RU2796426C1 - Method for reconstructing the plantar calcaneonavicular ligament in the treatment of patients with plano-valgus deformity of the foot - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention can be used in the treatment of patients with plano-valgus deformity of the foot. The method includes fixing the proximal end of the tendon graft in the formed horizontal bone canal on the sustentaculum tali of the calcaneus. The plantar navicular ligament graft is formed from the lower half of the longitudinal L-shaped dissected tendon of the posterior tibial muscle, the distal end of which retains its place of attachment on the navicular bone. The proximal end of the graft is blocked in the bone canal with an interference screw. The upper half of the tendon is strengthened and stretched with a shearing suture.

EFFECT: method increases the effectiveness of treatment and reduces the risk of loss of correction after surgical reconstruction due to the fact that it does not require the collection of a donor tendon, or the use of an allograft, or synthetic materials, the distal graft attachment site on the scaphoid bone remains intact, strengthening the tendon of the posterior tibial muscle allows restoring the function of the main dynamic stabilizer of the medial longitudinal arch of the foot, ensuring its stabilization.

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Description

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used to treat patients with plano-valgus deformity of the foot.

Currently, there is no consensus on the surgical tactics for the treatment of longitudinal flat feet. The search for new less traumatic and reliable methods of surgical treatment of this pathology is one of the main tasks set for orthopedists around the world.

A known method of anatomical reconstruction of the calcaneonavicular ligament from a flexible synthetic material (Arthrex) Acevedo J, Vora A. Anatomical reconstruction of the spring ligament complex: “internal brace” augmentation. Foot Ankle Spec 2013;6(6):441-5. The method is carried out as follows. From the incision along the medial edge of the foot, the tendon of the posterior tibial muscle is accessed, the weakened area is resected, and the tendon of the long flexor of the thumb, cut off distally at the medial pole of the navicular bone, is taken for transposition to the navicular bone. The damaged ends of the calcaneonavicular ligament are sutured together. Using a “3.5 mm swivel lock anchor”, a flexible synthetic band (Arthrex) is fixed to the sustentaculum tali of the calcaneus so that two free ends are formed. A bone canal is formed in the navicular bone in the dorsal-plantar direction. One of the free ends is passed in the channel from the rear to the sole, the other end, together with the distal end of the tendon of the long flexor of the thumb, is passed in the channel from the sole to the rear of the foot and they are fixed in the channel with an interference screw.

However, the method of augmentation with inextensible synthetic material cannot be used on the growing foot of children and adolescents, direct suture of the ligament is an unreliable method of its restoration, the tendon of the posterior tibial muscle no longer acts as the main inverter of the foot, only the tendon of the long flexor of the thumb is used as the main dynamic stabilizer , weakens the function of the foot inverters, which can lead to loss of correction of the medial longitudinal arch, and the use of two locking screws in two bone channels significantly reduces the fixation strength of the synthetic tape.

Closest to the proposed invention is a method for reconstructing the calcaneonavicular ligament (Lee WC, Yi Y. Spring ligament reconstruction using the autogenous flexor hallucis longus tendon. Orthopedics 2014; 37(7):467-71), which consists in accessing the long flexor the big toe in the region of the medial malleolus, which is extended first to the tuberosity of the navicular bone, then to the base of the first metatarsal bone. The distal portion of the tendon of the posterior tibial muscle is dissected at its insertion on the navicular bone. Another medial longitudinal incision is made from the first metatarsophalangeal joint, approximately 5 mm distal to the interphalangeal joint of the big toe. The visualized tendon of the long flexor of the thumb is crossed at the level of the first metatarsophalangeal joint, the proximal free end of the tendon is brought out in the middle part of the sole and stitched with a Krakow suture. Next, three bone canals are formed. The first bone channel with a diameter of 4 mm is formed in the medial sphenoid bone from the rear to the sole, the second oblique bone channel 4 mm in diameter is formed in the navicular bone from the dorsal surface to the sole. The last bone canal with a diameter of 5 mm is formed in the sustentaculum tali of the calcaneus from the medial surface to the lateral. The free end of the tendon is carried out in the bone canals from the sole to the rear in the sphenoid bone, from the rear to the sole in the navicular bone and then to the lateral surface of the foot through the canal in the calcaneus. The graft is tensioned in the bone canals by traction at its distal end with simultaneous inversion in the subtalar joint, without releasing the tension, fixation is performed in the sustentaculum tali with a 5.5 mm screw (Arthrex Ltd, Sheffield, United Kingdom)

However, the formation of three bone channels in different planes causes excessive traumatization of the bones of the midfoot, which may cause their fractures, the tendon of the posterior tibial muscle does not take part in the stabilization of the medial longitudinal arch, and the strength of the tendon of the long flexor of the thumb may not be enough to perform the function as both active and passive stabilizers, which can lead to loss of correction and instability of the medial longitudinal arch.

The objective of the invention is to improve the method for reconstructing the plantar calcaneal-navicular ligament and strengthening the tendon of the posterior tibial muscle.

EFFECT: increased efficiency of treatment, restoration of static and strengthening of dynamic stabilizers of the medial longitudinal arch of the foot, reduction of the risk of loss of correction after surgical reconstruction.

The technical result is achieved by performing a longitudinal L-shaped dissection of the tendon of the posterior tibial muscle into two halves so that the proximal end of the lower half of the graft remains free, and the distal one retains its place of attachment on the navicular bone, a horizontal bone canal is formed in the sustentaculum tali of the calcaneus with a diameter corresponding to the diameter of the graft, the proximal end of the tendon graft is pulled in the bone canal to the outside, the foot is inverted, the tendon graft is blocked in the bone canal with an interference screw of the appropriate size, the upper half of the tendon of the posterior tibial muscle is strengthened and stretched with a shirring suture along the graft harvesting zone.

The method is illustrated by graphic materials, where figure 1 shows an L-shaped dissection of the tendon of the posterior tibial muscle into two halves; figure 2 shows the stage of intervention: formed a horizontal bone channel in the sustentaculum tali of the calcaneus with a diameter corresponding to the diameter of the graft, the proximal end of the tendon graft stitched "pigtail" along; figure 3 shows the stage of intervention: the tendon graft is locked in the bone canal with an interference screw of the appropriate size, the upper half of the tendon of the posterior tibial muscle along the graft harvesting area is strengthened and stretched with a shirring suture.

The method is carried out as follows.

On the medial edge of the foot in the projection of the scaphoid and calcaneus, a wave-like shaped incision of the skin and subcutaneous fat is performed. Visualize and perform a longitudinal L-shaped dissection of the tendon of the posterior tibial muscle (Fig. 1, pos. 1) into two halves so that the proximal end of the lower half of the graft remains free, and the distal one retains its attachment site on the navicular bone (Fig. 2, pos. .2). The calcaneus sustentaculum tali is determined, the periosteum is separated with a raspator, and a guide pin is passed in a horizontal plane. On the needle, using a cannulated drill, form a through bone channel for the graft (Figure 2, pos. 3). A guide wire with an eye is inserted into the formed bone canal so that the end of the wire comes out from the opposite side of the calcaneus, perforating the skin. The proximal end of the tendon graft is sutured with a “pigtail” along (Figure 2, pos. 4), and the threads are inserted into the eye of the guide wire. Then it is pulled in the bone canal to the outside, the foot is inverted and the threads are pulled. The tendon graft is blocked in the bone canal with an interference screw with a size corresponding to the diameter of the formed bone canal (Figure 3, item 5). The upper half of the tendon of the posterior tibial muscle is strengthened and tightened by applying a shearing suture (Figure 3, pos. 6). The wound is sutured in layers. A plaster immobilization of the foot is performed in a neutral position in the ankle joint and a slight inversion of the foot.

The method has the following advantages: it does not require the collection of a donor tendon or the use of an allograft or synthetic materials, the distal graft attachment site on the navicular bone remains intact, strengthening the tendon of the posterior tibial muscle allows restoring the function of the main dynamic stabilizer of the medial longitudinal arch of the foot, ensuring its stabilization.

Clinical example.

Patient U., 27 years old, diagnosis: plano-valgus deformity of the foot.

On admission: pain along the medial edge of the foot during prolonged standing and walking, weakness of the posterior leg muscles, muscle strength 4 points, flattening of the medial longitudinal arch, positive test for standing on toes, weakly positive Jack's test, talonavicular covering angle of 30 degrees, according to the results adapted questionnaire for the foot and ankle AOFAS -75 points.

The operation was performed: Lengthening achilloplasty of the Stryer type, subtalar sinus tarsi arthroeresis with the “Arthrex” implant, corrective osteotomy of the medial sphenoid bone of the Cotton type, plastic of the plantar calcaneonavicular ligament.

Under spinal anesthesia, in the supine position under the arterial tourniquet, access to the sinus tarsi was made. Under the control of the image intensifier tube, a subtalar implant "Arthrex" with a size of 9 mm was introduced. Access to the medial sphenoid bone was made by a Cotton osteotomy with fixation with a compression screw. Access to the internal head of the gastrocnemius muscle was performed on the medial surface of the lower leg at the border of the middle and lower, and Stryer lengthening achilloplasty was performed. A wavy incision was made along the medial edge of the foot in the projection of the navicular bone 1 cm distal to the tuberosity to the calcaneus, 2.0 cm below the top of the inner malleolus. Then performed the reconstruction of the plantar calcaneal-navicular ligament according to the proposed method.

The tendon sheath of the posterior tibial muscle was isolated and longitudinally dissected. Departing from the distal site of attachment on the scaphoid bone 2 cm, the tendon of the posterior tibial muscle was cut longitudinally in an L-shaped manner into two halves in the proximal direction so that the proximal end of the lower half of the graft remained free, and the distal end retained its attachment site on the navicular bone. The length of the tendon graft is equal to 2/3 of the width of the calcaneus and was 3 cm. Palpation determined the sustentaculum tali of the calcaneus, separated the periosteum with a rasp, and passed a pin in a horizontal plane over the entire width of the calcaneus, perforating the skin of the opposite side. The graft diameter was 4 mm. A through bone channel was formed along the wire using a 5 mm cannulated drill for free passage of the graft in the formed channel. A guide wire with an eye was inserted into the bone canal. The free end of the tendon graft was sutured with an absorbable 3.0 pigtail suture in the longitudinal direction. The ends of the threads of the sutured tendon were brought into the eye of the guide wire and pulled through the bone canal, the foot was inverted with simultaneous pulling of the threads on the opposite side of the calcaneus. The tendon graft was blocked in the bone canal with an interference screw with a diameter of 5 mm.

We made sure that the tendon was firmly fixed in the canal. The ends of the threads were cut off.

The wound was sutured. The lower limb was immobilized with a plaster splint for 6 weeks.

The postoperative period proceeded without complications. The plaster cast was removed 6 weeks after the operation. 10 weeks after the operation: there are no active complaints of pain during prolonged standing and walking, muscle strength is 5 points. The medial longitudinal arch of the foot was restored and stabilized, the Jack test was positive, the angle of the talonavicular covering was 4 degrees, according to the results of the adapted questionnaire for the foot and ankle joint AOFAS 93 points. 12 months after surgery: according to Rg-graphy, there is no migration of the subtalar implant, the angle of the talonavicular covering is 4 degrees, there is no loss of correction. The patient has no active complaints.

Thus, the implementation of anatomical plastic surgery of the plantar calcaneonavicular ligament from half of the tendon of the posterior tibial muscle, allows you to restore the main static and dynamic stabilizers and stabilize the medial longitudinal arch of the feet, which eliminates the very cause of plano-valgus deformity and, in combination with additional methods of treatment, makes it possible maintain permanent arch correction and reduce the number of recurrences after surgical interventions.

This method is less traumatic and, in combination with the main methods of correction, will increase the effectiveness of treatment, reduce the risk of loss of correction after surgical reconstruction.

Claims (1)

A method for reconstructing the plantar calcaneonavicular ligament in the treatment of patients with planovalgus deformity of the foot, including fixing the proximal end of the tendon graft in the formed bone canal on the sustentaculum tali of the calcaneus, characterized in that a longitudinal L-shaped dissection of the tendon of the posterior tibial muscle is performed into two halves so that the proximal end of the lower half of the graft remains free, and the distal end retains its place of attachment on the navicular bone, a horizontal bone canal is formed in the sustentaculum tali of the calcaneus with a diameter corresponding to the diameter of the graft, the proximal end of the tendon graft is pulled in the bone canal to the outside, inversion is performed foot, the tendon graft is blocked in the bone canal with an interference screw of the appropriate size, the upper half of the tendon of the posterior tibial muscle is strengthened and tightened with a shirring suture throughout the graft harvesting area.

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