spring ligament in acquired adult flat foot deformity: static and … · 2017-10-19 · even fiber...

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Spring ligament in acquired adult flat foot deformity: staticand dynamic sonographic evaluation

Poster No.: P-0030

Congress: ESSR 2013

Type: Scientific Exhibit

Authors: E. GALLARDO AGROMAYOR1, H. Vidal Trueba2, B. González

Humara2, R. M. LANDERAS2, R. Garcia Barredo2, M. R. DE LA

PUENTE FORMOSO2; 1Santander, CANTABRIA/ES, 2Santander/ES

Keywords: Education and training, Technical aspects, Ultrasound,Musculoskeletal soft tissue

DOI: 10.1594/essr2013/P-0030

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Purpose

Recognize the normal sonoanatomy of the static and dynamic stabilizers of the mediallongitudinal arch pf the foot: porterior tibial tendon, calcaneonavicular ligament and sinustarsi ligaments. ( Fig. 1)

Illustrate the main findings of the spring ligament degeneration and rupture in patientswith acquired flatfoot deformity.

Propose a systematic exploration with a static and dynamic ecographic approach inpatients with suspicion of posterior tibial tendon insuficciency

Methods and Materials

During the last three years, we prospectively reviewed the sonographic findings inpatients referred to our department, from an orthopaedic surgeon, with a clinical diagnosisof flat foot (FF) due to posterior tibial insufficiency or pain in the medial aspect of theankle with physical examination and radiographs consistent with flatfoot assessed at themoment of ultrasound examination. All of them during the initial phase of the disease.

We performed a systematic exploration of the ankle with a high linear array transducer(8-13 MHz), focused on the evaluation of the medial stabilizers, posterior tibial tendon(PTT) and calcaneonavicular ligament or spring ligament complex (SLC). Sonographictechnique of the SLC was the same reported in other works. (Fig.1)

Ultrasound criteria for diagnosing PTT tendinosis are widely described. We consideredsigns of degeneration of the spring ligament the decrease of its echogenicity, increaseof thickness in the axial scan, >4mm, and the presence of loss of fibrillar pattern andeven fiber disruption.

We evaluated the presence of peritalar destabilization in all patients, measuring themedial talus bone motion from the sitting position to the standing position (fig. 2). Forthis purpose, we based on the coxa pedis model (Fig. 3(3,4)); we measured the talarhead coverage and medial subluxation as it is explained in figure 4 (5-8). We considerednormal when talar head location maintains lateral to the medial cortex of the navicularbone, medial subluxation when there is an adduction movement of the talus bone, leavingits head partially uncovered.

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Images for this section:

Fig. 1

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Fig. 2

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Fig. 5

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Fig. 8

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Results

We reviewed 47 cases in 38 patients, 27 women and 11 men, age range from 20 to 72years and mean age of 54 years.

PTT signs of tendinosis were present in 28 of the 47 (59,5%) studied ankles and thespring ligament was abnormal in 41 of them (87,2%) (Fig. 5(9)). The most affected area ofthe SLC was the distal part of the superomedial component in all cases and we visualizeda fibrillar disruption in 13 out of the 41cases (Figs. 6-8(10-12)).

The evaluation of the peritalar destabilization demonstrated the following data:

a) In 9 ankles there were no movement of the talar head from the sitting to the standingposition. All of them showed degeneration signs of SLC without rupture; only in 2 cases(22%) there were abnormalities of the PTT. (Fig.9(13))

b) In 13 cases a clear movement of the talar head was visualized, always in adduction.Degeneration signs of the spring ligament was assessed in 81% and 27% of them weredistally rupture. 63 % of them had also TTP degeneration. (Fig.10(14))

c) Finally there were 25 cases with medial subluxation of the talar head. Degenerationsigns of the SL was assessed in 95% of the cases and 63% of them were distally rupture.In this group tendinosis of the PTT was reported in 50% of the cases. (Figs. 11,12 (15,16))

Images for this section:

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Fig. 9

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Fig. 10

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Fig. 11

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Fig. 12

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Fig. 13

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Fig. 14

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Conclusion

The stimulus for this investigation was our belief that the treatment of symptomatic flatfoot in adults was not always based on objective data. We focused our study on theassessment of spring ligament degeneration and peritalar destabilization in an attemptto clarify two main points: first, the radiological literature of the acquired adult flat foot isbased on the study of the posterior tibial tendon and PTT insufficiency is considered themain cause of this disorder, however imaging techniques may show no abnormalities inthis structure. Secondly, in the last decade the spring ligament complex has raised animportant role in the study and treatment planning of patients with this disorder, mainlyin the early stage of the disease. However, preoperative integrity of the functional springligament is difficult to determine by physical examination alone.

For the design of this study we considered two important functions of the SLC:

First, it supports the head of the talus, forming the medial and plantar parts of the articularcavity of the talar head. The articular cavity of the talar head is also called the acetabulumpedis or "coxa pedis". This complex cavity consists of the anterior and middle articularfacets of the calcaneus, the proximal articular surface of the navicular bone, and thespring ligament complex. Besides that, the contiguous skeletal relations of the talus bonewith the navicular and calcaneus and the absence of muscular insertions; cause the pullof gravity to stimulate talar adduction and plantar flexion.

Second, the spring ligament-together with the PTT, the plantar fascia, and the plantarligaments- is an important stabilizer of the longitudinal arch of the foot. Lesions in thesestructures can result in flatfoot deformity.

In our study, all patients were referred, specifically, for flat foot with suspected PTTinsufficiency, however tendinosis ot that tendon was assessed only in 59,5% of theankles, whereas a significant degeneration of the SLC was visualized in 87% of the cases;demonstrating the capital importance of this ligament complex on its own, in maintainingthe normal alignment and height of the medial longitudinal arch.

Abnormality of the spring ligament has a high association with advanced posterior tibialtendon injury; in our study 92% of our patients with PTT tendinosis has also signs ofSLC degeneration. It is generally assumed that degeneration of SLC is secondary to thedynamic stabilizers tendons, however this study shows that degeneration signs aremore frequently visualized in SLC than in PTT, in this entity. The larger superomedialcomponent plays the most significant role in the contribution of the spring ligament toankle stability and is the component most often torn; as we corroborate in our study:the degeneration signs were more pronounced distally within the ligament and all of theruptures were visualized that area.

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Other important fact that we considered in this study, was the theory of Pisani about theperitalar destabilisation as a development deficiency, of one or more, of the stabilisingcomponents of the coxa pedis: a)the intrinsic articular disease that is often degenerative;b) a myotendinous disease that is frequent in the posterior tibial tendon; and c)loss of passive stability by superomedial and plantar calcaneonavicular ligaments, thelast one known as degenerative glenopathy . While standing upright the ligamentousstructures guarantee, passively, peritalar stabilisation. In this study, we attempted todemonstrate this later fact measuring the talar adduction on standing position: weassessed destabilisation more frequently in cases with both SLC degeneration andPTT tendinosis; additionally, in those patients with clear adduction of the talar headwhile standing, was more frequent the rupture of the SLC.

We proposed a new way to objectify and measure the peritalar destabilization, witha dynamic sonographic study; more studies are necessary to confirm these findings andto standardize the normal values of range motion in general population.

In conclusion, ultrasound is an accurate technique in the evaluation of the springligament, and its signs of degeneration are more frequently visualized than PTTtendinosis in patients with acquired flat foot in their initial phases. We considerthat the dynamic sonographic evaluation of talar adduction would be useful for amore accurate surgical planning.

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Deland JT. The adult acquired flatfoot and spring ligament complex: pathology andimplications for treatment. Foot Ankle Clin 2001; 6:129-135.

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Harish S, Jan E, Finlay K, Petrisor B, Popowich T, Friedman L, et al. Sonography of thesuperomedial part of the spring ligament complex of the foot: a study of cadavers andasymptomatic volunteers. Skeletal Radiol 2007; 36(3): 2218.

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spring ligament in acquired adult flat foot deformity: static and … · 2017-10-19 · even fiber...

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