Name: Spring Ligament or Posterior Tibial Tendon: Chicken or the Egg?
Uploaded: 2018-07-02T00:00:00Z
Channel: Arthrex

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VID1-01438-EN | A | Spring Ligament or Posterior Tibial Tendon: Chicken or the Egg?

Anish R. Kadakia

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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.

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

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