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FAS 1015 No. of Pages 4

Foot and Ankle Surgery xxx (2016) xxxxxx

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Foot and Ankle Surgery


journal homepage: www.elsevier.com/locate/fas

Arthroscopic approach to the spring (calcaneonavicular) ligament


T.H. Lui, MBBS (HK) FRCS (Edin) FHKAM FHKCOS* , C.Y.D. Mak, MBBS (HK)
Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China

A R T I C L E I N F O A B S T R A C T

Article history: Background: This research studied the safety and efcacy of a new portal to the spring ligament. This
Received 7 January 2017 portal is located just plantar to the insertion of the posterior tibial tendon and above the brous septum
Received in revised form 25 February 2017 between the posterior tibial and the exor digitorum longus tendons.
Accepted 25 February 2017
Methods: Twelve fresh frozen foot and ankle specimens were used. The distance between the accessory
Available online xxx
medial portal and the medial plantar nerve was measured. The relation between the medial plantar nerve
and the spring ligament was studied. The depth that can be reached through the portal was also assessed.
Keywords:
Results: The average distance between the insertion point of the 3 mm diameter metal rod and the medial
Tendoscopy
Tibialis posterior tendon
plantar nerve was 20(627) mm. The medial plantar nerve located at lateral third of the ligament in
Flatfoot 8 specimens (67%), middle third in 2 specimens (17%) and medial third in 2 specimens (17%). The tip of
Repair rod can reach Zone A in all specimens.
Arthroscopy Conclusion: This study demonstrated that arthroscopic approach and repair of the spring ligament can
injure the medial plantar nerve.
Clinical relevance: The clinical relevance of this cadaver study is that it conrmed the feasibility of
arthroscopic approach to the whole span of the spring ligament and alerted the potential risk of injury to
the medial plantar nerve during arthroscopic assisted repair of the ligament.
2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction brocartilage, creating an articular surface with the head of talus


[4,10]. The SL, along with the anterior and middle facets of the
The spring ligament (SL), also known as the calcaneonavicular calcaneus and the talar facet of the navicular, compose the
ligament, is a thick triangular hammock-like structure that extends acetabulum pedis supporting the talar head [12]. Injury to the SL is
from the undersurface of the sustentaculum tali to the inferior and commonly secondary to the failure of the tibialis posterior tendon
medial edges of the talar facet of the navicular [1,2]. Medially, the in adult-acquired atfoot deformity [13] although cases of isolated
SL is supported by the anterior bers of the supercial deltoid injury to the SL with normal tibialis posterior tendon have been
ligament with the posterior tibial tendon running supercially. The reported [1418]. Because the SL is a major anatomical contributor
plantar expansion of the posterior tibial tendon provides some to the integrity of the medial longitudinal arch, particularly if the
support to the inferior aspects of the SL. Laterally, the spring dynamic support of the posterior tibial tendon is compromised,
ligament is contiguous with the medial band of the bifurcate repair of the damaged spring ligament may be considered [6,9,19].
ligament, occasionally separated from it by a layer of fat [3,4]. The Exploration and repair of the injured SL requires extensive soft
SL consists of the superomedial ligament (SML), medioplantar tissue dissection. With the advance of the small joint arthroscopy,
oblique ligament (MPOL) and inferoplantar longitudinal ligament the medial and lateral part of the SL can be approached through
(IPLL) [1,510]. The SML and IPLL are consistently visible medial medial subtalar [20,21] and anterior subtalar [2225] arthroscopy,
and lateral portions of the SL, respectively. The medioplantar respectively. Endoscopic assisted reconstruction of the tibialis
oblique ligament is thinner and is seen less consistently [8]. There posterior tendon through the medial portals has been reported
is a synovial recess communicating with the talocalcaneonavicular [26]. Recently, endoscopic and arthroscopic approaches and repair
joint and can be mistaken to be a tear of the plantar components of of the SL have been reported [2729]. However, there is no single
the SL [11]. The articular surface of the SL is covered with portal that can access the whole span of the ligament (Fig. 1). An
accessory medial portal has been designed to approach and repair
the SL arthroscopically when it incorporates with the other medial
portals [27,28]. The purpose of this study is to evaluate the possible
* Corresponding author.
extent of reach of the spring ligament via the accessory medial
E-mail addresses: luith@ha.org.hk, luithderek@yahoo.co.uk,
luithderek@yahoo.co.uk (T.H. Lui), damianmak@gmail.com (C.Y.D. Mak). portal. We hypothesized that this portal can allow access of the

http://dx.doi.org/10.1016/j.fas.2017.02.012
1268-7731/ 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: T.H. Lui, C.Y.D. Mak, Arthroscopic approach to the spring (calcaneonavicular) ligament, Foot Ankle Surg
(2017), http://dx.doi.org/10.1016/j.fas.2017.02.012
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FAS 1015 No. of Pages 4

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Fig. 1. Arthroscopic view of medial side of talocalcaneonavicular joint of a left foot.


Arthroscopic view through the medial midtarsal portal which is just above the
Fig. 3. Photo of the midtarsal joint of a right foot specimen showing the
insertion of the tibialis posterior portal showed that only the medial part of the
accessibility of the spring ligament through the medial and accessory medial portal.
spring ligament can be seen.
The accessory medial portal is plantar to the tibialis posterior tendon and the
medial portal of midtarsal arthroscopy is dorsal to the tendon. The accessory medial
whole span of the SL and it is safe with respect to injury to the portal allows deep reach of the spring ligament (SL) while the medial portal can
medial plantar nerve. approach the medial part of the ligament.

2. Methods
conrms the location of the deeply seated accessory navicular. The
Twelve foot and ankle specimens from 6 fresh frozen cadavers deep portal can be created by an arthroscopic knife or shaver under
(4 male and 2 female) were used. The average age of death was 80.5 tendoscopic visualization. The distance between the insertion
year old (6790). None of the cadavers had deformity, trauma or point of the rod and the medial plantar nerve was measured
any surgery of their foot and ankle regions. The feet were dissected (Fig. 4). The plantar span of the spring ligament was divided into
to expose the posterior tibial tendon, exor digitorum longus 3 equal zones. Zone A was the lateral third of the ligament. Zone B
tendon, exor hallucis longus tendon and the medial tibial nerve. A was the middle third of the ligament and zone C was the medial
3 mm metal rod was inserted into the plantar recess of the third of the ligament (Fig. 5). The zone where the medial plantar
talonavicular joint just plantar to the insertion of the posterior nerve located was recorded (Fig. 6). The zone that can be reached
tibial tendon and above the brous septum between the posterior by the tip of the rod was also recorded.
tibial and the exor digitorum longus tendons (Fig. 2). This was the
proposed accessory medial portal (Fig. 3). In vivo, this deep portal 3. Results
can be established under tendoscopic guide. With the proximal
portal of the posterior tibial tendoscopy as the viewing portal, the The results of the cadaver study were summarized in Table 1.
tibialis posterior tendon insertion can be seen. A needle can be The average distance between the insertion point of the rod at the
inserted via the distal skin portal, plantar to the tbialis posterior medial capsuloligamentous complex of the talonavicular joint and
tendon, into the plantar recess of the talonavicular joint. This the medial plantar nerve was 20(627) mm. The medial plantar
nerve located at Zone A in 8 specimens (67%), Zone B in 2 specimens
(17%) and Zone C in 2 specimens (17%). The tip of rod could reach
Zone A in all specimens.

Fig. 2. Insertion of the metal rod into the plantar recess of the talonavicular joint of
a right foot specimen. The metal rod was inserted at a point above the brous
septum between the posterior tibial and the exor digitorum longus tendons and
plantar to the tibialis posterior tendon. The posterior tibial tendon and the exor
digitorum longus tendon were cut and reected to expose the septum between the Fig. 4. Measurement of the shortest distance between the accessory medial portal
tendons and the insertion point of the metal rod. and the medial plantar nerve in a right foot specimen.

Please cite this article in press as: T.H. Lui, C.Y.D. Mak, Arthroscopic approach to the spring (calcaneonavicular) ligament, Foot Ankle Surg
(2017), http://dx.doi.org/10.1016/j.fas.2017.02.012
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showed that the medial plantar nerve can be at any zone of the SL.
Most of the tears of the SL are located at the medial third (Zone C)
and based on the result of this cadaver study, the medial plantar
nerve lie on this zone in 17% of cases. Therefore, arthroscopic
assisted repair by inside out technique is expected to have 17%
chance of injury to the medial plantar nerve. Ligament repair using
the outside in technique may be safer than the inside out
technique. This is possible by introducing a slotted cannula
through the accessory medial portal and the cannula can pass to
the extra-articular side of the ligament through the tear. The suture
can be passed through the ligament through the slot in an inside
out manner.
Although the portal is away from the medial plantar nerve, the
nerve can be injured if the instrument is slipped extra-articularly.
This is especially in cases of severe atfoot as the plantarexed
talar head will close up the plantar recess of the talonavicular joint
and increase the risk of extra-articular slipping of the instrument.
Fig. 5. Photo showed the the plantar side of a right foot specimen. The plantar span In order to avoid this injury, it is important to ensure that the
of the spring ligament was divided into 3 equal zones. Zone A is the lateral third of instrument remains inside the talonavicular joint during the
the ligament. Zone B is the middle third of the ligament and Zone C is the medial
introduction of the instrument. First metatarsal plantarexion will
third of the ligament.
reduce the talar head and increase the space of the plantar recess of
the joint (see Supplementary Video S1 in the online version at DOI:
4. Discussion http://dx.doi.org/10.1016/j.fas.2017.02.012). Moreover, dorsiexion
of the great toe besides plantarexing the rst metatarsal can
In this study, the accessory medial portal wound is shown to be tension the exor hallucis longus tendon which may push the
safe with respect to injury to the medial plantar nerve. The whole medial plantar nerve plantarly as the nerve crosses the tendon
span of the SL can be accessed through this portal. There was no plantarly [30]. The portal can also be made a bit more plantar
safe zone of the SL allowing repair of the ligament by the inside out (closer to the brous septum than the tibialis posterior tendon) so
method. that the instrument would point dorsally during the introduction.
The arthroscope can be introduced through the accessory This may allow easier entrance into the plantar recess of the
medial portal which is usually within the open reconstruction talonavicular joint.
wound. Arthroscopic assisted repair of the ligament can be Clinical relevance of this report is that it conrmed the
attractive in case of isolated tear of the SL with normal tibialis feasibility of arthroscopic approach to the whole span of the SL
posterior tendon or during endoscopic assisted reconstruction of and alerted the potential risk of injury to the medial plantar nerve
the tibialis posterior tendon. This accessory medial portal shares during arthroscopic assisted repair of the ligament.
the same skin incision of the standard distal tibialis posterior The main limitation of this study is the small number of
portal of the endoscopic reconstruction approach. This study specimens. Moreover, the dissection of the medial plantar nerve

Fig. 6. Study of the location of the medial plantar nerve according to the zones of the spring ligament. This was a right foot specimen. (A) The spring ligament was exposed
with minimal soft tissue dissection. (B) The relation between the medial plantar nerve and the spring ligament was studied.

Please cite this article in press as: T.H. Lui, C.Y.D. Mak, Arthroscopic approach to the spring (calcaneonavicular) ligament, Foot Ankle Surg
(2017), http://dx.doi.org/10.1016/j.fas.2017.02.012
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Table 1
Summary of details of the specimens concerning the location of the medial plantar nerve related to the spring ligament and the distance between the medial plantar nerve
and the accessory medial portal.

Specimen no. Laterality Zone where the medial plantar Distance from the accessory medial Zone that was reached by the rod
nerve located portal to the medial plantar nerve (mm)
1 L A 27 A
2 L A 26 A
3 R B 15 A
4 L C 6 A
5 R C 6 A
6 L A 26 A
7 L A 24 A
8 R B 16 A
9 R A 24 A
10 R A 23 A
11 L A 25 A
12 R A 24 A

L: left.
R: right.
Zone A: lateral third of the spring ligament.
Zone B: middle third of the spring ligament.
Zone C: medial third of the spring ligament.

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Please cite this article in press as: T.H. Lui, C.Y.D. Mak, Arthroscopic approach to the spring (calcaneonavicular) ligament, Foot Ankle Surg
(2017), http://dx.doi.org/10.1016/j.fas.2017.02.012