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Incongruent Ankle Valgus with Intact Deltoid

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Incongruent Ankle Valgus with Intact Deltoid INCONGRUENT ANKLE VALGUS WITH INTACT DELTOID – A NEW PATTERN OF ARTHRITIS Jeffrey Christensen, DPM, FACFAS; Ian Burtenshaw, DPM; Gavin Ripp, DPM Statement of Purpose & Literature Review Literature Review Analysis & Discussion It has long been understood the different restrictive motions that each ankle ligament It is common knowledge that an ankle valgus deformity is associated with deltoid To the authors’ knowledge, there has never controls. (1) The anterior talofibular (ATF) ligament restricts anterior subluxation of ligament insufficiency. However, we present 13 cases of ankle valgus deformity with a been a description of ankle valgus deformity the talus from the ankle mortise, while the calcaneofibular ligament (CFL) is primarily functionally intact deltoid and insufficient lateral ligaments. This appears to be an as a sequela of lateral ankle instability. All responsible for restricting varus tilt of the talus in the ankle mortise. (2-5) A cadaveric unrecognized pattern of end stage ankle arthritis. Accurate ligamentous balancing is patients relate a history of lateral ankle sprain study by McCullough et al demonstrated that after sectioning the ATF there was critical during total ankle arthroplasty. Furthermore, the long-term effects and as the original ankle injury. These patients increased anterior subluxation of the talus from the ankle mortise. There was also pathomechanical importance of a pure anterior talofibular ligament lesion needs to be had long-term ankle instability symptoms and noted an increase in internal rotation of the talus of 5.9 ± 1.9 degrees. Further reevaluated. presented as a candidate for ankle Methodology & Study Design sectioning of the CFL and PTFL led to an additional 5.4 ± 1.9 degrees of internal replacement with a mild to moderate rotation of the talus in the ankle mortise. (2) In Ringleb and his colleagues’ cadaveric incongruent valgus ankle deformity. At the We performed a retrospective observational analysis of 13 valgus ankle patients who study, they again showed that sectioning of the ATF resulted in an average of 8.8 time of total ankle replacement, a fully intact underwent total ankle arthroplasty with lateral ligament plication . Preoperatively it was degrees of anterior translation and internal rotation. (4) deltoid ligament was identified, coupled with observed that each ankle had end stage degenerative joint disease with a mild to excessive wear of the lateral ankle moderate valgus wear pattern. Radiographic intrinsic ankle valgus was measured by an Bonnel et al in a biomechanical study noted that the natural contour of the ankle compartment. In all 13 cases, there was clear independent foot and ankle surgeon. These measurements were performed on an AP joint incentivizes some anterior translation and internal rotation. This natural motion evidence of lateral ligament deficiency which radiograph with the bisection of the tibia compared to a tangential line of the tibial occurs due to an elevated lateral talar shoulder relative to the medial. The anterior required Brostrom stabilization after plafond in relation to a tangential line over the talar dome. In each case after the sloped tibial plafond then results in a “sliding” or rotation of the talus. They observed placement of the total ankle prosthesis. prosthesis had been placed, the deltoid ligament was taut and the lateral ankle ligaments that the periankle ligaments act primarily to restrict excess anterior sliding and were insufficient. Therefore a lateral ankle stabilization procedure (Brostrom) was internal rotation of the talus. (5) Tochigi et al confirmed this phenomenon in another We theorize that a chronic anterior drawer performed on each of the ankles in our study. cadaveric study in measuring tensile strain in the periankle ligaments in a loaded mechanism without an inversion moment Results ankle joint. (3) Leardini et al noted in his comprehensive review that the ATF is the will cause excessive wear of the lateral ankle most important stabilizer of the ankle joint and subsequently the primary restraint to compartment and eventual migration into a Figures 4 & 5: MRI taken of patient with ankle valgus. ATF is absent with ossicle present (top). Deltoid remains There were twelve men and one female included supination and anterior translation of the ankle. (6) valgus alignment as the ankle approaches intact (bottom). in the study. The average age was 58.3 years. All end stage arthritis. We suggest that this occurs in the setting of an intact deltoid patients had prior history of ankle sprains. 12/13 which then acts as a rotation fulcrum. This rotatory moment occurs in the setting of patients were replaced with the STAR prosthesis an absent or attenuated ATF which would normally restrict this internal rotation and one was replaced with the Inbone prosthesis. movement. Understanding and managing ligament pathology during total ankle The average talar tilt was 9.2 degrees valgus (3.25- arthroplasty is critical for surgical planning and for reproducible long-term 19.25). Average follow up was 1.69 years. Two outcomes. References patients required revision with a modified 1 - Brostrum, L. "Sprained Ankles 1: Anatomic Lesions in Recent Sprains." Acta Chir Scand128 (1964): 483+. Print. Christman-Snook using peroneus longus allograft. 2 - McCullough, C., and P. Burge. "Rotatory Stability of the Load-bearing Ankle." Journal of Bone and Joint Surgery 4th ser. st 62-B (1980): 460-64. Print. One patient had 1 tarsometatarsal fusion at same 3 - Tochigi, Yuki, M. J. Rudert, Annunziato Amendola, Thomas D. Brown, and Charles L. Saltzman. "Tensile Engagement of the time as replacement. Peri-Ankle Ligaments in Stance Phase." Foot and Ankle International 26.12 (2005): 1067-073. Print. 4 - Ringleb, Stacie I., Ajaya Dhakal, Claude D. Anderson, Sebastain Bawab, and Rajesh Paranjape. "Effects of Lateral Ligament Sectioning on the Stability of the Ankle and Subtalar Joint." Journal of Orthopaedic Research 29.10 (2011): 1459-464. Print. Figure 2: CT Arthrogram of valgus ankle patient Figure 3: Arthroscopic image of the lateral ankle 5 - Bonnel, F., E. Toullec, C. Mabit, and Y. Tourné. "Chronic Ankle Instability: Biomechanics and Pathomechanics of Ligaments Injury and Associated Lesions." Orthopaedics & Traumatology: Surgery & Research 96.4 (2010): 424-32. Print. Figure 1: Ankle Valgus demonstrating intact medial cartilage and lateral wear pattern in setting of lateral ankle instability in cartilage wear patient with valgus ankle on plain radiographs 6 - Leardini, A., J. J. O'conner, F. Catani, and S. Giannini. "The Role of the Passive Structures in the Mobility and Stability of the Human Ankle Joint: A Literature Review." Foot and Ankle International 21.7 (2000): 602-15. Print..
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