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.

scholarly journals Tibiocalcaneonavicular Ligament Reconstruction in Simulated Flatfoot Deformity with Medial Ligament Insufficiency

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0032
Author(s):  
Ashlee MacDonald ◽  
David Ciufo ◽  
Emma Knapp ◽  
Hani Awad ◽  
John Ketz ◽  
...  
Keyword(s):  
Ligament Reconstruction ◽  
Reaction Force ◽  
Abduction Angle ◽  
Deltoid Ligament ◽  
Reconstruction Technique ◽  
Advanced Stage ◽  
Interosseous Ligament ◽  
Ligament Tear ◽  
Spring Ligament ◽  
Bone Tunnels

Category: Hindfoot Introduction/Purpose: Spring ligament tear is often present in advanced stages of the AAFD. Anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament to provide medial tibiotalar and talonavicular stability. Reconstruction of combined deltoid-spring ligament, or the Tibiocalcaneonvaicular ligament (TCNL) was proposed to augment medial stability in advanced AAFD with large spring ligament tears. A tendon allograft is placed to cross three peritalar (tibiotalar, talonavicular and subtalar) joints to augment medial stability. We aimed to 1) investigate the kinematic effects of TCNL reconstruction in cadaveric flatfoot model with medial ligament insufficiency, and 2) compare TCNL reconstruction with anatomic spring and anatomic deltoid ligament reconstructions (Figure 1). We hypothesized that TCNL reconstruction is effective in restoring peritalar kinematics. Methods: Five fresh-frozen cadaveric foot specimens were employed. Advanced stage flatfoot model was created by sectioning the medial and inferior talonavicular interosseous ligament and extending the release 2 cm proximally along the superomedial spring ligament. Cyclic axial load of 1150 N under a hydraulic loading frame with constant 350 N Achilles tendon load were applied until >15° talo-first metatarsal abduction was achieved. Bone tunnels were drilled for three reconstruction types, and the peroneus longus tendon was configured to reconstruct the 1) anatomic spring ligament, 2) anatomic deltoid ligament, and 3) TCNL. Reflective markers were mounted on the tibia, talus, navicula, calcaneus and first metatarsus. Each reconstruction type was loaded with 800 N ground reaction force, and kinematics of the peritalar joints were captured by 4-camera motion capture system. Forefoot abduction angle, Meary’s angle, and hindfoot valgus were calculated and compared to the severe flatfoot prior to reconstruction and to each using two-way ANOVA. Results: In creating the flatfoot deformity, both the tibiotalar and subtalar joints demonstrated an increase in valgus deformity by 5.6+3.7° and 6.1+5.3°, respectively, compared to the initial measurements. When comparing to the flatfoot deformity, the TCNL reconstruction achieved a significant improvement in percent correction of total hindfoot valgus (59.7+21.1%, p=0.017) and forefoot abduction angle (83.4+17.7%, p<0.01). The spring ligament reconstruction also demonstrated a significant improvement in forefoot abduction correction compared to the flatfoot (52+10.6%, p<0.05). No other reconstruction technique achieved a statistically significant improvement in percent correction compared to the flatfoot model in forefoot or hindfoot alignments. Additionally, no statistical differences were noted in the percent correction when comparing the three reconstructive techniques to each other. Conclusion: In advanced stage cadaveric flatfoot with spring ligament tear, we found increased valgus alignment at both the tibiotalar and subtalar joints. This kinematic changes reflects increased strain across the medial peritalar ligaments. The deltoid-spring ligament complex (TCNL) reconstruction demonstrated significantly improved alignment of hindfoot valgus and forefoot abduction compared to the severe flatfoot condition. This finding suggests that in addition to osseous correction and tendon transfer, the TCNL reconstruction may serve as an important component in augmenting medial stability in advanced AAFD with medial ligament insufficiency.

Indications for Deltoid and Spring Ligament Reconstruction in Progressive Collapsing Foot Deformity

2020 ◽  
Vol 41 (10) ◽  
pp. 1302-1306
Author(s):  
Jonathan T. Deland ◽  
Scott J. Ellis ◽  
Jonathan Day ◽  
Cesar de Cesar Netto ◽  
Beat Hintermann ◽  
...  
Keyword(s):  
Ligament Reconstruction ◽  
Joint Space ◽  
Valgus Deformity ◽  
Deltoid Ligament ◽  
Soft Tissue Reconstruction ◽  
Foot Deformity ◽  
Level Of Evidence ◽  
Lateral Column ◽  
Spring Ligament ◽  
Tissue Reconstruction

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.

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.

scholarly journals Deltoid-Spring Ligament Reconstruction in Stage IIB Adult Acquired Flatfoot Deformity with Spring Ligament Tear

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0037
Author(s):  
Irvin Oh ◽  
Ashlee MacDonald ◽  
Tochukwu Ikepeze ◽  
Jonathan Deland
Keyword(s):  
Computerized Adaptive Testing ◽  
Pain Patient ◽  
Deltoid Ligament ◽  
Advanced Stage ◽  
The Novel ◽  
Ligament Tear ◽  
Spring Ligament ◽  
Radiographic Outcomes ◽  
Sf 36 ◽  
Adult Acquired Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: Spring ligament tear is often present in advanced stages of the Adult Acquired Flatfoot Deformity (AAFD). Previous anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament to provide both medial tibiotalar and talonavicular stability. They form a large confluent ligament, the tibiocalcaneonavicular ligament, (TCNL) which is the most consistently found component of the deltoid ligament. For surgical reconstruction of advanced stage AAFD with large spring ligament tears, adding allograft TCNL reconstruction to osseous correction has suggested to augment medial peritalar stability. We aimed to investigate the clinical and radiographic outcomes of the novel TCNL reconstruction for stage IIB AAFD with spring ligament tear. Methods: Twelve feet in 11 patients (7 female, 4 male, mean age 56.1 years) who underwent osseous correction and TCNL reconstruction for stage IIB AAFD were employed. TCNL reconstruction was indicated in the presence of large spring ligament tears (1.5-3 cm) and when inadequate reduction remained after osseous corrections. All 12 feet underwent gastrocnemius recession, medializing calcaneal osteotomy, lateral column lengthening and Cotton or Lapidus procedures. Bone tunnels were made in the tibia (7 mm), sustetaculum tali (6 mm) and navicular (6 mm) for tendon allograft passage for TCNL reconstruction (Figure 1). Subjects were evaluated at mean of 24 months (range, 12-33 months) after surgery. Pre- and post-operative clinical outcomes were assessed by administrating FAAM_ADL, SF-36 PF and Pain, Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) domains using Computerized Adaptive Testing. Correction of forefoot abduction and sagittal arch were measured from weight bearing radiographs of the foot. Results: The FAAM_ADL improved from 69.3 to 90.1 (p = 0.001). SF-36 PF and Pain subscales both improved significantly (39.4 to 87.8, 44.6 to 93.1, respectively, p <0.001 for each). PROMIS PF improved from 38.2 to 46.8 (p = 0.002) and PI 62.6 to 50.1 (p = 0.003). All but one patient were satisfied with the result. Radiographic measures showed improved AP talo-first metatarsal angle of 24.7° to 11.8° (p < 0.001) and talonavicular coverage angle of 47.4° to 23.1° (p <0.01). The talar head uncoverage improved from 56.1% to 32.5% (p < 0.01). Improved Meary’s angle of 29.7° to 12.5° (P < 0.001) and calcaneal pitch angle of 11.7° to 16.9° (p = 0.14) were noted in the lateral view. Conclusion: The current study demonstrates that TCNL reconstruction is a viable surgical treatment option for augmentation of medial peritalar stability in advanced stage AAFD with spring ligament tear. This is the first short term clinical investigation to report the clinical and radiographic outcomes of the novel TCNL reconstruction. Considering the anatomic characteristic of the deltoid-spring ligament complex, the TCNL reconstruction may play a significant role in maintaining surgical correction of deformity.

Stage IV Adult-Acquired Flatfoot Deformity Deltoid Ligament Reconstruction

2010 ◽  
Vol 20 (3) ◽  
pp. 183-189 ◽  
Author(s):  
Benjamin R. Williams ◽  
Scott J. Ellis ◽  
Joseph C. Yu ◽  
Jonathan T. Deland
Keyword(s):  
Ligament Reconstruction ◽  
Stage Iv ◽  
Deltoid Ligament ◽  
Adult Acquired Flatfoot Deformity

scholarly journals Adult-Acquired Flatfoot Deformity

2019 ◽  
Vol 4 (1) ◽  
pp. 247301141882084 ◽  
Author(s):  
Jensen K. Henry ◽  
Rachel Shakked ◽  
Scott J. Ellis
Keyword(s):  
Wide Spectrum ◽  
Stage Iv ◽  
Ankle Arthrodesis ◽  
Nonoperative Treatment ◽  
Treatment Modalities ◽  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Triple Arthrodesis ◽  
Wide Range ◽  
Adult Acquired Flatfoot Deformity

Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.

scholarly journals Ankle and syndesmosis instability: consensus and controversies

2021 ◽  
Vol 6 (6) ◽  
pp. 420-431
Author(s):  
Nuno Corte-Real ◽  
João Caetano
Keyword(s):  
Surgical Treatment ◽  
Ankle Instability ◽  
Valgus Deformity ◽  
Diagnosis And Treatment ◽  
Deltoid Ligament ◽  
Ankle Sprains ◽  
Ankle Osteoarthritis ◽  
Permanent Disability ◽  
Spring Ligament ◽  
Repair Techniques

Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance. In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment. Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery. Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions. Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions. Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging. Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017

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 Intermediate to Long-Term Clinical and Radiographic Results of Deltoid Ligament Reconstruction with Tendon Graft

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0018
Author(s):  
Jonathan H. Garfinkel ◽  
Cesar de Cesar Netto ◽  
Harry G. Greditzer ◽  
Andrew Roney ◽  
Carolyn M. Sofka ◽  
...  
Keyword(s):  
Ligament Reconstruction ◽  
Stage Iv ◽  
Tendon Graft ◽  
Deltoid Ligament ◽  
Foot And Ankle ◽  
Ankle Arthritis ◽  
Radiographic Outcomes ◽  
Talar Tilt

Category: Ankle, Hindfoot, Flatfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a complex deformity characterized by hindfoot valgus, medial longitudinal arch collapse, midfoot abduction, and forefoot supination. In its most advanced stages (stage IV), the deltoid ligament is compromised, which leads to valgus talar tilt at the tibiotalar joint. This talar tilt puts patients at high risk of developing ankle arthritis necessitating ankle arthrodesis or arthroplasty. Tendon graft reconstruction of the deltoid ligament has previously demonstrated good clinical and radiographic outcomes at short to intermediate-term follow-up but controversy over efficacy of the procedure remains. The goal of the current study was to present the intermediate to long-term clinical and radiographic outcomes of the largest series to date of patients undergoing this procedure. Methods: Data from a prospectively collected Foot and Ankle Registry was reviewed. All consecutive patients undergoing deltoid ligament reconstruction with tendon allograft or autograft as part of their flatfoot surgery by the senior author prior to 1/1/2015 were eligible for inclusion. Patients with radiographic follow-up of <3 years were asked to return for follow-up under an IRB- approved study protocol. Patients missing preoperative radiographs or unable to complete follow-up were excluded from radiographic analysis. Measurements of talar tilt were performed on AP ankle x-rays by two observers (Figure 1). Reliability analysis was performed using intraclass correlation. Preoperative Foot and Ankle Outcome Scores (FAOS) were obtained from the registry. Patients were contacted to complete postoperative FAOS and PROMIS surveys. Paired t-tests were used to evaluate changes in talar tilt and clinical outcomes. P-values of less than 0.05 were considered significant. Results: 35 feet/34 patients were eligible. Two feet/patients failed treatment (one ankle fusion, one deep infection and amputation). Three patients were deceased, two unable to follow-up due to unrelated medical problems, one missing preoperative imaging, and five unwilling to return for long-term follow-up. None of these patients failed treatment at last follow-up. 21 feet/20 patients (7/7 female) underwent radiographic analysis. Mean age at surgery was 58.4 (43.8-80.9) years. Interobserver agreement assessing change in talar tilt was excellent (ICC=.892). At mean radiographic follow-up of 10.3 (4.1-18.3) years, talar tilt improved significantly from an average of 9.71 +/- 6.22 degrees preoperatively to 3.63 +/- 3.27 degrees valgus postoperatively (p<.001). All FAOS subscores improved significantly pre to postoperatively. Postoperative PROMIS scores were comparable to or better than population means. Conclusion: Our findings demonstrate that deltoid ligament reconstruction with tendon graft enables radiographic correction, though not always complete, in patients with stage IV AAFD over the medium to long-term. Although limited by the sample size, our study demonstrates overall good clinical outcomes with few treatment failures. Though accessory procedures performed routinely at the time of flatfoot reconstruction present possible confounding variables, untreated ankle valgus likely leads to worsening deformity and ankle arthritis. Although the correction is not necessarily full, surgical reconstruction of the ligament may preclude patients from requiring joint sacrificing procedures such as ankle fusion or replacement over the long-term.

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