1. Treatment of Deltoid Ligament Injuries
How is the deltoid ligament going to be exposed?
Gently curving medial incision from behind medial malleolus to TNJ
Division of lacinate ligament (Flexor retinaculum)
Inspection and mobilisation of Tib Post
Identification of elements of Deltoid Ligament and Spring Ligament
Ribbans WJ, Garde A. Tibialis Posterior Tendon, Deltoid and Spring Ligament Injuries in the Elite Athlete. Foot Ankle Clin Nth Am 18:

2. Deltoid Ligament Surgical Treatment Options
Midsubstance
Repair +/- Imbrication
Acute
Suture Anchors
Proximal Avulsion
Reattachment
Sutures & Drill Holes
“Medial Broström”
Tightening of Ligament
Osteoperiosteal Advancement flap
+/-
Chronic
Augmentation
InternalBrace
Autograft
Reconstruction
Allograft

3. Treatment of Deltoid Ligament Injuries - Acute
Can the ligament be repaired and, if so, what equipment is needed to achieve a satisfactory outcome?
Repair and/or reattachment – 72% will be proximal tear or detachment
Make sure all damaged elements identified - both superficial and deep
Clinical examination
Imaging
Surgical Inspection
Direct repair +/- imbrication – if mid-substance
Re-attachment if pull off – anchors or trans-osseous tunnels
Acute superficial mid-substance tear - repaired. (Hintermann)
Acute anterior pull off
Reattached with anchor
Ribbans WJ, Garde A. Tibialis Posterior Tendon, Deltoid and Spring Ligament Injuries in the Elite Athlete. Foot Ankle Clin Nth Am 18:

4. Treatment of Deltoid Ligament Injuries - Chronic
Proximal “medial Broström” (Hintermann)
using osseous tunnels for sutures or Bone Anchors to re-tension Tibio-Navicular and Tibio-Spring Ligament
Need sufficient tissue – if not reconstruction
Bone Anchors
Ribbans WJ, Garde A. Tibialis Posterior Tendon, Deltoid and Spring Ligament Injuries in the Elite Athlete. Foot Ankle Clin Nth Am 18:

5. Treatment of Deltoid Ligament Injuries - Chronic
Osteoperiosteal Advancement Flap (Beals, 2010)
Osteoperiosteal flap is detached containing superficial tibiocalcaneal ligament
Advanced into proximal trough and secured with suture button
Beals TC, Crim J, Nickisch F. Deltoid Ligament Injuries in Athletes: Techniques of Repair and Reconstruction. Operative Techniques in Sports Medicine. 2010;18:11-17.
Illustrations from Beals’ paper

6. Treatment of Deltoid Ligament Injuries
If the ligament needs augmenting, what techniques can be used?
InternalBrace
InternalBrace
Ribbans WJ, Garde A. Tibialis Posterior Tendon, Deltoid and Spring Ligament Injuries in the Elite Athlete. Foot Ankle Clin Nth Am 18:

7. Treatment of Deltoid Ligament Injuries
If the ligament needs reconstructing, what techniques can be used?
Options:
Free autografts
hamstring tendon, e.g.semitendinosus,
plantaris tendon,
FDL tendon
Attached autografts
split TPT
Peroneus Longus (Deland, 2004)
FHL (Bohay, 2003)
Allografts
(Bluman and Myerson, 2007)
Bohay DR, Anderson JG. Stage IV posterior tibial tendon insufficiency: the tilted ankle. Foot Ankle Clin Nth Am. 2003;8: )
Mostly in Stage IV Posterior Tibial Tendon Dysfunction
Ribbans WJ, Garde A. Tibialis Posterior Tendon, Deltoid and Spring Ligament Injuries in the Elite Athlete. Foot Ankle Clin Nth Am 18:

8. Deltoid Ligament Reconstruction using attached tendon graft – Split PTT

9. Deltoid Ligament Reconstruction using attached tendon graft – Peroneus Longus
Deland JT et al (2004)
Deland JT, de Asla RJ, Segal A. Reconstruction of the Chronically Failed Deltoid Ligament: A new technique. FAI 2004;25(11):

10. Deltoid Ligament Reconstruction using free tendon graft

11. Deltoid Ligament Reconstruction using Allograft
Bluman and Myerson (2007)
Bluman EM, Myerson MS. Stage IV Posterior Tibial Tendon Rupture. FACNA 2007;12:
Used washers to secure
Both Deep and Superficial components recreated

12. Treatment of Deltoid Ligament Injuries
What other structures need inspecting?
Tibialis Posterior tendon pathology
Spring Ligament Pathology
Lateral ligaments
Syndesmosis
Intra-articular pathology
Ribbans WJ, Garde A. Tibialis Posterior Tendon, Deltoid and Spring Ligament Injuries in the Elite Athlete. Foot Ankle Clin Nth Am 18:

13. Treatment of Deltoid Ligament Injuries
Are any additional osseous procedures required?
Osteotomies:
Medial displacement osteotomy
Lateral column lengthening (Evans)
Deltoid Ligament anchors
MDO
Ribbans WJ, Garde A. Tibialis Posterior Tendon, Deltoid and Spring Ligament Injuries in the Elite Athlete. Foot Ankle Clin Nth Am 18:

14. Deltoid Ligament Injuries – Learning Points
Isolated deltoid ligament injuries account ≤ 3-4% of all ankle ligament injuries
More commonly occur in conjunction with fractures or other ligament injuries – spring, lateral and syndesmotic
Features include medial pain and tenderness in conjunction with feeling of instability
Foot assumes progressive valgus hindfoot and pronated position
Stress testing in combination injuries can help document the degree of instability

15. Deltoid Ligament Injuries – Learning Points
Chronic cases often show valgus tilt within ankle mortise for which stress testing has little to add
MRI imaging can help define the extent and level of injury
Acute isolated deltoid ligament injuries promptly diagnosed can usually be treated conservatively
For chronic deltoid instability, variety of methods of repair and/or reconstruction described although most reported series are in conjunction with more severe grades of TPT dysfunction
Chronic deltoid injuries can produce both medial ankle impingement and associated with various osseous abnormalities at medial malleolar tip

16. Spring (Calcaneonavicular)Ligament

17. Spring Ligament Injuries
Usually occurs in association with TPT dysfunction
82% of TPT patients (Gazdag, 1997)
92% of TPT patients on MRI scanning (Balen, 2001)
Isolated injuries are rare
Borton, 1997; Deland, 2001; Subhas, 2007; Tryfonidis, 2008; Shuen, 2009;
Often during explosive activity
Does repetitive microtrauma > degeneration > sudden catastrophic failure

18. Spring Ligament Injuries: Location and Pattern
ICNL ligaments are rarer
BUT
more difficult to image
less important in foot mechanics ?
Usually SMCNL
Orientation:
Usually transverse with gapping on MRI and surgery
Hintermann (2011):
usually larger than expected
can be T-shaped and more distal

19. Spring Ligament Injury – Clinical Features
Acute:
Usually pronation injury
Medial swelling, bruising and tenderness

20. Spring Ligament Injury – Clinical Features
Chronic:
Increasing deformity
Valgus hindfoot
Medial arch collapse
Forefoot abduction
With TPT dysfunction
Usual features
Isolated SL injury
TP activation > corrects arch height
Single stance tiptoe
Usually able BUT
Heel remains valgus
Forefoot in abduction
Isolated SL
injury
Isolated SL
injury

21. Combined Deltoid and Spring Ligament Deficiency
Richard Gostellow. Medial and Deltoid Ligament Reconstruction – op date

22. Combined Deltoid and Spring Ligament Deficiency
Richard Gostellow. Medial and Deltoid Ligament Reconstruction – op date

23. Imaging – MRI of Spring Ligament
Yao (1999):
Chronic injuries:
54-77% sensitivity
100% specificity
Yao (1999) and Toye (2005):
Gapping
Thinning
Ligament waviness
BUT can be thickened
Normal subjects:
17-28% show abnormalities
White arrows = TPT
Black arrows = SMCNL of SL

24. MRI of 3-week old injury to midfoot in a 20 year old footballer
demonstrating an acute partial rupture of the SMCNL and intact ICNL and TCNL
Intact ICNL
Intact TCNL
Bone oedema inferior
talar neck
Partial rupture of SMCNL

25. Grade 2 disruption of the plantar spring ligament (ICNL) with fluid surrounding the ill-defined ligament fibres
Coronal PD FSE and T2 Fat Sat anterior talar dome

26. Spring Ligament Injury – Classification (Gazdag, 1997)
Grade
Description
Nos (N=18) I
Longitudinal tear 7 II
Laxity without obvious rupture
III
Complete rupture 4
Normal TPT
SL tear extending into TNJ capsule

27. Spring Ligament – Conservative Treatment
Little published data to guide us
Injury Type
Treatment
Acute partial
NWB cast for 6/52
RTS only after
- Correction of biomechanical issues – including orthotics
- Strength restoration
Tryfonidis (2008):
- Treated 6/9 conservatively with orthotics
Acute complete
SURGERY
Chronic injury

28. Spring Ligament Surgery - Options
TPT dysfunction
53% of Orthopaedic Surgeons routinely repair SMCNL as part of reconstruction for adult acquired planovalgus foot (Hiller, 2003)
Mann (1999): reported no difference in outcomes +/- SL repair

29. Spring Ligament Surgery – Decision Making
What is tear like?
What is tissue quality like?
Reasonable
Poor
Repair of tear
Resection/imbrication
Reconstruction
Autograft
Allograft
Synthetic material
Do other structures need reconstructing, e.g. Deltoid; TPT ?
Does repair/reconstruction need protection by including other procedures,
e.g. hindfoot osteotomy, arthroeresis ?

30. Spring Ligament Surgery - Repair
Direct Suturing of Tears
Gazdag (1997)
Tryfonidis (2008)
Hintermann (2003)
“Vest over Pants”
Borton and Saxby (1997)
Advancement and Plication
Goldner (1974)

31. Spring Ligament Surgery - Reconstruction
Autograft:
Peroneus Longus
Tibialis Anterior – split
Allograft:
Semitendinosus
Tibialis Anterior
Achilles Tendon
Synthetic:
Internal Brace
Patches, e.g. Artelon
Use of distal stump of Tibialis Posterior tendon to augment repair or reconstruction
Combination of options
e.g. Resection and shortening Internal Brace
Does placement of FDL transfer
through an inferior drill hole help Spring Ligament function?
Cavē: NO clinical trials that report outcome of ligament reconstruction alone or in combination with tendon transfer for adult acquired flat foot deformity

32. Reconstruction of Spring Ligament: Peroneus Longus
Strongest if 2 elements of SL reconstructed
Only reproduced in cadavers with biomechanical testing of different construct types
AB represents ICN
CD represents SMCN
PL left attached to 1st MT base
2 parallel tunnels in os calcis below sustenaculum tali
Choi, K., Lee, S., Otis, JC., and Deland, J. Anatomical Reconstruction of the Spring Ligament using Peroneus Longus Tendon Graft. Foot Ankle 24(5):

33. Reconstruction of Degenerate Spring Ligament: Stage II Tibialis Posterior tendon with incompetent TPT, symptomatic os naviculare and torn spring ligament.
Artelon patch overlying
repaired spring ligament
FDL transferred through
navicular bone tunnel
Distal stump of TPT
overlain Artelon patch
Medial reconstruction involved excision of the os naviculare, Spring ligament reconstruction with Artelon patch overlaid with the distal TPT and FDL transfer.

34. Reconstruction of Spring Ligament: Internal Brace
Spring Ligament reconstruction using InternalBrace (FibreWire)

35. Spring Ligament Surgery – Additional Procedures
MDO (Tryfonidis, 2008; Otis, 1999)
LCL
(Williams, 2010)
Arthroeresis ?

36. Spring Ligament Surgery - Results
Difficult to summarize because of:
Many different techniques
Small numbers in series
Gazdag (1997)
78% excellent results at months follow up
Williams (2010)
AOFAS score increase from 43 to 90 at average FU of 8.9 years

37. Spring Ligament Injuries – Learning Points
Isolated spring ligament injuries are rare
Deforming force is usually pronation and most commonly involves SMCNL
Features mimic many of those of TP dysfunction and commonly occur together
Intact and functioning TPT should raise suspicion of spring ligament injury
Confirmatory clinical signs include deformity correction from active TP contraction

38. Spring Ligament Injuries – Learning Points
MRI is most reliable imaging modality
Untreated acute tears can lead to progressive deformity similar to TP dysfunction
Little place for conservative Rx of complete acute tears – minor tears with no deformity may be considered for cast immobilisation
Preferred technique for surgical repair/reconstruction not established
Simple repair unlikely to be sufficient

39. Thank you

40. Imaging – Ultrasound of Spring Ligament
96% concordance between MRI and US (Harish, 2008) – in experienced hands
Navicular
Talus
White arrows = TPT; Black arrows = SL