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. 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. 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. Spring Ligament • Static Support of Medial Longitudinal Arch • Two Distinct Fibers Talus Navicular superomedial fibers Calcaneous inferior fibers Navicular Calcaneous Talus 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(1 Suppl):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. 2012 Oct;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 flexor hallucis 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.