- Email: [email protected]
Anatomic bundle reconstruction of the deltoid ligament
ORIGINALARBEIT/ORIGINAL PAPER
Orthop€adie Traumatologie
ORIGINALARBEIT/ORIGINAL PAPER
Abstract Background: The aim of this study was to evaluate the outcome of an anatomic bundle reconstruction of the deltoid ligament in patients with stage IV adult flatfoot deformity. Materials and Methods: Eleven patients (50.8 8.1 years, 4 females) were treated with such a procedure combined with osseous realignment as needed. Results: At 43 months the tibiotalar angle improved from 26.3 degrees (Range 18 – 35) to 11.0 degrees (Range 5 – 18). The AOFAS score improved from 37.4 points (Range 30 – 50) to 85.1 points (Range 82 – 90). No severe complications occurred in this group. Conclusion: Anatomic bundle reconstruction of the deltoid ligament is an effective method in the correction of the tibitalar tilt in servere adult pes planus deformity. Level-of-Evidence: Level IV - Case series Key words Flat foot – delta ligament – reconstruction
214
Sport Orthop. Traumatol. 29, 214–218 (2013) Elsevier – Urban&Fischer www.elsevier.de/SportOrthoTrauma http://dx.doi.org/10.1016/j.orthtr.2013.07.013
M.D. Wimmer et al.
Anatomic bundle reconstruction of the deltoid ligament Matthias D. Wimmer1,2, Patrick Vavken2,3,4, Alexander Barg2, Victor Valderrabano2, Geert I. Pagenstert2 1 Department of Orthopaedics and Trauma Surgery, University of Bonn, Bonn 53105, Germany 2 Orthopaedic Department, University of Basel, Basel 4031, Switzerland 3 Division of Orthopaedic Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 4 Harvard Center for Population and Development Studies, Harvard School of Public Health, Boston, MA, USA Eingegangen/submitted: 5.07.2013; akzeptiert/accepted: 24.07.2013
Introduction
While
lateral ankle instability is common, medial ankle instability is rare, especially involving insufficiency of the whole deltoid ligament [1,7]. Anteromedial ankle instability may result from inadequate deltoid ligament healing after eversion trauma during ankle sprain but may be caused in addition by chronic overuse caused by lateral ankle instability due to excessive ankle rotation [7]. While acute total deltoid rupture is most often included in an ankle fracture dislocation, chronic total medial ankle instability usually develops from primary or acquired flatfoot deformity. Common reasons for such acquired deformities include posterior tibial tendon deficiency (PTTD), segmentation problems such as congential osseous coaltion and an accessory navicular, or idiopathically because of hereditary predisposition [12,13]. Conservative treatment including shoe modification, orthotics, physical therapy and patient education are the first line of treatment, and successfully so in the brunt of the patient population. However, roughly one in five
Anatomic bundle reconstruction of the deltoid ligament
patients will continue to experience pain and require a surgical intervention [2]. This article concentrates on surgical reconstruction of the whole deltoid ligament in the setting of severe flat foot deformity, also referred to stage 4 flat foot deformity. This article is not meant to cover the whole treatment algorithm for flatfoot reconstruction. For advanced information regarding osteotomies and tendon procedures for flatfoot correction that should accompany chronic ligament reconstructions we refer to the published guidelines of Pagenstert et al. [10,11]. Surgical stabilization of chronic anteromedial ankle instability was introduced by Hintermann et al. [6]. However, if the whole deltoid ligament has failed the proposed procedure of Hintermann et al. is no longer sufficient and usually ankle arthrodesis has been recommended in the literature. Only a few cases of ankle salvage with complex surgical techniques have been reported [4]. We present the mid-term outcome of eleven patients treated with a newly developed surgical procedure to stabilize the medial ankle after
ORIGINALARBEIT/ORIGINAL PAPER Sport Orthop. Traumatol. 29, 214–218 (2013)
total deltoid failure using two TightRobe and two Swive-Lock Anchors R (Arthrex Inc.; Naples, FL, USA) in a case series of eleven patients. The flatfoot was corrected with established surgical realignment, described elsewhere, at the same surgery.
Material and Methods Patients A total of eleven patients (4 female, 7 male) were included. 8 (73%) patients suffered from total medial ligament insufficiency with flatfoot deformity stage 4. The mean age at surgery was 50.8 8.1 years (Range 40 to 63 years), the mean BMI was 28.6 1.8 These patients were followed for 43.3 18.4 months on average (Range: 12-68) Surgical technique Before the ligament reconstruction was done, the mid and hindfoot was evaluated for static pes planovalgus correcture as described elsewhere [10,11]. We recommend bony correction of all valgus forces caused by the foot and ankle to allow healing of the ligament reconstruction. For anatomic bundle reconstruction a skin incision over the medial malleolus to the navicular tuberosity, preparation down to the joint capsule and sheath of the posterior tibial tendon was performed. In all cases the tendon sheath was opened for evaluation of the tendon and the deltoid ligament located deep to the tendon. The whole capsule and deltoid ligament was significant elongated in all cases and at in four cases a rupture was identified in the tibionavicular (TN) or tibiospring (TS) part of the deltoid ligament. Reposition of the talus into the ankle mortise showed slack and insufficient tissue at the tibiocalcaneal (TC) and tibionavicular (TN) parts whereas
slack but abundant soft tissue was found at the tibiotalar (TT) and tibiospring (TS) parts of the deltoid ligament. Therefore, suture repair and autologous semitendinosus augmentation for the TC and TN parts but suture repair with tight-rope augmentation only for the TT and TS parts have been done. Drill holes 3.5 mm were placed through the medial malleolus from posterior-superior to anteriorinferior to the most anterior part of the tibiotalar ligament (TT) and from anterior-superior to posteriorinferior to the most posterior attachment of the TT. Than two additional drill holes 3.5 mm in the talus anterior and posterior to the TT attachment directed to the cartilage free zone of the lateral talar process. Now the elongated and scared TT was partially debrided but not removed to have sufficient fresh tissue for new scar formation. The talus was reduced into the mortise and the tight-rope buttons introduced through the tunnels of the medial malleolus and through the talus. In that way two strong bundles were constructed which held the talus in the mortise allowing close healing of the deep TT (Fig. 1).
Drill holes 4.5 mm were placed at the tuber naviculare, the sustentaculum tali of the calcaneus and the medial malleolus about 2 cm above the tip and about 5 mm above the 3.5 mm drill holes. Subsequently, the semitendinosus tendon harvested over a 2 cm incision at the proximal tibia was guided through the medial malleolus and attached first with one end at the calcaneus with the Swive-Lock anchor system. After tensioning the graft in the tunnel, the second end of the graft was attached to the tuber navicular with an additional Swive-Lock anchor. In addition to the deltoid reconstruction all the cases were treated by an additional osteotomy to reduce the load on the reconstructive deltoid: Supramalleolar closing wedge osteotomy in 4 cases, lateral calcaneal lengthenting osteotomy in 6 case, medial sliding calcaneal osteotomy in 2 cases. Endpoints and Statistical Assessment We collected data on the AOFAS score a general foot and ankle outcome score, the Swiss-symptomrelated-Ankle-Activity-Scale (SAAS)
Figure 1 shows the placement of drill holes in the sustentaculum tali of the calcaneus (A) and passage of the graft (B). The Swive-Lock anchor can be seen in the lower half of panel B.
M.D. Wimmer et al.
Anatomic bundle reconstruction of the deltoid ligament
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ORIGINALARBEIT/ORIGINAL PAPER Sport Orthop. Traumatol. 29, 214–218 (2013)
as a ankle-specific activity score, VAS for pain, and the tibiotalar angle in ap view preoperatively and at the last follow-up. The AOFAS score is a validated instrument that includes assessment of Pain and Function, divided into activity limitation, maximum walking distance, walking surfaces, gait abnormality sagittal motion, hindfoot motion, ankle-hindfoot stability, and alignment, for a total of 100 points as the best possible result. The SAAS includes data on
sports participation and related symptoms or complaints during activity, similar to the Tegner score. For the VAS for pain we anchored the scale at 0 for no pain and 10 for worst pain ever experienced. The tibiotalar anlge was measured on digital ap mortise radiographs using a digital goniometer. (Figure 2) Lateral images was not assessed as a primary endpoint. While we did see improvement in the lateral alignment postoperatively (Figure 3), this was only an
Figure 2 (A) Preoperative ap radiograph. Note the substantial talar tilt, the large calcaneal valgus and the resulting lateral impingement. (B) Postoperative ap radiograph with hardware in situ. Note the markedly improved talar tilt and almost normal joint line resulting in restoration of the lateral aligment with a freed fibular tip and lateral gutter.
Figure 3 The preoperative lateral radiograph (A) shows a significant narrowing of the anterior joint space and a negative Meary’s angle and a broken arch. (B) The postoperative situation shows a decompressed joint space with restoration of an anterior joint gap. Also, the talo-metatarsale angle has been restored to normal range.
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Anatomic bundle reconstruction of the deltoid ligament
additional, secondary effect of our intervention and therefore excluded as a primary outcome. Statistical assessment was done using two-sided testing. An alpha value of 5% was considered statistically significant. Results are given as mean with standard deviation.
Results All patients were available for final follow-up. Preoperatively, the mean AOFAS score was 37.4 points (Range 30 – 50). (Figure 4) The mean SAAS score was 7.3 points (Range 0-20). The VAS score for pain was 5.0 points (Range 3 – 8). The patients had an average ap tibiotalar angle of 26.3 degrees (Range 18 – 35). At a mean follow-up of 43.3 months (Range 12 – 68), the average AOFAS score had improved by 247% to an average of 85.1 points (Range 82 – 90), which is consistent with a statistically significant difference (p>0.001). Naturally, the highest improvements were seen for the subscores for aligment (Figure 4). The second and third highest improvements were seen for the ability to walk on uneven surfaces and general activity limitations (p>0.001 for all). We observed significant improvement in the SAAS score to 63.6 (Range 40 – 80, p>0.001) as well as in the independent VAS scaling to 2. 4 (Range 1 – 4) at final follow-up (p>0.001). The tibiotalar angle improved to 11.0 degrees (Range 5 – 18), and the SAAS to 63.6 (Range 40 – 80) We did not observe any major complications such as infection or recurrence of instability within the followup period. One patient had delayed wound healing which resolved without additional treatment.
ORIGINALARBEIT/ORIGINAL PAPER Sport Orthop. Traumatol. 29, 214–218 (2013)
Figure 4 Preoperative and Postoperative AOFAS scores by subgroups.
Discussion Stage 4 flat foot deformity is characterized by chronic complete deltoid failure treated with ankle fusion. As these cases are not frequent, experience to prevent ankle fusion is small. We present a new technique for deltoid reconstruction in combination with established procedures to correct the flat foot to save the ankle joint. Our outcomes show promising results in all patients at medium follow up of mean 3.6 years. Ankle fusion could be postponed and activities of daily living restored in all patients. Deland et al [3] published their own non-anatomical reconstruction technique in 2004. In their procedure, the peroneus longus is used as an in situ autologous graft which is shuttled through the talus and then obliquely through the tibia. 5 patients were treated with this single bundle technique, accompanied by osseus procedures in the hind foot and evaluated at 2 years
postoperatively. This reconstruction resulted in a reduction of the mortise angle from a range of 8 to 15 to values in the range of 1 to 9 degrees. However, two patients still experienced pain, and two needed orthotics for ambulation. While this technique produced promising results in an population with a comparatively low initial malalignment, the limitations of an isometric, single bundle reconstruction are obvious and seen even in a cohort as small as 5 patients. Jeng et al published a minimally invasive, double bundle docking technique using a folded hamstring allograft to create a tibiotalar and a tibiocalcaneal stabilizer [8].8 patients were treated with such a procedure, combined with a triple arthrodesis, for stage IV adult flatfoot deformity. Data on the 3 follow up are available and show failure in three of 8 patients. The remaining five showed a reduction of the tibiotalar anlge from the range of 4 to 11 to values in the range of 1 to 3 M.D. Wimmer et al.
degrees. Interestingly, the three failed intervention showed pathological ap imaging immediately after the procedure, suggesting intraoperative rather than postoperative failure. Of those with successful surgery, two went on to undergo tibiotalar fusion for painful ankle arthritis eventually. This findings, on the one hand, show the importance of an anatomical, double bundle reconstruction, but also, on the other hand, the temporizing nature of medial side reconstruction in stage IV disease. Lack et al published the technique for, but unfortunately not the results of, an anatomic repair of the medial deltoid ligament with an anchor-to-post suture reinforcement [9]. Briefly, the medial side of the ankle is dissected and suture anchors placed in the talar stump of the ligament. The sutures are first used to repair the deep portion of the ligament, then wrapped around a tibial post and then used to repair the superficial ligament tear or insufficiency. While this is a true anatomical repair, the question remains how durable such a technique is. From experience in other ligamentous procedures such as primary repairs in the knee or shoulder, such as cruciates, patellar tendon, or even the lateral ankle, it is known the suture repairs depend very much on the strength of the suture are, more often than not, require secondary reinforcement with a graft. However, this technique is probably of value for limited defects or early disease. In our series the initial tibiotalar tilt was 26 degrees on average, which is higher than in most ealier publications. We were able to correct this mortise angle to 11 degrees of valgus at last follow-up after mean 3.6 years indicating powerful but incomplete correction of the lateral valgus tilt in the ankle. We think that correction to
Anatomic bundle reconstruction of the deltoid ligament
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normal parallel joint space is not always possible in chronic long lasting deformities when the lateral tibiotalar joint space has been worn off partially but is not mandatory for a improved outcome. However, we believe that sufficient flat foot correction is paramount for unloading the lateral and arthritic ankle compartment to decrease the progress of deformity, overload and osteoarthritis. In addition, we strongly believe that the correction of the static alignment of the flat foot is paramount for successful deltoid ligament reconstruction [5]. Salvage of stage 4 flat foot deformity is not meant to restore high level sports activities, but serve as a temporizing procedure to provide improved function and quality-oflife until a more definitive treatment, usually joint replacement or fusion. We used the SAAS to demonstrate that activities of daily living can be restored in all of the studied patients by our new procedure without fusion of the ankle. In comparison with the Tegnerscore the SAAS has a higher sensitivity at lower level activities which is more adequate for salvage procedures. The upper half of the Tegner score cannot be reached by our patient series making this scale less useful. In conclusion, the new technique to reconstruct the deltoid ligament in stage 4 flat foot deformity was able to restore activities of daily living and prevented ankle fusion in all
patients for mean time of 3.6 years. Therefore, in selective patients combined correction of the deltoid ligament and the flat foot deformity can be done with success.
Conflict of interest The authors declare no conflict of interest.
References [1] A.P. Boss, B. Hintermann, Anatomical study of the medial ankle ligament complex, Foot Ankle Int. (2002) 232547–232553. [2] M.I. Boyer, V. Bowen, P. Weiler, Reconstruction of a severe grinding injury to the medial malleolus and the deltoid ligament of the ankle by using a free plamaris tendon graft and vascularized gracilis free muscle transfer: case report, J Trauma. 36 (1994) 454–457. [3] J.T. Deland, R.J. de Asla, A. Segal, Reconstruction of the chronically failed deltoid ligament: a new technique, Foot Ankle Int. 25 (11) (2004 Nov) 795–799. [4] N. Espinosa, J. Smerek, A.R. Kadakia, M. S. Myerson, Operative management of ankle instability: reconstruction with open and percutaneous methods, Foot Ankle Clin. 11 (2006 Sep) 547–565. [5] S.L. Haddad, S. Dedhia, Y. Ren, J. Rotstein, L.Q. Zhang, Deltoid ligament reconstruction: a novel technique with biomechanical analysis, Foot Ankle Int. 31 (7) (2010 Jul) 639–651. [6] B. Hintermann, V. Valderrabano, A. Boss, H.H. Trouillier, W. Dick, Medial ankle instability: an exploratory, prospective study of fifty-two cases, Am J Sports Med. 32 (2004) 183–190. Available online at www.sciencedirect.com
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[7] B. Hintermann, M. Knupp, G.I. Pagenstert, Deltoid ligament injuries: diagnosis and management, Foot Ankle Clin. 11 (2006 Sep) 625–637. [8] C.L. Jeng, E.M. Bluman, M.S. Myerson, Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity, Foot Ankle Int. 32 (1) (2011 Jan) 21–30. [9] W. Lack, P. Phisitkul, J.E. Femino, Anatomic Deltoid Ligament Repair with Anchor-to-Post Suture Reinforcement: Technique Tip, Iowa Orthop J. 32 (2012) 227–230. [10] G. Pagenstert, B. Hintermann, A. Barg, A. Leumann, V. Valderrabano, Realignment surgery as alternative treatment of varus and valgus ankle osteoarthritis, Clin Orthop Relat Res. 462 (2007 Sep) 156–168. [11] G. Pagenstert, M. Knupp, V. Valderrabano, B. Hintermann, Realignment surgery for valgus ankle osteoarthritis, Oper Orthop Traumatol. 21 (2009 Mar) 77–87. [12] O. Rasmussen, C. Krumann-Andersen, S. Boe, Deltoid ligament. Functional analysis of the medial collateral ligamentous apparatus of the ankle joint, Acta Orthop Scand. 54 (1983) 36–44. [13] J.T. Smith, E.M. Bluman, Update on stage IV acquired adult flatfoot disorder: when the deltoid ligament becomes dysfunctional, Foot Ankle Clin. 17 (2) (2012 Jun) 351–360.
Corresponding address: Geert Pagenstert MD, Assistant Professor Department of Orthopaedic Surgery University Hospital Basel, University of Basel Spitalstrasse 21 CH-4031 Basel E-Mail: [email protected]
Orthop€adie Traumatologie
ORIGINALARBEIT/ORIGINAL PAPER
Abstract Background: The aim of this study was to evaluate the outcome of an anatomic bundle reconstruction of the deltoid ligament in patients with stage IV adult flatfoot deformity. Materials and Methods: Eleven patients (50.8 8.1 years, 4 females) were treated with such a procedure combined with osseous realignment as needed. Results: At 43 months the tibiotalar angle improved from 26.3 degrees (Range 18 – 35) to 11.0 degrees (Range 5 – 18). The AOFAS score improved from 37.4 points (Range 30 – 50) to 85.1 points (Range 82 – 90). No severe complications occurred in this group. Conclusion: Anatomic bundle reconstruction of the deltoid ligament is an effective method in the correction of the tibitalar tilt in servere adult pes planus deformity. Level-of-Evidence: Level IV - Case series Key words Flat foot – delta ligament – reconstruction
214
Sport Orthop. Traumatol. 29, 214–218 (2013) Elsevier – Urban&Fischer www.elsevier.de/SportOrthoTrauma http://dx.doi.org/10.1016/j.orthtr.2013.07.013
M.D. Wimmer et al.
Anatomic bundle reconstruction of the deltoid ligament Matthias D. Wimmer1,2, Patrick Vavken2,3,4, Alexander Barg2, Victor Valderrabano2, Geert I. Pagenstert2 1 Department of Orthopaedics and Trauma Surgery, University of Bonn, Bonn 53105, Germany 2 Orthopaedic Department, University of Basel, Basel 4031, Switzerland 3 Division of Orthopaedic Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 4 Harvard Center for Population and Development Studies, Harvard School of Public Health, Boston, MA, USA Eingegangen/submitted: 5.07.2013; akzeptiert/accepted: 24.07.2013
Introduction
While
lateral ankle instability is common, medial ankle instability is rare, especially involving insufficiency of the whole deltoid ligament [1,7]. Anteromedial ankle instability may result from inadequate deltoid ligament healing after eversion trauma during ankle sprain but may be caused in addition by chronic overuse caused by lateral ankle instability due to excessive ankle rotation [7]. While acute total deltoid rupture is most often included in an ankle fracture dislocation, chronic total medial ankle instability usually develops from primary or acquired flatfoot deformity. Common reasons for such acquired deformities include posterior tibial tendon deficiency (PTTD), segmentation problems such as congential osseous coaltion and an accessory navicular, or idiopathically because of hereditary predisposition [12,13]. Conservative treatment including shoe modification, orthotics, physical therapy and patient education are the first line of treatment, and successfully so in the brunt of the patient population. However, roughly one in five
Anatomic bundle reconstruction of the deltoid ligament
patients will continue to experience pain and require a surgical intervention [2]. This article concentrates on surgical reconstruction of the whole deltoid ligament in the setting of severe flat foot deformity, also referred to stage 4 flat foot deformity. This article is not meant to cover the whole treatment algorithm for flatfoot reconstruction. For advanced information regarding osteotomies and tendon procedures for flatfoot correction that should accompany chronic ligament reconstructions we refer to the published guidelines of Pagenstert et al. [10,11]. Surgical stabilization of chronic anteromedial ankle instability was introduced by Hintermann et al. [6]. However, if the whole deltoid ligament has failed the proposed procedure of Hintermann et al. is no longer sufficient and usually ankle arthrodesis has been recommended in the literature. Only a few cases of ankle salvage with complex surgical techniques have been reported [4]. We present the mid-term outcome of eleven patients treated with a newly developed surgical procedure to stabilize the medial ankle after
ORIGINALARBEIT/ORIGINAL PAPER Sport Orthop. Traumatol. 29, 214–218 (2013)
total deltoid failure using two TightRobe and two Swive-Lock Anchors R (Arthrex Inc.; Naples, FL, USA) in a case series of eleven patients. The flatfoot was corrected with established surgical realignment, described elsewhere, at the same surgery.
Material and Methods Patients A total of eleven patients (4 female, 7 male) were included. 8 (73%) patients suffered from total medial ligament insufficiency with flatfoot deformity stage 4. The mean age at surgery was 50.8 8.1 years (Range 40 to 63 years), the mean BMI was 28.6 1.8 These patients were followed for 43.3 18.4 months on average (Range: 12-68) Surgical technique Before the ligament reconstruction was done, the mid and hindfoot was evaluated for static pes planovalgus correcture as described elsewhere [10,11]. We recommend bony correction of all valgus forces caused by the foot and ankle to allow healing of the ligament reconstruction. For anatomic bundle reconstruction a skin incision over the medial malleolus to the navicular tuberosity, preparation down to the joint capsule and sheath of the posterior tibial tendon was performed. In all cases the tendon sheath was opened for evaluation of the tendon and the deltoid ligament located deep to the tendon. The whole capsule and deltoid ligament was significant elongated in all cases and at in four cases a rupture was identified in the tibionavicular (TN) or tibiospring (TS) part of the deltoid ligament. Reposition of the talus into the ankle mortise showed slack and insufficient tissue at the tibiocalcaneal (TC) and tibionavicular (TN) parts whereas
slack but abundant soft tissue was found at the tibiotalar (TT) and tibiospring (TS) parts of the deltoid ligament. Therefore, suture repair and autologous semitendinosus augmentation for the TC and TN parts but suture repair with tight-rope augmentation only for the TT and TS parts have been done. Drill holes 3.5 mm were placed through the medial malleolus from posterior-superior to anteriorinferior to the most anterior part of the tibiotalar ligament (TT) and from anterior-superior to posteriorinferior to the most posterior attachment of the TT. Than two additional drill holes 3.5 mm in the talus anterior and posterior to the TT attachment directed to the cartilage free zone of the lateral talar process. Now the elongated and scared TT was partially debrided but not removed to have sufficient fresh tissue for new scar formation. The talus was reduced into the mortise and the tight-rope buttons introduced through the tunnels of the medial malleolus and through the talus. In that way two strong bundles were constructed which held the talus in the mortise allowing close healing of the deep TT (Fig. 1).
Drill holes 4.5 mm were placed at the tuber naviculare, the sustentaculum tali of the calcaneus and the medial malleolus about 2 cm above the tip and about 5 mm above the 3.5 mm drill holes. Subsequently, the semitendinosus tendon harvested over a 2 cm incision at the proximal tibia was guided through the medial malleolus and attached first with one end at the calcaneus with the Swive-Lock anchor system. After tensioning the graft in the tunnel, the second end of the graft was attached to the tuber navicular with an additional Swive-Lock anchor. In addition to the deltoid reconstruction all the cases were treated by an additional osteotomy to reduce the load on the reconstructive deltoid: Supramalleolar closing wedge osteotomy in 4 cases, lateral calcaneal lengthenting osteotomy in 6 case, medial sliding calcaneal osteotomy in 2 cases. Endpoints and Statistical Assessment We collected data on the AOFAS score a general foot and ankle outcome score, the Swiss-symptomrelated-Ankle-Activity-Scale (SAAS)
Figure 1 shows the placement of drill holes in the sustentaculum tali of the calcaneus (A) and passage of the graft (B). The Swive-Lock anchor can be seen in the lower half of panel B.
M.D. Wimmer et al.
Anatomic bundle reconstruction of the deltoid ligament
215
ORIGINALARBEIT/ORIGINAL PAPER Sport Orthop. Traumatol. 29, 214–218 (2013)
as a ankle-specific activity score, VAS for pain, and the tibiotalar angle in ap view preoperatively and at the last follow-up. The AOFAS score is a validated instrument that includes assessment of Pain and Function, divided into activity limitation, maximum walking distance, walking surfaces, gait abnormality sagittal motion, hindfoot motion, ankle-hindfoot stability, and alignment, for a total of 100 points as the best possible result. The SAAS includes data on
sports participation and related symptoms or complaints during activity, similar to the Tegner score. For the VAS for pain we anchored the scale at 0 for no pain and 10 for worst pain ever experienced. The tibiotalar anlge was measured on digital ap mortise radiographs using a digital goniometer. (Figure 2) Lateral images was not assessed as a primary endpoint. While we did see improvement in the lateral alignment postoperatively (Figure 3), this was only an
Figure 2 (A) Preoperative ap radiograph. Note the substantial talar tilt, the large calcaneal valgus and the resulting lateral impingement. (B) Postoperative ap radiograph with hardware in situ. Note the markedly improved talar tilt and almost normal joint line resulting in restoration of the lateral aligment with a freed fibular tip and lateral gutter.
Figure 3 The preoperative lateral radiograph (A) shows a significant narrowing of the anterior joint space and a negative Meary’s angle and a broken arch. (B) The postoperative situation shows a decompressed joint space with restoration of an anterior joint gap. Also, the talo-metatarsale angle has been restored to normal range.
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Anatomic bundle reconstruction of the deltoid ligament
additional, secondary effect of our intervention and therefore excluded as a primary outcome. Statistical assessment was done using two-sided testing. An alpha value of 5% was considered statistically significant. Results are given as mean with standard deviation.
Results All patients were available for final follow-up. Preoperatively, the mean AOFAS score was 37.4 points (Range 30 – 50). (Figure 4) The mean SAAS score was 7.3 points (Range 0-20). The VAS score for pain was 5.0 points (Range 3 – 8). The patients had an average ap tibiotalar angle of 26.3 degrees (Range 18 – 35). At a mean follow-up of 43.3 months (Range 12 – 68), the average AOFAS score had improved by 247% to an average of 85.1 points (Range 82 – 90), which is consistent with a statistically significant difference (p>0.001). Naturally, the highest improvements were seen for the subscores for aligment (Figure 4). The second and third highest improvements were seen for the ability to walk on uneven surfaces and general activity limitations (p>0.001 for all). We observed significant improvement in the SAAS score to 63.6 (Range 40 – 80, p>0.001) as well as in the independent VAS scaling to 2. 4 (Range 1 – 4) at final follow-up (p>0.001). The tibiotalar angle improved to 11.0 degrees (Range 5 – 18), and the SAAS to 63.6 (Range 40 – 80) We did not observe any major complications such as infection or recurrence of instability within the followup period. One patient had delayed wound healing which resolved without additional treatment.
ORIGINALARBEIT/ORIGINAL PAPER Sport Orthop. Traumatol. 29, 214–218 (2013)
Figure 4 Preoperative and Postoperative AOFAS scores by subgroups.
Discussion Stage 4 flat foot deformity is characterized by chronic complete deltoid failure treated with ankle fusion. As these cases are not frequent, experience to prevent ankle fusion is small. We present a new technique for deltoid reconstruction in combination with established procedures to correct the flat foot to save the ankle joint. Our outcomes show promising results in all patients at medium follow up of mean 3.6 years. Ankle fusion could be postponed and activities of daily living restored in all patients. Deland et al [3] published their own non-anatomical reconstruction technique in 2004. In their procedure, the peroneus longus is used as an in situ autologous graft which is shuttled through the talus and then obliquely through the tibia. 5 patients were treated with this single bundle technique, accompanied by osseus procedures in the hind foot and evaluated at 2 years
postoperatively. This reconstruction resulted in a reduction of the mortise angle from a range of 8 to 15 to values in the range of 1 to 9 degrees. However, two patients still experienced pain, and two needed orthotics for ambulation. While this technique produced promising results in an population with a comparatively low initial malalignment, the limitations of an isometric, single bundle reconstruction are obvious and seen even in a cohort as small as 5 patients. Jeng et al published a minimally invasive, double bundle docking technique using a folded hamstring allograft to create a tibiotalar and a tibiocalcaneal stabilizer [8].8 patients were treated with such a procedure, combined with a triple arthrodesis, for stage IV adult flatfoot deformity. Data on the 3 follow up are available and show failure in three of 8 patients. The remaining five showed a reduction of the tibiotalar anlge from the range of 4 to 11 to values in the range of 1 to 3 M.D. Wimmer et al.
degrees. Interestingly, the three failed intervention showed pathological ap imaging immediately after the procedure, suggesting intraoperative rather than postoperative failure. Of those with successful surgery, two went on to undergo tibiotalar fusion for painful ankle arthritis eventually. This findings, on the one hand, show the importance of an anatomical, double bundle reconstruction, but also, on the other hand, the temporizing nature of medial side reconstruction in stage IV disease. Lack et al published the technique for, but unfortunately not the results of, an anatomic repair of the medial deltoid ligament with an anchor-to-post suture reinforcement [9]. Briefly, the medial side of the ankle is dissected and suture anchors placed in the talar stump of the ligament. The sutures are first used to repair the deep portion of the ligament, then wrapped around a tibial post and then used to repair the superficial ligament tear or insufficiency. While this is a true anatomical repair, the question remains how durable such a technique is. From experience in other ligamentous procedures such as primary repairs in the knee or shoulder, such as cruciates, patellar tendon, or even the lateral ankle, it is known the suture repairs depend very much on the strength of the suture are, more often than not, require secondary reinforcement with a graft. However, this technique is probably of value for limited defects or early disease. In our series the initial tibiotalar tilt was 26 degrees on average, which is higher than in most ealier publications. We were able to correct this mortise angle to 11 degrees of valgus at last follow-up after mean 3.6 years indicating powerful but incomplete correction of the lateral valgus tilt in the ankle. We think that correction to
Anatomic bundle reconstruction of the deltoid ligament
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ORIGINALARBEIT/ORIGINAL PAPER Sport Orthop. Traumatol. 29, 214–218 (2013)
normal parallel joint space is not always possible in chronic long lasting deformities when the lateral tibiotalar joint space has been worn off partially but is not mandatory for a improved outcome. However, we believe that sufficient flat foot correction is paramount for unloading the lateral and arthritic ankle compartment to decrease the progress of deformity, overload and osteoarthritis. In addition, we strongly believe that the correction of the static alignment of the flat foot is paramount for successful deltoid ligament reconstruction [5]. Salvage of stage 4 flat foot deformity is not meant to restore high level sports activities, but serve as a temporizing procedure to provide improved function and quality-oflife until a more definitive treatment, usually joint replacement or fusion. We used the SAAS to demonstrate that activities of daily living can be restored in all of the studied patients by our new procedure without fusion of the ankle. In comparison with the Tegnerscore the SAAS has a higher sensitivity at lower level activities which is more adequate for salvage procedures. The upper half of the Tegner score cannot be reached by our patient series making this scale less useful. In conclusion, the new technique to reconstruct the deltoid ligament in stage 4 flat foot deformity was able to restore activities of daily living and prevented ankle fusion in all
patients for mean time of 3.6 years. Therefore, in selective patients combined correction of the deltoid ligament and the flat foot deformity can be done with success.
Conflict of interest The authors declare no conflict of interest.
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Corresponding address: Geert Pagenstert MD, Assistant Professor Department of Orthopaedic Surgery University Hospital Basel, University of Basel Spitalstrasse 21 CH-4031 Basel E-Mail: [email protected]