Peritalar Kinematic Changes Associated with Increased Spring Ligament Tear in Cadaveric Flatfoot Model

Category: Hindfoot Introduction/Purpose: Adult Acquired Flatfoot Deformity (AAFD) is a complex and progressive deformity characterized by abduction of the midfoot and valgus alignment of the hindfoot. Spring ligament tear is often present in advanced stages of the 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 aiding in coronal plane stability. Given that the spring ligament blends with the superficial deltoid ligament, we sought to investigate the kinematic effect of spring ligament tear in development of peritalar instability in cadaveric flatfoot model. We hypothesized that increased spring ligament tear size will result in increased talonavicular joint abduction (axial) and plantarflexion (sagittal), and increased valgus alignment of the tibiotalar and subtalar joints (coronal). Methods: Seven fresh-frozen cadaveric foot specimens were employed. Reflective markers were mounted on the tibia, talus, navicula, calcaneus and the first metatarsus. Kinematics of the peritalar joints were captured by multiple camera motion capture system. A flatfoot model was created by sectioning the medial and inferior talonavicular interosseous ligament, followed by cyclic axial load of 1150 N under a hydraulic loading frame with 350 N load applied to the Achilles tendon. The talo-first metatarsus (T- 1MT) abduction angle was calculated and cycles were applied until abduction of 5-10° (mild flatfoot) was achieved. Spring ligament sectioning was extended 1 cm proximally along the superomedial ligament followed by cyclic loading until 10-15° (moderate) of T- 1MT abduction was achieved. The spring ligament was sectioned for another 1 cm followed by cyclic loading until >15° (severe) abduction was noted. The relative kinematic changes were compared among the initial, mild, moderate, and severe flatfoot model using two-way ANOVA. Results: The average T-1MT abduction angles in the mild, moderate, and severe flatfoot were 7.79°+/-2.27°, 11.47°+/-2.82°, and 15.46°+4.15°. Meary’s angle increased with progression of the flatfoot (mild 6.17°+/-2.92°, moderate 9.71°+/-3.4°, severe 12.46°+/-4.13°). Hindfoot valgus angle also increased. The mild, moderate, and severe flatfoot showed 2.4°+/-3.85°, 4.13°+/-3.9°, and 4.75°+/-3.79° of tibiotalar valgus angle. The subtalar joint exhibited 2.94°+/-3.41°, 5.52°+/-4.34°, and 6.97°+/-4.83° valgus angle in the mild, moderate, and severe models. The T-1MT abduction angle and Meary’s angle were significantly different in all flatfoot models compared to the initial condition (p<0.001), and the severe vs. mild models (p<0.01). Tibiotalar valgus was significantly increased in severe compared to the initial model (p=0.02). Subtalar valgus angle significantly increased in the moderate and severe models compared to the initial (p<0.01, p<0.001). Conclusion: Serial increment in spring ligament tear size in simulated flatfoot increased relative talus adduction and plantarflexion. It also resulted in gradual increment of valgus alignment of the tibiotalar and subtalar joints in coronal plane. This finding demonstrates that a large spring ligament tear in advanced stage AAFD leads to increased strain across the medial peritalar ligaments. In addition to osseous correction and tendon transfer, medial ligament augmentation, may be a critical component in surgical correction of AAFD with a large spring ligament tear.

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Tibiocalcaneonavicular Ligament Reconstruction in Simulated Flatfoot Deformity with Medial Ligament Insufficiency

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00327 ◽

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.

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Stability of the Arch of the Foot

Foot & Ankle International ◽

10.1177/107110079701801008 ◽

1997 ◽

Vol 18 (10) ◽

pp. 644-648 ◽

Cited By ~ 57

Author(s):

Harold B. Kitaoka ◽

Tae-Kun Ahn ◽

Zong Ping Luo ◽

Kai-Nan An

Keyword(s):

Three Dimensional ◽

Deltoid Ligament ◽

Interosseous Ligament ◽

Magnetic Tracking ◽

Human Foot ◽

Spring Ligament ◽

Tarsal Bones ◽

Before And After ◽

Fresh Frozen ◽

Tracking Device

We defined the relative contributions of six ligaments in stabilizing the arch of the foot: plantar aponeurosis, long-short plantar ligaments, plantar calcaneonavicular ligament (spring ligament), medial talocalcaneal ligament, talocalcaneal interosseous ligament, and tibionavicular portion of the deltoid ligament. Nineteen fresh-frozen human foot specimens were used. A load of 445 N was applied axially to simulate standing-at-ease posture. Three-dimensional positions of tarsal bones before and after ligament sectioning were determined with the use of a magnetic tracking device. The motions were presented in the form of screw axis displacements, quantitating rotation, and axis of rotation orientation. After sectioning one structure, the arch did not collapse on any specimen and there was no obvious change by visual inspection. There were, however, measurable changes in tarsal bone position. Metatarsal-to-talus total rotation difference was greatest with spring ligament and deltoid ligament sectioning, with an average of 2.1° ± 1.7° and 2.0° ± 0.2° difference, respectively. Calcaneus-to-talus rotation difference was greatest with talocalcaneal interosseous ligament sectioning, with an average of 1.7° ± 1.5°. The spring ligament, deltoid ligament, and talocalcaneal interosseous ligament were most important for arch stability.

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Arthroscopic Characterization of Syndesmotic Instability

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00002 ◽

2018 ◽

Vol 3 (2) ◽

pp. 2473011418S0000

Author(s):

Mohamed Abdelaziz ◽

Jafet Massri-Pugin ◽

Bart Lubberts ◽

Bryan Vopat ◽

Daniel Guss ◽

...

Keyword(s):

Confidence Interval ◽

Stress Test ◽

Ankle Arthroscopy ◽

Coronal Plane ◽

Ligament Injury ◽

Deltoid Ligament ◽

Interosseous Ligament ◽

P Values ◽

Intact State ◽

Lateral Incision

Category: Arthroscopy, Sports, Trauma, Other, Syndesmosis Introduction/Purpose: Ankle arthroscopy is increasingly used to diagnose syndesmostic instability by visualizing the distal tibiofibular articulation and applying a lateral fibular stress. Precisely where in the incisura one should measure potential diastasis, however, remains unclear. The purpose of this study was to determine where within the incisura one should assess coronal plane instability in purely ligamentous syndesmotic injuries when performing a lateral hook stress test (LHT). Methods: Twenty-two above-knee cadaveric specimens underwent ankle arthroscopy, first with intact ligaments and thereafter after each sequential step of syndesmotic and deltoid ligament transection. At each step, a standard 100 N hook test was applied through a lateral incision 5 cm proximal to the ankle joint and the coronal plane diastasis in the stressed and unstressed states were measured at both anterior and posterior third of the distal tibiofibular joint using calibrated probes ranged from 0.1 to 6.0 mm, with 0.1 mm of increments. Results: Anterior third diastasis did not change significantly when applying a LHT, neither in the intact state nor after any stage of ligament transection (P values ranging from p=0.61 to p=0.94). In contrast, posterior third diastasis increased significantly by applying stress at the intact state at the following stages of transection: posterior-inferior tibiofibular ligament (PITFL), PITFL plus interosseous ligament, all syndesmosis ligaments, and all syndesmosis ligaments plus superficial and deep deltoid ligament (P values ranging p=0.001 to p=0.031). Interobserver agreement was substantial (ICC = 0.81; 95% confidence interval, 0.44-0.92), and moderate (ICC = 0.73; 95% confidence interval, 0.36-0.87) for anterior and posterior third diastasis measurements, respectively. Conclusion: Syndesmotic ligament injury results in coronal plane instability of the distal tibiofibular articulation that is readily identified arthroscopically with a LHT and when measured in the posterior third of the incisura. Measurement at the anterior third of the incisura may miss such injuries.

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

Foot & Ankle International ◽

10.1177/1071100720929004 ◽

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.

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Do Coronal or Sagittal Plane Measurements Have the Highest Accuracy to Arthroscopically Diagnose Syndesmotic Instability?

Foot & Ankle International ◽

10.1177/10711007211004151 ◽

2021 ◽

pp. 107110072110041

Author(s):

Rohan Bhimani ◽

Bart Lubberts ◽

Pongpanot Sornsakrin ◽

Jafet Massri-Pugin ◽

Gregory Waryasz ◽

...

Keyword(s):

Operating Characteristic ◽

Sagittal Plane ◽

Area Under The Curve ◽

Coronal Plane ◽

Deltoid Ligament ◽

Roc Curve Analysis ◽

Level Of Evidence ◽

Interosseous Ligament ◽

Tibiofibular Ligament ◽

Anterior Inferior Tibiofibular Ligament

Background: To compare the accuracy of arthroscopic sagittal versus coronal plane distal tibiofibular motion toward diagnosing syndesmotic instability. Methods: Arthroscopic assessment of the syndesmosis was performed on 21 above-knee cadaveric specimens, first with all ligaments intact and subsequently with sequential transection of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and the deltoid ligament. A lateral hook test, an anterior-to-posterior (AP) translation test, and a posterior-to-anterior (PA) translation test were performed under 100 N of applied force. Anterior and posterior third coronal plane diastasis and AP and PA sagittal plane fibular translations were measured relative to the static tibia. Results: Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) was higher for the combined AP and PA sagittal measurements (AUC, 0.91; accuracy, 83.5%; sensitivity, 78%; specificity, 89%) than the coronal plane measurements (anterior third: AUC, 0.65; accuracy, 60.5%; sensitivity, 63%; specificity, 59%; posterior third: AUC, 0.73; accuracy, 68.5%; sensitivity, 80%; specificity, 57%) ( P < .001), underscoring the higher accuracy of sagittal plane measurements. Conclusion: Arthroscopic measurement of sagittal plane fibular translation is more accurate than coronal plane diastasis for evaluating syndesmotic instability. Clinical Relevance: Clinicians should focus on distal tibiofibular motion in the sagittal plane when arthroscopically evaluating suspected syndesmotic instability. Level of Evidence: Biomechanical cadaveric study.

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00372 ◽

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.

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Role of the Deltoid Ligament in Syndesmotic Instability

Foot & Ankle International ◽

10.1177/1071100717750577 ◽

2018 ◽

Vol 39 (5) ◽

pp. 598-603 ◽

Cited By ~ 16

Author(s):

Jafet Massri-Pugin ◽

Bart Lubberts ◽

Bryan G. Vopat ◽

Jonathon C. Wolf ◽

Christopher W. DiGiovanni ◽

...

Keyword(s):

Lateral Force ◽

Coronal Plane ◽

Deltoid Ligament ◽

Lateral Stress ◽

Interosseous Ligament ◽

Intact State ◽

Tibiofibular Ligament ◽

Anterior Inferior Tibiofibular Ligament ◽

Cadaveric Model

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).

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Posterior Tibial Tendon Insufficiency: Which Ligaments are Involved?

Foot & Ankle International ◽

10.1177/107110070502600601 ◽

2005 ◽

Vol 26 (6) ◽

pp. 427-435 ◽

Cited By ~ 154

Author(s):

Jonathan T. Deland ◽

Richard J. de Asla ◽

Il-Hoon Sung ◽

Lauren A. Ernberg ◽

Hollis G. Potter

Keyword(s):

Progressive Failure ◽

Plantar Fascia ◽

Control Group ◽

Deltoid Ligament ◽

Posterior Tibial Tendon ◽

Cross Sectional ◽

Interosseous Ligament ◽

Posterior Tibial ◽

Spring Ligament ◽

Magnetic Resonance Imaging Mri

Background: The pathology manifested in posterior tibial tendon insufficiency (PTTI) is not limited to the posterior tibial tendon. The association of ligament failure with deformity has been discussed in numerous publications, but extensive documentation of the structures involved has not been performed. The purpose of this observational study was to identify the pattern of ligament involvement using standarized, high-resolution magnetic resonance imaging (MRI) in a series of 31 consecutive patients diagnosed with PTTI compared to an age matched control group without PTTI. Method: The structures evaluated by MRI were the posterior tibial tendon, superomedial and inferomedial components of the spring ligament complex, talocalcaneal interosseous ligament, long and short plantar ligaments, plantar fascia, deltoid ligament, plantar naviculocuneiform ligament, and tarsometatarsal ligaments. Structural derangement was graded on a five-part scale (0 to IV) with level 0 being normal and level IV indicating a tear of more than 50% of the cross-sectional area of the ligament. Standard flatfoot measurements taken from preoperative plain standing radiographs were correlated with the MRI grading system. Results: Statistically significant differences in frequency of pathology in the PTTI group and controls were found for the superomedial calcaneonavicular ligament ( p < 0.0001), inferomedial calcaneonavicular ligament ( p < 0.0001), interosseous ligament ( p = 0.0009), anterior component of the superficial deltoid ( p < 0.0001), plantar metatarsal ligaments ( p = 0.0002) and plantar naviculocuneiform ligament ( p = 0.0006). The ligaments with the most severe involvement were the spring ligament complex (superomedial and inferomedial calcaneonavicular ligaments) and the talocalcaneal interosseous ligament. Conclusion: Ligament involvement is extensive in PTTI, and the spring ligament complex is the most frequently affected. Because ligament pathology in PTTI is nearly as common as posterior tibial tendinopathy, treatment should seek to protect or prevent progressive failure of these ligaments.

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A Comparison of Knee Abduction Angles Measured by a 3D Anatomic Coordinate System Versus Videographic Analysis: Implications for Anterior Cruciate Ligament Injury

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118819831 ◽

2019 ◽

Vol 7 (1) ◽

pp. 232596711881983 ◽

Cited By ~ 2

Author(s):

Zoë A. Englander ◽

Hattie C. Cutcliffe ◽

Gangadhar M. Utturkar ◽

William E. Garrett ◽

Charles E. Spritzer ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Coordinate System ◽

Cruciate Ligament ◽

Acl Injury ◽

Magnetic Resonance Images ◽

Coronal Plane ◽

Ligament Injury ◽

Abduction Angle ◽

Knee Abduction ◽

Anterior Cruciate

Background: Knee positions involved in noncontact anterior cruciate ligament (ACL) injury have been studied via analysis of injury videos. Positions of high ACL strain have been identified in vivo. These methods have supported different hypotheses regarding the role of knee abduction in ACL injury. Purpose/Hypothesis: The purpose of this study was to compare knee abduction angles measured by 2 methods: using a 3-dimensional (3D) coordinate system based on anatomic features of the bones versus simulated 2-dimensional (2D) videographic analysis. We hypothesized that knee abduction angles measured in a 2D videographic analysis would differ from those measured from 3D bone anatomic features and that videographic knee abduction angles would depend on flexion angle and on the position of the camera relative to the patient. Study Design: Descriptive laboratory study. Methods: Models of the femur and tibia were created from magnetic resonance images of 8 healthy male participants. The models were positioned to match biplanar fluoroscopic images obtained as participants posed in lunges of varying flexion angles (FLAs). Knee abduction angle was calculated from the positioned models in 2 ways: (1) varus-valgus angle (VVA), defined as the angle between the long axis of the tibia and the femoral transepicondylar axis by use of a 3D anatomic coordinate system; and (2) coronal plane angle (CPA), defined as the angle between the long axis of the tibia and the long axis of the femur projected onto the tibial coronal plane to simulate a 2D videographic analysis. We then simulated how changing the position of the camera relative to the participant would affect knee abduction angles. Results: During flexion, when CPA was calculated from a purely anterior or posterior view of the joint—an ideal scenario for measuring knee abduction from 2D videographic analysis—CPA was significantly different from VVA ( P < .0001). CPA also varied substantially with the position of the camera relative to the participant. Conclusion: How closely CPA (derived from 2D videographic analysis) relates to VVA (derived from a 3D anatomic coordinate system) depends on FLA and camera orientation. Clinical Relevance: This study provides a novel comparison of knee abduction angles measured from 2D videographic analysis and those measured within a 3D anatomic coordinate system. Consideration of these findings is important when interpreting 2D videographic data regarding knee abduction angle in ACL injury.

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Extramedullary Guide Alignment Is not Affected by Obesity in Primary Total Knee Arthroplasty

The Journal of Knee Surgery ◽

10.1055/s-0040-1701438 ◽

2020 ◽

Author(s):

Jocelyn Compton ◽

Jessell Owens ◽

Jesse Otero ◽

Nicolas Noiseux ◽

Timothy Brown

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Tibial Component ◽

Primary Total Knee Arthroplasty ◽

Coronal Plane ◽

Coronal Alignment ◽

Primary Tkas ◽

Significant Difference ◽

Total Knee ◽

Valgus Alignment

AbstractCoronal alignment of the tibial implant correlates with survivorship of total knee arthroplasty (TKA), especially in obese patients. The purpose of this study was to determine if obesity affects coronal plane alignment of the tibial component when utilizing standard extramedullary tibial guide instrumentation during primary TKA. A retrospective review from June 2017 to February 2018 identified 142 patients (162 primary TKAs). There were 88 patients (100 knees) with body mass index (BMI) < 35 kg/m2 and 54 patients (62 knees) with BMI ≥ 35.0 kg/m2. The cohorts did not differ in age (p = 0.37), gender (p = 0.61), or Charlson's comorbidity index (p = 0.54). Four independent reviewers measured the angle between the base of the tibial component and the mechanical axis of the tibia on the anteroposterior view of long-leg film at first postoperative clinic visit. Outliers were defined as patients with greater than 5 degrees of varus or valgus alignment (n = 0). Reoperations and complications were recorded to 90 days postoperatively. There was no significant difference in mean tibial coronal alignment between the two groups (control alignment 90.8 ± 1.2 degree versus obese alignment 90.8 ± 1.2 degree, p = 0.91). There was no difference in varus versus valgus alignment (p = 0.19). There was no difference in the number of outliers (two in each group, p = 0.73). There was no difference in rate of reoperation (p = 1.0) or complication (p = 0.51). Obesity did not affect coronal plane alignment of the tibial component when using an extramedullary guide during primary TKA in our population.

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