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Background A combined reconstruction of chronic deltoid and spring ligament insufficiency is uncommon. Our study aims to share our experience in treating post-traumatic, chronic deltoid, and spring ligament insufficiency using the "quadrangular construct" technique. Material and methods Five patients who had post-traumatic combined deltoid and spring ligament insufficiency were included in the study. All patients reported a "giving-way" sensation. Preoperatively, each patient underwent weight-bearing radiographs of the ankle and foot. The talo-first metatarsal angle and hindfoot alignment angle were noted. The superficial deltoid ligament was repaired using a suture anchor augmented with Internal Brace TM (Arthrex, Naples, USA) FiberTape® to form a quadrangular construct that anatomically mimics various components of the deltoid-spring ligament complex. Due to the associated excessive heel valgus, three patients also underwent medial displacement calcaneum osteotomy. Additionally, one patient required lateral ligament repair, and another patient required syndesmotic stabilization. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to evaluate preoperative and postoperative ankle function. Results All five patients were followed up for a mean of 20 months (range: 12-24 months). The mean preoperative talo-first metatarsal angle improved from 8.46 degrees to 4.84 degrees. The preoperative mean hindfoot alignment angle was reduced from 10.9 to 5.76 degrees postoperatively. One patient had irritation due to the anchor, which needed removal after one year. Postoperatively, no patients re-experienced the feeling of "giving way". The AOFAS scores postoperatively showed two patients as excellent, two as good, and one as fair. All the patients returned to their pre-injury work. Conclusion  We have developed a technique for combined deltoid and spring ligament reconstruction using a quadrangular construct. This technique helps to restore anatomical stability, is safe, easily reproducible, and has shown positive short-term results in follow-up. The level of evidence is one of the methods used to categorize the quality and reliability of research, and our study falls under the category of level IV evidence., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Moonot et al.)

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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. [ABSTRACT FROM AUTHOR]

Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Adult-acquired flatfoot deformity (AAFD) is usually due to a combination of mechanical failure of the osteoligamentous complex that maintains the medial longitudinal arch of the foot and attenuation or complete tear of the posterior tibial tendon. Magnetic resonance imaging studies in patients with flatfoot deformities have reported the posterior tibial tendon to be pathologic in up to 100% of patients, the spring ligament in up to 87%, and the deltoid ligament in 33%. Many studies in the literature describe reconstruction of the spring ligament or the deltoid ligament associated with AAFD, but there is no study in which both (spring and deltoid) ligaments are reconstructed at the same time. We describe a novel technique to reconstruct the deltoid ligament and the spring ligament at the same time. Methods: We described the technique and evaluated 10 consecutive patients with AAFD and insufficient ankle and midfoot ligaments. Results: We found no postoperative complications, stiffness, or loss of correction. Conclusion: We present a novel technique to reconstruct the failed deltoid and spring ligament during flatfoot correction. It is unique in that it uses internal brace augmentation with FiberTape® to help and protect the soft tissue healing. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice.Methods: This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded.Results: All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases).Conclusion: In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials. [ABSTRACT FROM AUTHOR]

We evaluated the accuracy of the predictive injury sequences of the Lauge-Hansen (L-H) classification using magnetic resonance imaging (MRI) in patients with ankle fractures and determined the possible causes of mismatch. Sixty-five patients with ankle fractures who had a complete series of anteroposterior, lateral, and oblique radiographs and ankle MRI studies available were included. The fracture pattern was assigned by 2 senior orthopedic surgeons according to the L-H classification system. The syndesmotic ligaments, lateral collateral ligaments, and medial deltoid complex ligaments were evaluated on the preoperative MRI scans. Comparisons were performed between the predicted ankle ligamentous injury based on the radiographic L-H classification and preoperative MRI analysis. Of the 65 feet in 65 patients, 50 feet (76.9%) were classified as having a supination-external rotation (SER) fracture, 6 feet (9.2%) as having a pronation-external rotation fracture, 4 feet (6.2%) as having a supination adduction fracture, and 2 feet (3.1%) as having a pronation abduction fracture. The overall compatibility of the radiologic classification with the MRI classification was 66.1%. In the evaluation of 50 feet with the MRI SER designation, maximum compatibility was found for stage 4 (77.3%). The main cause for the discrepancy in the SER designation was missing the presence of deltoid ligament disruption on the plain radiographs, especially in the stage 2 and 3 SER fracture pattern. In the evaluation of deltoid complex injuries, all injuries were localized to the anterior part of the medial deltoid complex. The validity of the L-H classification system was low. A new classification system is needed to address the medial malleolus fracture or deltoid complex injuries without posterior injury. Also, stress radiographs could be added to standard radiographs for the classification to address deltoid complex injuries. [ABSTRACT FROM AUTHOR]

Evaluation and management of ankle fractures has progressed in parallel to an evolving understanding of ankle stability. While stability of the mortise had historically been attributed to the lateral malleolus, Lauge-Hansen's contributions followed by multiple other investigations increased the emphasis on the significance of medial-sided injury in destabilizing the mortise. As the importance of the deltoid ligament has been elucidated, the means of assessing ligamentous incompetence and the prognostic significance of an unstable mortise continue to be defined. [ABSTRACT FROM AUTHOR]

Background: Ankle joint stability dictates treatment in ligamentous supination external rotation ankle injuries (LSERAI). Investigation of the medial structures that support the ankle mortise is critical, and a small avulsion fracture, or "fleck", of the medial malleolus is occasionally encountered. This study aimed to assess the utility of this medial malleolus fleck sign (MMFS) in diagnosing instability requiring surgery in LSERAI.Methods: This retrospective observational study examined 166 LSERAI at a single level I trauma center. A standardized diagnostic and treatment protocol for ankle fractures was followed. LSERAI at presentation were reported as having a normal, dynamically wide, or statically wide medial clear space. Patient demographics, MMFS characteristics, and the use of operative management were recorded.Results: MMFS incidence in the cohort was 16 (10%) of 166 and was present in 25% of patients with unstable LSERAI. Fifteen (94%) of 16 patients with a MMFS were deemed to have an unstable LSERAI (P < .005). MMFS had a 25% sensitivity and 99% specificity in diagnosing an unstable LSERAI. For the subgroup of patients without a statically wide medial clear space, MMFS had a 50% sensitivity and 99% specificity in determining instability.Conclusion: A MMFS may be indicative of an unstable LSERAI. With previous MRI studies demonstrating complete deltoid disruption in unstable LSERAI, we deduce the MMFS may be associated with extensive deltoid incompetence. The MMFS may help to diagnose a complete deltoid injury in LSERAI with a normal medial clear space, which could influence treatment and reduce patient morbidity, radiation exposure, and healthcare costs.Levels Of Evidence: Level III: Retrospective Cohort Study. [ABSTRACT FROM AUTHOR]

Background: The spring ligament is an important medial arch stabilizer. However, when disrupted, it does not cause planovalgus deformity until the foot is cyclically loaded. We propose that the tibionavicular (TN) ligament plays an important role. However, this ligament is not imaged in routine magnetic resonance imaging (MRI) sequences. Methods: A prospective case-control study using a novel MRI sequence to image the TN ligament in 20 normal feet creating a baseline appearance of the ligament. We then scanned 20 patients with adult acquired flatfoot deformity (AAFD). All patients had weightbearing anteroposterior and lateral radiographs. We followed up patients, the end point being surgery or 18 months' follow-up. Results: The normal ligament was reliably identified on the novel sequences. It had a reproducible appearance in 2 views, and consistent length and width. Two groups of patients were identified in the AAFD cohort: Normal TN (11/20) (The mean Meary angle was 6.8 degrees) and Abnormal TN (9/20). The ligament was thickened proximally, with distal attenuation and intrasubstance edema. On sagittal sequence, it had dorsal bulging and high signal. The mean Meary angle was 13.2 degrees (P = .013). All patients had posterior tibial tendon dysfunction and 8 had spring ligament complex attenuation. Five patients have undergone corrective surgery compared to none in the other group. Conclusion: This study adds to the evidence that AAFD is multifactorial. With this imaging technique, we were able to reliably image the TN ligament. We hope that including this sequence into routine scanning will help us understand its role in flatfoot deformity. This poses the question of whether this structure will play a role in reconstructive surgery in future. Level of Evidence: Level II, prospective comparative study. [ABSTRACT FROM AUTHOR]

Background: The deltoid ligament (DL) is the principal ligamentous stabilizer of the medial ankle joint. Little is known, however, about the contribution of the DL toward stabilizing the syndesmosis. The aim of this study was to arthroscopically evaluate whether the DL contributes to syndesmotic stability in the coronal plane. Methods: Eight above-knee cadaveric specimens were used in this study. A lateral hook test was performed by applying 100 N of lateral force to the fibula in the intact state and after sequential transection of the DL, anterior-inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), and posterior-inferior tibiofibular ligament (PITFL). At each stage, distal tibiofibular diastasis was measured arthroscopically at both the anterior and posterior third of the incisura and compared to stress measurements of the intact syndesmosis. Measurements were performed using probes ranging from 0.1 to 6.0 mm, with 0.1-mm increments. Results: There was no significant increase in diastasis at either the anterior or posterior third of the tibiofibular articulation after isolated DL disruption, nor when combined with AITFL transection. In contrast, a significant increase in diastasis was observed following additional disruption of the IOL (anterior and posterior third diastasis, P= .012 and .026, respectively), and after transection of all 3 syndesmotic ligaments (anterior and posterior third diastasis, P=.001 and .001, respectively). Conclusion: When evaluating the syndesmosis arthroscopically in a cadaveric model under lateral stress, neither isolated disruption of the DL nor combined DL and AITFL injuries destabilized the syndesmosis in the coronal plane. In contrast, the syndesmosis became unstable if the DL was injured in conjunction with partial syndesmotic disruption that included the AITFL and IOL. Clinical relevance: Disruption of the DL appeared to destabilize the syndesmosis in the coronal plane when associated with partial disruption of the syndesmosis (AITFL and IOL). [ABSTRACT FROM AUTHOR]

• Posterior malleolus fracture (PMF) fixed with lag screws presents greater stability in the distal tibiofibular syndesmosis. • Higher tibiotalar joint loadings promoted greater displacement and ligaments stress, regardless of the fixation technique. • Fixation techniques that promote lower stress in the syndesmosis is accompanied by a greater load on the deltoid ligament. The objectives of this study were to compare syndesmosis dislocation and ankle ligament stress after the fixation of the posterior malleolus fracture (PMF) with four different techniques by Finite Element Analysis (FEM). Four internal fixation techniques used for fixation of PMF were assessed by FEM: posterior one-third tubular 3.5 mm buttress plate (PP) with one screw (PP 1 screw), PP with two screws (PP 2 screws), two cannulated 3.5 mm lag screws in the anteroposterior (AP) direction (AP lag screws), and two posteroanterior (PA) cannulated 3.5 mm lag screws (PA lag screws). PMF with 30% fragment size was simulated through computational processing reconstructed from computed tomography (CT). The simulated loads of 700 N and 1200 N were applied to the proximal tibial end. The FEM evaluated the syndesmosis dislocation (mm) and stress values of the posterior tibiofibular ligament (PTFL) (in Kpa) and deltoid ligament (in Kpa) in the four mentioned subgroups. We found that with a load of 700 N, syndesmosis dislocation varied from 6.5 to 7.9 mm, being the lowest and greatest for PA lag screw and PP 1 screw, respectively. In all groups was observed a greater dislocation in the syndesmosis at 1200 N of load. We observed that the stress values on the PTFL were lower for AP lag screws and PP 2 screws with 700 N and 1200 N, respectively. For both loads, PP 1 screw presented the greatest stress. Regarding the stress in the deltoid ligament, the AP lag screws presented the lowest stress for 700 N and PP 1 screw for 1200 N. For all fixation techniques, the syndesmosis displacement and ligament stresses were higher when 1200 N were imposed. This study demonstrated that PMF fixed with lag screws presents greater stability in the distal tibiofibular syndesmosis and higher joint loadings promoted greater displacement and ligaments stress, regardless of the fixation technique. Besides, lower stress in the syndesmosis is accompanied by a greater load on the deltoid ligament. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) with severe varus ankle deformity is balanced in the coronal plane by releasing medial soft tissue constraints. There are no previous reports examining the impacts of TAA with concomitant release of the deltoid. Progressive talar tilt and progressive collapsing foot deformity were evaluated. Methods: A retrospective review included patients undergoing TAA with confirmed preoperative varus deformity. Patients underwent complete soft tissue release of the deltoid ligament complex. Pre- and post-operative weightbearing radiographs quantified Meary's angle, lateral talo-1st metatarsal angle, calcaneal pitch, talar coronal alignment, and the lateral distal tibial angle. The primary endpoints were degrees of coronal plane correction, longitudinal arch position, and complication rates. Results: Thirty-two patients were included with median 12.5 month follow-up. Coronal plane alignment and VAS pain scores improved significantly in all patients, and statistical analysis revealed that complete deltoid ligament release had no bearing on calcaneal pitch and Meary's angle at final follow-up. Posterior tibial tenotomy was performed on 3 (9.3%) patients. Median coronal plane alignment correction averaged 17.5° improvement (X2(2)= 50.358, P<.001) from 19.5° varus (11.2-24.5°) to 2.0° varus (0.5- 3.5°)(P <.001). Two degrees of coronal plane varus alignment without tilt progression (0.6-3.4°)(P <.001) was maintained through follow-up. Final calcaneal pitch of 18.2° (14.4-23.2°) mirrored initial median measurement of 18.3° (15.7-21.1°). No significant differences were found between Meary's angle measurements at any time points (P=.568). Eight of 32 patients had complications with five requiring further ankle surgery. Conclusion: Complete release of the deltoid ligament may improve coronal malalignment when performing TAA. Release did not lead to radiographic or clinical medial instability, valgus talar tilt, or medial arch collapse. [ABSTRACT FROM AUTHOR]

Tibialis posterior tendon, deltoid ligament and spring ligament are the three most important structures on the medial aspect of the foot. They contribute to the stability of the foot and ankle and also to the maintenance of the arches of the foot. These structures get affected and dimensions get disrupted in various traumatic and degenerative conditions. Normal range of dimensions of these structures has not been studied in an Indian population. Our objective is to define the normal thicknesses of these structures using a cadaveric model. We also hypothesize that longer the foot, higher stresses on these structures and hence thicker they will be. We aim to assess this hypothesis as well. Dissection of the medial aspect of the foot was done on twenty cadaveric below knee specimens. Tibialis posterior tendon was identified and its thickness was measured. Deltoid and plantar calcaneonavicular ligaments were identified. Their lengths and thicknesses were measured. Length of the feet was also measured prior to dissection. Statistical analysis was done using the data obtained. Mean tibialis posterior thickness was 7.0165 ± 0.387 mm. Mean deltoid thickness was 5.124 ± 0.28 mm. Its mean length was 21.328 ± 2.22 mm. Mean plantarcalcaneonavicular ligament thickness was 2.491 ± 1.120 mm. Thicknesses of the tibialis posterior tendon and plantarcalcaneonavicular ligament correlated significantly with the length of the foot. The thicknesses of the tibialis posterior tendon and plantar calcaneonavicular ligament are shown to be a function of and significantly proportional to the length of the foot. This helps the surgeon to estimate the thicknesses which the structures had prior to the pathology, in order to recreate the non-pathological anatomy after a tendon transfer or a reconstruction procedure. The normal thicknesses of tibialis posterior, deltoid and plantar calcaneonavicular ligaments are described for an Indian setting and deviations can be used to assess various pathologies of the foot and ankle affecting these structures. [ABSTRACT FROM AUTHOR]