Isolated spring ligament failure as a cause of adult-acquired flatfoot deformity

2014 ◽  
Vol 12 (2) ◽  
pp. 120
Keyword(s):  
Spring Ligament ◽  
Ligament Failure ◽  
Adult Acquired Flatfoot Deformity

scholarly journals Predictors of Spring Ligament Degeneration and Outcomes of Reconstruction during Correction of Adult Acquired Flatfoot Deformity

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0039
Author(s):  
Steven M. Raikin ◽  
Ryan G. Rogero ◽  
Jared Raikin ◽  
Daniel Corr ◽  
Justin Tsai
Keyword(s):  
Regression Analysis ◽  
Multiple Logistic Regression Analysis ◽  
Functional Score ◽  
Tibialis Posterior ◽  
Foot And Ankle ◽  
Patient Age ◽  
Spring Ligament ◽  
Radiographic Parameters ◽  
Patient Âgé ◽  
Adult Acquired Flatfoot Deformity

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: It is currently unclear how injury to the spring ligament (SL) affects the preoperative presentation of adult acquired flatfoot deformity (AAFD). The purposes of this study were to retrospectively identify shared factors that could be used to preoperatively predict SL damage in patients undergoing AAFD correction as well as compare outcomes of patients undergoing SL reconstruction to those not undergoing reconstruction during AAFD correction. Methods: All patients undergoing operative correction of grade 2B AAFD secondary to tibialis posterior tendon dysfunction by a single fellowship-trained foot and ankle orthopaedic surgeon from 2011 to 2017 were reviewed. Operative reports were reviewed for the surgeon’s evaluation of the competency of the SL and to determine whether SL reconstruction was performed. Patient charts were reviewed for demographic information, preoperative Visual Analog Scale (VAS) pain level, and their Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and -Sports subscales. Preoperative radiographic parameters were assessed by a surgeon blinded to the intraoperative findings. Patient outcomes of VAS pain, FAAM-ADL, and FAAM-Sports were collected at a minimum of 24 months postoperatively. Multiple logistic regression analysis was performed to determine significant independent predictors of spring ligament tears. Results: The study included 115 feet undergoing corrective reconstruction, with 47 feet having a spring ligament tear (40.9%). Patients with tears were significantly older (p<0.001), with higher preoperative reported pain (p=0.01), and lower preoperative FAAM-ADL (p=0.04) and -Sports (p=0.006) scores than those without SL tears. Patients with a SLT demonstrated significant differences in AP talo-1st MT angle (p=.003), talonavicular uncoverage percentage (p<0.001), talonavicular angle (p=0.017), and Meary`s talo-1st MT angle (p=0.001). Based on multiple logistical regression analysis (odds ratio [95% confidence interval]), patient age (1.10 [1.03, 1.18]; p=0.003), talonavicular uncoverage percentage (1.35 [1.13, 1.60]; p<0.001), and talonavicular angle (0.82 [0.71, 0.96]; p=0.0133) were independently predictive of ligament degeneration. Patients undergoing SL reconstruction did not differ significantly in functional score improvements compared to those without reconstruction. Conclusion: Our findings suggest that a SLT is associated with more advanced flexible pes planovalgus, measured both by radiographic parameters as well as its impact on patient function. Increasing patient age, increasing talonavicular uncoverage percentage, and decreasing talonavicular angle are all independently associated with increased likelihood of patients with AAFD having a SLT. AAFD correction with concomitant SL reconstruction does not appear to influence absolute or changes in patient pain and function. [Table: see text]

Adult Acquired Flatfoot Deformity at the Talonavicular Joint: Reconstruction of the Spring Ligament in an in Vitro Model

Foot & Ankle ◽  
1992 ◽  
Vol 13 (6) ◽  
pp. 327-332 ◽  
Author(s):  
Jonathan T. Deland ◽  
Stephen P. Arnoczky ◽  
Francesca M. Thompson
Keyword(s):  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Joint Reconstruction ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Fresh Frozen ◽  
Adult Acquired Flatfoot Deformity ◽  
Vitro Model ◽  
Bone Autograft

The mobile unilateral flatfoot deformity of chronic posterior tibial tendon insufficiency has been difficult to correct by soft tissue procedures. The procedures can decrease pain, but they do not always correct the longitudinal arch or relieve all the symptoms. Using 10 fresh frozen cadaveric specimens and a rig for stimulation of weightbearing, the deformity associated with chronic posterior tibial tendon insufficiency was produced by multiple ligamentous release and documented by AP and lateral radiographs. Reconstruction of the spring ligament using a ligament bone autograft from the superficial deltoid ligament was then performed and tested under load. The mean correction was within 2.5° of normal (over or undercorrection) on both the AP and lateral radiographs with the specimens under load. Clinical Relevance. In posterior tibial tendon insufficiency, it may be possible to address the ligament as well as tendon insufficiency to gain a corrected arch. The success of such a procedure will depend upon adequate tendon and ligament reconstruction in a fully mobile deformity. Questions remain as to the adequacy of this ligament graft, and a stronger free ligament graft, as well as correction of any bony malalignment, may be required.

scholarly journals The Efficacy of Surgical Treatment in the Correction of Adult Acquired Flatfoot Deformity: A Three- dimensional Biometric Weightbearing Computed Tomography Evaluation

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0003
Author(s):  
Cesar de Cesar Netto ◽  
Jonathan Day ◽  
Alexandre L. Godoy-Santos ◽  
Jonathan H. Garfinkel ◽  
Chris Cychosz ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Ankle Joint ◽  
Surgical Procedures ◽  
Three Dimensional ◽  
Spring Ligament ◽  
Patient Reported ◽  
Significant Correction ◽  
Adult Acquired Flatfoot Deformity ◽  
The Mean

Category: Hindfoot; Ankle; Midfoot/Forefoot Introduction/Purpose: Multiple surgical techniques are used in the correction of Adult Acquired Flatfoot Deformity (AAFD). Assessment of the efficacy of a surgical treatment in the correction of the deformity is usually performed by clinical evaluation and conventional radiographic imaging. Weightbearing CT (WBCT) allows a more reliable and multiplanar evaluation of AAFD. The Foot and Ankle Offset (FAO) is a WBCT biometric semi-automatic measurement that gauges the relative positioning between the foot tripod and the center of the ankle joint. This study aimed to investigate the efficacy of surgical treatment in correcting AAFD, comparing preoperative and postoperative FAO measurements. We hypothesized that surgical treatment would provide significant correction of the deformity, centering the tripod of the foot underneath the ankle joint. Methods: In this prospective comparative study, 21 adult patients (22 feet) with flexible AAFD were included, mean age 55 (range, 23-81) years, 13 females and eight males. Patients underwent preoperative and postoperative standing WBCT examination. Three-dimensional coordinates (X, Y and Z planes) of the foot tripod (weightbearing point of the first and fifth metatarsals and calcaneal tuberosity) and center of the ankle (apex of the talar dome) were harvested by two independent and blinded observers. The FAO was automatically calculated from the harvested 3D coordinates by dedicated software. Data regarding the surgical technique used was recorded. Patient Reported Outcomes (PROs) were collected preoperatively and postoperatively at a mean follow-up of 22 (range, 8-36) months. Pre and postoperative FAO measurements were compared by paired T-tests. Multivariate analysis was used to assess the influence of surgical procedures in the amount of FAO correction. P-values of less than 0.05 were considered significant. Results: We found excellent intra (0.98) and interobserver reliability (0.96) for FAO measurements. The mean preoperative FAO was 10.4 (95% CI, 8.5 to 12.1). There was a significant correction of the deformity postoperatively (p<0.0001), with a mean postoperative FAO of 1.4 (CI, -0.1 to 2.9), and mean improvement of 8.9 (95% CI, 6.6 to 11.2). Average increase in PROs was (p<0.05): physical function (8; CI, 4 to 12), pain interference (10.3; CI, 4.8 to 15.9), pain intensity (5.3; CI, -10:20.6), mental health (4.2; CI, 0.2:8.2), physical health (4.3; CI, 0.9 to 9.8), and depression (10.4; CI, -0.6 to 21.4). The mean number of surgical procedures performed was 8 (range, 2-12). Spring ligament reconstruction was the only technique that influenced the amount of FAO correction (P<0.001). Conclusion: To the author’s knowledge, this is the first study to assess the amount of surgical correction of AAFD using standing WBCT images and semiautomatic 3D measurements. We found that surgical treatment provided a significant and pronounced amount of correction in the FAO, with the foot tripod more centered underneath the ankle joint. We also found a significant improvement in the PROMIS after an average postoperative follow-up of 22 months. Among multiple different surgical procedures performed, reconstruction of the spring ligament was the only technique that significantly influenced the amount of FAO correction. Longer-term follow-up studies are needed. [Figure: see text]

scholarly journals Short-Term Complications Following Early Protected Weight Bearing after Flatfoot Reconstruction when Utilizing a Fibertape Device for Spring Ligament Reefing Augmentation

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0029
Author(s):  
Morgan S. Kim ◽  
Emily Vannatta ◽  
Chris M. Stauch ◽  
Paul J. Juliano ◽  
Michael C. Aynardi ◽  
...  
Keyword(s):  
Weight Bearing ◽  
Radiographic Evaluation ◽  
Bony Union ◽  
Early Weight Bearing ◽  
First Metatarsal ◽  
Spring Ligament ◽  
Metatarsal Angle ◽  
Gastrocnemius Recession ◽  
Adult Acquired Flatfoot Deformity

Category: Ankle Introduction/Purpose: In an estimated 70% of cases of Adult Acquired Flatfoot Deformity (AAFD) reconstruction, the spring ligament is elongated and/or damaged. Spring ligament reefing can be performed through several techniques including augmentation with Fibertape devices. In addition, biomechanical studies have demonstrated its safety and suggest early weight bearing may be performed. The purpose of this study is to evaluate the outcomes of early weight bearing following flatfoot reconstruction with use of InternalBrace augmentation for spring ligament reefing when performed in combination with medical displacing calcaneal osteotomy (MCO) and FDL tendon transfer. Methods: From 2016-2018, 45 patients underwent flatfoot reconstruction (MCO, FDL transfer, and gastrocnemius recession) with spring ligament reefing and augmentation with the InternalBrace device. All surgeries were performed by the senior orthopaedic surgeons (PJJ & MCA). Institutional early post-operative weight bearing protocol involves weight bearing as tolerated in a splint with crutches for two weeks, transitioning at 2 weeks to a Cam boot with 1 wedge WBAT. At 4 weeks, the patient is weaned off crutches and recommended to start therapy restricting excessive eversion and concentrating on calf strengthening, gait, and ROM. At weeks 6-8 they are weaned from the Cam boot into lace up ASO and shoe with arch support. Data were recorded at 2 weeks, 6 weeks, 12 weeks, 6 months and at yearly intervals. Outcomes and complications were documented. Results: Of the 45 cases there were no complications related to early weight bearing. Radiographic bony union rate of the MCO was 100% (45/45). Moreover, there was no loss of fixation of either the FDL transfer or spring ligament reefing with InternalBrace augmentation with early weight bearing. Lastly, radiographic evaluation noted no loss of Meary’s talo-first metatarsal angle when comparing initial postoperative radiographic to their final follow up. Additional complications in our cohort included the following: removal of painful hardware (1, 2.22%), sural neuritis (2, 4.44%), superficial cellulitis (1, 4.44%), and delayed lateral wound healing (1, 2.22%). Conclusion: Preliminary data shows that early protected weight bearing after flatfoot reconstruction and augmentation of the spring ligament with the InternalBrace device is safe and demonstrates few complications and no early loss of correction.

Imaging of the Tibionavicular Ligament, and Its Potential Role in Adult Acquired Flatfoot Deformity

2018 ◽  
Vol 39 (5) ◽  
pp. 629-635 ◽  
Author(s):  
Neal Ormsby ◽  
Gillian Jackson ◽  
Paul Evans ◽  
Simon Platt
Keyword(s):  
High Signal ◽  
Posterior Tibial Tendon ◽  
Posterior Tibial Tendon Dysfunction ◽  
Level Of Evidence ◽  
Spring Ligament ◽  
Routine Magnetic Resonance Imaging ◽  
Prospective Comparative Study ◽  
Adult Acquired Flatfoot Deformity ◽  
The Mean ◽  
Magnetic Resonance Imaging Mri

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.

scholarly journals Outcomes after Tibiocalcaneonavicular Ligament Reconstruction in Stage IIB and Stage IV Adult Acquired Flatfoot Deformity

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0036
Author(s):  
Rusheel Nayak ◽  
Milap Patel ◽  
Anish R. Kadakia
Keyword(s):  
Patient Reported Outcomes ◽  
Stage Iv ◽  
Deltoid Ligament ◽  
First Metatarsal ◽  
Spring Ligament ◽  
Radiographic Outcomes ◽  
Radiographic Parameters ◽  
Metatarsal Angle ◽  
Patient Reported ◽  
Adult Acquired Flatfoot Deformity

Category: Hindfoot; Ankle; Midfoot/Forefoot Introduction/Purpose: The tibiocalcaneonavicular ligament (TCNL) is formed from the confluence of the superficial deltoid ligament and the superomedial spring ligament. In advanced flexible adult acquired flatfoot deformity (AAFD), progressive strain on the TCNL can lead to spring ligament tears, deltoid insufficiency, and eventual medial peritalar instability. Historically, medial peritalar instability was corrected using calcaneal osteotomy in conjunction with isolated spring or deltoid reconstruction. A recent study (Brodell et al.) demonstrated the efficacy of TCNL reconstruction in patients with medial peritalar instability. The purpose of this study is to add to this literature using patient-reported and radiographic outcomes in patients undergoing TCNL reconstruction. Patient-reported outcomes were collected using Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Methods: Sixteen patients (mean age 50.25 years; 11 female, 5 male) who underwent TCNL reconstruction were prospectively identified. TCNL reconstruction was indicated for stage IIB patients (n=13) with large spring ligament tears (>1.5cm on MRI or intraoperatively) or if osseous correction did not provide adequate talonavicular joint correction. TCNL reconstruction was indicated in stage IV patients (n=3) if deltoid reconstruction required additional medial stabilization. No patients underwent lateral column lengthening osteotomies. PROMIS scores were obtained at baseline and at minimum 12-months follow-up (average 16 months). Surgical success was determined using minimum clinically important differences (MCID), defined as improvement greater than one-half the standard deviation of each pre-operative PROMIS domain (PF: +2.9 and PI: -2.5). Pre- and post-operative radiographic parameters were measured: talonavicular uncoverage angle, talonavicular uncoverage percentage, AP talo-first metatarsal angle, Meary’s angle, and medial cuneiform height (MCH). Correlation coefficients determined the relationship between radiographic parameters and PROMIS scores. Results: PROMIS PF scores improved significantly from 38.1+-5.8 to 44.1+-7.1 (p=0.0087). PROMIS PI scores improved significantly from 62.9+-5.1 to 52.3+-8.9 (p=0.0025). Seventy-nine and 77 percent of patients had successful surgeries, as defined by MCIDs in the PROMIS PF and PI domains, respectively. Talonavicular uncoverage percentage and Meary’s angle improved significantly from 34.4+-13.4 to 26.3+-9.9 percent (p=0.0360) and 19.2+-8.8 to 15.3+-6.2 degrees (p=0.0089), respectively. Talonavicular uncoverage angle improved from 29.3+-9.6 to 23.3+-8.0 degrees (p=0.0562), AP talo-first metatarsal angle improved from 15.2+-10.2 to 10.4+-9.0 degrees (p=0.0555), and MCH improved from 13.5+-6.2 to 15.9+-4.8 millimeters (p=0.1374). Post- operative MCH correlated significantly with post-operative PROMIS PF scores (r=0.5941; p=0.0152). Change in AP talo-first metatarsal angle correlated significantly with change in PROMIS PI scores (r=0.5682; p=0.0427). No other correlations were significant. Conclusion: Patients with stage IIB and stage IV AAFD who undergo TCNL reconstructions have excellent patient-reported and radiographic outcomes. Reconstruction of the medial longitudinal arch, as measured by post-operative MCH, is associated with higher post-operative functionality. Surgical correction of midfoot abduction, as measured by change in the AP talo-first metatarsal angle after surgery, is associated with improvements in pain. In patients with medial peritalar instability, TCNL reconstruction can be a valuable technique to correct the sagittal arch, prevent excessive midfoot abduction, and improve pain and functionality.

Peritalar Kinematics With Combined Deltoid-Spring Ligament Reconstruction in Simulated Advanced Adult Acquired Flatfoot Deformity

2020 ◽  
Vol 41 (9) ◽  
pp. 1149-1157
Author(s):  
Ashlee MacDonald ◽  
David Ciufo ◽  
Eric Vess ◽  
Emma Knapp ◽  
Hani A. Awad ◽  
...  
Keyword(s):  
Ligament Reconstruction ◽  
Axial Loading ◽  
Stage Iv ◽  
Valgus Deformity ◽  
Deltoid Ligament ◽  
Camera Motion ◽  
Ligament Tear ◽  
Spring Ligament ◽  
Reconstruction Methods ◽  
Adult Acquired Flatfoot Deformity

Background: Adult acquired flatfoot deformity (AAFD) is a complex and progressive deformity involving the ligamentous structures of the medial peritalar joints. Recent anatomic studies demonstrated that the spring and deltoid ligaments form a greater medial ligament complex, the tibiocalcaneonavicular ligament (TCNL), which provides medial stability to the talonavicular, subtalar, and tibiotalar joints. The aim of this study was to assess the biomechanical effect of a spring ligament tear on the peritalar stability. The secondary aim was to assess the effect of TCNL reconstruction in restoration of peritalar stability in comparison with other medial stabilization procedures, anatomic spring or deltoid ligament reconstructions, in a cadaveric flatfoot model. Methods: Ten fresh-frozen cadaveric foot specimens were used. Reflective markers were mounted on the tibia, talus, navicular, calcaneus, and first metatarsal. Peritalar joint kinematics were captured by a multiple-camera motion capture system. Mild, moderate, and severe flatfoot models were created by sequential sectioning of medial capsuloligament complex followed by cyclic axial loading. Spring only, deltoid only, and combined deltoid-spring ligament (TCNL) reconstructions were performed. The relative kinematic changes were compared using 2-way analysis of variance (ANOVA). Results: Compared with the initial condition, we noted significantly increased valgus alignment of the subtalar joint of 5.1 ± 2.3 degrees ( P = .031) and 5.8 ± 2.7 degrees ( P < .01) with increased size of the spring ligament tear to create moderate to severe flatfoot, respectively. We noted an increased tibiotalar valgus angle of 5.1 ± 2.0 degrees ( P = .03) in the severe model. Although all medial ligament reconstruction methods were able to correct forefoot abduction, the TCNL reconstruction was able to correct both the subtalar and tibiotalar valgus deformity ( P = .04 and P = .02, respectively). Conclusion: The TCNL complex provided stability to the talonavicular, subtalar, and tibiotalar joints. The combined deltoid-spring ligament (TCNL) reconstructions restored peritalar kinematics better than isolated spring or deltoid ligament reconstruction in the severe AAFD model. Clinical Relevance: The combined deltoid-spring ligament (TCNL) reconstruction maybe considered in advanced AAFD with medial peritalar instability: stage IIB with a large spring ligament tear or stage IV.

Patient Specific Modeling of a Stage II Flatfoot Population

2013 ◽  
Author(s):  
Edward M. Spratley ◽  
Erika A. Matheis ◽  
Curtis W. Hayes ◽  
Robert S. Adelaar ◽  
Jennifer S. Wayne
Keyword(s):  
Patient Specific ◽  
Mechanical Degradation ◽  
Spring Ligament ◽  
Kinematic Models ◽  
Foot Function ◽  
Anterior Deltoid ◽  
Body Kinematic ◽  
Adult Acquired Flatfoot Deformity ◽  
Patient Specific Modeling ◽  
Specific Modeling

Adult Acquired Flatfoot Deformity (AAFD) is a degenerative disease characterized by chronic changes in the joint alignment of the bones of the foot leading to significant pain and dysfunction. The hallmark of this disease is the functional loss in posterior tibialis tendon (PTT) strength though mechanical degradation of passive support structures of the foot have also been implicated, namely the spring ligament, talocalcaneal interosseous ligaments, fibers of the anterior deltoid, and the long and short plantar ligaments. [1] Clinically, AAFD patients present with midfoot collapse, forefoot abduction, and valgus tilting of the hindfoot and the magnitudes of these deformities are most often graded using plane radiographs in the mediolateral (ML), oblique anteroposterior (AP) and posteroanterior (PA) views. [1–3] The objective of this study was to develop a population of patient-matched rigid-body kinematic models using a standardized methodology that can be used to predict pathologic foot function with agreement between patient and model assessed through clinically relevant radiographic joint angles.

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