Chronic Deltoid Ligament Insufficiency Repair with Internal Brace
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Foot and Ankle Surgery 25 (2019) 812–818 Contents lists available at ScienceDirect Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas TM Chronic deltoid ligament insufficiency repair with Internal Brace augmentation$ a, a a b c a M.J. Pellegrini *, N. Torres , N.R. Cuchacovich , P. Huertas , G. Muñoz , G.M. Carcuro a Department of Orthopaedic Surgery, Hospital Clinico Universidad de Chile, Clinica Universidad de Los Andes, Santos Dumont 999, Independencia, Santiago, 7640275, Chile b Medical Education Department, Senior Clinical Specialist Foot and Ankle, Naples, FL, USA c Department of Orthopaedic Surgery, Clinica Las Condes, Lo Fontecilla 441, Las Condes, Santiago, 7591046, Chile A R T I C L E I N F O A B S T R A C T Article history: Background: Patients with chronic deltoid ligament insufficiency (CDLI) present a challenging situation. Received 4 April 2018 Although numerous procedures have been described, optimal treatment is still a matter of debate. While Received in revised form 8 October 2018 the treatment armamentarium ranges from simple ligament repair to complex reconstructions with or Accepted 16 October 2018 TM without realignment osteotomies, direct repair augmented with an Internal Brace device appears to be an attractive intermediate option. We investigated functional outcomes and complications in patients Keywords: TM with CDLI operated on using Internal Brace augmentation. Chronic deltoid ligament insufficiency Methods: A prospective study was conducted. Patients were included if they presented medial ankle pain Augmentation and/or giving way, exhibited asymmetric flexible hindfoot valgus, failed conservative treatment, and had Internal Brace a positive MRI evaluated by an independent radiologist. Patients with stage IV flatfoot deformity, Ankle instability neuropathy and/or inflammatory arthritis were excluded. CDLI was confirmed intraoperatively with the arthroscopic drive-through sign. Patients were evaluated preoperatively and postoperatively using FAAM, SF-36 and grade of satisfaction. Paired t-tests were used to assess FAAM and SF-36 scores variation. Results: Thirteen patients met inclusion criteria. No patient was lost to follow-up, with a mean follow-up time of 13.5 months (range 6-21). Preoperative FAAM and SF-36 scores improved from 58.7 to 75.3 and from 60.2 to 84.4 postoperatively, respectively (p<.01). Two implant failures were observed, with no apparent compromise of construct stability. No patient was re-operated. TM Conclusions: Our results suggest that deltoid ligament repair with Internal Brace augmentation in patients with CDLI is a reliable option with good functional outcomes and high satisfaction grade in short term follow-up. Level of evidence: Level IV. © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. 1. Introduction Several anatomic descriptions have been enunciated, being the division into superficial and deep components the most widely The deltoid ligament is the main stabilizer of the ankle joint, accepted [1–4]. Traditional anatomic knowledge describes three being the primary medial stabilizer and valgus restrainer. constant bands for the medial collateral ligament; namely, Moreover, not only restricts anterior translation of the talus, but tibiospring and tibionavicular ligaments (superficial); and deep lateral translation as well [1]. posterior tibiotalar ligament. Other ligaments have been variably described and include the superficial posterior tibiotalar ligament, tibiocalcaneal ligament, and deep anterior tibiotalar ligament [1,2,5,6]. However, more recent investigations suggest that this $ anatomic structure should not be falsely divided into these Investigation performed at Hospital Clinico Universidad de Chile and Clinica Las components, as they function anatomically and biomechanically Condes, Department of Orthopaedic Surgery, Faculty of Medicine, Universidad de as a single “unit”: the medial ligament complex; including the Chile, Santiago, Chile. * Corresponding author. deltoid, spring ligament and posterior tibial tendon [7–9]. E-mail addresses: [email protected] (M.J. Pellegrini), In such scenario, not only does the medial ligament complex [email protected] (N. Torres), [email protected] stabilize the ankle against pronation, but also provides rotational (N.R. Cuchacovich), [email protected] (P. Huertas), stability [1,6]. Despite this anatomic and biomechanical relevance, [email protected] (G. Muñoz), [email protected] (G.M. Carcuro). the value of the medial ligament complex has been neglected by https://doi.org/10.1016/j.fas.2018.10.004 1268-7731/© 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. M.J. Pellegrini et al. / Foot and Ankle Surgery 25 (2019) 812–818 813 Fig. 1. Left asymmetric valgus with pronation of the forefoot that corrects with the activation of the posterior tibial tendon. the orthopedic literature and only recently has come to orthopedic literature [21–23,26], with no one demonstrating superiority over surgeon’s attention [10–12]. In fact, anatomic repair in ankle others. To complicate things more, it is hard to draw definitive fractures with deltoid rupture is the treatment of choice for many conclusions from the available literature as most of these surgeons [13–15]. procedures are performed in conjunction with calcaneal and/or Patients failing non-operative treatment, including neuromus- supramalleolar osteotomies. cular and proprioceptive training, for lateral chronic ankle We believe there is an intermediate alternative between instability will frequently undergo surgery, most commonly some repairing and reconstructing the deltoid ligament, without sort of Brostrom repair. Nevertheless, about 26% will not be realignment osteotomies. However, clinical data of augmented satisfied with the procedure at 9 years follow up [16]. In such medial ligament repair are lacking. Therefore, we designed a scenario, possible failure causes must be ruled out; including prospective case series to investigate functional performance of technical errors, malalignment or unrecognized medial or patients undergoing medial ligament repair with augmentation multidirectional instability. A high index of suspicion must be using Internal Brace (Arthrex,Inc., Naples FL, USA) and their surgical maintained in those patients presenting with medial ankle pain, complications. giving way sensation and asymmetric hindfoot valgus deformity that can be corrected by plantarflexion of the affected ankle [11,26] 2. Methods (Fig.1). In those cases, multidirectional instability should remain as the main diagnostic possibility [10,17]. After obtaining IRB approval, a prospective study was con- Surgical management of this pathology is still controversial. ducted. Between January 2015 and October 2016, thirteen patients Most of the available evidence regarding medial ankle instability were operated on with this technique. Patients were included in constitute a poor body of knowledge, including cases series with a the study if they presented clinical findings compatible with small number of patients, cases report and standardization paucity chronic medial insufficiency, failed conservative treatment, and [9,14,18–24]. Despite these inherited limitations, some authors will had a MRI evaluated by an independent radiologist confirming advocate tightening and repairing the native deltoid ligament to medial complex disruption. No case with bilateral ankle instability the medial malleolus. Moreover, some authors even suggest that was included in the study. All patients underwent a minimum of complete rupture of the deltoid ligament could benefit from being three months of non-operative treatment including physiotherapy acutely repaired if the lateral ligaments or syndesmosis are with neuromuscular training. Patients with stage IV flatfoot unstable [25]. deformity, neuropathy and/or inflammatory arthritis were exclud- However, some concern remains regarding quantity and ed from the study. All patients underwent functional evaluation quality of the residual ligament and the fact that repairing is through Spanish version of 36 item short form survey (SF-36), Foot not always possible, in particular in those patients with long term and Ankle Ability Measure (FAAM) and satisfaction survey. Finally, deformities. diagnosis was confirmed during surgery using the ankle drive For the above-mentioned reasons, other investigators have through sign [27], which consists of introducing a 5 mm probe into suggested that the medial ligament should be reconstructed using the back of the ankle through the medial gutter during arthroscopy allograft or autograft. Several techniques have been reported in the (Fig. 2). Fig. 2. a. Diagnosis was confirmed during surgery using the ankle drive through sign, which consists of introducing a 5 mm probe into the back of the ankle through the medial gutter during arthroscopy; b. denuded medial malleolus demonstrating the absence of medial ligament complex proximal insertions. MM = medial malleolus; MG = medial gutter; Ta = talus. 814 M.J. Pellegrini et al. / Foot and Ankle Surgery 25 (2019) 812–818 2.1. Surgical technique All patients were operated on in the supine position. After antibiotic prophylaxis was administered and the extremity was prep and draped, gravity exsanguination was performed and maintained through a thigh tourniquet. Ankle arthroscopy was realized though standard anteromedial and anterolateral portals using a 2.9 mm, 30 arthroscope