On Anatomy Case Report and Technique Descrip?

Introducon Ligamentous stability is paramount in op)mizing func)on of the ankle joint. Although varus ankle malalignment is far more common, valgus ankle alignment involves 8% all end stage- Case Report and TechniQue Descrip)on arthri)c deformi)es.1 Clarke et al found that complete sec)oning of the deltoid resulted in This case we present was part of a staged total ankle. His index procedure included an ankle 15-20% decrease in ankle joint contact area as well as anterior talar translaon.2 arthrotomy with cement spacer and posi)onal screw placement, as well as a deltoid ligment Harper and colleagues demonstrated that injury to the deep deltoid leads to anterior and reconstruc)on. The pa)ent was a 76yo M with end stage ankle arthri)s and 12.1 degrees of lateral talar transla)on and compromise of the superficial deltoid has no effect.3 When preoperave ankle valgus, who failed an adequate trial of conservave care. Following his index encountered, valgus )lt and deltoid insufficiency need to be addressed to allow for long-term procedure as described below, he underwent a total ankle replacement approximately five weeks acer success of a total ankle prosthesis. Recrea)ng ligament balance may expand the limit of ankle this procedure He has been followed for 13 months post-opera)vely and has maintained neutral ankle prosthesis and allow for less early failure due to edge loading of the polyethylene component. alignment, without valgus )lt. Figure 4 Figure 5 It is important to understand ligamentous reconstruc)on is an adjunc)ve repair and proper An anterolateral ankle arthrotomy is u)lized to gain access to the ankle joint. A 2.4mm pin is inserted Then the 4.0mm reamer is inserted over the guidewires to drill your bial tunnels. A third tunnel osseous alignment is reQuired and can be achieved with hind foot osteotomies and/or fusions. into the talus to act as a lever arm and manually hold the ankle in the neutral posi)on. While an comple)ng the inverted “Y” shape that will connect the two bial tunnels and allow a common exit Insufficiency of the medial column may also need to be addressed in late stage flaToot. The assistant holds the ankle in a reduced, neutral posion, the surgeon will place a guide wire for a fully point 4-5cm proximal to the )p of the medial malleolus. This third bial tunnel is then reamed with the differences found in all cadaveric studies show we have yet to gain a complete understanding of threaded 4.5mm cannulated screw from the anterolateral distal leg that passes just anterior to the 4mm reamer (Figure 4) the anatomic complexity of the deep deltoid. Therefore, the most cri)cal bands for fibula, from the )bia into the talus. This guide wire for screw placement is just above the incision for reconstruc)on are also not known. One conclusion drawn from several studies is that ankle the ankle arthrotomy. Posi)on of guide wire is confirmed under intraopera)ve fluoroscopy. Once Finally, using a tendon passer each talar strand is passed from distal to proximal out the common exit congruence does rely on an intact deep deltoid. It is in our experience that deep deltoid sa)sfied, the length for the screw is determined with a depth gauge. The 3.2mm drill is u)lized to point (Figure 5 and 6). Next, hold the anterior allograc under manual tension out of the proximal hole integrity is the primary medial ligamentous restraint and reconstruc)on of the deep deltoid break through the bial cortex and engage the lateral bia. The appropriate screw is next inserted into grasping the excess tendon and whip-s)tch suture while a a 4x10mm PEEk anchor is inserted in the provides reliable and reproducible results. This case report and technique descripon for the distal )bia and across the talus. This screw is placed to maintain the neutrally aligned ankle. To anterior bial tunnel distally, securing the recreated DaTT ligament (Figure 7). The prior step is deltoid ligament reconstruc)on is in the context of end stage ankle arthri)s with incongruent protect this alignment, an)bio)c impregnated bone cement is prepared and then placed into the duplicated for the posterior strand and the posterior bial tunnel. The anterior and posterior allogracs ankle valgus. ankle joint. Once sa)sfied that the cement has set, the ankle can be released and it will be adeQuately are then sutured together with 2-0 non-absorbable suture and the excess tendon is excised. maintained in neutral alignment. A_en)on is then directed to the medial ankle where a curved longitudinal incision is planned just anterior to midline of the medial malleolus. The flexor re)naculum Anatomy The medial ankle ligament complex is most commonly thought to be composed of five separate is incised. The posterior bial tendon sheath is released and the tendon is retracted inferiorly. This exposes the medial ankle joint capsule and superficial deltoid complex. The superficial deltoid is then segments, however, it has been demonstrated that the makeup of the deltoid is more elaborate transversely incised as far back as it is necessary to expose the deep ligament complex and the and variable.4,5,6 The most cri)cal components of the deltoid ligament (DL) to repair or reconstruct are not yet known. superficial ligaments and joint capsule are retracted to allow exposure of the deep deltoid. Pankovich and Shivaram4 performed a cadaveric study describing the detailed anatomy of the DL. They found the deep component consists of two por)ons, the deep anterior biotalar If the ligament is ruptured it allows access to the medial talus where you insert your guide pins. If the ligament is not ruptured and only a_enuated it should be incised and retracted to allow for anatomic (DaTT) and the deep posterior talo)bial (DpTT). The DaTT is covered in)mately by the placement of your grac. The guide pins for the talar anchors are then inserted and their posi)on is biocalcaneal (TC) and is some)mes not discernable. The origin of the DaTT is the intercollicular groove and anterior colliculus, conguous with the DpTT. And travels distal and confirmed under fluoroscopy. The posterior pin should be at posterosuperior aspect of the medial talar body and the anterior pin should be at the anterior superior por)on of the medial talus body Figure 6 Figure 7 slightly anterior and inserts on the medial surface of the talus near the neck. The DpTT is thick, and takes origin from the posterior colliculus, posterior sulcus, medial surface of the posterior immediately inferior to the ar)cular car)lage of the trochlea. colliculus, and the en)re anterior margin of the intercollicular groove. It travels posterior, lateral Discussion Several techniQues have been described for reconstruc)on of the deltoid ligament. Deland and and distal and inserts onto the medial surface of the talus from the medial tubercle to the edge 7 of the posterior third of the ar)cular surface of the talar trochlea colleagues used peroneus longus autogra. In their technique they release the peroneus longus at midcalf and leave the inser)on intact. The freed proximal end is passed through the talus from lateral to Boss and Hintermann5 analyzed DL anatomy and found five primarily constant bands. These five ligaments are described in two layers, the superficial and a deep layers. The superficial layer medial and the tendon is then passed through a second tunnel from medial malleolus to the lateral typically crosses the biotalar and subtalar joints, while the deep layer crosses the biotalar bia. They used this technique in five paents achieving 5-8 degrees of valgus correcon in all (average 10 degrees preop to 3.6 degrees postop). Their lone failure among the five pa)ents came in a pa)ent joint only. In the majority of ankles, the superficial fibers originate from the anterior half and the p of the anterior colliculus, while the deep fibers arise from posterior half and the with a preopera)ve valgus )lt of 15 degrees, which may push the limit of their reconstruc)ve Figure 2 Figure 3 techniQue. Haddad and colleagues8 described a novel techniQue in a cadaveric study. Their techniQue intercollicular notch. They concluded that the TC and DpTT are the thickest and strongest of the medial ligaments, they are also close to parallel to the long axis of the )bia with the foot in recreates both the TC and the deep deltoid with a single strand techniQue u)lizing suture bu_on fixa)on in combina)on with a bial “post” screw and washer. Their techniQue did recreate s)ffness and neutral in the sagi_al plane. Because of this orienta)on and strength they are important in The talar inser)on holes are then reamed 17mm deep with a 5.5mm drill to allow inser)on of 5.5mm stability comparable to the intact deltoid. It is a technically challenging procedure and if a long resis)ng valgus )lt. In the most recent cadaveric study, x 15mm anchor (Figure 2) Prior to placing talar anchors, the peroneus longus allograc is prepared by crea)ng two 8cm separate gracs (strands) on the back table and they are trimmed to appropriate size stemmed bial component is u)lized, the post screw may interfere with the bial component of the prosthesis. Campbell et al6 described six total bands within the superficial and deep components of the (approximately 5.5mm in diameter) to make a snug fit in each tunnel without over-stuffing.

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