spring ligament repair during flatfoot reconstruction apma ... ligament repair during flatfoot...

Spring Ligament Repair During Flatfoot Reconstruction: Why it Should be Addressed When

Correcting Sagittal Plane Deformities

Nicholas A. Campitelli, DPM, FACFAS APMA National

7/28/2017

Nicholas A. Campiteli, DPM, FACFAS

• Practice in multi-specialty group -Akron, OH

• Board Certified in Foot Surgery and Reconstructive Rearfoot and Ankle Surgery

• Consultant for Medline Foot & Ankle Surgery

Flat Foot Deformity

• Frontal Plane

• Transverse Plane

• Sagittal Plane

PTTD

• Posterior Tibial Tendon

• Is it “dysfunctional”

Pathology• Spring Ligament

• Attenuation leads to increased force on the posterior tibial tendon.

DiDomenico LA, Thomas ZM, Fahim R. Addressing stage II posterior tibial tendon dysfunction: biomechanically repairing the osseous structures without the need of performing the flexor digitorum longus transfer. Clin Podiatr Med Surg. 2014 Jul;31(3):391-404.

Hentges MJ, Moore KR, Catanzariti AR, Derner R. Procedure selection for the flexible adult acquired flatfoot deformity. Clin Podiatr Med Surg. 2014 Jul;31(3):363-79.

Spring Ligament

• Static Support of Medial Longitudinal Arch

• Two Distinct Fibers

Calcaneous

TalusNavicular

superomedial fibers

inferior fibers

CalcaneousTalus

Navicular

http://radsource.us/spring-ligament-tear/

Pathology

• spring ligament abnormality = flatfoot deformity

• Equal importance posterior tibial tendon dysfunction

Williams BR, Ellis SJ, Deyer TW, Pavlov H, Deland JT. Reconstruction of the spring ligament using a peroneus longus autograft tendon transfer. Foot Ankle

Int. 2010 Jul;31(7):567-77.

Pathology

• Spring Ligament and PT Tendon play essential role in elastic support of joint complex

• Progressive strain on the mid-plantar sling is the most common cause of flatfoot, causing midfoot abduction

Toullec E. Adult flatfoot. Orthop Traumatol Surg Res. 2015 Feb;101(1Suppl):S11-7. doi: 10.1016

Pathology

• Regardless of the etiology, literature is demonstrating the spring ligament is failing and becoming attenuated, needs fixed

• The most important static structure to be repaired for AAFD is the spring ligament.

Wei S, Cai X, Yun G. [Progress in soft tissue reconstruction of adult-acquired flatfoot deformity]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2012Oct;26(10):1259-62.

Posterior Tibial Tendon

• May Still be functioning

Spring Ligament

• Soft tissue structure most open to fail

• TN Joint Deformity

Lee WC, Yi Y. Spring ligament reconstruction using the autogenous flexorhallucis longus tendon. Orthopedics. 2014 Jul;37(7):467-71.

Isolated Spring Ligament Rupture

• Acquired pes planus is due to a failure of the osseoligamentous complex

• Could still perform a single heel rise

Borton DC, Saxby TS. Tear of the plantar calcaneonavicular (spring) ligament causing flatfoot. A case report. J Bone Joint Surg Br. 1997 Jul;79(4):641-3.

Procedure Selection

• Lateral Column Lengthening

• MDCO with FLD Transfer

• Spring Ligament Repair

Zanolli DH, Glisson RR, Nunley JA 2nd, Easley ME. Biomechanical assessment of flexible flatfoot correction: comparison of techniques in a cadaver model. J Bone

Joint Surg Am. 2014 Mar 19;96(6):e45.

MDCO

• Reduces the load

• adding FDL transfer small effect

Arangio GA, Salathe EP. A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus

transfer in adult acquired flat foot. Clin Biomech (Bristol, Avon). 2009 May;24(4):385-90.

Arthrodesis

Spring Ligament Repair

Spring Ligament Repair

Spring Ligament Repair

Spring Ligament Repair

Summary

• Repair needs focused on the stage and type of deformity.

• Talonavicular Joint needs addressed

• Flexible Need to repair Spring Ligament Complex

Thank You