Miki Dalmau-Pastor

Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay.

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström–Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.

Ankle Arthroscopy: An Update

A number of evidence-based arthroscopic techniques have been advocated to treat ankle pathology, including ankle instability, impingement, osteochondral lesions, and end-stage osteoarthritis.For anterior ankle arthroscopy, one technique that has gained favor involves insertion of the arthroscope wit

Letter Regarding: Cadaveric Analysis of the Distal Tibiofibular Syndesmosis

Dear Editor: We read carefully and with great interest the anatomic study performed by Lilyquist et al. They performed an interesting study of the tibiofibular syndesmosis using a 3-dimensional method that can be of help when performing anatomic studies. As the authors report in the study, a controversy exists regarding the anatomic structures of the syndesmosis, and a huge confusion can be observed when reading the related literature. However, anatomic confusion between the inferior transverse ligament and the intermalleolar ligament is present in the manuscript: the intermalleolar ligament is erroneously identified as the “inferior” transverse ligament. The transverse ligament is the name that receives the deep component of the posterior tibiofibular ligament. The posterior tibiofibular ligament is a ligament located in the posterior aspect of the ankle that joins the distal epiphysis of tibia and fibula; it is formed by 2 fascicles, one superficial and one deep. The deep fascicle or transverse ligament is difficult to see from a posterior ankle view, but easily from a plantar view of the tibiofibular syndesmosis (Figure 1). Instead, the intermalleolar ligament is a thickening of the posterior ankle joint capsule, located between the posterior talofibular ligament and the transverse ligament. It originates from the medial facet of the lateral malleolus and directs medially to tibia and talus (Figure 2). The intermalleolar ligament was observed in 100% of the specimens by Golanó et al in contrast with 70% in Lilyquist’s study. On the other hand, structures of the ankle syndesmosis have not been named according to the International Anatomical Terminology (IAT). In 1955, the VI Federative International Congress of Anatomy accorded to eliminate eponyms from the IAT. Because of this measure, the Chaput, Wagstaff, or Volkman tubercles used in the manuscript should be eliminated in order to avoid increasing confusion. Lilyquist et al also defined the tibiofibular syndesmosis as being formed by the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, the interosseous ligament, and the inferior transverse ligament. The anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament of the tibiofibular syndesmosis (or inferior tibiofibular joint) should be referred to as the anterior tibiofibular ligament and posterior tibiofibular ligament. The reason why it is not necessary to use “inferior” in its description is that the ligaments of the superior tibiofibular joint are the anterior ligament of the fibular head and the posterior ligament of the fibular head, not the “anterior superior tibiofibular ligament” and “posterior superior tibiofibular ligament.” The ankle syndesmosis is one of the areas of the human body where chronic anatomic errors exist: the transverse ligament (deep component of the posterior tibiofibular ligament), the anterior tibiofibular ligament (“anterior 689614 FAIXXX10.1177/1071100716689614Foot & Ankle InternationalLetter to the Editor letter2017

X-shaped inferior extensor retinaculum and its doubtful use in the Bröstrom-Gould procedure

PurposeThe inferior extensor retinaculum (IER) is an aponeurotic structure located in the anterior aspect of the ankle. According to the literature, it can be used to reinforce a repair of the anterior talofibular ligament in ankle instability. Despite its usual description as an Y-shaped structure, it is still unclear which part of the retinaculum is used for this purpose, or if it is instead the crural fascia that is being used. The purpose of this study is to define the anatomical characteristics of the IER to better understand its role in the Broström–Gould procedure.MethodsTwenty-one ankles were dissected. The morphology of the IER and its relationship with neighbouring structures were recorded.ResultsSeventeen (81%) of the IER in this study had an X-shaped morphology, with the presence of an additional oblique superolateral band. This band, by far the thinnest of the retinaculum, is supposed to be used to reinforce the repair of the anterior talofibular ligament. The intermediate dorsal cutaneous nerve (lateral branch of the superficial peroneal nerve) was found to cross the retinaculum in all cases.ConclusionsThe IER is most commonly seen as an X-shaped structure, but the fact that the oblique superolateral band is a thin band of tissue probably indicates that it may not add significant strength to ankle stability. Furthermore, the close relationship of the retinaculum with the superficial peroneal nerve is another factor to consider before deciding to perform a Broström–Gould procedure. These anatomical findings advise against the use of the Gould augmentation.

Minimally Invasive Distal Metatarsal Diaphyseal Osteotomy (DMDO) for Chronic Plantar Diabetic Foot Ulcers

Background: The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive distal metatarsal diaphyseal osteotomies (DMDOs) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs) and second to assess their clinical-functional and radiographic outcomes. Methods: A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous nonoperative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System (UTDWC). Demographic parameters, Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, healing times, and complications were recorded. Maestro et al criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out (P < .05). Thirty consecutive enrolled patients with a mean age of 66.7 (range, 53-75) years presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%). Results: All ulcers recovered with a mean healing time of 7.9 ± 4.0 (range, 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points (P < .001). At a mean follow-up of 25.3 months (range, 18-71), no cases of ulcer recurrence were recorded, while a major complication or a wound infection required longer healing time. Conclusion: Minimally invasive DMDO was a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads. This technique improved functional and radiographic outcomes with few complications. Level of Evidence: IV, case series.

Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality

Purpose An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic ATFL all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality. Methods Fifteen patients [9 men and 6 women, median age 30 (19–47) years] with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing non-operative management. Median follow-up was 18 (12–23) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor’s residual suture limbs were not cut, but were recycled and used for augmentation of the ligament repair. Results Arthroscopic examination demonstrated an isolated anterior talofibular ligament (ATFL) injury with poor remnant ligament tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median AOFAS score increased from 66 (44–87) preoperatively to 100 (85–100) at the final follow-up. Conclusion Chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality. Level of evidence IV, retrospective case series

Minimally invasive surgery for hallux valgus: a systematic review of current surgical techniques.

PurposeThe aim of this study was to systematically evaluate the available literature on minimally invasive surgical (MIS) treatment for hallux valgus and to provide an overview of the different surgical techniques.MethodsA systematic review of the literature available in MEDLINE, EMBASE, and the Cochrane database was performed including studies from January 2001 to 1 January 2018. The radiological outcomes (hallux valgus angle (HVA), intermetatarsal angle (IMA)), complication rates, and clinical outcome scores were evaluated. The MINORS scale was used to assess the methodological quality of included articles.ResultsOf 278 reviewed articles, 23 met the inclusion criteria. The included studies reported on the results of 2279 procedures in 1762 patients. The surgical techniques were divided into five categories: the Bosch technique, MIS Chevron-Akin, Reverdin-Isham procedure, Endolog system, and techniques involving distal soft tissue release and fixation. Results regarding radiological correction, clinical outcomes, and complication rate varied widely.ConclusionsThe studies included were of too little level of evidence to allow for data pooling or meta-analysis. There were too few studies on each surgical technique category to assess whether one is more effective than the rest. However, there is some evidence that the Chevron and Akin showed the most potential for improvement of the HVA and the Endolog for the IMA. An overall complication rate of 13% was obtained among all included studies. Appropriately powered randomized controlled trials, utilizing validated outcome measures, blinded assessors, and long-term follow up are needed to assess the efficacy of MIS techniques.

Access to the talar dome surface with different surgical approaches

BACKGROUND Access to the talar dome for the treatment of osteochondral lesions (OCLs) can be achieved via several different approaches to the ankle joint. The recent description of an anatomical nine-grid scheme of the talus has proven useful to localise OCLs but no studies have demonstrated which approaches are indicated to access each of these zones. The aim of this study is to demonstrate the access afforded to each zone by each approach. METHODS Four standard soft tissue ankle approaches were performed simultaneously in ten fresh-frozen cadavers (anterolateral - AL, anteromedial - AM, posterolateral - PL, posteromedial - PM). The area of the talus, which was accessible with an instrument perpendicular to the surface was documented for each of the approaches. Using ImageJ software the surface area exposed with each approach was calculated. The talar dome was then divided using a nine-grid scheme and exposure to each zone was documented. RESULTS The AL, AM, PL and PM approaches allow for exposure of 24%, 25%, 5%, 7% of the talar dome respectively. The AL gives access to zones 3 (completely) and 2, 5, 6 (partially); the AM to zones 1 (completely) and 2, 4, 5 (partially); the PL to zones 9 and 8 (partially); and the PM to zones 7 and 8 (partially). CONCLUSIONS A large area of the talar dome cannot be easily accessed with the use of standard soft tissue approaches (39%). Minimal or no access is achieved for grid zones 4-6 and 8. In those instances careful preoperative planning is necessary and extended exposure can be achieved with the use of osteotomies, section of the ATFL or through modified approaches.

Spring Ligament Instability

The crucial role of the spring ligament complex within the pathologic process that leads to flatfoot deformity has evolved recently. There has been improvement in the anatomic knowledge of the spring ligament and understanding of its complex relationship to the deltoid complex and outstanding advances in biomechanics concepts related to the spring ligament. Optimization of flatfoot treatment strategies are focused on a renewed interest in the spring ligament and medial soft tissue reconstruction in concert with bony correction to obtain an adequate reduction of the talonavicular deformity and restoration of the medial longitudinal arch.

Tendoscopic Treatment of Peroneal Intrasheath Subluxation: A New Subgroup With Superior Peroneal Retinaculum Injury:

Background: Snapping peroneal tendons is a rare cause of lateral ankle pain. Two subgroups have been described: chronic subluxation with superior peroneal retinaculum (SPR) injury and intrasheath subluxation with SPR intact. The aim of the study was to report the tendoscopic findings and results in patients affected by snapping peroneal tendons without evident dislocation. Methods: Between 2010 and 2015, a total of 18 patients with a retromalleolar “click” sensation and no clinical signs of peroneal tendon dislocation underwent tendoscopy. Mean age was 29 years (range, 18-47). Mean follow-up was 45 months (range, 18-72). Results: Tendoscopic examination revealed an intact SPR in 12 patients. Of these 12, a space-occupying lesion was present in 7, a superficial tear of peroneus brevis in 4, and a shallow fibular groove in 7. An SPR injury without peroneal tendon dislocation was observed in the remaining 6 patients. All these 6 patients presented a shallow fibular groove. Although the SPR was injured, they had been diagnosed as intrasheath subluxation. Patients with intrasheath subluxation and intact SPR underwent debridement of a space-occupying lesion in 11 cases and fibular groove deepening in 5 cases. Patients with intrasheath subluxation and SPR injury underwent fibular groove deepening without addressing the SPR. At follow-up, the mean American Orthopaedic Foot & Ankle Society score increased from 76 (range, 69-85) preoperatively to 97 (range, 84-100). No recurrence or major complications were reported. Conclusion Intrasheath subluxation of peroneal tendons was successfully treated tendoscopically. A new subgroup of intrasheath subluxation with SPR injury but no clinically evident peroneal tendon dislocation is reported. Level of Evidence: Level IV, case series.