The deltoid ligament is primary responsible for stabilizing the medial side of the ankle joint. It is fairly complex ligament consisting of both superficial and deep fibers. Injuries to the deltoid ligament can occur in multiple settings including simultaneous lateral ankle sprains, ankle fractures or posterior tibial tendon deformities. Chronic injuries to the deltoid ligament can lead to laxity of the medial side of the ankle or ankle valgus. Typically, these chronic injuries require surgical intervention.

Foot and Ankle

Procedure

The Deltoid Ligament Reconstruction Implant System provides a turnkey repair technique to treat this previously difficult to manage pathology using a TightRope® and gold standard Bio-Tenodesis Screws. Utilizing the TightRope construct provides the benefit of cortical fixation and gives surgeons complete control of the final construct tension. By using a free tendon graft to recreate both the superficial and deep deltoid ligament attachments, surgeons are able to achieve a reproducible, rigid, anatomic reconstruction for patients presenting with medial sided ligament laxity. 
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This convenient all-in-one implant kit includes all of the necessary implants and instrumentation to perform this procedure. 
Designed to be used in conjunction with our presutured and sized allograft, Arthrex® removes all of the guesswork from the repair technique and allows physicians to focus on the task at hand.

The Deltoid Ligament Reconstruction Implant System is a convenient all‐in‐one implant and drill system designed to help facilitate a strong, reproducible reconstruction of the deltoid ligament complex. This implant system is designed to be used in conjunction with the VersaGraft™ presutured tendon which has been designed specifically to meet the requirements of the Deltoid Ligament Reconstruction Technique.

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video

Human

Deltoid Ligament Reconstruction

Arthrex presents the deltoid ligament reconstruction technique utilizing the deltoid ligament reconstruction implant system. A 4 to 6 centimeter incision is created to visualize the insertion sites of the deltoid ligament on the medial malleolus, talus, and sustentaculum. Insert the spade tip drill pin into the medial malleolus at the site of the intra-articular groove. The drill pin should be aimed laterally to a point 5 to 6cm above the ankle joint, and lateral to the anterior tibial crest. The drill pin should exit the leg and tear laterally, medial to the course of the superficial peroneal nerve. The drill pin is over drilled to a depth of 40mm. Do not violate the far cortex of the tibia. The tendon graft is looped through the TightRope device, and the four FiberWire sutures from the TightRope construct are then loaded through the open eyelet of the pin to be shuttled through the medial tunnel. Pull the sutures proximally until the Until the button exits the tibial cortex. Under Fluoroscopic visualization, pull tension on the free limbs of the graft construct distally to ensure proper tensioning of the button. Toggle the white sutures proximally to pull 15mm of the graft loop into the tunnel, aiming in a slight plantar direction. A guide pin is placed at the insertion site of the deep anterior tibial Taylor ligament. This is one centimeter posterior to the anterior corner of the medial Taylor trochlea, immediately inferior to the articular cartilage. The guide pin is over drilled to a depth of 17mm. The graft will still slide through the tibial tunnel. Pull on the posterior limb of the graft to shorten the anterior limb. Insert and fix the anterior limb of the graft, which has been previously whip stitched into the talus using blind tunnel tenodesis technique. For cortical button fixation in the calcaneus. Use the spade tip drill pin to create a bicortical tunnel in the calcaneus, starting one centimeter anterior to the posterior edge of the sustentaculum Aime, slightly planter and posterior to avoid the subtalar joint and peroneal tendons. Over. Drill the guidewire to a depth of 15mm. Tension the free limb of the graft and make a pen mark at the insertion point of the graft into the calcaneal tunnel. Trim the graft 15mm distal to this mark and whipstitch the distal 15mm of the graft. Using a number two FiberLoop suture, pass the free ends of the whipstitch through the cortical button as shown to create a tension slide. Construct. Insert the button and sutures through the calcaneal tunnel until the button exits the lateral aspect of the calcaneus. The button is engaged laterally by unscrewing the back of the driver body and toggling on the blue FiberWire sutures. Further toggling of the FiberWire sutures. Exiting medially properly. Tensions the graft. Securely suture the tendon at the calcaneal tunnel entry using a free needle. Finally, insert the screw into the Calcaneal tunnel. For additional interference fixation, final tension of the construct is achieved by once again toggling the white TightRope sutures exiting superiorly at the tibia. Once proper tension is achieved, the blue TightRope sutures are pulled out of the button and the white sutures are cut. Alternatively, calcaneal fixation may be provided solely by an interference screw. In this case, a guide pin is inserted into the sustentaculum and directed slightly palatally and posteriorly. The guide pin is over drilled to a depth of 17mm. The free limb of the graft is tensioned. The insertion site to the calcaneus is marked with a pen, and the graft is trimmed 15mm distal to this mark. The distal 15mm of the graft is then whip stitched with FiberLoop. The tendon is inserted into the Calcaneal tunnel using blind tunnel technique and fixed using the tenodesis screw. Final tension of the construct is achieved by once again toggling the white TightRope sutures exiting superiorly at the tibia. Once proper tension is achieved, the blue TightRope sutures are pulled out of the button and the white limb should be cut. This completes the repair.

George Lian, MD, (Sacramento, CA) demonstrates how to perform a deltoid ligament reconstruction utilizing the Arthrex® Deltoid Ligament Reconstruction System in conjunction with the Pre-Sutured Ankle Tendon Allograft. With a consistent diameter of 4.5 mm, the pre-sutured and pre-sized tendon is designed specifically to meet the requirements for the deltoid ligament reconstruction technique. Dr. Lian provides an extensive overview of the procedure from dissection to final fixation. The Deltoid Ligament Reconstruction Implant System provides all of the necessary implants, instrumentation and accessories in order to create a reproducible, rigid and anatomic reconstruction.

Deltoid Ligament Reconstruction Utilizing the Arthrex TightRope® RT and Pre-Sutured Allograft

So make skin incision. Here's my posterior tibial tendon. And just coming up just behind the malleolus. So I want to find out where my sustentaculum is. This is really the the base of the posterior tibial tendon sheath. I'm coming down underneath. And I'm just going a little bit further here to find the FHL. So it's coming down right under there. So the sustentaculum is there. And then the Taylor point is going to be there. Here's the medial malleolus. So that's where we'll start our pin for the medial malleolus tunnel. Right about that point. So aim for the anterior tibial crest which I can feel under my middle finger here and shoot to come out there and I can feel it. I've just come through that and I can feel the end of the guide pin under the skin. So I'm going to make a cut just superior to that because I want it to pop out. And then I'll take the 6.5 reamer and we'll ream over that to about 30mm. So that's 30 there. So then we've got the TightRope. So the graft has a whip stitch in one end and then just a couple of stitches in the other end. And so I usually take the whip stitch in and put it through the tunnel that will make in the talus first. So I'm going to pass this through the loop in the TightRope and then put it in sort of asymmetrically. So the length of the limb that has the whip stitch on it is shorter than the other. Then I'll pass all four of those threads for the ACL TightRope and then pull that up. And then find the four that are loose. So bring those four up And then with a little traction on that. We'll pull it up into the tunnel. And then you can see approximately the button coming out. And then we'll pull that back. And then I will start pulling the white stitches up to draw it up into the tunnel. I want to leave enough of the whip stitched end out, so that I'm going to be able to put it into a tunnel. And you can toggle it back and forth. Now I need a guide pin to put into the Taylor hole just anterior to the tip of the malleolus. And then I'll pop it through the skin. The other side. Okay. Then I need to ream over that. This is A50 reamer. That out of the way? That's between 15 and 20 there. Okay. So then I need to pass the ends of that whip stitch. So I use the oscillating Function to draw the suture. So I use a pull through technique. And that pulls it out through the other. But here's the tip of the malleolus. And the tunnel we made just kind of pops out and dives back in again. So there's not a great distance that it's out. Now I need the Bio-Tenodesis screw. I put that into the tunnel where I'm going to put the screw. And. I think that's good. So again, I'm sort of on that inferior portion of the sustentaculum. And I'm going to aim slightly inferior because I don't want to enter the subtalar joint off to the other side. Okay. Just make this tunnel first. That's 20 there. So that's going to going to be where the entrance of the tunnel should be. So I'll have that a little bit longer than that. And I'll take a knife and then the FiberLoop. I'll put one more in to lock it. So that should be pretty good. Then we'll oscillate that one across pulls that through to there. You can see it's going into that tunnel there. I'm putting pretty maximal tension on the two stitches pulling through. The foot is in a little bit of inversion and some plantar flexion in this position. And you're going to hold the paddles and we'll twist that. And has a nice sound to that okay. So then I have to give a final toggle to the white stitches to seat that as Firmly as possible. Okay, now I need to pull these out. So there's the sustentaculum one that goes down here. The Taylor goes to there, which is just anterior to that. And then the medial tunnel right there. Most of the procedures that I've done have been just deltoid reconstructions themselves. Patients who have had chronic problems, they have instability and they have tenderness along the deltoid on the medial side. Most of them have an MRI study that shows abnormalities in the deltoid ligament, also about a third of the deltoid ligament reconstructions I've done for that just have ligament problems. Also have lateral ligament problems. And I have done this procedure combined with a broström procedure in some cases and also in some cases combined with an allograft. Bio-tenodesis procedure on the lateral side also. I've done this procedure also in some patients who have a stage four posterior tibial tendon dysfunction, who may have a spring ligament that needs to be augmented, and also the deltoid ligament reconstructed. And I've also done it in several patients who have had reconstructions about total ankle replacements, who have a fairly complex problems with their total ankle replacements. But I think it's a fairly straightforward procedure, and it can be combined with some of these other procedures as needed. It can be certainly done by itself as a standalone procedure.

The Deltoid Ligament Reconstruction Implant System provides a turnkey repair technique to treat chronic deltoid ligament pathology utilizing a TightRope® construct and the Bio‐Tenodesis Screw™ system. Utilizing the TightRope construct provides the benefit of cortical fixation and gives surgeons complete control of the final construct tension. By using a free tendon graft to recreate both the superficial and deep deltoid ligament attachments, surgeons are able to achieve a reproducible, rigid, anatomic reconstruction for patients presenting with medial‐sided ligament laxity.

Deltoid Instability

Deltoid Ligament Reconstruction