Article
Anatomical double-bundle reconstruction of the deltoid ankle ligament using transosseous button cerclages and bone anchors
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Authors
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M.D. Wimmer
- Universitätsklinikum Bonn, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Bonn, Germany
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S. Gravius
- Universitätsklinikum Bonn, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Bonn, Germany
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D.C. Wirtz
- Universitätsklinikum Bonn, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Bonn, Germany
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G. Pagenstert
- Universitätsspital Basel, Department Orthopädie, Basel, Switzerland
| Published: | October 21, 2010 |
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Outline
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Objective: Surgical treatment of chronic anteromedial ankle instability was recently introduced by Hintermann et al. (2006). We present a new and simple procedure to stabilize the medial ankle after total deltoid failure using two transosseous button cerclages (FlippTack®, Karl Storz, Tuttlingen, Germany) and two bone anchors (BioComposite Push Lock®, Arthrex, Naples, FL, USA).
Methods: A 61-year-old gentleman presented with early valgus ankle osteoarthritis and a progredient flatfoot deformity. A prominent tilt of the talus was caused both by a narrow joint space of the lateral ankle and an insufficient deltoid ligament.
Realignment of the foot was achieved by a medial sliding osteotomy of the calcaneus and corrective arthrodesis of the lisfranc joints 1 and 2 as described in literature. The deltoid ligament and the capsule appeared vital but with an extended inferior lesion. The profound part of the deltoid ligament was detached from the medial malleolus; a scare formation and partial merge of the superficial parts became visible. Two drillholes were placed and prepared with Fibre-Wires® (Arthrex, Naples, FL, USA) for placement of the transosseous button cerclages. Both drillholes were placed in order to assure positioning of the FlippTacks® ventral and dorsal of the medial malleolus at the border zone of the profound part of the deltoid ligament. The button cerclages were then guided extra-articularly to the lateral process of the talus and fixed when finally positioned. After manual reposition of the talus, FlippTacks® were fixed in two additional drillholes through the medial malleolus. The reposition was then protected with two BioComposite Push Lock® anchors attaching the capsula tightly to the tibia.
Results and conclusions: Postoperativly the foot and ankle deformation was evidently reduced. No talus tilt could be observed and the deltoid ligament was articulately tensed. The pes planovalgus was clearly diminished, the joint space of the ankle was widened, and the covering of the distal fibulo - tibial joint was readdressed. Although a marginal talus tilt was observable six weeks after the operation, the situation was considerably less distinct. Three months after surgery full weight bearing was possible. After six months the patient started jogging on even surface. One year after surgery the readressment and covering in the fibula-tibial joint was still improved with a wider joint space. The talus tilt showed a light progredient tendency. Nevertheless our patient is still painfree, satisfied, and mobile without subjective instability.
We transferred established stabilization procedures of the knee to the ankle. The FlippTacks® ensure controlled reconstruction and positioning while the BioComposite Push Lock® anchors secure a stable fixation. The need of an arthrodesis could be avoided or at least clearly delayed. Our approach is an interesting way of surgical reconstruction, even though long term results have to be presented.
