Interosseous Talocalcaneal Ligament Research Articles

Reconstruction of the interosseous talocalcaneal ligament using allograft for subtalar joint stabilization is effective

PurposeThe aim of this study was to assess the biomechanical effects of subtalar ligament injury and reconstruction on stability of the subtalar joint in all three spatial planes.MethodsFifteen fresh frozen cadaveric legs were used, with transfixed tibiotalar joints to isolate motion to the subtalar joint. An arthrometer fixed to the lateral aspect of the calcaneus measured angular displacement in all three spatial planes on the inversion and eversion stress tests. Stress manoeuvres were tested with the intact joint, and then repeated after sequentially sectioning the inferior extensor retinaculum (IER), cervical ligament (CL), interosseous talocalcaneal ligament (ITCL), arthroscopic graft reconstruction of the ITCL, and sectioning of the calcaneo-fibular ligament (CFL).ResultsSectioning the ITCL significantly increased angular displacement upon inversion and eversion in the coronal and sagittal planes. Reconstruction of the ITCL significantly improved angular stability against eversion in the axial and sagittal planes, and against inversion in the axial and coronal planes, at the zero time point after reconstruction. After sectioning the CFL, resistance to eversion decreased significantly in all three planes.ConclusionProgressive injury of ligamentous stabilisers, particularly the ITCL, led to increasing angular displacement of the subtalar joint measured with the inversion and eversion stress tests, used in clinical practice. Reconstruction of the ITCL using tendon graft significantly stabilised the subtalar joint in the axial and sagittal planes against eversion and in the axial and coronal planes against inversion, immediately after surgery.

The Role of the Plantar Fascia in Supporting the Arch in Flatfoot Deformity

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: The osseous structure of the foot has been described as an arch-like triangular structure or truss where the plantar fascia (PF) functions as the tensile element, maintaining the overall length of the arch. The importance of the PF in maintaining the arch has likely been underestimated because only minor abnormalities in its structure are seen on MRI studies in patients with flatfoot deformity. However, the importance of a ligament in preventing deformity may not be correlated with its attenuation seen on MRI. We hypothesized that the degenerative elongation of the plantar fascia would be a necessary precursor of arch collapse. The goal of this study was to evaluate the role of the plantar fascia in arch stability in flatfoot deformity. Methods: We used a validated finite element model of the foot reconstructed from CT scan of a female cadaveric foot weighing 60 kg. The model included 28 bones, 72 ligaments, cartilage, and an encapsulating soft tissue. The flatfoot model was created by simulated transection of the ligaments and unloading of the posterior tibial tendon. The model was used to assess the impact of isolated PF failure on the development of flatfoot deformity, evaluate the capability of the PF when reconstructed to restore foot alignment, and determine the amount of progressive strain that constitutes failure for each ligament. Foot alignment angles were used to evaluate the foot alignment. For comparison, the angles were also evaluated for other ligament tears. The impact of PF failure on force changes in the remaining ligaments was also investigated by quantifying ligament force changes during simulated PF cutting in the foot model. Results: When compared to the intact and flatfoot models, we found that the individual release of the PF cannot cause deformity (Figure 1). However, it significantly increased the force in the long (142%) and short plantar (156%), deltoid (45%), and spring ligaments (60%), potentially putting the foot at risk of arch instability over time. Moreover, we found that the PF was the structure most able to restore the arch (Figure 1a). The PF was also found to play a secondary role in reducing hindfoot valgus and forefoot abduction deformities (Figures 1b,1c). Moreover, to produce deformity, a considerable amount of attenuation in the spring (strain= 41%) and interosseous talocalcaneal ligament (strain= 27%), but only a small amount in the plantar fascia (strain= 10%) was needed. Conclusion: In comparing normal to flatfoot models of the foot, we found that isolated PF release did not cause arch collapse, but that arch collapse could not occur without elongation of the PF. While the progressive strain in the PF needed to enable arch collapse was small, the PF is a very long ligament, thus even small strain within the PF corresponds to substantial change in overall length of the arch. Chronic degeneration of the PF leading to plantar fasciitis may be an early sign of impending flatfoot deformity.

Role of the intrinsic subtalar ligaments in subtalar instability and consequences for clinical practice.

Subtalar instability (STI) is a disabling complication after an acute lateral ankle sprain and remains a challenging problem. The pathophysiology is difficult to understand. Especially the relative contribution of the intrinsic subtalar ligaments in the stability of the subtalar joint is still controversial. Diagnosis is difficult because of the overlapping clinical signs with talocrural instability and the absence of a reliable diagnostic reference test. This often results in misdiagnosis and inappropriate treatment. Recent research offers new insights in the pathophysiology of subtalar instability and the importance of the intrinsic subtalar ligaments. Recent publications clarify the local anatomical and biomechanical characteristics of the subtalar ligaments. The cervical ligament and interosseous talocalcaneal ligament seem to play an important function in the normal kinematics and stability of the subtalar joint. In addition to the calcaneofibular ligament (CFL), these ligaments seem to have an important role in the pathomechanics of subtalar instability (STI). These new insights have an impact on the approach to STI in clinical practice. Diagnosis of STI can be performed be performed by a step-by-step approach to raise the suspicion to STI. This approach consists of clinical signs, abnormalities of the subtalar ligaments on MRI and intraoperative evaluation. Surgical treatment should address all the aspects of the instability and focus on a restoration of the normal anatomical and biomechanical properties. Besides a low threshold to reconstruct the CFL, a reconstruction of the subtalar ligaments should be considered in complex cases of instability. The purpose of this review is to provide a comprehensive update of the current literature focused on the contribution of the different ligaments in the stability of the subtalar joint. This review aims to introduce the more recent findings in the earlier hypotheses on normal kinesiology, pathophysiology and relation with talocrural instability. The consequences of this improved understanding of pathophysiology on patient identification, treatment and future research are described.

Relationship between Joint and Ligament Structures of the Subtalar Joint and Degeneration of the Subtalar Articular Facet.

This study aimed to clarify the relationship between the joint and ligament structures of the subtalar joint and degeneration of the subtalar articular facet. We examined 50 feet from 25 Japanese cadavers. The number of articular facets, joint congruence, and intersecting angles were measured for the joint structure of the subtalar joint, and the footprint areas of the ligament attachments of the cervical ligament, interosseous talocalcaneal ligament (ITCL), and anterior capsular ligament were measured for the ligament structure. Additionally, subtalar joint facets were classified into Degeneration (+) and (-) groups according to degeneration of the talus and calcaneus. No significant relationship was identified between the joint structure of the subtalar joint and degeneration of the subtalar articular facet. In contrast, footprint area of the ITCL was significantly higher in the Degeneration (+) group than in the Degeneration (-) group for the subtalar joint facet. These results suggest that the joint structure of the subtalar joint may not affect degeneration of the subtalar articular facet. Degeneration of the subtalar articular facet may be related to the size of the ITCL.

Total Talar Replacement: Surgical Technique.

Total talar replacement is a salvage procedure for end-stage osteonecrosis of the talus. A customized total talar implant is designed with use of computed tomography scans of the healthy opposite side and made of alumina ceramic. The use of such an implant is potentially recommended, with a guarded prognosis, for the treatment of traumatic, steroidal, alcoholic, systemic lupus erythematous, hemophilic, and idiopathic pathologies. The talus is surrounded by the tibia, fibula, calcaneus, and navicular bones, which account for a large portion of the articular surface area. Yoshinaga9 reported that alumina ceramic prostheses were superior in terms of congruency and durability of articular cartilage compared with 316L stainless steel in an in vivo test in dogs. Therefore, alumina ceramic is an ideal material for replacement of the talus to preserve postoperative hindfoot mobility. Total talar replacement is performed with the patient in a supine position. The anterior ankle approach is utilized to exteriorize the talus, facilitating dissection of the ligaments and joint capsule attached to talus. The first osteotomy is performed around the talar neck, perpendicular to the plantar surface of the foot. The talar head fragment is then removed. Subsequent talar osteotomies are performed parallel to the first cutting line, at approximately 2-cm intervals. The attaching articular capsule and ligaments are dissected in each step. The removal of the posterior talar bone fragments is succeeded by careful dissection of the ligament and joint capsule under the periosteum. After dissecting the remaining interosseous talocalcaneal ligament, the foot is distally retracted and a customized talar implant is inserted. After testing and confirming the stability and mobility of the implant, the wound is irrigated with use of normal saline solution. A suction drain is placed anterior to the implant, and the skin is closed after repairing the extensor retinaculum. In cases with a limited area of necrosis, symptoms may improve with a patellar tendon-bearing brace. However, in many cases of symptomatic osteonecrosis of the talus, nonoperative treatment is not expected to improve symptoms. Alternative surgical procedures include ankle arthrodesis and hindfoot arthrodesis, but there are risks of nonunion, leg-length discrepancy as a result of extensive bone loss, and functional decline because of loss of hindfoot motion. Total talar replacement is a fundamentally unique treatment concept in which the entire talus is replaced with an artificial implant. Compared with ankle or hindfoot arthrodesis, this procedure preserves the range of motion of the foot and allows for earlier functional recovery. Postoperative results were satisfactory in the subjective evaluation, with no failure requiring revision. This procedure reduces the risk of postoperative failure in patients who are elderly and/or have underlying diseases, who often require a long recovery time. As the talus is a small bone with uniquely vulnerable vascularity, treatment of talar pathology is usually difficult; however, total talar replacement is a potential treatment option for patients with end-stage osteonecrosis of the talus without obesity. The greatest advantage of total talar replacement is the preservation of ankle and hindfoot mobility. Second, a customized talar prosthesis based on a mirrored model of the contralateral, unaffected talus will allow the smooth transfer of body weight from the lower leg to the heel and forefoot-a requirement for a stable gait. Third, the artificial talar prosthesis has a potential advantage in that it minimizes leg-length discrepancy, preventing daily inconvenience for the patient. Twenty years after the development of the implant, replacement with a total talar prosthesis resulted in a median score of 97 out of 100 on the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale as an objective evaluation and yielded a significant improvement in the subjective evaluation of the Ankle Osteoarthritis Scale (AOS) in a follow-up study over 10 years. The median ankle joint range of motion was 45°, and complications requiring implant replacement never occurred. The skin incision should be placed at the center of the inferior tibial articular surface and curved medially to avoid the medial branch of the superficial peroneal nerve.During the resection of the talus, the attaching ligament and joint capsule are recommended to be debrided prior to osteotomy.Bone fragments should be removed as an entire block in order to avoid leaving small fragments.When inserting the artificial talus, pull the entire foot distally by grasping the heel in order to avoid excessive plantar flexion.During wound closure, the extensor retinaculum should be repaired to avoid skin bowstringing.Although favorable long-term results have been reported, postoperative outcomes in patients with high body mass index have not been adequately investigated. This procedure should be carefully selected on the basis of the physical characteristics of the patient. AVN = avascular necrosis (osteonecrosis)SLE = systemic lupus erythematousCAD = computer-aided designCT = computed tomographyJSSF = Japanese Society for Surgery of the FootIQR = interquartile rangeAOS = Ankle Osteoarthritis ScalePWB = partial weight-bearingW = weeks.

A Relationship between Anterior Talar Migration in the Sinus Tarsi on Weightbearing Computed Tomography and Failure of the Talocalcaneal Interosseous Ligament in Progressive Collapsing Foot Deformity

Category: Hindfoot; Midfoot/Forefoot Introduction/ Purpose: Progressive collapsing foot deformity (PCFD) is a complex condition thought to be incited by ligament failure. The spring ligament has been extensively studied, and its reconstruction as part of the PCFD correction is becoming more popular. Failure of the interosseous ligament may also be a key contributor, although its role is less described. Since the advent of weightbearing computed tomography (WBCT), the sinus tarsi talocalcaneal relationship has been shown to correlate with the foot deformity as well as the ligament status surrounding the talus. This study aimed to identify when the interosseous and spring ligaments begin to fail in PCFD. Both WBCT and high-quality magnetic resonance imaging (MRI) were used to identify sinus tarsi morphologies involved in failure of the interosseous and spring ligaments. Methods: This study included 82 PCFD patients (mean age: 51.8 years) who underwent preoperative WBCT and MRI. Sinus tarsi morphology on WBCT was categorized into two major categories based on the anterior migration of the talus over the calcaneus on sagittal images: No-migration (Type 1) and Migration (Type 2). Then, a subgroup was established based on the presence of bony impingement: a: no-impingement; b: impingement (Figure 1). Two radiologists evaluated the status of the ligaments around the talus, including the spring and interosseous ligaments, as normal, insufficiency, or tear. On WBCT images, axial plane talocalcaneal subluxation was determined by comparing the talar and calcaneal axes to the transmalleolar axis. The status of the ligaments, degree of talocalcaneal subluxation and calcaneofibular impingement on WBCT, and four plain radiographic parameters of each type were compared. A weighted kappa test was used to determine the interrater reliability of the classification system among six observers. Results: Major categorization revealed distinct differences between the two types, with the migration type (n=38) demonstrating a larger prevalence of torn spring (superomedial: 47.4% and inferomedial: 42.1%) and interosseous (47.4%) ligaments, a greater degree of internal rotation of the talus and talocalcaneal subluxation, and a greater deformity on plain radiographs than the no- migration type (n=44, Table 1). Out of 21 patients with torn interosseous ligament, only 6 (28.6%) exhibited bony calcaneofibular impingement, and these were all Type 2b patients. Except for differences in Meary's angle and Talonavicular coverage angle between Type1a and Type1b, subtypes based on impingement did not exhibit significant differences on MRI, WBCT, or plain radiographic findings. Interrater reliability testing showed substantial agreement between observers, with a kappa of 0.792 (95% confidence interval: 0.713-0.877). Conclusion: While failure of the interosseous ligament is known to occur at the latest stage of PCFD when there is bone on bone calcaneofibular impingement, our study reveals that failure commences during the transition from moderate to severe deformities. This correlates with the anterior migration of the talar process relative to the angle of Gissane in the sagittal plane as well as talar internal rotation in the axial plane. These findings imply that like spring ligament reconstruction, interosseous ligament reconstruction may serve a role in correcting PCFD in somewhat earlier as well as more advanced stages.

Comparative Analysis of Subtalar Ligaments Between Patients With Talocalcaneal Coalition and Control Subjects Using 3-Dimensional Magnetic Resonance Imaging.

The purpose of this study was to find the differences in the subtalar ligaments between patients with talocalcaneal (TC) coalition and control subjects using 3-dimensional isotropic magnetic resonance imaging. Magnetic resonance imaging of 27 ankles with TC coalition and 27 age- and sex-matched controls were retrospectively reviewed. Absence of cervical ligament, anterior capsular ligament (ACL), interosseous TC ligament (ITCL), and partial or complete absence of 3 roots of the inferior extensor retinaculum was analyzed. Thickness and width of ACL and ITCL were measured when possible. Absence of ACL and ITCL was significantly more frequent in TC coalition patients than in controls (59.2% vs 7.4%, P < 0.0001; 44.4% vs 7.4%, P = 0.004). Absence of cervical ligament and 3 roots of the inferior extensor retinaculum did not differ between the 2 groups. Thickness and width of ACL were significantly smaller in TC coalition patients than in control subjects (0.81 ± 0.23 vs 1.27 ± 0.41 mm, P < 0.0001; 5.26 ± 1.17 vs 7.07 ± 1.46 mm, P = 0.001). Thickness and width of ITCL did not differ between the 2 groups. In the TC coalition group, the absence of ACL and ITCL did not differ according to coalition type, patient demographics, and magnetic resonance imaging units. Anterior capsular ligament and ITCL are frequently absent in TC coalition patients. Even when present, the ACL is attenuated in TC coalition patients compared with controls.

Talocalcaneal Interosseous Ligament Provides Greatest Talar Stability in the Sagittal Plane

Category:Hindfoot; AnkleIntroduction/Purpose:Talar ANV, trauma, and implant failure or collapse after TAR are major challenges in foot and ankle surgery. Custom total talar implants are a promising option for such conditions and have shown promising results. However, there are no biomechanical studies examining the kinematics of total talus implant. We aimed to investigate the critical stabilizers of the native talus and the biomechanics of a total talar replacement. We hypothesize that the stability an implant is less affected by medial and lateral ligaments, with partial stability provided by the tibiotalar mortise, and the most instability occurs on the talocalcaneal joint due to absence of plantar restraint. Total talar implant will be most unstable in the sagittal plane, especially in heel-raise position.Methods:Eight cadaveric samples underwent biomechanical testing in a midstance and seated heel-raise models in an E10000 Instron testing system. An OptiTrack system was used to record the 3D positions of the tibia, talus, calcaneus, navicular and first metatarsus throughout testing. The Achilles tendon was loaded in tension, while the tibia was cyclically loaded. The lateral ligaments, deep deltoid ligaments, talonavicular joint capsule, and the talocalcaneal interosseous ligament (TCIL) were sequentially released and underwent cycles in midstance and heel-raise positions after each release. The talus was removed and replaced to simulate total talar implant. Lastly, TA, EHL, and EDL were sutured into place to provide static soft tissue coverage of the talus, and final kinematics were measured. Data was analyzed to determine the joint motion and joint angles. Each ligament release was compared to one another using a one-way ANOVA, and compared to the initial condition using a one-sample t-test.Results:Eight cadaveric foot and ankle models were examined (four left feet and four right feet). Under maximum force in a simulated seated plantarflexion position, gradual increase in talonavicular sagittal angle compared to initial condition was noted with sequential soft tissue releases. The talar dorsiflexion angle showed no significant change after lateral ligament, deltoid ligament, and talonavicular joint capsular releases. However, a significant increase in the talar dorsiflexion angle (4.38+/-4.04o ) was noted after the interosseous ligament release compared to initial condition (p= 0.02). Similarly, the displacement of the talus relative to the navicular was significantly increased after the talonavicular joint capsule release (1.47+/-1.33 mm, p = 0.03) and the interosseous ligament release (5.28+/-3.82 mm, p = 0.01).Conclusion:In this study, we utilized native talus as a surrogate for a custom total talar implant to investigate the peritalar kinematics of the total talus implant. We found that the TCIL provides the most talar stability in the native ankle joint. Without the TCIL, the talus is most unstable in the sagittal plane, especially during the simulated heel-raise position. Significant medial and lateral stability of the tibiotalar joint maybe provided by the mortise of the ankle joint. Taken together, recreation of the TCIL or plantar stabilization of the implant should be considered to improve stability of a total talar implant.

The role of medial ligaments and tibialis posterior in stabilising the medial longitudinal foot arch: a cadaveric gait simulator study

BackgroundDebate exists whether adult acquired flatfoot deformity develops secondary to tibialis posterior (TibPost) tendon insufficiency, failure of the ligamentous structures, or a combination of both. AimThe aim of this study is to determine the contribution of the different medial ligaments in the development of acquired flatfoot pathology. Also to standardise cadaveric flatfoot models for biomechanical research and orthopaedic training. MethodsFive cadaveric feet were tested on a dynamic gait simulator. Following tests on the intact foot, the medial ligaments – fascia plantaris (FP), the spring ligament complex (SLC) and interosseous talocalcaneal ligament (ITCL) – were sectioned sequentially. Joint kinematics were analysed for each condition, with and without force applied to TibPost. ResultsEliminating TibPost resulted in higher internal rotation of the calcaneus following the sectioning of FP and SLC (d>1.28, p = 0.08), while sectioning ITCL resulted in higher external rotation without TibPost (d = 1.24, p = 0.07). Sequential ligament sectioning induced increased flattening of Meary’s angle. ConclusionFunction of TibPost and medial ligaments is not mutually distinctive. The role of ITCL should not be neglected in flatfoot pathology; it is vital to section this ligament to develop flatfoot in cadaveric models.

A high rate of talocalcaneal interosseous ligament tears was found in chronic lateral ankle instability with sinus tarsi pain.

To evaluate the arthroscopic findings of subtalar joints, including interosseous talocalcaneal ligament (ITCL) tear, in patients with chronic lateral ankle instability (CLAI) and sinus tarsi pain. A total of 118 ankles (109 patients) having CLAI with sinus tarsi pain who had undergone subtalar arthroscopy and lateral ankle ligament surgery were evaluated. The medical records, radiologic images, and the arthroscopic images and videos were reviewed. ITCL tears were classified into 4 grades: grade 0 (no tear), grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The efficacy of magnetic resonance imaging (MRI) in diagnosing ITCL tears was also evaluated by comparing preoperative official readings of MRI to arthroscopic findings. The pre- and postoperative functional scores were also assessed. The overall tear rate of ITCL was 107/118 (90.7%). There were 29 ankles (23.6%) with grade 1, 42 ankles (35.6%) with grade 2, and 36 ankles (30.5%) with grade 3 tears. Isolated lateral ankle instability (LAI) was diagnosed in 43 ankles (36.4%), subtalar instability (STI) in 30 ankles (25.4%), and LAI with STI in 45 ankles (38.1%). There was a statistically significant relationship between the ITCL tear grade and the final diagnosis. ITCL tear was confirmed or suspected in 81 ankles (68.6%) on preoperative MRI. Pain Visual Analog Score and functional outcome scores including the American Orthopaedic Foot & Ankle Society and Karlsson-Peterson scores showed significant improvement after the surgery. A high rate (90.7%) of ITCL tears was noted in CLAI patients with sinus tarsi pain. ITCL damage may play an important role in subtalar instability in patients with CLAI and sinus tarsi pain. Subtalar arthroscopic evaluation for ITCL tear is important for correct diagnosis for CLAI with sinus tarsi pain. IV.

Combined weightbearing CT and MRI assessment of flexible progressive collapsing foot deformity

BackgroundThe objective of this study was to evaluate the correlation between Weightbearing CT (WBCT) markers of pronounced peritalar subluxation (PTS) and MRI findings of soft tissue insufficiency in patients with flexible Progressive Collapsing Foot Deformity (PCFD). We hypothesized that significant correlation would be found. MethodsRetrospective comparative study with 54 flexible PCFD patients. WBCT and MRI variables deformity severity were evaluated, including markers of pronounced PTS, as well as soft tissue degeneration. A multiple regression analysis and partition prediction models were used to evaluate the relationship between bone alignment and soft tissue injury. P-values of less than .05 were considered significant. ResultsDegeneration of the posterior tibial tendon was significantly associated with sinus tarsi impingement (p = .04). Spring ligament degeneration correlated to subtalar joint subluxation (p = .04). Talocalcaneal interosseous ligament involvement was the only one to significantly correlate to the presence of subfibular impingement (p = .02). ConclusionOur results demonstrated that WBCT markers of pronounced deformity and PTS were significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal interosseus ligaments.LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Anatomic Arthroscopic Graft Reconstruction of the Interosseous Talocalcaneal Ligament for Subtalar Instability

Instabilities of the subtalar joint are commonly overlooked or mismanaged, and chronic instability is a debilitating condition leading to premature joint degeneration. Several methods of treatment have been described, mainly screw fixation, arthrodesis, or ligament reconstruction. Most studies describe open methods for ligament reconstruction. We describe an original technique for “all-inside” arthroscopic graft reconstruction of the interosseous talocalcaneal ligament for subtalar instability.

Secondary Effects of the Rupture and Reconstruction of the Interosseous Talocalcaneal Ligament on the Peritalar Joints.

BackgroundThe interosseous talocalcaneal ligament (ITCL) is the main soft-tissue contributor to subtalar joint stability. The role of ITCL reconstruction in retaining this stability is minimally reported. Therefore, we conducted this study to investigate the effects of rupture and reconstruction of the ITCL on the subtalar and peritalar joints.Material/MethodsThis experimental study randomly divided 72 rabbits into 3 equal groups of 24 rabbits each. Group I underwent reconstruction surgery, group II underwent resection, and group III was the control group. The cartilages between the talocrural and calcaneocrural joints, and between the subtalar and talonavicular joints on both sides were assessed by gross observation, ink staining, histology, and immunohistochemistry at weeks 4, 8, 16, and 32, postoperatively.ResultsIn group II, the quantitative ink staining analysis revealed degeneration of the articular cartilages on the talonavicular joint (T=2.070, P=0.038) and the posterior subtalar joint (T=2.121, P=0.034) compared with the 2 sides of the same rabbit at 4 and 8 postoperative weeks. Comparing the operated sides of all the groups showed the posterior subtalar joints (Hc=9.563, P=0.008) and talonavicular joints (Hc=9.714, P=0.008) had an obvious difference at postoperative week 4; and in the calcaneocrural joints (Hc=6.750, P=0.034), it was noticed at postoperative week 8. Histology and immunohistochemistry findings confirm these observations.ConclusionsAn ITCL resection can lead to the progressive degeneration of the talonavicular and posterior subtalar joints, while an ITCL reconstruction can be beneficial in restoring the stability of these joints, preventing or postponing their degeneration, and protecting the articular cartilages.

Biomechanical comparison of tenodesis reconstruction for subtalar instability: a finite element analysis

BackgroundThere are several types of tenodesis reconstruction designed for subtalar instability. However, no comprehensive comparison has been conducted among these procedures in terms of their correcting power so far. The objective of this study is to evaluate the biomechanical behaviors of 5 representative procedures through finite element analysis.MethodsFinite element models were established and validated based on one of our previous studies. The Pisani interosseous talocalcaneal ligament (ITCL) reconstruction, Schon cervical ligament (CL) reconstruction and Choisne calcaneofibular ligament (CFL) reconstruction were compared on the model with the CFL, ITCL and CL sectioned. The Schon triligamentous reconstruction and Mann triligamentous reconstruction were compared on the model with the CFL, ITCL and CL, as well as the ATFL sectioned. The inversion and external/internal rotation were quantified at different ankle positions based on the rotational moment. Then, the stress in ligaments and reconstructed grafts and the contact characteristics of the subtalar joint under inversional stress test were calculated and compared accordingly.ResultsFor single ligament reconstruction, the Choisne CFL reconstruction provided the greatest degree of correction for subtalar instability, followed by the Schon CL reconstruction and then the Pisani ITCL reconstruction. For triligamentous reconstruction, the Mann procedure outperformed the Schon procedure in alleviating the subtalar instability.ConclusionThe finite element analysis showed that the Choisne CFL reconstruction and Mann triligamentous reconstruction provided the greatest degree of immediate postoperative subtalar stability. However, both procedures could not restore the biomechanical behaviors of the subtalar joint to normal. The long-term efficacy of these procedures warrants further investigation using a substantially larger sample of clinical cases.

Retraction Notice: Surgical Treatment of Subtalar Joint Instability With Reconstruction of the Interosseous Talocalcaneal Ligament: Safety and Accuracy of a New Technique in a Cadaver Model.

Retraction Notice: Surgical Treatment of Subtalar Joint Instability With Reconstruction of the Interosseous Talocalcaneal Ligament: Safety and Accuracy of a New Technique in a Cadaver Model.

Case Report on Medial Swivel Dislocation of Ankle

A rare type of Chopart dislocation called swivel dislocation has been reported. This injury presents as dislocation of the talonavicular joint, but the calcaneocuboid joint remains unaffected. There is a typical rotational movement without inversion or eversion in the foot. The axis of rotation is the interosseous talocalcaneal ligament, which remains unaffected. We report the case of an 18-year-old male who had experienced a medial swivel dislocation of the talonavicular joint associated with displaced fracture of the base of fifth metatarsal. The occurrence, features, and method of treatment of this rare injury are presented.

The intrinsic subtalar ligaments have a consistent presence, location and morphology

BackgroundChronic subtalar instability is a disabling complication after acute ankle sprains. Currently, the literature describing the anatomy of the intrinsic subtalar ligaments is limited and equivocal which causes difficulties in diagnosis and treatment of subtalar instability. The purpose of this study is to assess the anatomical characteristics of the subtalar ligaments and to clarify some points of confusion. MethodsIn 16 cadaveric feet, the dimensions and locations of the subtalar ankle ligaments were assessed and measured. CT-scans before dissection and after indication of the footprints with radio-opaque paint allowed to generate 3D models and assess the footprint characteristics. ResultsThe cervical ligament (CL) had similar dimensions as the lateral ligaments: anterior length 13.9 ± 1.5 mm, posterior length 18.5 ± 2.9 mm, talar width 13.6 ± 2.2 mm, calcaneal width 15.8 ± 3.7 mm. The anterior capsular ligament (ACaL) and interosseous talocalcaneal ligament (ITCL) were found to be smaller structures with consistent dimensions and locations. ConclusionThis study identified consistent characteristics of the intrinsic subtalar ligaments and clarifies the local anatomical situation. The dimensions and footprints of the intrinsic ligaments of the subtalar joint suggest a more important role of the CL and ACaL in the stability of the subtalar joint. The results of this study are relevant to improve diagnostic tools and offer some guidelines when reconstructing the injured ligaments.

RETRACTED: Surgical Treatment of Subtalar Joint Instability With Reconstruction of the Interosseous Talocalcaneal Ligament: Safety and Accuracy of a New Technique in a Cadaver Model.

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. Most reconstruction options focus on the interosseous talocalcaneal ligament (ITCL.) We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to develop an ITCL reconstruction technique that could easily and safely be performed with commonly available and familiar technology. A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to ITCL on the calcaneus improved between groups 1 and 2: 4.04 mm and 1.80 mm, respectively (P = .04). Mean distances from the tunnel to ITCL on the talus improved between groups 1 and 2: 6.23 mm and 1.84 mm, respectively (P = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints. Levels of Evidence: Level V: Experimental research, Expert opinion.

Surgical Treatment of Subtalar Joint Instability: Safety and Accuracy of a New Technique in a Cadaver Model

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to show that a tunnel intended to facilitate STJ stabilization surgery could safely be drilled across the footprints of the interosseous talocalcaneal ligament (ITCL). A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to the ITCL on the calcaneus improved between groups 1 and 2: 4.04 and 1.80 mm, respectively (p = .04). Mean distances from the tunnel to the ITCL on the talus improved between groups 1 and 2: 6.2 and 1.8 mm, respectively (p = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints.

Posterior Tibial Tendon and Spring Ligament Lesions in Rheumatoid Arthritis

In rheumatoid arthritis, a significant number of patients have hindfoot pain while they are considered in low disease activity. Then the rheumatoid hindfoot may evolve in valgus flat foot with disability. The aim of our study was to observe the lesions of the main stabilizers of the hindfoot in rheumatoid arthritis to improve the followup and the treatment of the disease. Thirty-three feet (from 21 patients) with rheumatoid arthritis and pain of the hindfoot were consecutively observed. The patients have had no biologic treatment. Every foot had Magnetic Resonance Imaging (MRI) of the hindfoot with gadolinium injection. The tendon of the tibialis posterior muscle, the spring ligament and the inter-osseous talocalcaneal ligament were considered. All the feet presented tenosynovitis of the posterior tibial tendon. Structural lesions of the posterior tibial tendon (23/33 feet, 69.7%) were more frequent than lesions of the spring ligament (12/33 feet, 36.4%). There was no inferior spring ligament lesion without superior spring ligament lesion. No interosseous talocalcaneal ligament lesion was observed. In rheumatoid arthritis, the hindfoot, and particularly the posterior tibial tendon, should be evaluated during patient follow-up to detect a possible lesion. Posterior tibial tendon lesion arises at the same time as the spring ligament lesion, before interosseous talocalcaneal ligament lesion. Imaging, especially MRI, may complete clinical examination. If rheumatoid involvement of the posterior tibial tendon is observed, treatment intensification is required.