Anteromedial Ankle Impingement Due to a Talar Cam Lesion and Anterior Deep Deltoid Ligament With Variant Anatomy: A Case Report.
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SUBMITTER: Glenzer SR
PROVIDER: S-EPMC8564926 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:In an effort to better restore normal joint function and kinematics, recent emphasis has been placed on surgical techniques that provide a more anatomic reconstruction of the anterior cruciate ligament (ACL). With femoral tunnel placement shown to play a vital role in the biomechanics, stability, and clinical outcomes after ACL reconstruction, approaches that better approximate the ACL's native femoral origin have been adopted. The independent anteromedial portal technique is thought to better position the femoral tunnel within the native ACL footprint and leave the graft more posteroinferior on the wall of the lateral femoral condyle than the more traditional transtibial approach. This article outlines the surgical technique for an anteromedial portal ACL reconstruction with a tibialis anterior allograft fixed with the Mitek Femoral and Tibial Intrafix sheath and screw system (DePuy Synthes, Raynham, MA).
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Project description:BackgroundThe purpose of this article is to document the normal arthroscopic appearance of the posterior ankle capsular and ligamentous structures, and variations in their anatomical relationships.Methods102 ankle arthroscopy videotapes were evaluated retrospectively for the configuration of the posterior capsuloligamentous structures. Based on these observations, the variations in the appearance and position of the posterior tibiofibular ligament (PTFL) and transverse (tibiofibular) ligament (TTFL) were documented. In addition, differences in the appearance of the flexor hallucis longus (FHL) were also noted.ResultsAll patients had evidence of both a PTFL and TTFL, which formed a labrum or meniscus-like addition to the posterior distal tibia. No patients demonstrated disruption of the PTFL; 3 had tears of the TTFL. We noted 4 distinct patterns of the PTFL and the TTFL. Thirty-four patients (33%) had a gap of ≥2 mm between the 2 ligamentous structures. Thirty-three (32.4%) had a gap <2 mm between the PTFL and TTFL. Twenty-six (25.5%) had a confluence of the 2 ligaments without a gap. Nine (9%) demonstrated a sizable gap between the 2 ligaments, and the TTFL appeared as a "cord-like" structure.ConclusionTo our knowledge, this is the first article to describe the variations in the arthroscopic normal posterior capsuloligamentous structures and FHL of the ankle.Level of evidenceLevel IV, case series.
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Project description:Injuries of the deltoid ligament of the ankle are increasingly recognized with the widespread use of magnetic resonance (MR) imaging. The use of higher magnetic field strengths requires familiarity with the anatomic substructure of the deltoid ligament to better localize and characterize pathologic findings. Specifically, improved image resolution allows components of the superficial (tibiocalcaneal, tibionavicular, posterior superficial tibiotalar, and tibiospring ligaments) and deep (anterior tibiotalar and posterior deep tibiotalar ligaments) portions of the ligament to be evaluated separately. Awareness of the deltoid ligament substructure and associated injury patterns can guide the radiologist in defining underlying mechanical derangement, such as that seen in various impingement disorders. In this review article, the MR imaging technique for the deltoid ligament is summarized, and the normal and abnormal MR imaging appearances of various components of the deltoid ligament and associated impingement syndromes are presented.
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Project description:BackgroundConventionally, transsyndesmotic fibula fractures with concomitant signs of deltoid ligament injury have been considered unstable and thus treated operatively. Recent studies have indicated that partial deltoid ligament rupture is common and may allow for nonoperative treatment of stress-unstable ankles if normal tibiotalar alignment is obtained in the weightbearing position. Biomechanical support for this principle is scarce. The purpose of this study was to evaluate the biomechanical effects of gradually increasing deltoid ligament injury in transsyndesmotic fibula fractures.MethodsFifteen cadaveric ankle specimens were tested using an industrial robot. All specimens were tested in 4 states: native, SER2, SER4a, and SER4b models. Ankle stability was measured in lateral translation, valgus, and internal and external rotation stress in 3 talocrural joint positions: 20 degrees plantarflexion, neutral, and 10 degrees dorsiflexion. Talar shift and talar valgus tilt in the talocrural joint was measured using fluoroscopy.ResultsIn most tests, SER2 and SER4a models resulted in a small instability increase compared to native joints and thus were deemed stable according to our predefined margins. However, SER4a models were unstable when tested in the plantarflexed position and for external rotation in all positions. In contrast, SER4b models had large-magnitude instability in all directions and all tested positions and were thus deemed unstable.ConclusionThis study demonstrated substantial increases in instability between the SER4a and SER4b states. This controlled cadaveric simulation suggests a significant ankle-stabilizing role of the deep posterior deltoid after oblique transsyndesmotic fibular fracture and transection of the superficial and anterior deep deltoid ligaments.Clinical relevanceThe study provides new insights into how the heterogenicity of deltoid ligament injuries can affect the natural stability of the ankle after Weber B fractures. These findings may be useful in developing more targeted and better treatment strategies.
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Project description:Posterior ankle endoscopy is a safe and effective approach for treatment of posterior ankle impingement. This is usually performed with the patient in prone position. The purpose of this technical note is to describe an arthroscopic approach of decompression of posterior ankle impingement with the patient in supine position. This is indicated if there is posterior ankle impingement together with other ankle pathology requiring anterior ankle arthroscopy. This approach allows treatment of both anterior ankle and posterior ankle pathology with the patient in the supine position. Concomitant anterior ankle arthroscopy can be performed with the usual orientation without the need of change of patient's position.
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Project description:IntroductionOsteoblastoma of the talus, a benign tumor, is rare in orthopedics. The choice of treatment is usually open surgery for excision of tumor. Limited data is available concerning arthroscopic approaches.Presentation of caseA 36-year-old male patient was evaluated for pain and swelling of the left ankle joint. Based on the findings of physical examination, X-rays and MRI investigations, the tumor was isolated. Standard anterior arthroscopic surgery was performed due to ankle pain. A diagnosis of osteoblastoma of the talar neck was made following the pathological survey. He had no recurrent pain and normal joint mobility 5 years postoperatively during he was regularly followed up.DiscussionOsteoblastoma of the talar neck is slowly progressive and it is a palpable painful mass. Open or arthroscopic surgery can be performed. Treatment strategies are decided on according to the tumor's location, extent and size. Some advantages of arthroscopic surgery are wide visualization areas, minimally invasion, low morbidity, no necessity for casting and immobilization, early rehabilitation and quick recovery.ConclusionIn conclusion, arthroscopic management can be successful in selected patients with small benign tumor localized to the ankle joint.
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Project description:This procedure represents an update on traditional primary repair methods by taking advantage of technological advancements to optimize soft tissue fixation and allow for an anatomic double-bundle primary repair with independent bundle tensioning and an internal brace construct to restore normal anterior cruciate ligament biomechanics.
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Project description:Preservation of the anterior cruciate ligament (ACL) remnant during ACL reconstruction has the advantages of improved vascularity and synovial encircling of the graft tendon. We describe a technique called single-anteromedial bundle biological augmentation (SAMBBA) using complete preservation of the ACL remnant, as well as preservation of the semitendinosus tibial insertion, that uses standard portals and equipment.
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Project description:BackgroundBone fragments are often found in ankles with anterior bony impingement. However, whether they are detached osteophytes or accessory bones remains unknown.MethodsAmong the 66 continuously enrolled cases of ankles with anterior bony impingement, 32 had a fragment located at the anterior margin of the tibia. The cases of posterior impingement, lateral instability, osteochondral lesions, or free bodies simultaneously treated were excluded. The enrolled subjects were classified into 2 groups: ankles without (group A) and with remarkable spurs (group B). The patients' backgrounds, location of the fragments, clinical scores, and other parameters required to resume sports were compared. The Japanese Society for Surgery of the Foot (JSSF) ankle rating scale was used to evaluate preoperative and postoperative ankle conditions, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) was used to evaluate postoperative sports abilities.ResultsEight (seven subjects) and 11 ankles were classified into groups A and B, respectively, and the mean age of the 18 patients was 25.4 (range, 16-37) years. No statistical differences in patient backgrounds or fragment sizes between the groups existed. In group A, the fragments were located on the lateral plateau in 7 of the 8 ankles, whereas in group B, their locations varied. The patients were followed up for a median of 48 months (range, 24-168). No complications were observed. The postoperative JSSF and SAFE-Q sports activity scores were significantly higher in group A than in group B (P <.01 and <.001, respectively). The postoperative term to return to their original sports activities was significantly shorter in group A (P < .05).ConclusionAnterior bony fragments of the ankle without a remarkable spur were located at a specific site, and the results of arthroscopic treatment were better than in those with remarkable spurs. Such a fragment may be called an os talotibiale.Level of evidenceLevel III, retrospective cohort study.
| S-EPMC10823857 | biostudies-literature
Project description:BackgroundOperative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established.Questions/purposesThe objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures.MethodsPatients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation.ResultsUsing intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%).ConclusionCompared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.
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