Combined Deltoid and Spring Ligament Reconstruction Using Quadrangular Construct

Category: Trauma; Hindfoot Introduction/Purpose: Combined reconstruction of chronic deltoid and spring ligament insufficiency is pretty uncommon and literature surrounding that is rare. The purpose of our study was discuss our experience in treating post-traumatic, chronic deltoid and spring ligament insufficiency utilising a technique called the “Quadrangular Construct” (combined deltoid and spring ligament reconstruction), which uses fibertape together with suture anchor fixation which anatomically resembles the ligament complex. Methods: A total of five patients were included in the study who had post traumatic combined deltoid and spring ligament insufficiency. All patients had a “giving away sensation”. Preoperatively, every patient had underwent weight-bearing radiographs of ankle and foot. Talo 1st Metatarsal angle & hind-foot alignment angle using Saltzman view were noted. Ankle arthroscopy was performed for diagnosis and removal of intra-articular fibrous tissue. Superficial deltoid ligament was repaired using suture anchor. This was augmented with Internal Brace TM (Arthrex, Naples, USA) fibertape forming a quadrangular construct which anatomically mimics tibio-navicular, anterior tibio-talar, tibio-calcaneal and spring ligament components of the deltoid-spring complex. Due to associated excessive heel valgus, three patients also underwent medial displacement calcaneum osteotomy. Additionally, one patient required lateral ligament repair and one patient required syndesmotic stabilisation. American Orthopaedic Foot & Ankle Society (AOFAS) hind foot score was used to evaluate pre and post operative ankle function. Results: All five patients were followed up for a mean of 20 months (12–24 months). The mean angle between the long axes of the talus and first metatarsal bone on preoperative weight-bearing radiographs improved from 8.46° to 4.84°. Preoperative mean angle of hind-foot alignment in the Saltzman view was reduced from 10.9° to 5.76° post operatively. Pain was relieved postoperatively in all patients. One patient has irritation due to metal anchor which needed removal after one year. Postoperatively, none of the patients had re-experienced “feeling of giving way” sensation. AOFAS scores showed, two patients being considered excellent, two good, and one fair. All the patients could perform their ADL & recreational activities independently, and returned to their pre injury work. Conclusion: It is uncommon and challenging to treat post-traumatic chronic deltoid and spring ligament insufficiency. Our technique of combined deltoid and spring ligament reconstruction using a quadrangular construct aids in anatomical restoration of stability, is safe, cost effective, and easily reproducible, and has a positive short-term follow-up.