Medial Ligament Reconstruction Research Articles

Biomechanical Effects of Subtalar Joint Fusion and Medial Ligament Reconstruction in Simulated Progressive Collapsing Foot Deformity.

The purpose of this study is to investigate the biomechanical effect of medial displacement calcaneal osteotomy (MDCO), subtalar joint fusion (SF), and medial ligament reconstruction (MLR: deltoid-spring ligament) in a severe flatfoot model. We hypothesized that (1) combination of MDCO and SF improves the tibiotalar and foot alignment in severe progressive collapsing foot deformity (PCFD) cadaver model. (2) However, if a residual valgus heel alignment remains after MCDO and SF, it can lead to increased medial ligament strain, foot malalignment, and tibiotalar valgus tilt, which will be mitigated by the addition of MLR. Ten fresh-frozen cadaveric foot specimens were used to create a severe flatfoot model. The foot alignment changes, including the talo-first metatarsal angle in the axial and sagittal planes, subtalar angle, and tibiotalar angle in the coronal plane, were measured. The angles were measured at the initial condition, after creating the severe flatfoot model, and after each successive reconstructive procedure in the following order: (1) MDCO, (2) SF, and (3) MLR. Tibiotalar valgus tilt was decreased with the MDCO procedure: 4.4 vs 1.0 degrees (P = .04). Adding in situ SF to the MDCO led to increased tibiotalar tilt to 2.5 degrees was different from the initial condition (P = .01). Although the tibiotalar valgus tilt was significantly decreased after adding the MLR to the MDCO/SF procedure compared with the severe flatfoot model (0.8 vs 4.4 degrees, P = .03), no significant difference in the tibiotalar valgus tilt was observed between MDCO/SF and MDCO/SF with MLR. Our results demonstrated that MDCO significantly improved forefoot abduction and medial arch alignment, with no significant additional improvement observed with addition of SF. Following SF, a residual valgus heel alignment can contribute to subsequent tibiotalar valgus tilt. The addition of MLR did not show significantly decreased tibiotalar valgus tilt following SF. Residual valgus heel alignment after subtalar joint fusion in the surgical treatment of PCFD can lead to increased medial ligament strain. Although MLR might be considered for providing medial stability, it may not necessarily prevent the development of tibiotalar valgus tilt.

Peritalar Kinematics Restored with Combined Subtalar Fusion and Medial Ligament Reconstruction in a Simulated Advance Progressive Collapsing Flatfoot Deformity Model

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Progressive collapsing flatfoot deformity (PCFD) leads to a disruption of the medial peritalar ligaments with progressive loss of the medial arch and further valgus alignment of the subtalar and tibiotalar joints. This ultimately leads to peritalar instability with subtalar and tibiotalar osteoarthritis. Conventional joint sparing reconstruction methods alone may not correct the valgus heel alignment. Some have suggested subtalar fusion (SF) with or without combined medializing calcaneal osteotomy (MCO) as an option. Although SF provides a more effective correction of hindfoot alignment, a resultant increase in valgus moment arm with a larger strain on the medial ankle ligament has been reported. The study aim is to investigate the efficacy of a combined MCO with SF and medial tibionavicular ligament (TNL) reconstruction on restoring peritalar stability.Methods:Ten fresh-frozen cadaveric foot specimens were employed to create a severe PCFD model. Reflective markers were placed on the tibia, talus, navicular, calcaneus, and first metatarsal. A multiple-camera motion capture system (OptiTrack, Prime13) was utilized to document peritalar joint kinematics. Severe AAFD model was created by sectioning the medial capsuloligamentous complex followed by cyclic axial loading. Sequential surgical procedures were performed, including MCO, SF, MCO + SF, and MCO + SF + medial tibionavicular ligament (TNL) reconstruction. Subtalar joint coronal angle, tibiotalar coronal angle, forefoot abduction axial angle, and talo-first metatarsus (Meary's) lateral angle were calculated for each sequential procedure and compared to the severe flatfoot model. The kinematic changes were calculated between groups utilizing a custom MatLab code and statistical significance was determined using a one-way ANOVA and a Tukey's multiple comparison test.Results:The subtalar joint valgus angle of the severe PCFD model (mean 8.1°) was significantly reduced by the MCO+SF+TNL reconstruction (mean 3.2°, p = 0.019). The tibiotalar joint valgus angle of the severe flatfoot model (mean 4.4°) was significantly reduced by the MCO (mean 1.0°, p = 0.04), but increased after combined MCO with SF (mean 2.5°, p = 0.01). The increased valgus tibiotalar angle of the MCO+SF was reduced by adding TNL reconstruction (mean 0.75°, p = 0.027). Forefoot abduction angle was found to be significantly reduced in all reconstruction methods compared to the severe flatfoot model. Meary's angle was also significantly improved after the MCO+SF and MCO+SF+TNL reconstruction (P= 0.015 and 0.006, respectively).Conclusion:Although addition of SF to MCO improved forefoot abduction and Meary's angles of advanced PCFD model, it resulted in increased tibiotalar valgus angle. The subsequent increase in medial ligament strain may be reduced by adding TNL reconstruction which can support medial stability while improve kinematics in all planes. Addition of TNL may be considered when performing SF for correction of PCFD, especially when a residual valgus heel alignment remains.

Effect of Medial Ligament Reconstruction in Flatfoot Deformity: How It Affects the Soft Tissue Improvement and Radiological Outcome of the Surgery?

Category:Ankle; Hindfoot; SportsIntroduction/Purpose:Surgical treatment of adult flatfoot deformity has traditionally be driven by tendon transfers and osteotomy. In acquired deformity, injury to the spring ligament and superficial deltoid ligament is common. The procedures mentioned previously do nothing to restore the function of the medial ligament complex. Studies have shown that reconstruction of the medial ligament complex, and thus the medial talonavicular joint, has benefit to patient outcomes. The question still remains of how much correction the medial ligament reconstruction confers on its own. The purpose of this study is to compare isolated medial ligament reconstruction procedures to other flat foot correcting procedures in the treatment of acquired flat foot deformity.Methods:18 patients were identified that underwent procedure for flatfoot deformity. Of these patients there were 7 patients that underwent isolated medial ligament complex reconstruction and 11 patients that underwent non-tendon transfer procedure for correction of flat foot deformity. Imaging was performed on patient's weight bearing (WB) and non-weight bearing (NWB) before and after surgery. Measurements included Angles: calcaneal pitch, talo-1st metatarsal, talocalcaneal, talar declination, calcaneal 1st metatarsal and Distances: talar height, navicular height, 1st cuneiform height, cuboid height, and 1st to 5th metatarsal distance in lateral X-ray, and Angles: talonavicular coverage, talar 1st metatarsal, talar 2nd metatarsal and Distances: talonavicular uncoverage distance in AP. The differences in measurement between the pre-op and post-op non-weight bearing are considered as bony correction effect while differences between pre-op and post-op weight bearingare considered as soft tissue correctionResults:For non-weight bearing; medial ligament reconstruction impact was seen on calcaneal pitch (19 to 35 degrees, p=0.007), 1st cuneiform height (21 to 28mm, p=0.016), talonavicular coverage (6 to 3 degrees, p=0.026), and Talar 1st metatarsal angle (14 to 7 degrees, p=0.008). Other corrections had an impact on calcaneal pitch (15 to 24 degrees, p=0.006), Talo-1st metatarsal angle (11 to 6 degrees, p=0.019), Calcaneal 1st metatarsal (139 to 129 degrees, p=0.044), Talar height (31 to 42mm, p=0.001), navicular height (24 to 34mm, p=0.002), and 1st cuneiform height (18 to 22mm, p=0.016). For weight bearing; reconstruction impact was seen on talocalcaneal angle (36 to 44 degrees, p=0.011), 1st-5thmetatarsal distance (12 to 18mm, p=0.047), and hindfoot moment arm (16 to 6mm, p=0.031). Other corrections had an impact on talar height (34 to 40mm, p=0.028), navicular height (26 to 30mm, p=0.031), cuboid height (p=0.021), and hindfoot alignment angle (17 to 7 degrees, p=0.003).Conclusion:When compared to procedures that only address bony changes in the foot, it is clear from this study that medial ligament repair plays a different, but significant, role in correction of flat foot deformity. Interestingly, the non-weight bearing and weight bearing results show that medial ligament reconstruction affects different aspects of the correction in these two distinct phases. This study serves to suggest that medial ligament reconstruction has a role in the correction of flat foot deformity that is not completely addressed in the more common procedures performed.

THE EXTENT OF MEDIAL QUADRICEPS TENDON FEMORAL LIGAMENT (MQTFL) PATELLAR AND QUADRICEPS ATTACHMENT: A PEDIATRIC CADAVERIC STUDY

Background:The most common modern procedure for medial patellar stabilization involves reconstruction of the medial patellofemoral ligament (MPFL) and involves reconstructed ligament attachment to the femur and patella. However, cases of patellar fracture have been reported, particularly in the smaller anatomy of the pediatric population, leading to further investigations of patella stabilizing structures. The medial quadriceps tendon femoral ligament has been identified as a separate structure, connecting the patella to the femur and playing a significant role in patella stability. Reconstruction of this ligament may serve a role in patellar stabilization similar to pedicled quadriceps tendon medial ligamentous reconstructions. The anatomy and relationship of the MQTFL attachment to the quadriceps tendon and proximal pole of the patella has not been described in pediatric specimens.Purpose:To determine the anatomical relationship and attachment of the medial quadriceps tendon femoral ligament (MQTFL) on the patella and quadriceps tendon.Methods:Six pediatric cadaveric knee specimens were dissected to identify the patellar and quadriceps attachment site of the MQTFL. Dissection was facilitated by lateral arthrotomy and identification of the MQTFL thickened fibers from the undersurface of the ligament.Results:Six specimens included patients a mean age of 6 years at time of patient death (three 10-year-old specimens, one 4-year-old, and one 2-month-old specimen). The MQTFL was identified in all specimens. As identified from the undersurface of the everted extensor mechanism, it was found to insert a mean distance of 10.5 mm (range 3.9 – 18.2) from the superior pole of the patella. The attachment distally along the edge of the bony patella measured a mean of 12.7 mm (range 5.4-19.4). Total patellar length, as measured from the posterior articular surface, was a mean of 24.5 mm (range 11.0-35.6). Attachment to the quadriceps tendon averaged 47% of total attachment to both the quadriceps tendon and patella; conversely, direct patellar measurement averaged 53%.Conclusion:This study provides quantitative anatomy to attachment of the MQTFL to the patella and quadriceps tendon. Precise knowledge of these structures will assist to more precisely define the complex relationship between stabilizing structures to the medial patellofemoral joint and assist in patella stabilization procedures, particularly in skeletally immature patients. A lower risk of patellar fracture may be one of the key benefits of this procedure, compared with MPFL reconstruction.FIGURESFigure 1:.View from the posterior surface (ie inside joint) following lateral arthrotomy. Note MQTFL attachment point in relation to the proximal extent of the cartilaginous articular surface.ReferencesFulkerson JP, Edgar C. Medial quadriceps tendon-femoral ligament: Surgical anatomy and reconstruction technique to prevent patella instability. Arthrosc Tech 2013;2:e125- e128.Joseph SM, Fulkerson JP. Medial Quadriceps Tendon Femoral Ligament Reconstruction Technique and Surgical Anatomy. Arthroscopy techniques. 2019 Jan 1;8(1):e57-64.Parikh SN, Wall EJ. Patellar fracture after medial patel- lofemoral ligament surgery: A report of five cases. J Bone Joint Surg Am 2011;93. e97(1-8)Dhinsa BS, Bhamra JS, James C, Dunnet W, Zahn H. Patella fracture after medial patellofemoral ligament reconstruction using suture anchors. Knee 2013;20:605- 608.Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2012;40:1916-1923Tanaka MJ. The anatomy of the medial patellofemoral complex. Sports Med Arthrosc 2017;25:e8-e11.Kruckeberg BM, Chahla J, Moatshe G, et al. Quantitative and qualitative analysis of the medial patellar ligaments: An anatomic and radiographic study. Am J Sports Med 2017. 363546517729818LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am 2007;89:2000- 2010.Mochizuki T, Nimura A, Tateishi T, Yamaguchi K, Muneta T, Akita K. Anatomic study of the attachment of the medial patellofemoral ligament and its characteristic relationships to the vastus intermedius. Knee Surg Sports Traumatol Arthrosc 2013;21:305-310.Nelitz M, Williams SR. Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents using a pedicled quadriceps tendon graft. Arthroscopy techniques. 2014 Apr 1;3(2):e303-8.

Peritalar Kinematics With Combined Deltoid-Spring Ligament Reconstruction in Simulated Advanced Adult Acquired Flatfoot Deformity.

Adult acquired flatfoot deformity (AAFD) is a complex and progressive deformity involving the ligamentous structures of the medial peritalar joints. Recent anatomic studies demonstrated that the spring and deltoid ligaments form a greater medial ligament complex, the tibiocalcaneonavicular ligament (TCNL), which provides medial stability to the talonavicular, subtalar, and tibiotalar joints. The aim of this study was to assess the biomechanical effect of a spring ligament tear on the peritalar stability. The secondary aim was to assess the effect of TCNL reconstruction in restoration of peritalar stability in comparison with other medial stabilization procedures, anatomic spring or deltoid ligament reconstructions, in a cadaveric flatfoot model. Ten fresh-frozen cadaveric foot specimens were used. Reflective markers were mounted on the tibia, talus, navicular, calcaneus, and first metatarsal. Peritalar joint kinematics were captured by a multiple-camera motion capture system. Mild, moderate, and severe flatfoot models were created by sequential sectioning of medial capsuloligament complex followed by cyclic axial loading. Spring only, deltoid only, and combined deltoid-spring ligament (TCNL) reconstructions were performed. The relative kinematic changes were compared using 2-way analysis of variance (ANOVA). Compared with the initial condition, we noted significantly increased valgus alignment of the subtalar joint of 5.1 ± 2.3 degrees (P = .031) and 5.8 ± 2.7 degrees (P < .01) with increased size of the spring ligament tear to create moderate to severe flatfoot, respectively. We noted an increased tibiotalar valgus angle of 5.1 ± 2.0 degrees (P = .03) in the severe model. Although all medial ligament reconstruction methods were able to correct forefoot abduction, the TCNL reconstruction was able to correct both the subtalar and tibiotalar valgus deformity (P = .04 and P = .02, respectively). The TCNL complex provided stability to the talonavicular, subtalar, and tibiotalar joints. The combined deltoid-spring ligament (TCNL) reconstructions restored peritalar kinematics better than isolated spring or deltoid ligament reconstruction in the severe AAFD model. The combined deltoid-spring ligament (TCNL) reconstruction maybe considered in advanced AAFD with medial peritalar instability: stage IIB with a large spring ligament tear or stage IV.

Weight-bearing CT Technology in Musculoskeletal Pathologies of the Lower Limbs: Techniques, Initial Applications, and Preliminary Combinations with Gait-Analysis Measurements at the Istituto Ortopedico Rizzoli.

Musculoskeletal radiology has been mostly limited by the option between imaging under load but in two dimensions (i.e., radiographs) and three-dimensional (3D) scans but in unloaded conditions (i.e., computed tomography [CT] and magnetic resonance imaging in a supine position). Cone-beam technology is now also a way to image the extremities with 3D and weight-bearing CT. This article discusses the initial experience over a few studies in progress at an orthopaedic center. The custom design of total ankle replacements, the patellofemoral alignment after medial ligament reconstruction, the overall architecture of the foot bones in the diabetic foot, and the radiographic assessment of the rearfoot after subtalar fusion for correction of severe flat foot have all taken advantage of the 3D and weight-bearing feature of relevant CT scans. To further support these novel assessments, techniques have been developed to obtain 3D models of the bones from the scans and to merge these with state-of-the-art gait analyses.

PO 18123 - Syndesmosis assessment in postoperative patients subjected to surgical treatment of supra-syndesmotic fracture

Objective: To demonstrate the patterns of syndesmosis reconstruction in ankle fractures via the measurement of pre-established and universally accepted parameters. Methods: In a retrospective study, fractures with radiographic images obtained during the postoperative period and showing fixation of the distal tibiofibular syndesmosis were selected. Fracture reduction and syndesmosis fixation were evaluated by measuring radiographic parameters in the selected cases. Results: Twenty-three patients (63.8%) were male. Fourteen fractures (38.8%) were operated on by a senior surgeon (foot and ankle specialist). All syndesmoses were fixed with only one screw, and 35 patients (97.2%) had syndesmosis fixation involving 3 cortices. The mean syndesmosis fixation height from the articular surface was 2.20 cm. Four fractures (11.1%) presented radiographic signs of medial ligament reconstruction. Regarding the measurement of the tibiofibular space, in the anteroposterior (AP) view, 33 patients (91.6%) had values within the normal range. Regarding the tibiofibular overlap, in the AP view, 19 patients (52.7%) had measurements with values greater than 10 mm (normal). In the evaluation of tibiofibular overlap, in the true anteroposterior (AP) view, all patients (100%) presented measurements greater than 1 mm (normal). Regarding the measurement of the talocrural angle, only 1 patient did not have normal parameters. Regarding the medial clear space, only 2 patients (5.5%) had values above normal during the postoperative period. Conclusion: The adoption of objective, standardized parameters relative to the contralateral side adds value to the evaluation and ensures an accessible and reproducible method for evaluating syndesmotic ankle fractures.

Syndesmosis assessment in postoperative patients subjected to surgical treatment of supra-syndesmotic fracture

Objective: To demonstrate the patterns of syndesmosis reconstruction in ankle fractures via the measurement of pre-established and universally accepted parameters. Methods: In a retrospective study, fractures with radiographic images obtained during the postoperative period showing fixation of the distal tibiofibular syndesmosis were selected. After this selection, fracture reduction and syndesmosis fixation were evaluated by measuring radiographic parameters in the selected cases. Results: Twenty-three patients (63.8%) were male. Fourteen fractures (38.8%) were operated on by a senior surgeon (foot and ankle specialist). All syndesmoses were fixed with only 1 screw, and 35 patients (97.2%) had syndesmosis fixation involving 3 cortices. The mean syndesmosis fixation height from the articular surface was 2.20cm. Four fractures (11.1%) presented radiographic signs of medial ligament reconstruction. Regarding measurement of the tibiofibular space, in the anteroposterior (AP) view, 33 patients (91.6%) had values within the normal range. Regarding the tibiofibular overlap, in the AP view, 19 patients (52.7%) had measurements with values greater than 10mm (normal). In the evaluation of tibiofibular overlap, in the true AP view, all patients (100%) presented measurements greater than 1mm (normal). Regarding the measurement of the talocrural angle, only 1 patient did not have normal parameters. Regarding the medial clear space, only 2 patients (5.5%) had values above normal during the postoperative period. Conclusion: The adoption of objective parameters, in a standardized manner and relative to the contralateral side, adds additional value to the evaluation and ensures an accessible and reproducible method for the evaluation of these injuries. Level of Evidence II; Prognostics Studies; Retrospective Study.

Anatomical Lateral and Medial Ligament Reconstruction in Rotational Chronic Ankle Instability

Category: Sports. Introduction/Purpose: Rotational (combined lateral and medial) chronic ankle instability (CAI) can present with pain and tenderness at the ankle joint, and can be associated with feeling of giving way, repetitive sprains, and life quality limitation. In case of surgery, anatomical reconstruction of the ligaments and treatment of comorbidities are essential for a solid outcome. Methods: A retrospective chart review of 81 rotational CAI patients (average age: 35.3 years, age range: 16-64; right sided: 41(50.6%); left sided: 40(49.4%)) was performed. The average latest follow-up visit was 10.8 months (range: 3-47 months). The patients underwent in our center a standardized surgical treatment protocol. Following diagnostic ankle arthroscopy, a combined lateral and medial anatomical ligament reconstruction was performed. Hindfoot realignment procedures and treatment of associated pathologies (such as talar osteochondral lesions) were carried out at the same time. Postoperatively, all patients were mobilised with partial weight bearing (15 kg) for six weeks in an Aircast walker ® (DJO, LLC, USA). Adequate postoperative analgesia and physiotherapy were initiated. Results: Combined lateral and medial ligament reconstruction without additional surgeries was performed in 20 cases (24.7%). In the other cases, to address associated pathologies, additional surgeries were performed, such as: lateral calcaneal lengthening osteotomy (LCLO) in 42 cases (51.9%), medial sliding calcaneal osteotomy (MSCO) in 3 Cases (3.7%), osteochondral lesion reconstruction in 20 cases (24.7%), peroneal tendon pathology treatment in 3 cases (3.7%), cavovarus foot correction in 1 case (1.2%), supramalleolar osteotomy in 1 case (1.2%), and calcaneonavicular coalition excision in 1 case (1.2%). The outcome variables will be presented at the conference. Conclusion: Anatomical lateral and medial ligament reconstruction of rotational CAI is a safe surgical treatment and leads to a favourable outcome. Beside the ligament reconstruction, associated comorbidities, as malalignment, osteochondral lesions, and others, have to be addressed at the same surgery to achieve physiological biomechanics and a complete pain relieve.

Tratamiento quirúrgico de la luxación recidivante de rótula en el niño asociada a displasia patello-femoral./ Surgical treatment of recurrent patellar dislocation in children associated with patello-femoral dysplasia

Objetivo:El objetivo del presente trabajo es mostrar los resultados en una serie cortade pacientes con inestabilidad patelo-femoral o luxación recurrente de rótula en niñosoperados con la técnica de realineamiento proximal. La inestabilidad patelo-femoralse define como una enfermedad en la cual no hay suficiente acople de la rótula con latróclea femoral durante el rango de movimiento de la rodilla. En niños esta inestabilidadpuede deberse a diversos factores anatómicos conduciendo a luxación recurrente dela rótula. Hay cirugías sobre la parte proximal o distal de la rótula.Materiales y mé-todos:tratamos una serie de 10 rodillas en 7 niños, con un realineamiento proximalde la rótula según la técnica de Insall.Resultados:se obtuvieron buenos resultadosen 8 rodillas, sin dolor, sin luxación ni inestabilidad residual, presentando buenaestabilidad y seguridad durante la marcha. Un paciente presento reluxación y otrocon Síndrome de Down, presento con el tiempo una subluxación.Conclusiones:Elrealineamiento proximal en esta serie muestra buenos resultados en pacientes quetenían poca displasia troclear y sin mucha alteración del ángulo Q. Es una técnicano muy usada, que tiene indicación en casos escogidos. Hoy en día con el conceptode la reconstrucción del ligamento patelo- femoral medial, este puede ser usado encombinación con las técnicas de realineamiento proximal. Hay que estar alerta conlos pacientes con síndromes que se acompañan de hiperlaxitud como el S. de Down. Objective: The aim of this paper is to show the results in a small series of patients withpatellofemoral instability or recurrent patellar dislocation in children operated with theproximal realignment technique. Materials and methods: It is a series of 10 knees in7 children, with proximal patela realignment patela using the Insall technique. The mostimportant role of the patela is to increase the quadriceps efficiency. The patelo -femoralinstability is defined as a condition in which there is insufficient coupling of the patelawith the femoral trochlea during the knee range of motion. In children this instabilitymay be due to various anatomical factors leading to recurrent dislocation of the patela.There are surgeries proximal o distal to the patela level. Results: Good results wereobtained on 8 knees, without pain, neither dislocation nor residual instability and havinggood stability and safety during the gait. One patient showed redislocation and anotherpatient with Down syndrome had a subluxation. Conclusions: proximal realignment inthis series shows good results in patients who had little trochlear dysplasia with mildalteration of the Q angle. It is a technique not widely used but has indicated in selectedcases. Today, the patelo - femoral medial ligament reconstruction, can be used incombination with proximal realignment techniques. Patients with collagen problemslike Marfan and Down syndrome usually have redislocation and require some otherprocedures for patelar stabilization.

Combined Medial and Lateral Anatomic Ligament Reconstruction for Chronic Rotational Instability of the Ankle

This study aimed to extend knowledge on the arthroscopic evaluation of the unstable ankle joint and the outcome of ligament reconstruction on rotational instability. In contrast to previous studies, we investigated the combined repair of lateral and medial ligaments. Ninety-six patients underwent medial and lateral ligament reconstruction between 2006 and 2008, 81 of whom, with a mean age of 31.9 (range, 14 to 44) years, completed the 12-month followup and were therefore included in this study (Table 1). Clinical, radiographic, and concomitant arthroscopic examination was performed prior to the ligament stabilization. Postoperative followup included clinical and radiographic evaluation after 3, 6, and 12 months. Arthroscopy showed a lesion of the anterior fibulotalar ligament (AFTL), calcaneofibular ligament (CFL), and tibiocalcanear ligament (TCL) (Deep part of deltoid ligament complex) in 67 patients. An avulsion of the proximal insertion point of the ATTL was additionally found in 14 cases. Clinical results 3 months after surgery showed a significant increase in the AOFAS-Hindfoot Score as well as a significant decrease of the Visual Analogue-Scale for pain (VAS) (p < 0.0001). This outcome persisted at the 12-month examination. Rotational instability of the ankle joint in most cases has an injury of the lateral ligaments and a component of the deltoid, the TCL, but rarely with a combined lesion of the TCL and the anterior tibiotalar ligament (ATTL) (Superficial part of deltoid ligament complex). The combined lateral and medial ligament reconstruction with an anchor technique had a good clinical outcome with high patient satisfaction with few complications.

Die Therapie der Patellaluxation mittels Weichteilrekonstruktion

In the clinic of Nuernberg between 1999 - 2002 55 patients were treated by ligament reconstruction after patellar dislocation, 43 could be reviewed. In 23 cases patients reached our clinic as first time dislocators, 20 after multiple dislocations (1 - 15). In 3 cases only arthroscopy was done, in 40 cases with an additional medial ligament reconstruction, in 11 cases combined with lateral release. In follow-up examination redislocation rate was 9%, only concerning habituell dislocations. According to Lysholm score 70% of the patients showed more than 90 points out of 100, according to Larsen and Lauridsen score 81% had excellent to good results. We recommend arthroscopy after patellar dislocations, if necessary combined with medial ligament reconstruction and lateral release.

Lateral Column Lengthening by Calcaneal Osteotomy

The surgical treatment of adult acquired flatfoot deformity secondary to posterior tibial tendon dysfunction is controversial, especially for the stage 2 posterior tibial tendon dysfunction in which the deformity is still flexible. It has been widely recognized that isolated soft tissue procedures do not provide stable correction of the deformity, which often progresses and becomes painful. For this reason, bony osteotomies have been combined with tendon transfers and ligament reconstruction in an attempt to give long-lasting correction of both pain and deformity. Lateral calcaneal lengthening osteotomy, as originally described by Evans in child flatfoot, was found to restore the medial longitudinal arch and to correct forefoot abduction, thus allowing to minimize the strain and to reach a successful function of the medial ligament reconstruction and tendon transfers. The closer the osteotomy of the calcaneus is to the calcaneocuboid joint, the more likely the anterior calcaneus becomes unstable, which, in turn, may provoke incongruency and pressure increase at the calcaneocuboid joint. This article describes the author's preferred more posteriorly located calcaneal osteotomy along the anterior border of the posterior subtalar facet.