"use strict";
const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  ImageRun, HeadingLevel, AlignmentType, BorderStyle, WidthType,
  ShadingType, VerticalAlign, PageNumber, Header, Footer, PageBreak
} = require("docx");
const fs   = require("fs");
const path = require("path");

const IMG = path.join(__dirname, "images");

// ── palette ────────────────────────────────────────────────────────────────
const DARK_BLUE  = "1B3A6B";
const MID_BLUE   = "2E5FA3";
const LIGHT_BLUE = "D6E4F7";
const ACCENT     = "EBF3FF";
const WHITE      = "FFFFFF";
const DARK_TEXT  = "1A1A2E";
const GREY       = "B0BEC5";
const GREEN_BG   = "EBF5EB";
const YELLOW_BG  = "FFF8E1";
const RED_BG     = "FFEBEE";
const DEEP_BG    = "E3EDF9";
const SURF_BG    = "F0F7FF";

// ── border helpers ─────────────────────────────────────────────────────────
function solidBorder(color = GREY, sz = 4) {
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}
function noBorder() {
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}
function leftAccentBorder(color = MID_BLUE) {
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}

// ── shading ────────────────────────────────────────────────────────────────
function shade(fill) {
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}

// ── image helper ───────────────────────────────────────────────────────────
function imgPara(filename, wPx, hPx) {
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    alignment: AlignmentType.CENTER,
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}

// ── text helpers ───────────────────────────────────────────────────────────
function run(text, opts = {}) {
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    color: opts.color || DARK_TEXT, bold: !!opts.bold, italics: !!opts.italic });
}
function caption(text) {
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function spacer(after = 120) {
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function body(text, opts = {}) {
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function bullet(text, level = 0) {
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    spacing: { before: 40, after: 40 },
    children: [run(b, { bold: true }), run(n)]
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}

// ── section title bar ──────────────────────────────────────────────────────
function secTitle(text) {
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    spacing: { before: 300, after: 120 },
    shading: shade(DARK_BLUE),
    children: [run(`  ${text}`, { bold: true, size: 26, color: WHITE })]
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// ── sub-heading ────────────────────────────────────────────────────────────
function subHead(text) {
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               right: { style: BorderStyle.NONE, size: 0, color: "FFFFFF" } },
    children: [run(`  ${text}`, { bold: true, size: 22, color: MID_BLUE })]
  });
}

// ── note box (single-cell table) ───────────────────────────────────────────
function noteBox(text) {
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    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [new TableRow({ children: [new TableCell({
      shading: shade(ACCENT),
      borders: { left: { style: BorderStyle.SINGLE, size: 24, color: MID_BLUE },
                  top: noBorder().top, bottom: noBorder().bottom, right: noBorder().right },
      margins: { top: 80, bottom: 80, left: 160, right: 160 },
      children: [new Paragraph({ children: [run("📌  " + text, { size: 19 })] })]
    })]})],
  });
}

// ── TABLE BUILDERS ─────────────────────────────────────────────────────────

function hCell(text, pct) {
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    width: { size: pct, type: WidthType.PERCENTAGE },
    shading: shade(DARK_BLUE),
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    margins: { top: 80, bottom: 80, left: 100, right: 100 },
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    children: [new Paragraph({
      alignment: AlignmentType.CENTER,
      children: [run(text, { bold: true, size: 19, color: WHITE })]
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}

function dCell(text, pct, opts = {}) {
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    width: { size: pct, type: WidthType.PERCENTAGE },
    shading: opts.bg ? shade(opts.bg) : undefined,
    borders: solidBorder(),
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      children: [run(text, { size: 19, bold: !!opts.bold })]
    })]
  });
}

// Table 1 – Components
function tComponents() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("Layer",14), hCell("Component",30), hCell("Origin",30), hCell("Insertion",26)] }),
      new TableRow({ children: [dCell("DEEP",14,{bg:DEEP_BG,bold:true}),  dCell("Deep Anterior Tibiotalar",30,{bg:DEEP_BG}),    dCell("Intercollicular groove + anterior colliculus",30,{bg:DEEP_BG}),  dCell("Medial surface of talus",26,{bg:DEEP_BG})] }),
      new TableRow({ children: [dCell("DEEP",14,{bg:DEEP_BG,bold:true}),  dCell("Deep Posterior Tibiotalar ★",30,{bg:DEEP_BG,bold:true}), dCell("Posterior colliculus + intercollicular groove",30,{bg:DEEP_BG}), dCell("Medial talus — posterolateral course",26,{bg:DEEP_BG})] }),
      new TableRow({ children: [dCell("SUPERFICIAL",14,{bg:SURF_BG}),     dCell("Tibionavicular",30,{bg:SURF_BG}),               dCell("Anterior colliculus",30,{bg:SURF_BG}),                          dCell("Dorsomedial navicular + spring ligament",26,{bg:SURF_BG})] }),
      new TableRow({ children: [dCell("SUPERFICIAL",14,{bg:SURF_BG}),     dCell("Tibiocalcaneal",30,{bg:SURF_BG}),               dCell("Distal medial malleolus",30,{bg:SURF_BG}),                     dCell("Sustentaculum tali of calcaneus",26,{bg:SURF_BG})] }),
      new TableRow({ children: [dCell("SUPERFICIAL",14,{bg:SURF_BG}),     dCell("Superficial Posterior Tibiotalar",30,{bg:SURF_BG}), dCell("Distal medial malleolus",30,{bg:SURF_BG}),                  dCell("Medial tubercle of talus",26,{bg:SURF_BG})] }),
    ]
  });
}

// Table 2 – Functions
function tFunctions() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("Layer",28), hCell("Primary Function",45), hCell("Secondary",27)] }),
      new TableRow({ children: [dCell("Deep (intraarticular, extrasynovial)",28,{bg:DEEP_BG}), dCell("Resist lateral talar translation & external rotation",45,{bg:DEEP_BG}), dCell("Secondary restraint to anterior talar translation",27,{bg:DEEP_BG})] }),
      new TableRow({ children: [dCell("Superficial (tibiotalar + subtalar joints)",28,{bg:SURF_BG}), dCell("Resist valgus / eversion forces (talar tilt)",45,{bg:SURF_BG}), dCell("Secondary restraint to anterior talar translation",27,{bg:SURF_BG})] }),
    ]
  });
}

// Table 3 – Sprain grading
function tGrading() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("Grade",12), hCell("Pathology",34), hCell("Clinical Features",29), hCell("Management",25)] }),
      new TableRow({ children: [dCell("I",12,{center:true,bg:GREEN_BG}),  dCell("Microscopic tears; intact ligament",34,{bg:GREEN_BG}),  dCell("Mild pain, minimal swelling, full WB",29,{bg:GREEN_BG}),        dCell("RICE, functional rehab",25,{bg:GREEN_BG})] }),
      new TableRow({ children: [dCell("II",12,{center:true,bg:YELLOW_BG}), dCell("Partial macroscopic tear",34,{bg:YELLOW_BG}),            dCell("Moderate pain, swelling, difficulty walking",29,{bg:YELLOW_BG}), dCell("Boot, physio, protected WB",25,{bg:YELLOW_BG})] }),
      new TableRow({ children: [dCell("III",12,{center:true,bg:RED_BG}),   dCell("Complete rupture",34,{bg:RED_BG,bold:true}),             dCell("Severe pain, instability, unable to WB",29,{bg:RED_BG}),        dCell("NWB cast / surgical repair",25,{bg:RED_BG})] }),
    ]
  });
}

// Table 4 – Location type
function tLocation() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("Type",14), hCell("Description",46), hCell("Clinical Note",40)] }),
      new TableRow({ children: [dCell("Type 1",14,{bg:DEEP_BG,bold:true}),  dCell("Proximal avulsion from medial malleolus",46,{bg:DEEP_BG}), dCell("Most common; suture anchor repair",40,{bg:DEEP_BG})] }),
      new TableRow({ children: [dCell("Type 2",14,{bg:"EDF4FF",bold:true}), dCell("Mid-substance (interstitial) tear",46),                    dCell("End-to-end repair / imbrication",40)] }),
      new TableRow({ children: [dCell("Type 3",14,{bg:SURF_BG,bold:true}),  dCell("Distal avulsion from tarsal attachment",46,{bg:SURF_BG}), dCell("Suture anchor at navicular / sustentaculum",40,{bg:SURF_BG})] }),
    ]
  });
}

// Table 5 – Lauge-Hansen SER
function tLH() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("SER Stage",18), hCell("Structure Injured",58), hCell("Deltoid?",24)] }),
      new TableRow({ children: [dCell("I",18,{center:true}),    dCell("Anterior inferior tibiofibular ligament (AITFL)",58),          dCell("No",24,{center:true})] }),
      new TableRow({ children: [dCell("II",18,{center:true}),   dCell("Spiral / oblique fibular fracture at or above syndesmosis",58), dCell("No",24,{center:true})] }),
      new TableRow({ children: [dCell("III",18,{center:true}),  dCell("Posterior tibiofibular ligament / posterior malleolus",58),     dCell("No",24,{center:true})] }),
      new TableRow({ children: [dCell("IV",18,{center:true,bg:RED_BG}), dCell("Deltoid ligament OR medial malleolus fracture",58,{bg:RED_BG,bold:true}), dCell("YES ★",24,{center:true,bg:RED_BG,bold:true})] }),
    ]
  });
}

// Table 6 – Radiology
function tRadiology() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("Parameter",36), hCell("Normal Value",28), hCell("If Abnormal",36)] }),
      new TableRow({ children: [dCell("Medial clear space (MCS)",36),                       dCell("≤ 4 mm — mortise view, neutral",28), dCell("Deep deltoid incompetence",36)] }),
      new TableRow({ children: [dCell("MCS vs. superior tibiotalar joint space",36),         dCell("Equal",28),                         dCell("MCS > superior space → deltoid injury",36)] }),
      new TableRow({ children: [dCell("Tibiofibular clear space",36),                        dCell("< 6 mm (AP view)",28),              dCell("Syndesmotic diastasis",36)] }),
      new TableRow({ children: [dCell("Tibiofibular overlap",36),                            dCell("> 6 mm AP; > 1 mm mortise",28),     dCell("Syndesmotic injury if reduced",36)] }),
      new TableRow({ children: [dCell("Lateral talar shift 1 mm",36,{bg:YELLOW_BG}),        dCell("— ",28,{bg:YELLOW_BG}),             dCell("Reduces tibiotalar contact area 20–40%",36,{bg:YELLOW_BG})] }),
      new TableRow({ children: [dCell("Lateral talar shift 5 mm",36,{bg:RED_BG}),           dCell("— ",28,{bg:RED_BG}),                dCell("Reduces tibiotalar contact area 80%",36,{bg:RED_BG,bold:true})] }),
    ]
  });
}

// Table 7 – Treatment summary
function tTreatment() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("Scenario",40), hCell("Treatment",35), hCell("Key Points",25)] }),
      new TableRow({ children: [dCell("Isolated Grade I–II sprain",40),                           dCell("RICE → boot → physio",35),                  dCell("Rehab prolonged vs lateral sprains",25)] }),
      new TableRow({ children: [dCell("Isolated Grade III — low demand",40),                      dCell("NWB below-knee cast 6 weeks",35),            dCell("Serial X-ray monitoring",25)] }),
      new TableRow({ children: [dCell("Grade III — active / talar shift",40,{bg:YELLOW_BG}),     dCell("Primary repair + suture anchor",35,{bg:YELLOW_BG}), dCell("+ ORIF fibula if fractured",25,{bg:YELLOW_BG})] }),
      new TableRow({ children: [dCell("Bimalleolar equivalent fracture",40,{bg:YELLOW_BG}),       dCell("ORIF fibula ± deltoid repair",35,{bg:YELLOW_BG}),   dCell("Repair if mortise not restored by fibular fixation",25,{bg:YELLOW_BG})] }),
      new TableRow({ children: [dCell("Chronic instability / Stage IV flatfoot",40,{bg:RED_BG}), dCell("Reconstruction (tape + graft)",35,{bg:RED_BG}),      dCell("± Calcaneal osteotomy + spring repair",25,{bg:RED_BG})] }),
    ]
  });
}

// Table 8 – Recent advances
function tRecent() {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ children: [hCell("#",7), hCell("Advance",40), hCell("Significance",53)] }),
      new TableRow({ children: [dCell("1",7,{center:true}), dCell("3T MRI + AI-based reconstruction",40),              dCell("< 10 min high-quality imaging of all ligament components",53)] }),
      new TableRow({ children: [dCell("2",7,{center:true}), dCell("Suture tape augmentation (InternalBrace)",40,{bg:ACCENT}), dCell("Biomechanically superior; early WB; now preferred adjunct",53,{bg:ACCENT})] }),
      new TableRow({ children: [dCell("3",7,{center:true}), dCell("Arthroscopic-assisted repair",40),                  dCell("Identifies OCD + confirms ligament pathology pre-open repair",53)] }),
      new TableRow({ children: [dCell("4",7,{center:true}), dCell("Deltoid repair vs. syndesmotic fixation",40,{bg:ACCENT}), dCell("Equivalent outcomes shown; shifting toward deltoid repair in selected cases",53,{bg:ACCENT})] }),
      new TableRow({ children: [dCell("5",7,{center:true}), dCell("Minimally invasive allograft reconstruction",40),   dCell("Anatomic restoration of both layers; superior to non-anatomic tenodesis",53)] }),
      new TableRow({ children: [dCell("6",7,{center:true}), dCell("Revised prevalence data",40,{bg:ACCENT}),           dCell("72% of lateral instability cases have deltoid injury; routine MRI now advocated",53,{bg:ACCENT})] }),
    ]
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// COVER PAGE
// ══════════════════════════════════════════════════════════════════════════════
function cover() {
  return [
    spacer(600),
    new Paragraph({
      alignment: AlignmentType.CENTER,
      children: [run("DELTOID LIGAMENT", { bold: true, size: 64, color: DARK_BLUE })]
    }),
    new Paragraph({
      alignment: AlignmentType.CENTER,
      spacing: { before: 100, after: 100 },
      children: [run("Medial Ligament of the Ankle", { size: 36, color: MID_BLUE, italic: true })]
    }),
    new Paragraph({
      alignment: AlignmentType.CENTER,
      spacing: { before: 160, after: 160 },
      border: {
        top:    { style: BorderStyle.SINGLE, size: 8, color: MID_BLUE },
        bottom: { style: BorderStyle.SINGLE, size: 8, color: MID_BLUE },
        left:   { style: BorderStyle.NONE, size: 0, color: "FFFFFF" },
        right:  { style: BorderStyle.NONE, size: 0, color: "FFFFFF" }
      },
      children: [run("PG Summary  •  Anatomy  •  Classification  •  Imaging  •  Treatment  •  Recent Advances",
                     { size: 22, color: MID_BLUE })]
    }),
    spacer(300),
    imgPara("anatomy_medial.png", 370, 408),
    caption("Fig. 1 – Medial (Deltoid) Ligament of the Right Ankle  (Gray's Anatomy for Students)"),
    spacer(200),
    new Paragraph({
      alignment: AlignmentType.CENTER,
      children: [run("Sources: Campbell's Operative Orthopaedics 15th Ed 2026  •  Rockwood & Green's Fractures 10th Ed 2025",
                     { size: 16, color: "888888", italic: true })]
    }),
    new Paragraph({
      alignment: AlignmentType.CENTER,
      children: [run("Gray's Anatomy for Students  •  Miller's Review of Orthopaedics 9th Ed  •  Imaging Anatomy Vol. 3",
                     { size: 16, color: "888888", italic: true })]
    }),
    new Paragraph({ children: [new PageBreak()] })
  ];
}

// ══════════════════════════════════════════════════════════════════════════════
// FULL BODY
// ══════════════════════════════════════════════════════════════════════════════
function buildBody() {
  return [
    ...cover(),

    // 1. INTRODUCTION ────────────────────────────────────────────────────────
    secTitle("1.  Introduction"),
    body("The deltoid ligament is the primary stabilizing structure on the medial side of the talocrural (ankle) joint. It is large, flat, strong, and triangular — its apex attaches to the medial malleolus and its broad base fans inferiorly across multiple tarsal bones. It is the primary ankle stabilizer during stance phase and resists lateral talar translation, external rotation, and valgus tilt. Unlike the three-band lateral complex, the deltoid is a continuous but multi-component structure."),
    spacer(),

    // 2. ANATOMY ─────────────────────────────────────────────────────────────
    secTitle("2.  Anatomy"),
    subHead("Bony Attachments"),
    boldBullet("Proximal (apex): ", "Medial malleolus — anterior colliculus, posterior colliculus, intercollicular groove"),
    boldBullet("Distal (base): ", "Tuberosity of navicular, plantar calcaneonavicular (spring) ligament, sustentaculum tali of calcaneus, medial surface of talus (anterior + posterior)"),
    spacer(80),

    subHead("Five-Component Structure"),
    body("The deltoid has 5 named components in 2 layers:"),
    spacer(60),
    tComponents(),
    spacer(80),
    noteBox("★ Deep Posterior Tibiotalar ligament = STRONGEST component of the entire deltoid complex. It is intraarticular but extrasynovial, and is the principal stabilizer of the talus in the mortise."),
    spacer(120),

    subHead("Functional Summary by Layer"),
    tFunctions(),
    spacer(120),

    subHead("Anatomy Diagram"),
    imgPara("anatomy_medial.png", 420, 463),
    caption("Fig. 2 – Medial Ligament of the Ankle: Tibionavicular, Tibiocalcaneal, Anterior Tibiotalar and Posterior Tibiotalar parts  (Gray's Anatomy for Students)"),
    spacer(80),

    // 3. ETIOLOGY ────────────────────────────────────────────────────────────
    secTitle("3.  Etiology of Injury"),
    boldBullet("Eversion injury: ", "Forced pronation-abduction — most common"),
    boldBullet("External rotation: ", "Supination-external rotation (SER) — deltoid torn at Stage IV"),
    boldBullet("Pronation-Abduction / PER: ", "Deltoid is torn FIRST (Stage I)"),
    boldBullet("Chronic attenuation: ", "Stage IV PTTD flatfoot — progressive valgus talar tilt from posterior tibial tendon dysfunction"),
    boldBullet("Iatrogenic: ", "Excessive eversion during ankle arthroplasty or hindfoot reconstruction"),
    spacer(120),

    // 4. MECHANISM ───────────────────────────────────────────────────────────
    secTitle("4.  Mechanism of Injury"),
    subHead("Lauge-Hansen Classification — SER Pattern (most common, 60–70% of ankle fractures)"),
    tLH(),
    spacer(80),
    noteBox("In Pronation-Abduction (PA) and Pronation-External Rotation (PER) patterns, the deltoid or medial malleolus is the FIRST structure injured (Stage I)."),
    spacer(80),
    body("Key biomechanical consequences of talar shift:", { bold: true }),
    bullet("1 mm lateral talar shift → reduces tibiotalar contact area by 20–40%"),
    bullet("5 mm lateral talar shift → reduces tibiotalar contact area by 80%"),
    spacer(120),

    // 5. PATHOLOGY ───────────────────────────────────────────────────────────
    secTitle("5.  Pathology"),
    boldBullet("Partial tear: ", "More common; disruption of individual bands, usually superficial layer"),
    boldBullet("Complete rupture: ", "Rare in isolation; usually with fibular fracture or syndesmotic injury"),
    boldBullet("Avulsion: ", "Ligament torn from medial malleolus (proximal, most common) or from tarsal insertions (distal)"),
    boldBullet("Entrapment: ", "Avulsed stump can become interposed between medial malleolus and talus, blocking mortise reduction"),
    boldBullet("Chronic attenuation: ", "Seen in Stage IV PTTD — ligament is incompetent, allowing valgus talar tilt"),
    spacer(80),
    noteBox("Of patients with lateral ankle instability: 72% have concurrent deltoid injury; 43% have injuries to BOTH deep and superficial components.  (Campbell's 15th Ed, 2026)"),
    spacer(120),

    // 6. CLINICAL FEATURES ───────────────────────────────────────────────────
    secTitle("6.  Clinical Features"),
    subHead("Symptoms"),
    bullet("Medial ankle pain after eversion or external rotation injury"),
    bullet("Swelling and ecchymosis medially"),
    bullet("Difficulty or inability to bear weight (Grade II–III)"),
    bullet("Sense of instability / giving way in chronic cases"),
    spacer(80),
    subHead("Signs"),
    bullet("Tenderness over the medial malleolus and medial ligament complex"),
    bullet("Hematoma on medial side — suggests significant tear"),
    bullet("Eversion / external rotation stress — pain with medial gapping"),
    bullet("Valgus hindfoot + medial arch collapse in chronic Stage IV flatfoot"),
    spacer(80),
    noteBox("Medial tenderness alone does NOT reliably predict deep deltoid rupture (no statistically significant correlation). Always palpate the full fibula to exclude a Maisonneuve fracture."),
    spacer(120),

    // 7. INVESTIGATIONS ──────────────────────────────────────────────────────
    secTitle("7.  Investigations"),
    subHead("Plain Radiograph — Mortise View (First Line)"),
    tRadiology(),
    spacer(80),
    body("Stress views: Gravity external rotation stress or manual eversion stress. MUST be obtained with ankle in neutral — plantarflexion allows the narrower part of the talar dome into the mortise and gives a spuriously wide medial clear space.", { italic: true }),
    spacer(120),

    subHead("Radiograph — Clinical Example"),
    imgPara("xray_tear.png", 500, 350),
    caption("Fig. 3 – A: Acute deltoid tear with oblique fibular fracture and lateral talar shift. B: After deltoid repair and fibular ORIF.  (Campbell's Operative Orthopaedics 15th Ed)"),
    spacer(80),

    // 8. CT ──────────────────────────────────────────────────────────────────
    secTitle("8.  CT Scan"),
    bullet("Not routinely needed for isolated deltoid injury"),
    bullet("Indicated for: complex fracture patterns (trimalleolar, pilon), syndesmotic 3D assessment, pre-operative planning for reconstruction, associated osteochondral lesions"),
    bullet("CT may reveal tibiofibular diastasis not visible on plain films"),
    spacer(120),

    // 9. MRI ─────────────────────────────────────────────────────────────────
    secTitle("9.  MRI"),
    boldBullet("Gold standard ", "for deltoid ligament assessment"),
    boldBullet("Axial sequences: ", "Optimal for deep layers and tibionavicular component"),
    boldBullet("Coronal sequences: ", "Best for tibiocalcaneal, posterior tibiotalar, and CFL; allows complete differentiation of superficial vs deep layers"),
    boldBullet("3T + AI reconstruction: ", "< 10 minutes for high-resolution imaging of all components (Recent advance)"),
    bullet("MRI is more specific than sensitive (especially for CFL)"),
    bullet("Bone bruises seen in significant proportion of sprains; multiple bruises → multiple ligament injury"),
    bullet("Bone bruise-like lesions may persist > 1 year after injury"),
    spacer(80),
    imgPara("mri_tear.png", 380, 393),
    caption("Fig. 4 – Coronal T1 fat-suppressed MRI showing deltoid ligament tear  (Imaging Anatomy Vol. 3)"),
    spacer(120),

    // 10. CLASSIFICATION ─────────────────────────────────────────────────────
    secTitle("10.  Classification"),
    subHead("A.  Sprain Grading (Universal)"),
    tGrading(),
    spacer(120),
    subHead("B.  Anatomic Location Classification"),
    tLocation(),
    spacer(120),
    subHead("C.  Lauge-Hansen (Mechanism-Based) — see Section 4"),
    body("Deltoid injury occurs at Stage IV in SER pattern and at Stage I in Pronation-Abduction (PA) and Pronation-External Rotation (PER) patterns."),
    spacer(80),
    subHead("D.  Johnson & Strom / Myerson (Flatfoot / PTTD)"),
    boldBullet("Stage IV: ", "Deltoid insufficiency with valgus talar tilt superimposed on Stage III deformity. Deltoid reconstruction is required as part of flatfoot correction at this stage."),
    spacer(120),

    // 11. TREATMENT ──────────────────────────────────────────────────────────
    secTitle("11.  Treatment"),
    subHead("Overview"),
    tTreatment(),
    spacer(120),

    subHead("A.  Non-Operative"),
    boldBullet("Acute (0–2 wks): ", "RICE; non-weight-bearing (NWB) below-knee cast or boot"),
    boldBullet("Sub-acute (2–6 wks): ", "Progressive WB in boot with orthotic arch support; physiotherapy"),
    boldBullet("Rehab: ", "Proprioceptive training, peroneal strengthening, ROM — prolonged vs lateral sprains"),
    bullet("Serial radiographic monitoring to confirm mortise congruence"),
    spacer(80),

    subHead("B.  Operative — Acute Primary Repair"),
    body("Indications:", { bold: true }),
    bullet("Grade III in active / high-demand patient"),
    bullet("Deltoid tear + fibular fracture with talar shift or positive stress test"),
    bullet("Avulsed deltoid interposed in joint (blocking reduction)"),
    bullet("Bimalleolar equivalent fracture with confirmed mortise instability"),
    spacer(60),
    body("Technique:", { bold: true }),
    boldBullet("1. ", "Curvilinear medial incision over medial malleolus extending toward navicular"),
    boldBullet("2. ", "Identify disrupted ligament (usually avulsed from medial malleolus)"),
    boldBullet("3. ", "Debride torn edges; create shallow bony trough on medial malleolus with rongeur"),
    boldBullet("4. ", "Insert suture anchor in distal medial malleolus"),
    boldBullet("5. ", "Repair deltoid in imbricated fashion — approximate tibionavicular + tibiocalcaneal bands to native attachment"),
    boldBullet("6. ", "Below-knee cast in 5–10° plantarflexion + inversion; concurrent ORIF of fibula if fractured"),
    spacer(60),
    noteBox("Many surgeons do NOT routinely repair the deltoid — fibular ORIF alone often restores mortise congruence. Medial exploration reserved for persistent wide medial clear space or blocked reduction."),
    spacer(80),

    subHead("C.  Operative — Chronic Reconstruction"),
    body("Indications:", { bold: true }),
    bullet("Chronic deltoid instability after failed conservative management"),
    bullet("Stage IV PTTD flatfoot with valgus talar tilt"),
    spacer(60),
    body("Techniques:", { bold: true }),
    boldBullet("1. Suture tape augmentation (preferred): ", "Primary imbrication repair + suture tape from medial malleolus to sustentaculum tali. Guide pin 15° plantar to avoid subtalar joint violation."),
    boldBullet("2. Peroneus longus autograft (Deland): ", "Peroneus longus preferred over brevis — longer and inserts medially."),
    boldBullet("3. Minimally invasive allograft — Jeng / Myerson 2011: ", "Semitendinosus allograft through tibial tunnel (6.5 mm) → talar tunnel (5 mm) → sustentaculum tali. Combined with medial displacement calcaneal osteotomy + spring ligament repair."),
    boldBullet("4. Hamstring allograft: ", "Alternative to autograft."),
    spacer(60),
    body("Postoperative Protocol:", { bold: true }),
    bullet("Sutures out at 2 weeks"),
    bullet("Short leg cast — 5° plantarflexion + inversion — for 5 weeks"),
    bullet("Boot with orthotic arch support at 5 weeks; WB as tolerated"),
    bullet("Physiotherapy at 8 weeks; stiff-soled shoe + carbon orthotic"),
    bullet("Impact activity (running) from 16 weeks with carbon insert protection"),
    spacer(120),

    // 12. RECENT ADVANCES ────────────────────────────────────────────────────
    secTitle("12.  Recent Advances"),
    tRecent(),
    spacer(200),

    // SOURCES ────────────────────────────────────────────────────────────────
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    }),
    body("Campbell's Operative Orthopaedics 15th Ed 2026  |  Rockwood & Green's Fractures in Adults 10th Ed 2025", { italic: true }),
    body("Gray's Anatomy for Students  |  Miller's Review of Orthopaedics 9th Ed  |  Imaging Anatomy Vol. 3: Bones, Joints, Vessels and Nerves", { italic: true }),
  ];
}

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// ── Tables ──────────────────────────────────────────────────────────────────
function tComponents() {
  return new Table({ width:{size:100,type:WidthType.PERCENTAGE}, rows:[
    new TableRow({ children:[hCell("Layer",14),hCell("Component",30),hCell("Origin",30),hCell("Insertion",26)] }),
    new TableRow({ children:[dCell("DEEP",14,{bg:DEEP_BG,bold:true}),dCell("Deep Anterior Tibiotalar",30,{bg:DEEP_BG}),dCell("Intercollicular groove + anterior colliculus",30,{bg:DEEP_BG}),dCell("Medial surface of talus",26,{bg:DEEP_BG})] }),
    new TableRow({ children:[dCell("DEEP",14,{bg:DEEP_BG,bold:true}),dCell("Deep Posterior Tibiotalar ★",30,{bg:DEEP_BG,bold:true}),dCell("Posterior colliculus + intercollicular groove",30,{bg:DEEP_BG}),dCell("Medial talus — posterolateral course",26,{bg:DEEP_BG})] }),
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    new TableRow({ children:[dCell("Superficial (tibiotalar + subtalar)",28,{bg:SURF_BG}),dCell("Resist valgus / eversion forces (talar tilt)",45,{bg:SURF_BG}),dCell("Secondary restraint to anterior talar translation",27,{bg:SURF_BG})] }),
  ]});
}
function tGrading() {
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    new TableRow({ children:[hCell("Grade",12),hCell("Pathology",34),hCell("Clinical Features",29),hCell("Management",25)] }),
    new TableRow({ children:[dCell("I",12,{center:true,bg:GREEN_BG}),dCell("Microscopic tears; intact ligament",34,{bg:GREEN_BG}),dCell("Mild pain, minimal swelling, full WB",29,{bg:GREEN_BG}),dCell("RICE, functional rehab",25,{bg:GREEN_BG})] }),
    new TableRow({ children:[dCell("II",12,{center:true,bg:YELLOW_BG}),dCell("Partial macroscopic tear",34,{bg:YELLOW_BG}),dCell("Moderate pain, swelling, difficulty walking",29,{bg:YELLOW_BG}),dCell("Boot, physio, protected WB",25,{bg:YELLOW_BG})] }),
    new TableRow({ children:[dCell("III",12,{center:true,bg:RED_BG}),dCell("Complete rupture",34,{bg:RED_BG,bold:true}),dCell("Severe pain, instability, unable to WB",29,{bg:RED_BG}),dCell("NWB cast / surgical repair",25,{bg:RED_BG})] }),
  ]});
}
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    new TableRow({ children:[dCell("Type 2",14,{bold:true}),dCell("Mid-substance (interstitial) tear",46),dCell("End-to-end repair / imbrication",40)] }),
    new TableRow({ children:[dCell("Type 3",14,{bg:SURF_BG,bold:true}),dCell("Distal avulsion from tarsal attachment",46,{bg:SURF_BG}),dCell("Suture anchor at navicular / sustentaculum",40,{bg:SURF_BG})] }),
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    new TableRow({ children:[dCell("III",18,{center:true}),dCell("Posterior tibiofibular ligament / posterior malleolus",58),dCell("No",24,{center:true})] }),
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  ]});
}
function tRadiology() {
  return new Table({ width:{size:100,type:WidthType.PERCENTAGE}, rows:[
    new TableRow({ children:[hCell("Parameter",36),hCell("Normal",28),hCell("If Abnormal",36)] }),
    new TableRow({ children:[dCell("Medial clear space (MCS)",36),dCell("≤ 4 mm (mortise, neutral)",28),dCell("Deep deltoid incompetence",36)] }),
    new TableRow({ children:[dCell("MCS vs superior tibiotalar space",36),dCell("Equal",28),dCell("MCS > superior space → deltoid injury",36)] }),
    new TableRow({ children:[dCell("Tibiofibular clear space",36),dCell("< 6 mm (AP view)",28),dCell("Syndesmotic diastasis",36)] }),
    new TableRow({ children:[dCell("Tibiofibular overlap",36),dCell("> 6 mm AP; > 1 mm mortise",28),dCell("Syndesmotic injury if reduced",36)] }),
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    new TableRow({ children:[dCell("Lateral talar shift 5 mm",36,{bg:RED_BG}),dCell("—",28,{bg:RED_BG}),dCell("Tibiotalar contact area reduced 80%",36,{bg:RED_BG,bold:true})] }),
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function tTreatment() {
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    new TableRow({ children:[dCell("Isolated Grade III — low demand",40),dCell("NWB below-knee cast 6 weeks",35),dCell("Serial X-ray monitoring",25)] }),
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function tRecent() {
  return new Table({ width:{size:100,type:WidthType.PERCENTAGE}, rows:[
    new TableRow({ children:[hCell("#",7),hCell("Advance",40),hCell("Significance",53)] }),
    new TableRow({ children:[dCell("1",7,{center:true}),dCell("3T MRI + AI-based reconstruction",40),dCell("< 10 min high-quality imaging of all ligament components",53)] }),
    new TableRow({ children:[dCell("2",7,{center:true}),dCell("Suture tape augmentation (InternalBrace)",40,{bg:ACCENT}),dCell("Biomechanically superior; early WB; now preferred adjunct",53,{bg:ACCENT})] }),
    new TableRow({ children:[dCell("3",7,{center:true}),dCell("Arthroscopic-assisted repair",40),dCell("Identifies osteochondral lesions + confirms ligament pathology",53)] }),
    new TableRow({ children:[dCell("4",7,{center:true}),dCell("Deltoid repair vs. syndesmotic fixation",40,{bg:ACCENT}),dCell("Equivalent outcomes shown; shifting toward deltoid repair in selected cases",53,{bg:ACCENT})] }),
    new TableRow({ children:[dCell("5",7,{center:true}),dCell("Minimally invasive allograft reconstruction",40),dCell("Anatomic restoration of both layers; superior to non-anatomic tenodesis",53)] }),
    new TableRow({ children:[dCell("6",7,{center:true}),dCell("Revised prevalence data",40,{bg:ACCENT}),dCell("72% of lateral instability cases have deltoid injury; routine MRI now advocated",53,{bg:ACCENT})] }),
  ]});
}

// ── Cover ────────────────────────────────────────────────────────────────────
function cover() {
  return [
    spacer(600),
    new Paragraph({ alignment:AlignmentType.CENTER,
      children:[run("DELTOID LIGAMENT",{bold:true,size:64,color:DARK_BLUE})] }),
    new Paragraph({ alignment:AlignmentType.CENTER, spacing:{before:100,after:100},
      children:[run("Medial Ligament of the Ankle",{size:36,color:MID_BLUE,italic:true})] }),
    new Paragraph({ alignment:AlignmentType.CENTER, spacing:{before:160,after:160},
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        bottom:{style:BorderStyle.SINGLE,size:8,color:MID_BLUE},
        left:noBorder().left, right:noBorder().right
      },
      children:[run("PG Summary  •  Anatomy  •  Classification  •  Imaging  •  Treatment  •  Recent Advances",{size:22,color:MID_BLUE})] }),
    spacer(300),
    imgPara("anatomy_medial.png",370,408),
    caption("Fig. 1 – Medial (Deltoid) Ligament of the Right Ankle  (Gray's Anatomy for Students)"),
    spacer(200),
    new Paragraph({ alignment:AlignmentType.CENTER,
      children:[run("Sources: Campbell's Operative Orthopaedics 15th Ed 2026  •  Rockwood & Green's Fractures 10th Ed 2025",{size:16,color:"888888",italic:true})] }),
    new Paragraph({ alignment:AlignmentType.CENTER,
      children:[run("Gray's Anatomy for Students  •  Miller's Review of Orthopaedics 9th Ed  •  Imaging Anatomy Vol. 3",{size:16,color:"888888",italic:true})] }),
    new Paragraph({ children:[new PageBreak()] })
  ];
}

// ── Full body ────────────────────────────────────────────────────────────────
function buildBody() {
  return [
    ...cover(),

    secTitle("1.  Introduction"),
    body("The deltoid ligament is the primary stabilizing structure on the medial side of the talocrural joint. It is large, flat, strong, and triangular. Its apex attaches to the medial malleolus; its broad base fans inferiorly across multiple tarsal bones. It is the primary ankle stabilizer during stance phase and resists lateral talar translation, external rotation, and valgus tilt."),
    spacer(),

    secTitle("2.  Anatomy"),
    subHead("Bony Attachments"),
    boldBullet("Proximal (apex): ","Medial malleolus — anterior colliculus, posterior colliculus, intercollicular groove"),
    boldBullet("Distal (base): ","Tuberosity of navicular, plantar calcaneonavicular (spring) ligament, sustentaculum tali of calcaneus, medial surface of talus (anterior + posterior)"),
    spacer(80),
    subHead("Five-Component Structure (2 Layers)"),
    body("The deltoid has 5 named components arranged in 2 layers:"),
    spacer(60),
    tComponents(),
    spacer(80),
    noteBox("★ Deep Posterior Tibiotalar ligament = STRONGEST component of the entire deltoid complex. It is intraarticular but extrasynovial, and is the principal stabilizer of the talus in the ankle mortise."),
    spacer(120),
    subHead("Functional Summary by Layer"),
    tFunctions(),
    spacer(120),
    subHead("Anatomy Diagram"),
    imgPara("anatomy_medial.png",420,463),
    caption("Fig. 2 – Medial Ligament of the Ankle: Tibionavicular, Tibiocalcaneal, Anterior Tibiotalar, Posterior Tibiotalar parts  (Gray's Anatomy for Students)"),
    spacer(80),

    secTitle("3.  Etiology of Injury"),
    boldBullet("Eversion injury: ","Forced pronation-abduction — most common"),
    boldBullet("External rotation: ","Supination-external rotation (SER) — deltoid torn at Stage IV"),
    boldBullet("Pronation-Abduction / PER: ","Deltoid is the FIRST structure torn (Stage I)"),
    boldBullet("Chronic attenuation: ","Stage IV PTTD flatfoot — progressive valgus talar tilt"),
    boldBullet("Iatrogenic: ","Excessive eversion during ankle arthroplasty or hindfoot reconstruction"),
    spacer(120),

    secTitle("4.  Mechanism of Injury"),
    subHead("Lauge-Hansen Classification — SER Pattern (most common, 60–70% of ankle fractures)"),
    tLH(),
    spacer(80),
    noteBox("In Pronation-Abduction (PA) and Pronation-External Rotation (PER) patterns, the deltoid or medial malleolus is the FIRST structure injured (Stage I)."),
    spacer(80),
    body("Biomechanical consequences of lateral talar shift:",{bold:true}),
    bullet("1 mm shift → reduces tibiotalar contact area by 20–40%"),
    bullet("5 mm shift → reduces tibiotalar contact area by 80%"),
    spacer(120),

    secTitle("5.  Pathology"),
    boldBullet("Partial tear: ","More common; disruption of individual bands — usually superficial layer"),
    boldBullet("Complete rupture: ","Rare in isolation; usually with fibular fracture or syndesmotic injury"),
    boldBullet("Avulsion: ","Torn from medial malleolus (proximal, most common) or from tarsal insertions"),
    boldBullet("Entrapment: ","Avulsed stump interposed between medial malleolus and talus — blocks mortise reduction"),
    boldBullet("Chronic attenuation: ","Seen in Stage IV PTTD — incompetent ligament allows valgus talar tilt"),
    spacer(80),
    noteBox("72% of patients with lateral ankle instability have concurrent deltoid injury; 43% have injuries to BOTH deep and superficial components.  (Campbell's Operative Orthopaedics 15th Ed, 2026)"),
    spacer(120),

    secTitle("6.  Clinical Features"),
    subHead("Symptoms"),
    bullet("Medial ankle pain after eversion or external rotation injury"),
    bullet("Swelling and ecchymosis medially"),
    bullet("Difficulty or inability to bear weight (Grade II–III)"),
    bullet("Sense of instability or giving way in chronic cases"),
    spacer(80),
    subHead("Signs"),
    bullet("Tenderness over medial malleolus and medial ligament complex"),
    bullet("Hematoma on medial side — suggests significant tear"),
    bullet("Eversion / external rotation stress — pain with medial gapping"),
    bullet("Valgus hindfoot + arch collapse in chronic Stage IV flatfoot"),
    spacer(80),
    noteBox("Medial tenderness alone does NOT reliably predict deep deltoid rupture — no statistically significant correlation demonstrated. Always palpate the full fibula to exclude a Maisonneuve fracture."),
    spacer(120),

    secTitle("7.  Investigations"),
    subHead("Plain Radiograph — Mortise View (First Line)"),
    tRadiology(),
    spacer(80),
    body("Stress views must be obtained with ankle in neutral — plantarflexion allows the narrower talar dome into the mortise giving a spuriously wide medial clear space.",{italic:true}),
    spacer(120),
    subHead("Radiograph — Clinical Example"),
    imgPara("xray_tear.png",500,350),
    caption("Fig. 3 – A: Acute deltoid tear with oblique fibular fracture and lateral talar shift. B: After deltoid repair and fibular ORIF.  (Campbell's Operative Orthopaedics 15th Ed)"),
    spacer(80),

    secTitle("8.  CT Scan"),
    bullet("Not routinely needed for isolated deltoid injury"),
    bullet("Indicated for: complex fracture patterns (trimalleolar, pilon), syndesmotic assessment, pre-operative planning, associated osteochondral lesions"),
    bullet("3D CT may reveal tibiofibular diastasis not visible on plain films"),
    spacer(120),

    secTitle("9.  MRI"),
    boldBullet("Gold standard ","for deltoid ligament assessment"),
    boldBullet("Axial sequences: ","Optimal for deep layers and tibionavicular component"),
    boldBullet("Coronal sequences: ","Best for tibiocalcaneal, posterior tibiotalar, CFL; complete differentiation of superficial vs deep layers"),
    boldBullet("3T + AI reconstruction: ","< 10 minutes high-resolution imaging of all components (recent advance)"),
    bullet("MRI is more specific than sensitive (especially for CFL)"),
    bullet("Bone bruises present in significant proportion of ankle sprains; multiple bruises suggest multiple ligament injury"),
    bullet("Bone bruise-like lesions may persist > 1 year after injury"),
    spacer(80),
    imgPara("mri_tear.png",380,393),
    caption("Fig. 4 – Coronal T1 fat-suppressed MRI showing deltoid ligament tear  (Imaging Anatomy Vol. 3)"),
    spacer(120),

    secTitle("10.  Classification"),
    subHead("A.  Sprain Grading (Universal)"),
    tGrading(),
    spacer(120),
    subHead("B.  Anatomic Location Classification"),
    tLocation(),
    spacer(120),
    subHead("C.  Lauge-Hansen (Mechanism-Based) — see Section 4"),
    body("Deltoid injury at Stage IV in SER pattern; Stage I in PA and PER patterns."),
    spacer(80),
    subHead("D.  Johnson & Strom / Myerson (Flatfoot / PTTD)"),
    boldBullet("Stage IV: ","Deltoid insufficiency with valgus talar tilt. Deltoid reconstruction is mandatory as part of Stage IV flatfoot correction."),
    spacer(120),

    secTitle("11.  Treatment"),
    subHead("Overview"),
    tTreatment(),
    spacer(120),
    subHead("A.  Non-Operative"),
    boldBullet("Acute (0–2 wks): ","RICE; non-weight-bearing below-knee cast or boot"),
    boldBullet("Sub-acute (2–6 wks): ","Progressive WB in boot with orthotic arch support; physiotherapy"),
    boldBullet("Rehab: ","Proprioceptive training, peroneal strengthening, ROM — prolonged vs lateral sprains"),
    bullet("Serial radiographic monitoring to confirm mortise congruence"),
    spacer(80),
    subHead("B.  Operative — Acute Primary Repair"),
    body("Indications:",{bold:true}),
    bullet("Grade III in active / high-demand patient"),
    bullet("Deltoid tear + fibular fracture with talar shift or positive stress test"),
    bullet("Avulsed deltoid interposed in joint (blocking reduction)"),
    bullet("Bimalleolar equivalent fracture with confirmed mortise instability"),
    spacer(60),
    body("Technique:",{bold:true}),
    boldBullet("1. ","Curvilinear medial incision over medial malleolus extending toward navicular"),
    boldBullet("2. ","Identify disrupted ligament — usually avulsed from medial malleolus"),
    boldBullet("3. ","Debride torn edges; create shallow trough on medial malleolus with rongeur"),
    boldBullet("4. ","Insert suture anchor in distal medial malleolus"),
    boldBullet("5. ","Repair deltoid in imbricated fashion — tibionavicular + tibiocalcaneal bands to native attachment"),
    boldBullet("6. ","Below-knee cast in 5–10° plantarflexion + inversion; concurrent ORIF of fibula if fractured"),
    spacer(60),
    noteBox("Many surgeons do NOT routinely repair the deltoid. Fibular ORIF alone often restores mortise congruence. Medial exploration reserved for persistent wide medial clear space or blocked reduction."),
    spacer(80),
    subHead("C.  Operative — Chronic Reconstruction"),
    body("Indications:",{bold:true}),
    bullet("Chronic deltoid instability after failed conservative management"),
    bullet("Stage IV PTTD flatfoot with valgus talar tilt"),
    spacer(60),
    body("Techniques:",{bold:true}),
    boldBullet("1. Suture tape augmentation (preferred): ","Primary imbrication repair + suture tape from medial malleolus to sustentaculum tali. Guide pin 15° plantar to avoid subtalar joint."),
    boldBullet("2. Peroneus longus autograft (Deland): ","Peroneus longus preferred over brevis — longer and inserts medially."),
    boldBullet("3. Minimally invasive allograft (Jeng/Myerson 2011): ","Semitendinosus allograft through tibial tunnel (6.5 mm) → talar tunnel (5 mm) → sustentaculum tali. Combined with medial displacement calcaneal osteotomy + spring ligament repair."),
    boldBullet("4. Hamstring allograft: ","Alternative to autograft."),
    spacer(60),
    body("Postoperative Protocol:",{bold:true}),
    bullet("Sutures out at 2 weeks"),
    bullet("Short leg cast — 5° plantarflexion + inversion — for 5 weeks"),
    bullet("Boot + orthotic arch support at 5 weeks; WB as tolerated"),
    bullet("Physiotherapy at 8 weeks; stiff-soled shoe + carbon orthotic"),
    bullet("Impact activity (running) from 16 weeks with carbon insert protection"),
    spacer(120),

    secTitle("12.  Recent Advances"),
    tRecent(),
    spacer(200),

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    body("Campbell's Operative Orthopaedics 15th Ed 2026  |  Rockwood & Green's Fractures in Adults 10th Ed 2025",{italic:true}),
    body("Gray's Anatomy for Students  |  Miller's Review of Orthopaedics 9th Ed  |  Imaging Anatomy Vol. 3: Bones, Joints, Vessels and Nerves",{italic:true}),
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