Die Sehne des M. flexor digitorum longus wird in den inferomedialen Quadranten des Os naviculare verlagert und mit einer Tenodesis-Schraube fixiert.

Foot and Ankle

Trauma Lower Extremities

Not Hidden

English  - en

application/pdf

Human

A comprehensive overview of a product team’s portfolio.

Ein umfassender Überblick über das Portfolio eines Produktteams.

Kataloge

Visão geral e abrangente do portfólio de produtos de cada segmento.

Catálogos

Descripción general y completa sobre la cartera de productos de cada segmento. 

Catalogs

Foot and Ankle: Next Generation in Foot and Ankle Technology 2023

video

Animationen für die Patientenaufklärung

Animações — Educação do paciente

Animaciones de educación para el paciente

Patient Education Animations

Flatfoot Repair With the InternalBrace™ Ligament Augmentation Procedure

The Arthrex internal brace. Spring Ligament Augmentation Repair is a surgery for people who have flat foot due to weakness or rupture of the spring ligament or posterior tibial tendon. Spring ligament is the connecting tissue located under the foot that connects the calcaneus and navicular bone. This ligament is often repaired in people that have a condition called flat foot. It is when the arch of the foot collapses coming into contact with the ground. The repair begins with the surgeon making a cut on the side of the ankle, where the calcaneus, navicular bone, and medial cuneiform are located. Next, the surgeon will create a bone tunnel by drilling into the sustentaculum tally of the calcaneus using a guidewire and drill guide. The bone tunnel is made in the calcaneus to prepare for a SwiveLock suture anchor loaded with FiberTape. The SwiveLock anchor is screwed into place. Next, the FTL tendon, also known as flexor digitorum longus, located on the medial side of the leg, is identified, cut, and then tagged with a FiberLoop stitching technique. A bone tunnel is made in the navicular to prepare for an additional SwiveLock anchor. The ankle structures are tensioned and fixed into place by taking one part of the FiberTape and passing it from top to bottom with a suture passing wire. Then take the other part of the FiberTape with the sutures from the FTL tendon, and passing it from bottom to top. The surgeon then holds it in place by inserting the SwiveLock from bottom to top. The remaining sutures are cut. The supporting structures of the arch of the foot are now repaired and held together, with the internal brace, causing the arch of the foot to be restored.

Jorge Acevedo, MD (Royal Palm Beach, FL), presents a spring ligament repair technique with the InternalBrace ligament augmentation repair system using BioComposite SwiveLock® anchors and FiberTape® suture. InternalBrace ligament augmentation repair can be used in conjunction with an FDL transfer for the repair of spring ligament instability and flatfoot repair.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Videos - OP-Anleitung

Vídeos — Técnicas cirúrgicas

Videos de técnicas quirúrgicas

Surgical Technique Videos

InternalBrace™ Ligament Augmentation Repair: Spring Ligament Surgical Technique

Today, I'm going to demonstrate an internal brace for the repair of the spring ligament, along with an FDL tendon transfer. The initial anchor is placed in the sustentaculum talai of the calcaneus. As you can see, I have already whip stitched the FDL with a FiberLoop. Next, you can drill and tap with a 2.7mm drill and then the 3.5mm tap for the 3.5mm. Swivelock anchor. Hold the paddle and turn the handle clockwise. You will countersink to the black line indicated on the tip of the driver. Some surgeons may prefer to take both limbs of the FiberTape from plantar to dorsal, but my preference is to split the strands of the FiberTape. One branch will go dorsal to planar and one plantar to dorsal. In conjunction with the FDL tendon into the navicular, this creates what we call a hammock effect, so that tension is more evenly distributed because we are doing this with an FDL tendon transfer. I will use a Tenodesis reamer and Overeem, usually with a five millimeter or 5.5mm reamer, depending on tendon size, in order to accommodate for the anchor, the tendon, and the FiberTape. You will then take one branch of the FiberTape and pass it from dorsal to planar using a suture passing wire. Afterwards, you take the second branch of the FiberTape along with the whip stitched fdl, and pass it from planter to dorsal. You now have one limb of the FiberTape going dorsal to planar, and one in conjunction with the FDL tendon going from plantar to dorsal. It is the surgeon's preference if you want the SwiveLock anchor going dorsal to planar or planar to dorsal. Here we show the dorsal to planar approach. You will have your assistant then hold tension on the FiberTape in both directions while you place the 4.75mm swivel lock anchor. Finalize the construct by cutting excess FiberTape. The internal brace, we feel, serves as a check rein for the primary repair to prevent latent elongation of the spring ligament.

The FDL Implant System comes in two size offerings of 4.75 mm × 15 mm and 5.5 mm × 15 mm with everything included for an FDL tendon transfer in association with the tension-slide technique. The addition of the Spring Ligament InternalBrace™ procedure completes this simple and reproducible method of fixation that reliably seats the tendon against the cortex of the bone socket, maximizing the surface area for tendon-to-bone healing as well as augmenting the repair of the superior and inferior band of the spring ligament complex.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

A general overview including the relevant steps of an Arthrex surgical technique. These animations always include a voice-over explaining the process.

Eine allgemeine Übersicht, einschließlich der relevanten Schritte einer Arthrex Operationsanleitung. Diese Animationen enthalten immer Voice-Overs, die den Prozess erklären.

Operationstechnik-Animationen

Visão geral incluindo as etapas relevantes de uma técnica cirúrgica Arthrex. Essas animações sempre incluem uma narração explicando o processo.

Animações de técnicas cirúrgicas

Descripción general que incluye los pasos relevantes de una técnica quirúrgica de Arthrex. Estas animaciones siempre incluyen una voz en off que explica el proceso.

Animaciones de técnicas quirúrgicas

Surgical Technique Animations

FDL Tendon Transfer Using Tension-Slide Technique and InternalBrace™ Spring Ligament Augmentation

Flexor digitorum longus tendon transfer using the DH button and tension slide technique with spring ligament. Internalbrace ligament augmentation. Make a 5cm to 6cm incision from the posterior aspect of the medial malleolus to just below the palpable navicular tuberosity. Use a combination of blunt and sharp dissection to identify the posterior tibial tendon sheath just distal to the medial malleolus. Open the sheath. Expose and debride, or excise the posterior tibial tendon. Insert the 1.35mm K-wires in the sustentaculum tali at 15 degrees palatally and slightly posterior, avoiding the subtalar joint. Shaverdrill with a 2.7mm cannulated drill. Then use the 3.5mm. Tap down to the laser line. Insert a 3.5mm SwiveLock anchor loaded with collagen coated FiberTape suture. Hold the paddle and turn the paddle clockwise until the black line is slightly countersunk. Then move the FiberTape SutureTak to the side. Identify the FDL tendon and open the sheath and dissect into the plantar medial foot. Making sure there is enough length for insertion into the navicular. Then cut the FDL tendon at that point. Place a traction stitch through the tendon using a number two FiberWire or number two. Fiberloop suture. Size the tendon through the tenodesis graft sizer based on the tendon diameter. Open either the 4.75mm or 5.5mm FDL implant system. At the most plantar point of insertion of the posterior tibial tendon on the plantar medial navicular tuberosity. Drill the 3.2mm spade tip pin bicortical across the body of the navicular from plantar to dorsal. Note it is recommended to use fluoroscopy to confirm spade tip pin is centered and just breaches the dorsal cortex with the foot in maximum plantar flexion and inversion. Pull the traction stitch so the FDL is tensioned appropriately at the interface of the bone and drill pen. Use a marking pen and mark the entry point of the tendon. Then make a second mark 15mm distal to the entry point. Use an Allis clamp to secure the end of the tendon. Speedwhip stitch with the FiberLoop SutureTape and lock the construct by making the final pass proximal to the previous pass and having the needle exit through distal tip of tendon. Remove the traction stitch and any excess tendon past the second mark. Use the reamer in the implant system based on the size of the tendon. Drill 20mm or just up to the dorsal cortex, but do not breach the cortex. Remove the spade. Tip. Drill pin. Irrigate to remove bone debris. It is important for surgeons to do a primary repair or imbrication of the spring ligament before the spring ligament. Internalbrace ligament augmentation is Is completed at this point. Take one lib of the FiberTape from the SwiveLock and pass it dorsal to planter using the nitinol wire. Passer and repeat with the other FiberTape limb planter to dorsal confirm concentric reduction of the talonavicular joint. Thread one suture limb from the tendon. Whip stitch through one side of the eight millimeter DX button and back through the opposite side with a straight needle. Thread the other suture limb in the same manner, starting on the opposite side. Make sure the suture limbs are not tangled, pulling each limb to ensure the button slides freely. Hold tension on the suture limbs and insert the tip of the button inserter into the button. Now hold tension on the sutures and insert the button through the navicular under fluoroscopy, ensuring it is deployed through both cortices. Pull lever back on the inserter handle to release the button. Note leave the button inserter in the hole when pulling tension back on button. Pull on the free ends to seat the button against the against the dorsal navicular cortex. Confirm with fluoroscopy that the button is in appropriate position resting against cortical bone. Remove the button. Inserter. Grasp each suture limb and slowly apply axial tension on each suture limb to dock the tendon into the bone tunnel. Once the tendon is fully seated, use the free needle and pass one suture limb through the tendon and tie 3 to 4 knots to complete the construct. Hold one limb of the FiberTape under tension from dorsal to planter, and the second limb under tension from planter to dorsal. Then insert the tenodesis screw next to the tendon and FiberTape sutures, securing it so it is flush with the cortex. Cut the excess suture and fixation is complete.

A step-by-step demonstration of how a product would (or could) be used in a surgical technique.

Eine schrittweise Demonstration, wie ein Produkt in einer Operationsanleitung verwendet werden würde (oder könnte).

Operationsanleitungen

Demonstração passo a passo de como um produto seria utilizado em uma técnica cirúrgica.

Guias de técnicas cirúrgicas

Demostración paso a paso de cómo se utilizaría un producto en una técnica quirúrgica.

Guías de técnicas quirúrgicas

Surgical Technique Guides

Flexor Digitorum Longus Tendon Transfer With DX Button and Tension-Slide Technique

Elbow

Shoulder

Chirurgen-Newsletter

Boletins para cirurgiões

Boletines para cirujanos

Surgeon Newsletters

Arthrex Presents: Breakthroughs in Foot and Ankle Technology Summer 2019

David I. Pedowitz, MD (Philadelphia, PA), demonstrates a tibialis anterior reconstruction using the Tension-Slide Technique with the newly released Tension-Slide Tenodesis System.

Surgeons presenting one or more clinical cases

Chirurg:innen präsentieren einen oder mehrere klinische Fälle

Videos von Fallpräsentationen

Cirurgiões que apresentam um ou mais casos clínicos.

Vídeos apresentações de casos

Cirujanos que presentan uno o más casos clínicos.

Video presentaciones de casos

Case Presentation Videos

Tibialis Anterior Reconstruction

My name is David Pedowitz. I am a foot and ankle surgeon at the Rothman Institute in Philadelphia. And today we're going to talk about tibialis anterior tendon reconstruction. This case is a 78 year old male who plays tennis three times a week and golfs every weekend. He relays a new four week history of having tripped while playing tennis, and he's felt weak ever since. His wife states that he drags his toe and he's tripped many times, although he's not fallen. As you can see in the clinical photograph, he inverts when he attempts dorsiflexion, recruiting both the perineal tendons and the extensor digitorum longus. He has a palpable mass right below the extensor retinaculum, and all other muscle groups are five out of five strength without pain. And he really has no palpable tibialis anterior tendon, as you can see here in the MRI. He has a tibialis anterior tendon tear. It sort of disappears as we go down a little bit further. He does have a complex tear of the Peroneus brevis, but it's clinically silent regarding his options. The patient was unhappy with his function, and he wanted to be able to resume tennis and golf. So we presented to him the possibility of using a plastic ankle foot orthosis or a brace or surgical reconstruction, and he elected to go ahead with surgical reconstruction. So the overview of the plan, and this is really important because the actual order of the steps helps prevent additional errors. So the first step was just exposure and tendon debridement. Then the pin for the bony tunnel preparing part of the graft, repairing the extensor retinaculum, determining the length of the graft needed. Preparing the distal graft, passing that graft with a tension slide technique and then securing it with a screw. So here's our exposure. It's an anterior medial incision along the course of the tibialis anterior tendon. And we then debride the proximal tibialis anterior to get down to healthy tendon and then remove the non salvageable distal tendon. We then go towards the bone and find the mid portion of the medial caniform. This is an important step. One might think that we were just working with the tendon. Why are we now going to the bone? We'll start doing this step at this point allows us to not tangle up sutures in the wires. We're passing the wire in the reamer. The concept here is we're going to advance the pin through the plantar cortex of the Cartiform. Then we're going to ream over that pin, too, but not through the plantar cortex. The next step is we prepare the tibialis anterior tendon allograft with a locking stitch at one end. I used a number two FiberWire, and we were really only preparing the proximal end of the graft at this point. Here you can see the pin in the medial cuneiform. Right below that is the native distal tendon with a locking stitch and then the graft with a locking stitch proximally. We then sew the native tendon to the graft itself. And then what we do is we repair the extensor retinaculum. It's important to understand that you need to repair the extensor retinaculum under no tension, because once the tendon has been repaired, the retinaculum will be under too much tension and will just rupture. This prevents bowstringing. Next step is we dorsiflex the ankle in order to prepare the distal graft. So what we're doing here is we want to determine the length needed for the distal end of the graft. And when it goes into the bony tunnel. And I generally think of this as about one centimeter longer than the distance of the graph to the bone. And we mark that distance with a pen. We then place a FiberLoop in the distal graph for transfer, and we sort of trim down the graph so that it's almost bullet shaped. So it will go into the bony tunnel very nicely. We then paste a suture button on the distal sutures. And this is just a graphic of that. And the suture button is passed through the pinhole. And you can see it going through there. It is then flipped and then brought back up against the planar aspect of the medial cuneiform. And you can see where we're passing the needle with our graft sutures through the button. There is a suture passer where we pass the button. We then dorsiflex the ankle and pull the tendon into the bony tunnel. You can see that I have a bump against my chest pushing this into dorsiflexion. And as this next video shows, you can show us tensioning and really shimmying the tendon graft into the bony tunnel. And then subsequently it's fixed using an interference screw, and you can hear the interference screw, making that bony contact and reassuring us that we have good strength for our time. Zero fixation on the AP. You can see that the button has been placed through the bony tunnel, and it's subsequently been flipped. And on the lateral x ray you can see it's on the plantar cortex of the medial cuneiform. When you take away this bump, the ankle should not plantar flex. And this is a good example of how our repair is nice and strong. This is that patient nine months post-operatively. You can see he's walking without any great difficulty. As you can see, this tension slide technique allows me to get suture button fixation underneath the cuneiform, which gives me reassurance as well as the cortical fixation of the interference screw, allowing this patient to rehabilitate quicker and really get an outstanding result that he was expecting after this surgery. Thank you very much.

Michael Aynardi, MD, (Hershey, PA) describes his clinical experiences and biomechanical research with InternalBrace™ ligament augmentation in treating flatfoot deformities.

Presentation Videos

InternalBrace™ Ligament Augmentation for Spring Ligament in Flatfoot Reconstruction

Good morning, I'm Michael Leonardi, I'm from Penn State. Hershey. And today I'll be talking about our work with the internal brace for spring ligament augmentation in flat foot reconstruction. The reason I got interested in this were concerns over my spring ligament repairs and refits in the past. I believe they elongated and I was looking for something to augment my repairs in the early post-operative recovery period. I was also concerned about how long I was immobilizing my flat feet for after reconstruction, and I also had concerns over lateral column lengthening and complications associated with it. And I was wondering if there was anything we could do to augment this and accelerate our recoveries, and maybe avoid some of these additional procedures. Today, we're going to go over my rationale for the use of internal brace for spring ligament augmentation. We'll talk about some of the outcome studies that have that have been performed for lateral ligament reconstruction and repair. I'll go through briefly some of the spring ligament anatomy, and we'll talk about some of the recent biomechanical results from a study we've performed at Penn State. Hershey evaluating the internal brace for spring ligament augmentation. So one concern is, are we able to move patients early after surgery? And a group out of Baltimore looked at this with respect to the anterior talofibular ligament. And they found that if you move patients too early after ArthroBrostrom reconstruction, the atfl actually elongates. And that unprotected motion was associated with a significant amount of lengthening in their cadaveric study. We also think that our brochure repairs are strong and we're confident we can move them quickly. But if you look at the literature, it would suggest otherwise in that traditional brostrom reconstruction with or without anchors is significantly weaker than our native atfl. When the brostrom is augmented with the internal brace, there's been excellent outcomes functionally with this and been reported in the literature. And it got me thinking, well, what if we used it for another ligament that we repair? And so when you look at the spring ligament, it works kind of like a hammock supporting the talus and the talonavicular joint from collapsing and deviating medially. But in people with posterior tibial tendon dysfunction and flat feet, this structure often elongates and weakens and can lead to additional sag and medial deviation of the talus. When we repair these, we classically perform a reefing at the time of surgery. I worry that maybe this simple reefing with suture isn't strong enough. And so we ask the question with flat feet that we did with brostrom's our repairs as strong as they need to be, do they really do as well as we think they do? And are we confident that we can move them early? And we went to the literature, and there was a very nice study that looked at 26 patients and averaged roughly a year and a half follow up. And it showed that the augmentation of the spring ligament reefing with internal InternalBrace is very safe and has maintained correction. But there's really no biomechanical data which would support these clinical findings. And so we sought to address this. If you look at the technique, the device is typically inserted in the sustentaculum. And then the two limbs of FiberTape are passed plantar dorsal and dorsal planter with your FDL transfer through a navicular bone tunnel. Alternatively, a limb planter leaf can be brought to the medial cuneiform. If you notice SAG at the time of surgery intraoperatively I typically don't perform this additional extension because of concern with the osteotomy. I don't want to violate this with my osteotomy site, so I typically bring it through a bone tunnel in the navicular at Penn State in our biomechanics lab. We evaluated the internal brace spring ligament augmentation. We had eight matched pairs of cadaveric limbs, we created a flat foot, according to the. Previously described by Dumontier et al. We statically loaded this on a specialized device seen here in the bottom right. We were able to insert text scanners and take digitized measurements, angular measurements, and pressure measurements of the talonavicular joint. Once we had created a flat foot, we then performed a flat foot reconstruction. Eight of the limbs randomly underwent a FTL transfer. Medial displacing calcaneal osteotomy and a spring ligament reefing with the number two FiberWire suture. The experimental group underwent the same procedure, but also had augmentation of the internal brace at the time of reconstruction. We then underwent cyclically loading using one hertz cycles, beginning with 400 newtons of ground reaction force. We performed 100 cycles and increased at 100 Newtons steps as we were doing this. You can see here also in the bottom right, we performed digitized angular measurements to evaluate the merits of first metatarsal angle and evaluate for any further collapse. And then we also took measurements in the coronal plane to evaluate for abduction on coverage, as well as alignment of the ankle and hindfoot. We then performed analysis of these specimens. In total, we had 16 limbs that underwent reconstructions eight matched pairs, average age 53, average weight 170 pounds, and average height 67in. There were five males and three females in the control group. Eight of eight of the briefings of the spring ligament failed. The most common failure mechanism was our suture cutout. The next common was suture fatigue and elongation, and there was one knot failure in the experimental group. There was one suture cutout of the spring ligament reefing. However, the InternalBrace device remained intact in this specimen. With our loading, there was capsular disruption that occurred dorsally where we inserted our test scan pressure monitors. This occurred in three pairs at loads of over 1500 newtons. However, in each of these, the InternalBrace device. The FTL transfer and the medial displacing osteotomy all remained intact. Here's one such specimen that failed. This is through the tibiotalar joint where the sensor was placed. But if you look closely at this specimen, what is interesting is that the spring ligament repair or reefing, as well as the internal brace and the FTL transfer all remained intact. You can very nicely see her in the picture here on the left, that the hammock effect supporting the Taylor head is still completely intact, despite the dorsal disruption at the talonavicular joint where the sensor was inserted. If you analyze the digital angular measurements of alignment and correction, you can see that the internal brace device was superior to controls at maintaining Mary's first metatarsal angle. This was statistically significant, and if you look as you increase loads, it loads greater than greater than 1600 newtons, the separation and difference becomes even wider and more noticeable between the two groups. If you look at Talonavicular coverage, there is also a significant difference clinically between the two groups, and it nears statistical significance of the p value of 0.07 maintained at a final stages of loading compared to their preoperative correction. Lastly, if you look at the joint contact pressures, there was no statistical significance between the two groups. And this is important because whenever you're using a device to augment a repair, you don't want to over constrain the joint or increase abnormal forces across the joint. And in this study, using our tech scanners, we noticed no pressure difference between control and experimental groups. Here's some data from a brace experimental group. You can see pressure before reconstruction of the flat foot after reconstruction and after cyclic loading, you see no difference in contact pressure. And here's a control group. Again before correction after correction and after loading. So in summary from our biomechanical study, we found that the internal brace ligament augmentation for spring ligament repair and a flat foot model demonstrated a lower failure rate of spring ligament repairs under cyclic loading up to 1800 newtons, and that the group with internal brace augmentation maintained correction in both the first metatarsal angle and talonavicular coverage angles, and that there was no significant increase or change in intra-articular contact pressures compared to controls in these groups. One of the most important things that my partners and I have gained from our biomechanical study and translated it into our clinical practice, is the accelerated protocols we now endorse for flat foot reconstruction. The specimens, both controls and experimental groups with with stood up to 1800 newtons of force. And so we've begun to weight bear our flat feet much earlier than before. We endorse the following protocol. Where we have early protected weight bearing, all patients go into a splint until their wound heals. They're then transitioned to a cam boot with a wedge and begin physical therapy at the two week appointment. We avoid any excessive eversion and protect them. However, until about the eighth week, we advance them to full weight bearing as tolerated by the sixth week. We then wean them from the cam boot at six weeks. Continuing physical therapy. We then transition them to a lace up posterior tibial tendon brace with a shoe. And then we begin work on strengthening and motioning these visits as well. By the eighth to 12th week we're then weaning them from the brace. We're allowing for full unrestricted motion and return to any activities as they tolerate and begin to strengthen. I think that the accelerated protocol has several advantages of improving not only motion, but increasing their strength and doing it faster than before, and these patients seem to return faster and return stronger to work and sport. While we've looked at this in the short term, we will continue to follow these patients out to a further time period and continue to study these outcomes as they progress. This is a clinical photos of an 18 year old male with posterior tibial tendon dysfunction, hindfoot valgus and pain over his spring ligament. He had failed conservative treatment here. His weight bearing radiographs you can see on the lateral view decrease in the first metatarsal angle. You can see on coverage at the tail end of the joint and sub fibular impingement. Intraoperative technique photo here demonstrating a spring ligament or reefing and sutures in that ligament. The tapes inserted the 3.5 SwiveLock and a whipstitch through the FDL. Here's localization after harvest of the flexor digitorum longus at the knot of Henry. Here is after correction you can see just doing medial work alone significantly improved talonavicular coverage in this patient and assessing the foot. There appears to be excellent coverage and assessing forefoot supination. There was no need for additional osteotomy. So with just the medial displacing calcaneal osteotomy, flexor digitorum longus transfer, spring ligament reefing, and augmentation of internal brace, this patient had a very nice corrected flat foot. And there. These are the postoperative films from nine months and the initial preoperative films demonstrating the maintained correction at nine months. Here are my references. Thank you very much for your time.

Spring Ligament or Posterior Tibial Tendon: Chicken or the Egg?

And this was the title that I was given. Spring ligament or posterior tib tendon, chicken or the egg. And initially, I didn't know what to do with this talk. And maybe at the end you'll get that same feeling that I had no idea what I was doing with this talk. But I think it's a question that they gave me ten minutes to answer, something that we get asked all the time from our patients. Why did this happen? And the answer is, I really honest to God, don't know. And this is the opposite of my syndesmosis talk that was based on science. There's a mic drop and I can stand by what I said in that talk. In this talk, I'm putting my heart out there and feel free to crush it in your hands if you so choose. Because this whole thing is literally made up. And that's just what it is. So I'm going to try to venture an answer, because I've thought about this a lot, and I thought I would make a career about being a spring ligament reconstruction guy. And I solved flat foot. And I've only made people sometimes way worse and slightly better. So I don't have the answer. But congenital flat foot. When I think about these people, these are like the pancake people. I was a kid. My foot's always been flat. It didn't hurt. I'm 35 now. It's giving me some grief. Their medial soft tissue restraints are nonfunctional. They've been born flat. That's what God wanted them to be. Whatever your religious preference is, the latter column in these people is developmentally short. And I know Thorson has the article that a lot of columns are not short. I believe that, but I believe that for someone that had a normal foot that became flat on these flat foot congenital people, the lateral column is probably relatively short for them or functionally short. The failure of the tip tendon is probably the root cause in these people. Because the ligaments have been pathologic for life, it's probably the chronic strain that leads to tendinosis and the cycle of failure begins. That's my theory on this. So they developed the patulous spring. That's why this patient this what this patient is used to, you should not tension to a normal position. And Lord knows I have tried. So this kid came in. It's a flat foot. No question about it. I did all this usual stuff, but I don't think you should tension these people to a normal position. What that means is don't create a very rigid medial column. We're all looking to get a great x ray, come up on the podium and show you how awesome we are. Because nobody wants to show you a foot that's slightly flat or basically the same as the pre-op. I will show you plenty of those in a few minutes. And so I did a lot of arm lengthening, slide cotton osteotomy, FDL, all that stuff for this person. And it looks really, really good in trop. But I think for these people you get a good inch drop and they're going to collapse. I'm going to show you that. So this is a mild stage four congenital flat foot. That's her foot. I mean you can all see that this is a flat foot. It's not one of those mildly flat. This is a real flat foot. There's definitely first team instability. And so I did all the stuff I'm supposed to do. Spring ligament. And I will show you that was poorly executed in a second. A lot of column lengthening, first fusion, gastroc, post hip tendon transfer, all of that stuff to make the x ray look better. And I thought that lateral. That looks pretty good. That's a you know I didn't draw the lines, but that's a pretty good looking foot. But then you look at her AP and it's not so hot. She. I fractured her navicular tunnel because that's what I do. So I threw in a suture anchor to put the allograft in. So I did a talus to navicular tunnel, and I split it. So then I shot it into the cuneiform. You can see that big hole in the cuneiform. Her foot is still pretty flat when you look at that. It's abducted. I did a lot of column lengthening. Her abduction still 30%. And if you saw this foot pre-op on the right side, you'd say you need a flat foot reconstruction. Ma'am, you have a deformed foot. But that's my post-op x ray. I know she's happy because she doesn't glare at me when I walk in the O.R., and the nurses still keep coming to me for surgery. So I think on these congenitally flat foot people, getting them better is taking the strain off the post tib tendon, doing your tendon transfer and leaving their medial column kind of sloppy. And you can try as hard as you want. And I tried again. There's another another nurse in the operating room, 55 year old aunt of a foot and ankle colleague. You may know him, Brian Lipinski. He's out in the west suburbs of Chicago. Nice guy. She came in with this foot and he told me to fix it, So I did the medial slide, FTL, all the usual stuff, a lot of column lengthening, spring ligament reconstruction. Because I thought, I'm going to get this foot to be perfect. He texted me the day of surgery. The day before surgery that night, like 11:00. And he says, I say, don't screw it up. But that was not the text. It was something else. And I said, all right, and that's a flat foot. And I call that a pancake foot that is flat as flat can be. And I was in the operating room and I was very proud of myself. I did everything, got some sweet x rays. That's a foot with an arch on it. And I was like, yes, I am a genius. And then she walked on it and then not so much. And it just went back to where God wanted it to be. It was still sloppy in the medial column. This is her lateral pre-op three months, six months. And it just I had it at six weeks. And you can see as you go around the corner, it slowly collapses back to a sloppy medial column. Your graph is not going to hold. If you do an NC fusion it's going to find some laxity. So I think in these people it is the post hip tendon, not the not the spring ligament. And are these all failures? Am I that bad? A surgeon? And you can keep your thoughts to yourselves. But if you look at Dylan's article, he's proven that perfect x rays do not mean a perfect outcome. You have to be careful not to create a rigid foot. They never had a stable or tight spring ligament complex. Maybe we should not be creating that for them. So relieve the tension off the medial side, which a lot of common lengthening of cotton. If you want to do a first team, T if it's unstable gastroc and tendon transfer. But the spring ligament reconstruction for those people does not seem like it holds, and probably may not be the right thing to do. And over tensioning them with an NC fusion and doing all these things to get a good x ray may end up causing them to collapse somewhere else. The deltoid may collapse and may get a stage four, and there's not enough time to talk about more problems that I've created. And there's some literature showing that if you stiffen up the hind foot too much, their ankle will give. So it's not the x ray. So that's in short. Summary. Congenital flat foot is the posture tip, not the spring ligament. So is there a role for the spring ligament. Of course this is the patient says, my foot never looked like this, doc. I had normal feet. One is not. One is flat. The other one looks good. What happened to me? And in these people, I think the spring ligament is the root cause of the problem. You can see here this is a patient pre-op on the left, post-op on the right. And I did a slide tendon transfer of gastroc, but I and the spring ligament. And you can see with these patients you get good looking X-rays. They're not super flat pre-op. It's not that bad. And when you correct them you can really restore the alignment. And I think in these people the spring ligament makes sense because if you don't do that you do a tendon transfer in isolation. There's a lot of tension on the medial side, and they're not used to it and they hate it. And this is her at three months. And it holds. These people are stable, unlike the congenital flatfoot where they will fall apart again. So if that's the case, if the spring ligament is the problem and not to push it to the tendon, what's the only example we have in our practice where we actually cut the posterior hip and see what happens? This is not a normal population, but if you have a foot drop from a transfer, we cut the posterior Poster tip. Very few people will transfer the FTL to to stabilize it, and you throw it into the top of the foot. There's only one case report that shows that they get a flat foot. Now, there's not a ton of these that are done. They looked at this 18 months out, and they had one case that had a flat foot, and they had flat foot meet a large pain at five months post op. And they said it was because they took out the posterior tib. The funny thing is, if you look at that X-ray critically, they look the same to me. The line is drawn differently and I'm sure this patient has slightly collapsed arch. But that is a very soft call to say that patient's foot is flat. I've looked at this X-ray a lot. I think that lateral Taylor declination line was just changed a little bit more. It looks worse, but that's not really flat. So I think if you cut the post, you tip in a normal human being. They probably do not get a flat foot that quickly. I'm sure over ten, 20 years it is, but it is. A spring ligament holds the foot, maintains its shape. But if you tear your spring ligament, I promise you you're going to have pain. So clearly, the spring ligament is a static structure that, if failed, allows excess tension on the medial side gives you pain. The 18 year old isolated spleen ligament rupture. Ice skater a year and a half. Can't walk, can't stand. She's a little weird because, you know, that's how these people are. And they came in and they wanted to ice skate, which is not a goal that you're ever going to achieve properly subtle, but it's clear on the lateral as well that the lateral tail, the declination angle is high. You can see on the AP she's abducted relative to the normal side. And I think all of us have probably seen this at some point. I did this nonsense operation. I do an isolated spring ligament reconstruction, which has no basis in the literature, with an allograft and with a internal brace on top of it. As I put a FiberTape inline, I put it in the talus for extra rigidity. Based on Dylan's article, the tibial spring is really one structure and the lateral improved. It's not normal. It's very difficult to see if it's real. When I compare it to the other side, it's slightly the same, slightly better but not different. But look at the AP six months out. There's a definite difference. The Taylor navicular coverage is better and it's maintained with weight bearing. Here she is at 18 months. She's skating for the first time. She looks good. That's not 18 months. That's like six like six months because of the swelling. But she's able. She went back to ice skating. Not professional. The feet look about the same. And so this does work. It does fail to. I have a guy that I did the same thing on. He's an ex-military and has got RSD. I'm going to do a BC next week. So it was a disaster. So just because it worked once doesn't mean it works all the time. We've published on this as well, but the whole point is that if your spring ligament fails, you get pain and you get deformity. If you cut the posterior tib and you do not get deformity immediately. So clearly the spring ligament is pathologic. And this is the technique with the InternalBrace, which I do a lot of. And you can see you put in the sustentaculum. And then you can put it up and down the navicular and tension it. I also take this limb and stick it into the tibia based on Dylan's article. So a little bit more oomph because it's not just the calcaneonavicular ligament, it's the tibial spring complex that you want to reconstruct. This is just my theory, based on Dylan's biomechanical article. And there we are putting it in. And this gives you a beautiful reconstruction at time zero. The foot is stable to abduction. But if you want more stability, you take the long FiberTape and you put it into the tibia as well. And put a you can put it over an interference graph if you want, or you can do an ACL TightRope on top to loop it over different options. It does work really well. It's a very controversial conclusion, needs a good discussion, but I don't think it's a chicken or egg phenomenon. It's more of a chicken or a duck phenomenon. Congenital flat foot is maybe the primary failure. Not to say the spring ligament hasn't gotten looser, but their main problem is their posture. Tib just failed over time and their foot needs to be flat in the adult acquired flat foot. I think spring is the root cause, and we should focus heavily on fixing that in addition to everything else. But maybe in those patients, the lateral column lengthening and all those other procedures may not be important or as important, because if you tighten up the spring ligament slide, you'll be able to correct them to a more neutral position and not have to over stiffen those patients. Thank you very much.

BioComposite-Tenodesis Screw with Disposable Driver Pack, 4.75 x 15 mm

Tenodesenschraube, BioComposite, 4.75 mm x 15 mm, mit Einwegsetzinstrument

BioComposite-Tenodesis Screw 4.75 mm x 15 mm, with Disposable Driver

Tornillo de Tenodesis de BioComposite, Ø 4.75 mm x 15 mm,con insertador

BioComposite-Tenodesis Screw with Disposable Driver Pack, 5.5 x 15 mm

Tenodesenschraube, BioComposite, 5.5 mm x 15 mm, mitEinwegsetzinstrument

BioComposite-Tenodesis Screw 5.5 mm x 15 mm, with Disposable Driver

Tornillo de Tenodesis de BioComposite, Ø 5.5 mm x 15 mm,con insertador

FDL-Sehnentransfer

Informationsmaterialien und Produkte

Vorgestellte Informationsmaterialien

Alle Informationsmaterialien

Alle Produkte

Flatfoot Repair With the InternalBrace™ Ligament Augmentation Procedure

Flexor Digitorum Longus Tendon Transfer With DX Button and Tension-Slide Technique

FDL Tendon Transfer Using Tension-Slide Technique and InternalBrace™ Spring Ligament Augmentation

Videos

Dokumente

Sprachen

Videos - OP-Anleitung (1)

InternalBrace™ Ligament Augmentation Repair: Spring Ligament Surgical Technique

Animationen für die Patientenaufklärung (1)

Flatfoot Repair With the InternalBrace™ Ligament Augmentation Procedure

Chirurgen-Newsletter (1)

Arthrex Presents: Breakthroughs in Foot and Ankle Technology Summer 2019

Kataloge (1)

Foot and Ankle: Next Generation in Foot and Ankle Technology 2023

Operationsanleitungen (1)

Flexor Digitorum Longus Tendon Transfer With DX Button and Tension-Slide Technique

Operationstechnik-Animationen (1)

FDL Tendon Transfer Using Tension-Slide Technique and InternalBrace™ Spring Ligament Augmentation

Presentation Videos (2)

InternalBrace™ Ligament Augmentation for Spring Ligament in Flatfoot Reconstruction

Spring Ligament or Posterior Tibial Tendon: Chicken or the Egg?

Videos von Fallpräsentationen (1)

Tibialis Anterior Reconstruction

Ähnliche Produkte (5)

AR-1547BC-CP

AR-1555BC-CP

AR-1676ST

AR-1688-CP

AR-1678-CP

Bio-Tenodesis, Einweg-Sets (2)

AR-1547CDS

AR-1555CDS