography with the patient lying in a lateral decubitus position to replicate a GST with the ankle held in a neutral and plantarflexed position as well as while weight-bearing. The MCS was assessed in mm at the anteromedial and inferomedial aspect of the ankle joint. RESULTS With weight-bearing, the average anterior MCS and inferior MCS were 3.6 and 3.3 mm, respectively. During the GST in neutral ankle position, the average anterior MCS was 4.1 mm, whereas the average inferior MCS was 4.0 mm. When measured during the GST in plantarflexed ankle position, the averages anterior MCS and inferior MCS increased to 4.4 mm. MCS values were notably higher with GST than with weight-bearing measurements (P < 0.001). MCS values were notably higher with the foot in a plantarflexed compared with a neutral position when doing GST (P < 0.001). No notable differences in MCS distance were found when comparing laterality (P > 0.05). Height had a notable effect on all MCS values (P < 0.05). Inter- and intra-rater reliabilities for ultrasonographic MCS measurements were all excellent (interclass correlation coefficient >0.75). DISCUSSION Ultrasound can reliably measure the MCS of the ankle while doing dynamic stress manoeuvres. With the deltoid ligament intact, a GST increases MCS widening more than weight-bearing, and holding the ankle in plantarflexion while doing a gravity stress view, further increases this difference. LEVELS OF EVIDENCE Diagnostic studies-investigating a diagnostic test: Level III.
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Liu WJ, Lin LF, Chiang SL, Lu LH, Chen CY, Lin CH. Impacts of Stroke on Muscle Perceptions and Relationships with the Motor and Functional Performance of the Lower Extremities. SENSORS 2021; 21:s21144740. [PMID: 34300480 PMCID: PMC8309499 DOI: 10.3390/s21144740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 11/16/2022]
Abstract
Stroke results in paretic limb disabilities, but few studies have investigated the impacts of stroke on muscle perception deficits in multiaxis movements and related functional changes. Therefore, this study aimed to investigate stroke-related changes in muscle perceptions using a multiaxis ankle haptic interface and analyze their relationships with various functions. Sixteen stroke patients and 22 healthy participants performed active reproduction tests in multiaxis movements involving the tibialis anterior (TA), extensor digitorum longus (EDL), peroneus longus, and flexor digitorum longus (FDL) of the ankle joint. The direction error (DE), absolute error (AE), and variable error (VE) were calculated. The lower extremity of Fugl-Meyer Assessment (FMA-LE), Barthel Index (BI), Postural Assessment Scale for Stroke Patients, Tinetti Performance-Oriented Mobility Assessment (POMA), and 10-m walk test (10MWT) were evaluated. VE of EDL for the paretic ankle was significantly lower than that for the nonparetic ankle (p = 0.009). AE of TA, EDL, and FDL and VE of EDL and FDL of muscle perceptions were significantly lower in healthy participants than in stroke patients (p < 0.05 for both). DE of TA for the paretic ankle was moderately correlated with FMA-LE (r = -0.509) and POMA (r = -0.619) scores. AE and VE of EDL for the paretic ankle were moderately correlated with the 10MWT score (r = 0.515 vs. 0.557). AE of FDL for the paretic ankle was also moderately correlated with BI (r = -0.562). This study indicated poorer accuracy and consistency in muscle perception for paretic ankles, which correlated with lower limb functions of stroke patients.
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Affiliation(s)
- Wan-Ju Liu
- Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei 110, Taiwan;
| | - Li-Fong Lin
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan;
| | - Shang-Lin Chiang
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114, Taiwan;
| | - Liang-Hsuan Lu
- Department of Physical Therapy and Assistive Technology, National Yang-Ming University, Taipei 112, Taiwan;
| | - Chao-Ying Chen
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong 999077, China;
| | - Chueh-Ho Lin
- Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei 110, Taiwan;
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Correspondence: ; Tel./Fax: +886-2-27361661 (ext. 6325)
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Abstract
Undiagnosed medial ankle instability can be a prerequisite for pathogenic progression in the foot, particularly for adult acquired flatfoot deformity. With the complex anatomy in this region, and the limitations of each individual investigational method, accurately identifying peritalar instability remains a serious challenge to clinicians. Performing a thorough clinical examination aided by evaluation with advanced imaging can improve the threshold of detection for this condition and allow early proper treatment to prevent further manifestations of the instability.
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Affiliation(s)
- Yantarat Sripanich
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok 10400, Thailand
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Martinistr. 52, Hamburg 20246, Germany.
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Abstract
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.
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Affiliation(s)
- Beat Hintermann
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland.
| | - Roxa Ruiz
- Center of Excellence for Foot and Ankle Surgery, Kantonsspital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland
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Espinosa N, Klammer G. The Failed Deltoid Ligament in the Valgus Misaligned Ankle-How to Treat? Foot Ankle Clin 2021; 26:391-405. [PMID: 33990260 DOI: 10.1016/j.fcl.2021.03.011] [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: 02/02/2023]
Abstract
This article deals with the treatment of a chronically failed deltoid ligament complex in the valgus misaligned ankle. This is a challenging task in every orthopedic foot and ankle surgery. Before embarking on any surgery that relates to the deltoid ligament complex, it is mandatory to analyze any underlying cause that could promote the impairment. Once this is done, it might be of value in considering anatomic reconstructions. The article provides an anatomic reconstruction technique, which should help address the problem.
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Affiliation(s)
- Norman Espinosa
- Institute for Foot and Ankle Reconstruction, Beethovenstrasse 3, Zurich 8002, Switzerland.
| | - Georg Klammer
- Institute for Foot and Ankle Reconstruction, Beethovenstrasse 3, Zurich 8002, Switzerland
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33
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Abstract
A thorough knowledge of the anatomy of the deltoid and spring ligament complex is important for treatment of deformities that impact the foot and ankle. Both ligaments are interconnected, and the study of their anatomic characteristics is better performed together than in isolation. The deltoid ligament is a group of ligaments that derives its origin from the medial malleolus, and the spring ligament complex consist of a group of ligaments that connects the navicular and the sustentaculum tali of the calcaneus. They both play an important role in stabilization of the medial ankle and medial column of the foot.
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Affiliation(s)
- Jarrett D Cain
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - Miki Dalmau-Pastor
- Human Anatomy Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; MIFAS By GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France.
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34
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Sado N, Shiotani H, Saeki J, Kawakami Y. Positional difference of malleoli-midpoint from three-dimensional geometric centre of rotation of ankle and its effect on ankle joint kinetics. Gait Posture 2021; 83:223-229. [PMID: 33176233 DOI: 10.1016/j.gaitpost.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUNDS Joint kinetic calculations are sensitive to joint centre locations. Although geometric hip and knee joint centre/axis are generally developed, the ankle joint centre (AJC) is conventionally defined as the midpoint between the malleolus lateralis and medialis (AJCMID) in most gait analyses. RESEARCH QUESTION We examined the positional difference of the AJCMID from the geometric centre of rotation (AJCFUN) and its effect on the ankle joint kinetics in representative human gaits. METHODS In the first experiment, we calculated the AJCFUN and indicated its location on the ankle MRI in 14 (seven male and seven female) participants. In the second experiment, we compared ankle kinematics/kinetics based on AJCFUN and AJCMID during walking and hopping at 2.6 Hz in 17 (nine male and eight female) participants. RESULTS In both experiments, AJCFUN was located at positions significantly medial (-9.2 ± 5.4 mm and -10.1 ± 4.4 mm) and anterior (17.0 ± 7.4 mm and 15.3 ± 5.2 mm) from the AJCMID. Furthermore, the AJCMID underestimated peak dorsiflexion (AJCMID/AJCFUN: 52.6 ± 17.1%) and inversion (AJCMID/AJCFUN: 62.2 ± 11.5%) torques and their durations in walking. Additionally, AJCMID overestimated the plantar flexion torque in both gait modes [AJCMID/AJCFUN: 111.3 ± 4.8% (walking) and 112.7 ± 6.3% (hopping)]. SIGNIFICANCE We therefore concluded that the positional difference between the geometric and landmark-based AJC definitions significantly affected ankle kinetics, thereby indicating that the functional method should be used for defining AJC for gait analysis.
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Affiliation(s)
- Natsuki Sado
- Faculty of Sports Sciences, Waseda University, Tokorozawa, Japan.
| | - Hiroto Shiotani
- Graduate School of Sport Sciences, Waseda University, Tokorozawa, Japan; Japan Society for the Promotion of Science, Tokyo, Japan
| | - Junya Saeki
- Faculty of Sports Sciences, Waseda University, Tokorozawa, Japan; Japan Society for the Promotion of Science, Tokyo, Japan
| | - Yasuo Kawakami
- Faculty of Sports Sciences, Waseda University, Tokorozawa, Japan
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Casado-Hernández I, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, Santiago-Nuño F, Mazoteras-Pardo V, López-López D, Rodríguez-Sanz D, Calvo-Lobo C. Association between anterior talofibular ligament injury and ankle tendon, ligament, and joint conditions revealed by magnetic resonance imaging. Quant Imaging Med Surg 2021; 11:84-94. [PMID: 33392013 DOI: 10.21037/qims-20-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Fernando Santiago-Nuño
- Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry, Universidade da Coruña, Ferrol, Spain
| | | | - Daniel López-López
- Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry, Universidade da Coruña, Ferrol, Spain
| | - David Rodríguez-Sanz
- Facultad de Enfermería, Fisioterapia y Podología. Universidad Complutense de Madrid, Spain
| | - César Calvo-Lobo
- Facultad de Enfermería, Fisioterapia y Podología. Universidad Complutense de Madrid, Spain
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Mansur NSB, Lemos AVKC, Baumfeld DS, Baumfeld TS, Prado MPD, Raduan FC, Nery CAS. Medial and Lateral Combined Ligament Arthroscopic Repair for Multidirectional Ankle Instability. FOOT & ANKLE ORTHOPAEDICS 2021; 6:2473011420986150. [PMID: 35097429 PMCID: PMC8702971 DOI: 10.1177/2473011420986150] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: The high prevalence of ankle sprains in the population produces a significant number of patients with lateral instability. Persistence of this condition may lead to the progressive involvement of medial structures, causing a multidirectional rotational instability. Methods: This is a retrospective study with patients diagnosed with multidirectional instability who underwent ankle arthroscopy with medial (arthroscopic tensioning) and lateral repair (arthroscopic Bröstrom) between January 2018 and January 2020. All patients were evaluated for pain and function according to the visual analog scale (VAS) score and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score at a mean of 14.8 months (5-27 months) in follow-up. A total of 30 ankles (29 patients) were included in the study. Results: The AOFAS score increase from a 49.7 (CI 5.8) to a 91.9 (CI 2.4) mean (P = .001) and was followed by significant improvement in the mean VAS score (6.8, CI 0.37-0.95, CI 0.31). The majority of patients had associated procedures (53.3%), and a low complication rate was found (16.6%). Conclusion: Combined medial and lateral arthroscopic repair might be an effective and safe alternative in the treatment of multidirectional instability. Inclusion of the deltoid ligament complex and the low invasiveness of the arthroscopic technique may improve the clinical outcomes of these patients. Level of Evidence: Level IV, retrospective case series.
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37
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Luo G, Ni W, Guo S, Guo S. [Effectiveness of repairing the deep layer of deltoid ligament by suture anchor repair method in treatment of mixed medial injury associated with ankle fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1387-1391. [PMID: 33191695 DOI: 10.7507/1002-1892.202004148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore the necessity of repairing the deep layer of deltoid ligament in the treatment of mixed medial injury associated with ankle fractures. Methods Between January 2016 and December 2018, 12 patients with mixed medial injury associated with ankle fractures were treated with the fixation of the lateral malleolus by bone plates, the fixation of the anterior colliculus of medial malleolus by cannulated screws, and the repair of the deltoid ligament by suture anchors. There were 8 males and 4 females, with an average age of 42 years (range, 18-56 years). According to the Lauge-Hansen classification criteria, there were 11 cases of supination-external rotation type and 1 case of pronation-external rotation type. According to the Weber classification criteria, all cases were type B. The time from injury to operation was 3-6 days, with an average of 4.7 days. In each patient, X-ray films of anteroposterior and lateral views and mortise view of ankle were taken postoperatively. The motion range of ankle joints was observed. The function of the ankle and the outcome of the treatment were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Olerud-Molander scoring system, and the visual analogue scale (VAS) score. Results All cases were followed up 12-42 months (mean, 28 months). The 12 patients returned to their pre-injury jobs. Five patients with sports injury completely recovered to their pre-injury motor function. No patient experienced persistent medial ankle pain or ankle instability. At last follow-up, the ankle range of motion in dorsiflexion was 9°-25° (mean, 17.96°), which was 0°-11° (mean, 4.02°) less than that in normal side; the range of motion in plantar flexion was 38°-50° (mean, 43.90°), which was 0°-7° (mean, 2.53°) less than that in normal side. The AOFAS score was 88-100 (mean, 96.7); the Olerud-Molander score was 90-100 (mean, 96.5); the VAS score was 0-3 (mean, 1.1). Conclusion It is necessary to repair the deep layer of deltoid ligament in the mixed medial injuries associated with ankle fracture, which include anterior colliculus fracture and deep deltoid ligament injury. A better outcome can be achieved by employing the suture anchor repair method.
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Affiliation(s)
- Gang Luo
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - Weidong Ni
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - Shihang Guo
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
| | - Shuquan Guo
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China
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Plaass C, Louwerens JW, Claassen L, Ettinger S, Yao D, Lerch M, Stukenborg-Colsman C, Donken C. Treatment concepts for pes valgoplanus with concomitant changes of the ankle joint : Tibiotalocalcaneal arthrodesis, total ankle replacement and joint-preserving surgery. DER ORTHOPADE 2020; 49:991-999. [PMID: 33104862 DOI: 10.1007/s00132-020-03996-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Concomitant valgus deformities of the ankle joint are found in approximately 3% of patients with symptomatic flat foot deformities. Conservative treatment is mostly successful only in the short term or in low-demand patients. The operative treatment of flat foot deformities follows the standard algorithm for flat foot treatment. The ankle joint can be treated while retaining mobility or by arthrodesis depending on the degree and rigidity of the deformity, degenerative changes, patient factors and expectations. Achieving an orthograde hindfoot and midfoot is obligatory for successful treatment as well as in ankle reconstructive or arthrodesis procedures.
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Affiliation(s)
- Christian Plaass
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany.
| | - Jan Willem Louwerens
- Foot and Ankle Reconstruction Unit of the Orthopaedic Department, St. Maartenskliniek, Hengstdal 3, 6574, Ubbergen, NA, The Netherlands
| | - Leif Claassen
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Sarah Ettinger
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Daiwei Yao
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Matthias Lerch
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Christina Stukenborg-Colsman
- Department for Foot and Ankle surgery, DIAKOVERE Annastift, Orthopedic Clinic of the Hannover Medical School, Anna-von-Borries Straße 1-7, 30627, Hannover, Germany
| | - Christian Donken
- Foot and Ankle Reconstruction Unit of the Orthopaedic Department, St. Maartenskliniek, Hengstdal 3, 6574, Ubbergen, NA, The Netherlands
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39
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Glenzer SR, Domingue GA, Perry MD. Anteromedial Ankle Impingement Due to a Talar Cam Lesion and Anterior Deep Deltoid Ligament With Variant Anatomy: A Case Report. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420977427. [PMID: 35097418 PMCID: PMC8564926 DOI: 10.1177/2473011420977427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Scott R. Glenzer
- Department of Orthopaedic Surgery, University of South Alabama, Mobile, AL, USA
| | | | - Mark D. Perry
- Department of Orthopaedic Surgery, University of South Alabama, Mobile, AL, USA
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40
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Deland JT, Ellis SJ, Day J, de Cesar Netto C, Hintermann B, Myerson MS, Sangeorzan BJ, Schon LC, Thordarson DB, Johnson JE. Indications for Deltoid and Spring Ligament Reconstruction in Progressive Collapsing Foot Deformity. Foot Ankle Int 2020; 41:1302-1306. [PMID: 32851857 DOI: 10.1177/1071100720950742] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Cesar de Cesar Netto
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | | | - Mark S Myerson
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Lew C Schon
- Mercy Medical Center, Baltimore, MD, USA.,New York University Grossman School of Medicine, New York, NY, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA.,Georgetown School of Medicine, Washington, DC, USA
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41
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Flores DV, Mejía Gómez C, Fernández Hernando M, Davis MA, Pathria MN. Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings. Radiographics 2020; 39:1437-1460. [PMID: 31498747 DOI: 10.1148/rg.2019190046] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Adult acquired flatfoot deformity (AAFD) is a common disorder that typically affects middle-aged and elderly women, resulting in foot pain, malalignment, and loss of function. The disorder is initiated most commonly by degeneration of the posterior tibialis tendon (PTT), which normally functions to maintain the talonavicular joint at the apex of the three arches of the foot. PTT degeneration encompasses tenosynovitis, tendinosis, tendon elongation, and tendon tearing. The malaligned foot is initially flexible but becomes rigid and constant as the disorder progresses. Tendon dysfunction commonly leads to secondary damage of the spring ligament and talocalcaneal ligaments and may be associated with injury to the deltoid ligament, plantar fascia, and other soft-tissue structures. Failure of multiple stabilizers appears to be necessary for development of the characteristic planovalgus deformity of AAFD, with a depressed plantar-flexed talus bone, hindfoot and/or midfoot valgus, and an everted flattened forefoot. AAFD also leads to gait dysfunction as the foot is unable to change shape and function adequately to accommodate the various phases of gait, which require multiple rapid transitions in foot position and tone for effective ambulation. The four-tier staging system for AAFD emphasizes physical examination findings and metrics of foot malalignment. Mild disease is managed conservatively, but surgical procedures directed at the soft tissues and/or bones become necessary and progressively more invasive as the disease progresses. Although much has been written about the imaging findings of AAFD, this article emphasizes the anatomy and function of the foot's stabilizing structures to help the radiologist better understand this disabling disorder. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Dyan V Flores
- From the Department of Radiology, Philippine Orthopedic Center, St. Luke's Medical Center-Global City, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); Department of Radiology, Diagnóstico Médico Cantabria, Santander, Spain (M.F.H.); Department of Radiology, University of Texas Health Science Center, San Antonio, Texas (M.A.D.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Catalina Mejía Gómez
- From the Department of Radiology, Philippine Orthopedic Center, St. Luke's Medical Center-Global City, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); Department of Radiology, Diagnóstico Médico Cantabria, Santander, Spain (M.F.H.); Department of Radiology, University of Texas Health Science Center, San Antonio, Texas (M.A.D.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Moisés Fernández Hernando
- From the Department of Radiology, Philippine Orthopedic Center, St. Luke's Medical Center-Global City, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); Department of Radiology, Diagnóstico Médico Cantabria, Santander, Spain (M.F.H.); Department of Radiology, University of Texas Health Science Center, San Antonio, Texas (M.A.D.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Michael A Davis
- From the Department of Radiology, Philippine Orthopedic Center, St. Luke's Medical Center-Global City, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); Department of Radiology, Diagnóstico Médico Cantabria, Santander, Spain (M.F.H.); Department of Radiology, University of Texas Health Science Center, San Antonio, Texas (M.A.D.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
| | - Mini N Pathria
- From the Department of Radiology, Philippine Orthopedic Center, St. Luke's Medical Center-Global City, Maria Clara St, Santa Mesa Heights, Quezon City, Metro Manila, Philippines 1100 (D.V.F.); Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia (C.M.G.); Department of Radiology, Diagnóstico Médico Cantabria, Santander, Spain (M.F.H.); Department of Radiology, University of Texas Health Science Center, San Antonio, Texas (M.A.D.); and Department of Radiology, UCSD Health System, San Diego, Calif (M.N.P.)
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Acevedo JI, Kreulen C, Cedeno AA, Baumfeld D, Nery C, Mangone PG. Technique for Arthroscopic Deltoid Ligament Repair With Description of Safe Zones. Foot Ankle Int 2020; 41:605-611. [PMID: 32100553 DOI: 10.1177/1071100720909138] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level V, expert opinion.
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Affiliation(s)
- Jorge I Acevedo
- Department of Orthopedics, Southeast Orthopedic Specialists, Jacksonville, FL, USA
| | - Christopher Kreulen
- Department of Orthopaedics, University of California, Davis, Sacramento, CA, USA
| | | | | | - Caio Nery
- Federal University of São Paulo, SP, Brazil
| | - Peter G Mangone
- Department of Orthopedics, Blue Ridge Division of EmergeOrtho, Foot and Ankle Center, Arden, NC, USA
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43
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Arthroscopic Reconstruction of the Anterior Tibiotalar Ligament Using a Free Tendon Graft. Arthrosc Tech 2020; 9:e541-e547. [PMID: 32368476 PMCID: PMC7189568 DOI: 10.1016/j.eats.2020.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/02/2020] [Indexed: 02/03/2023] Open
Abstract
Deltoid ligament injuries account for 5.1% to 15.8% of ankle sprains and occur with concomitant lateral ankle sprains. The anterior tibiotalar ligament (ATTL), located within the deep layer of the deltoid ligament complex, connects the talus and the tibia on the medial side of the ankle and controls ankle eversion and rotation. If conservative treatment for chronic medial ankle instability after an ankle sprain fails, ATTL repair or reconstruction might be necessary. Arthroscopic reconstruction techniques of the lateral ankle ligaments recently have been reported. Here, we describe arthroscopic reconstruction of the ATTL using a free tendon graft (ARATTL). This technique is less invasive than other treatments and results in a more stable medial ankle joint.
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44
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Vega J, Allmendinger J, Malagelada F, Guelfi M, Dalmau-Pastor M. Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability. Knee Surg Sports Traumatol Arthrosc 2020; 28:132-140. [PMID: 28983653 DOI: 10.1007/s00167-017-4736-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/28/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. METHODS Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique. RESULTS During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up. CONCLUSION Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Jordi Vega
- Foot and Ankle Unit, Hospital Quirón Barcelona, Plaza Alfonso Comín 5, 08023, Barcelona, Spain.
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain.
| | | | - Francesc Malagelada
- Foot and Ankle Unit, Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matteo Guelfi
- Orthopaedic and Traumatology Unit, Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Chieti, Italy
| | - Miki Dalmau-Pastor
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain
- Faculty of Health Sciences at Manresa, University of Vic-Central University of Catalonia, Manresa, Barcelona, Spain
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45
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Deltoid Insufficiency and Flatfoot—Oh Gosh, I’m Losing the Ankle! What Now? TECHNIQUES IN FOOT AND ANKLE SURGERY 2019. [DOI: 10.1097/btf.0000000000000245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pellegrini MJ, Torres N, Cuchacovich NR, Huertas P, Muñoz G, Carcuro GM. Chronic deltoid ligament insufficiency repair with Internal Brace™ augmentation. Foot Ankle Surg 2019; 25:812-818. [PMID: 30478015 DOI: 10.1016/j.fas.2018.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 10/08/2018] [Accepted: 10/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with chronic deltoid ligament insufficiency (CDLI) present a challenging situation. Although numerous procedures have been described, optimal treatment is still a matter of debate. While the treatment armamentarium ranges from simple ligament repair to complex reconstructions with or without realignment osteotomies, direct repair augmented with an Internal Brace™ device appears to be an attractive intermediate option. We investigated functional outcomes and complications in patients with CDLI operated on using Internal Brace™ augmentation. METHODS A prospective study was conducted. Patients were included if they presented medial ankle pain and/or giving way, exhibited asymmetric flexible hindfoot valgus, failed conservative treatment, and had a positive MRI evaluated by an independent radiologist. Patients with stage IV flatfoot deformity, neuropathy and/or inflammatory arthritis were excluded. CDLI was confirmed intraoperatively with the arthroscopic drive-through sign. Patients were evaluated preoperatively and postoperatively using FAAM, SF-36 and grade of satisfaction. Paired t-tests were used to assess FAAM and SF-36 scores variation. RESULTS Thirteen patients met inclusion criteria. No patient was lost to follow-up, with a mean follow-up time of 13.5 months (range 6-21). Preoperative FAAM and SF-36 scores improved from 58.7 to 75.3 and from 60.2 to 84.4 postoperatively, respectively (p<.01). Two implant failures were observed, with no apparent compromise of construct stability. No patient was re-operated. CONCLUSIONS Our results suggest that deltoid ligament repair with Internal Brace™ augmentation in patients with CDLI is a reliable option with good functional outcomes and high satisfaction grade in short term follow-up. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- M J Pellegrini
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
| | - N Torres
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
| | - N R Cuchacovich
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
| | - P Huertas
- Medical Education Department, Senior Clinical Specialist Foot and Ankle, Naples, FL, USA.
| | - G Muñoz
- Department of Orthopaedic Surgery, Clinica Las Condes, Lo Fontecilla 441, Las Condes, Santiago, 7591046, Chile.
| | - G M Carcuro
- Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile.
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Warner SJ, Garner MR, Fabricant PD, Schottel PC, Loftus ML, Hentel KD, Helfet DL, Lorich DG. The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures. HSS J 2019; 15:115-121. [PMID: 31327941 PMCID: PMC6609669 DOI: 10.1007/s11420-018-09655-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established. QUESTIONS/PURPOSES The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures. METHODS Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation. RESULTS Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%). CONCLUSION Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.
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Affiliation(s)
- Stephen J. Warner
- University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 1700, Houston, TX 70030 USA
| | | | | | | | - Michael L. Loftus
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY USA
| | - Keith D. Hentel
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY USA
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Shi E, Weinraub GM. Lateral Column Lengthening for Revision Triple and Double Arthrodesis and Severe End-Stage Flatfoot Deformity. J Foot Ankle Surg 2019; 58:577-580. [PMID: 30744919 DOI: 10.1053/j.jfas.2018.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Indexed: 02/03/2023]
Abstract
Few options exist for the treatment of revision and severe cases of end-stage flatfoot deformity. Triple arthrodesis or medial-approach double arthrodesis have been the standard but often do not provide enough correction of the deformity. Lateral column lengthening is a powerful procedure performed either with an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis that can be used as an adjunct in realigning the flatfoot. We performed a retrospective radiographic review and looked at 11 consecutive cases of patients who underwent hindfoot arthrodesis with a lateral column lengthening procedure. We matched these patients with 11 control patients who underwent isolated medial-approach double arthrodesis. For the patients who underwent a lateral column lengthening procedure, we found a significant improvement in calcaneal inclination angle (p = .001) and greater correction in talar declination angle, cuboid abduction angle, and talocalcaneal angle when compared with the control group. Lateral column lengthening is a useful adjunct to hindfoot arthrodesis in the correction of revision and severe end-stage flatfoot deformity.
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Affiliation(s)
- Eric Shi
- Fellow, Silicon Valley Reconstructive Foot and Ankle Surgery Fellowship, Palo Alto Medical Foundation, Mountain View, CA.
| | - Glenn M Weinraub
- Attending Physician, Kaiser Permanente San Leandro, San Leandro, CA
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Amaha K, Nimura A, Yamaguchi R, Kampan N, Tasaki A, Yamaguchi K, Kato R, Akita K. Anatomic study of the medial side of the ankle base on the joint capsule: an alternative description of the deltoid and spring ligament. J Exp Orthop 2019; 6:2. [PMID: 30689117 PMCID: PMC6890913 DOI: 10.1186/s40634-019-0171-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/17/2019] [Indexed: 01/14/2023] Open
Abstract
Background Adult acquired flatfoot deformity (AAFD) is caused by impaired medial ligamentous structures and posterior tibialis tendon dysfunction (PTTD). Although degeneration and trauma could separately cause AAFD, how these factors interact in the pathomechanism of AAFD is unclear. The joint capsule in the medial ankle is considered an important structure, providing passive stability by limiting joint movement. Previous reports on the joint capsule suggest its involvement in pathological changes of the ankle, but because of the high priority placed on the ligaments, few reports address the ankle joint from the joint capsule standpoint. The current study aimed to anatomically examine the medial ankle joint, focusing on the deltoid and spring ligaments in perspective of the joint capsule. Methods We conducted a descriptive anatomical study of 19 embalmed cadavers (mean 82.7 years, range 58 to 99). We included 22 embalmed cadaveric ankles. We detached the joint capsule in 16 ankles from the anterior to posteromedial joint, analyzed the capsular attachments of the ankle and adjacent joints, and measured the widths of the bony attachments. We histologically analyzed the joint capsule using Masson’s trichrome staining in 6 ankles. Results The capsule could be separated as a continuous sheet, including 3 different tissues. The anterior capsule was composed of fatty tissue. Between the medial malleolus and talus, the capsule was strongly connected and was composed of fibrous tissue, normally referred to as the deep deltoid ligament. The tibial attachment formed a steric groove, and the talar side of the attachment formed an elliptical depressed area. On the medial part of the subtalar and talonavicular joints, the capsule covered the joints as cartilaginous tissue, normally referred to as the superomedial ligament of the spring ligament. The outer side of the cartilaginous and fibrous tissue formed the sheath floor of the posterior tibialis tendon. Histological analysis revealed three different tissue types. Conclusions The capsules of the ankle, subtalar, and talonavicular joints could be detached as a continuous sheet. The deltoid and the superomedial ligament of the spring ligaments could be interpreted as a part of the continuous capsule, which had different histological features. Level of evidence Descriptive Laboratory Study.
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Affiliation(s)
- Kentaro Amaha
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopaedic Surgery, St. Luke's International Medical center, Tokyo, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Reiko Yamaguchi
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Natnicha Kampan
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Tasaki
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopaedic Surgery, St. Luke's International Medical center, Tokyo, Japan
| | - Kumiko Yamaguchi
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Kato
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,JA Kyosai Research Institute, Tokyo, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Persaud S, Catanzariti AR. Repair of the Deltoid Ligament Using Posterior Tibial Tendon Autograft:A Novel Technique. J Foot Ankle Surg 2019; 58:165-170. [PMID: 30583777 DOI: 10.1053/j.jfas.2018.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Indexed: 02/03/2023]
Abstract
Posterior tibial tendon dysfunction (PTTD) is a progressive disorder secondary to advanced degeneration of the posterior tibial tendon, leading to the abduction of the forefoot, valgus rotation of the hindfoot, and collapse of the medial longitudinal arch. Eventually, the disease becomes so advanced that it begins to affect the deltoid ligament over time. This attenuation and eventual tear of the deltoid ligament leads to valgus deformity of the ankle. Surgical correction of PTTD is performed to protect the ankle joint at all costs. Generally, this is performed using osteotomies of the calcaneus and repair or augmentation of the deltoid ligament. Unfortunately, there has been no universal procedure adapted by foot and ankle surgeons for repair or augmentation of the deltoid ligament. Articles have discussed the use of suture and suture anchors, suture tape, nonanatomic allograft repair, nonanatomic autograft repair with plantaris, peroneal and extensor halluces longus tendons to repair and augment the deltoid ligament. There is very little literature, however, in regard to using the posterior tibial tendon to augment the deltoid ligament in accordance with hindfoot fusion for end-stage PTTD deformity. In general, the posterior tibial tendon in triple and medial double arthrodesis is generally removed because it is thought to be a pain generator. This article presents a case study and novel technique using the posterior tibial tendon to augment and repair the laxity of the deltoid ligament in an advanced flatfoot deformity.
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Affiliation(s)
- Sham Persaud
- Resident, Postgraduate Year 3, Division of Foot & Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA
| | - Alan R Catanzariti
- Faculty, Division of Foot & Ankle Surgery, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA.
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