Ligament Balancing for Total Ankle Arthroplasty: An in vitro Evaluation of the Elongation of the Hind- and Midfoot Ligaments

Abstract

Components of the deltoid ligament complex elongated largest at the ankle joint with any hindfoot movement but inversion. Therefore, selective release of components of the deltoid ligament complex may provide a means for achieving optimal ligament balancing in total ankle arthroplasty. Specifically, release of the superficial and deep posterior tibiotalar ligament may improve range of motion in total ankle arthroplasties, whereas the release of the tibiocalcaneal ligament may correct a varus talar tilt.

Impact of Diabetes on Outcome of Total Ankle Replacement

“…are dependent on preoperative planning, operative technique, and anatomic balancing. 12,22 Currently, contraindications for a TAR include 1,2,4 a history of infection, neuromuscular dysfunction, Charcot arthropathy, severe osteopenia, and osteonecrosis of the talus. Relative contraindications include a prior arthrodesis and diabetes.…”

Vascular Disruption of the Talus

“…A recent study by Miller et al demonstrated the presence a rich anastomotic network of arterial supply to the talus both intraosseously and extraosseously. 24 A reduction in blood supply to the talus by disrupting arterial branches over a certain threshold may increase the risk of AVN similar to the phenomenon observed in a displaced talar neck fracture. 4,7,10,15,21,23 AVN of the talus is a rare but recognized complication after a triple arthrodesis.…”

Total Ankle Arthroplasty: Management of Varus Deformity at the Ankle

“…Direct release of the superficial deltoid ligament for the varus ankle during replacement surgery has been advocated by many. 7,12 This can be easily done by sweeping the fibers of the superficial deltoid ligament off the medial malleolus superiorly with an elevator. The release is done carefully until the medial joint space opens up and the ankle is balanced.…”

“…Recently, Merian et al 12 published results on a cadaveric study that evaluated the elongation of ligaments about the hindfoot in response to alterations in ankle orientation. They found that components of the deltoid ligament complex elongated the most at the ankle joint with any hindfoot movement but inversion.…”

“…Specifically, they think that in routine total ankle arthroplasties, release of the superficial and deep posterior deltoid ligament may improve range of motion, whereas release of the tibiocalcaneal portion of the deltoid may help correct varus talar tilt. 12 We are not sure that this has any clinical relevance. There remain questions as to where the deltoid is released, i.e., off the tibia or off the talus.…”