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