Tibiocalcaneonavicular Ligament Reconstruction in Simulated Flatfoot Deformity with Medial Ligament Insufficiency

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00326 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0032 ◽

Cited By ~ 1

Author(s):

Ashlee MacDonald ◽

David Cifo ◽

Emma Knapp ◽

Hani Awad ◽

John Ketz ◽

...

Keyword(s):

Cyclic Loading ◽

Coronal Plane ◽

Abduction Angle ◽

Deltoid Ligament ◽

Interosseous Ligament ◽

Ligament Tear ◽

Spring Ligament ◽

Valgus Angle ◽

Valgus Alignment ◽

Tear Size

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

Foot & Ankle International ◽

10.1177/1071100720950742 ◽

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.

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Cadaveric Testing of a Novel Scapholunate Ligament Reconstruction

Journal of Wrist Surgery ◽

10.1055/s-0037-1607326 ◽

2017 ◽

Vol 07 (02) ◽

pp. 141-147

Author(s):

Lana Kang ◽

Christopher Dy ◽

Mike Wei ◽

Krystle Hearns ◽

Michelle Carlson

Keyword(s):

Repeated Measures ◽

Dorsal Surface ◽

Tendon Graft ◽

Interference Screw ◽

Bone Tunnel ◽

Reconstruction Technique ◽

Interosseous Ligament ◽

Lunate Bone ◽

Radiocarpal Joint ◽

Bone Tunnels

Background Existing scapholunate interosseous ligament (SLIL) reconstruction techniques include fixation spanning the radiocarpal joint, which do not reduce the volar aspect of the scapholunate interval and may limit wrist motion. Questions/Purpose This study tested the ability of an SLIL reconstruction technique that approximates both the volar and dorsal scapholunate intervals, without spanning the radiocarpal joint, to restore static scapholunate relationships. Materials and Methods Scapholunate interval, scapholunate angle, and radiolunate angle were measured in nine human cadaveric specimens with the SLIL intact, sectioned, and reconstructed. Fluoroscopic images were obtained in six wrist positions. The reconstruction was performed by passing tendon graft through bone tunnels from the dorsal surface toward the volar corner of the interosseous surface. After reduction of the scapholunate articulation, the graft was tensioned within the lunate bone tunnel, secured with an interference screw in the scaphoid, and sutured to the dorsal SLIL remnant. Differences among testing states were evaluated using repeated measures ANOVA. Results There was a significant increase in the scapholunate interval in all wrist positions after complete SLIL disruption. Compared with the disrupted state, there was a significant decrease in scapholunate interval in all wrist positions after reconstruction using a tendon graft and interference screw. Conclusion Our SLIL reconstruction technique reconstructs the volar and dorsal ligaments of the scapholunate joint and adequately restores static measures of scapholunate stability. This technique does not tether the radiocarpal joint and aims to optimize volar reduction. Clinical Relevance Our technique offers an alternative option for SLIL reconstruction that successfully restores static scapholunate relationships.

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Anatomic Reconstruction Technique for a Plantar Calcaneonavicular (Spring) Ligament Tear

The Journal of Foot & Ankle Surgery ◽

10.1053/j.jfas.2015.06.013 ◽

2015 ◽

Vol 54 (6) ◽

pp. 1124-1126 ◽

Cited By ~ 15

Author(s):

Ezequiel Palmanovich ◽

Shay Shabat ◽

Yaron S. Brin ◽

Viktor Feldman ◽

Benny Kish ◽

...

Keyword(s):

Anatomic Reconstruction ◽

Reconstruction Technique ◽

Ligament Tear ◽

Spring Ligament

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Novel reconstruction technique for an isolated plantar calcaneonavicular (SPRING) ligament tear

The Foot ◽

10.1016/j.foot.2016.10.004 ◽

2017 ◽

Vol 30 ◽

pp. 1-4 ◽

Cited By ~ 5

Author(s):

Ezequiel Palmanovich ◽

Shay Shabat ◽

Yaron S. Brin ◽

Sabri Massrawe ◽

Iftach Hestroni ◽

...

Keyword(s):

Reconstruction Technique ◽

Ligament Tear ◽

Spring Ligament

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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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Kinematic analysis of two scapholunate ligament reconstruction techniques

Journal of Orthopaedic Surgery ◽

10.1177/23094990211025830 ◽

2021 ◽

Vol 29 (2) ◽

pp. 230949902110258

Author(s):

Seungbum Chae ◽

Junho Nam ◽

Il-Jung Park ◽

Steven S. Shin ◽

Michelle H. McGarry ◽

...

Keyword(s):

Kinematic Analysis ◽

Clinical Relevance ◽

Ligament Reconstruction ◽

Operative Time ◽

Efficient Technique ◽

Scapholunate Ligament ◽

Interosseous Ligament ◽

Flexion Extension

Purpose: This study compares the kinematic changes after the procedures for scapholunate interosseous ligament (SLIL) reconstruction—the modified Brunelli technique (MBT) and Mark Henry’s technique (MHT). Methods: Ten cadaveric wrists were used. The scapholunate (SL) interval and angle and radiolunate (RL) angle were recorded using the MicroScribe system. The SL interval was measured by dividing the volar and dorsal portions. Four motions of the wrist were performed—neutral, flexion, extension, and clenched fist (CF) positions—and compared among five conditions: (1) intact wrist, (2) volar SLIL resection, (3) whole SLIL resection, (4) MBT reconstruction, and (5) MHT reconstruction. Results: Under the whole SLIL resection condition, the dorsal SL intervals were widened in all positions. In all positions, the dorsal SL intervals were restored after MBT and MHT. The volar SL interval widened in the extension position after volar SLIL resection. The volar SL interval was not restored in the extension position after MBT and MHT. The SL angle increased in the neutral and CF positions under the whole SLIL resection condition. The SL angle was not restored in the neutral and CF positions after MBT and MHT. The RL angle increased in the neutral and CF positions under the whole SLIL resection condition. The RL angle was not restored in the neutral and CF positions after MBT and MHT. Conclusion: The MBT and MHT may restore the dorsal SL interval. No significant differences in restoration of the SL interval between MBT and MHT were found in the cadaveric models. Clinical relevance: No significant differences between MBT and MHT were found in the cadaveric models for SLIL reconstruction. When considering the complications due to volar incision and additional procedures in MHT, MBT may be a more efficient technique in terms of operative time and injury of the anterior structures during surgery, but further research is needed.

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