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FAS 1015 No. of Pages 4

Foot and Ankle Surgery xxx (2016) xxxxxx

Contents lists available at ScienceDirect

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

The spring ligament (SL), also known as the calcaneonavicular
ligament, is a thick triangular hammock-like structure that extends
from the undersurface of the sustentaculum tali to the inferior and
medial edges of the talar facet of the navicular [1,2]. Medially, the
SL is supported by the anterior bers of the supercial deltoid
ligament with the posterior tibial tendon running supercially. The
plantar expansion of the posterior tibial tendon provides some
support to the inferior aspects of the SL. Laterally, the spring
ligament is contiguous with the medial band of the bifurcate
ligament, occasionally separated from it by a layer of fat [3,4]. The
SL consists of the superomedial ligament (SML), medioplantar
oblique ligament (MPOL) and inferoplantar longitudinal ligament
(IPLL) [1,510]. The SML and IPLL are consistently visible medial
and lateral portions of the SL, respectively. The medioplantar
oblique ligament is thinner and is seen less consistently [8]. There
is a synovial recess communicating with the talocalcaneonavicular
joint and can be mistaken to be a tear of the plantar components of
the SL [11]. The articular surface of the SL is covered with
* Corresponding author.
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).
[4,10]. The SL, along with the anterior and middle facets of the
calcaneus and the talar facet of the navicular, compose the
acetabulum pedis supporting the talar head [12]. Injury to the SL is
commonly secondary to the failure of the tibialis posterior tendon
in adult-acquired atfoot deformity [13] although cases of isolated
injury to the SL with normal tibialis posterior tendon have been
reported [1418]. Because the SL is a major anatomical contributor
to the integrity of the medial longitudinal arch, particularly if the
dynamic support of the posterior tibial tendon is compromised,
repair of the damaged spring ligament may be considered [6,9,19].
Exploration and repair of the injured SL requires extensive soft
tissue dissection. With the advance of the small joint arthroscopy,
the medial and lateral part of the SL can be approached through
medial subtalar [20,21] and anterior subtalar [2225] arthroscopy,
respectively. Endoscopic assisted reconstruction of the tibialis
posterior tendon through the medial portals has been reported
[26]. Recently, endoscopic and arthroscopic approaches and repair
of the SL have been reported [2729]. However, there is no single
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
extent of reach of the spring ligament via the accessory medial
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
2 T.H. Lui, C.Y.D. Mak / Foot and Ankle Surgery xxx (2016) xxxxxx
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
insertion of the tibialis posterior portal showed that only the medial part of the
spring ligament can be seen.
whole span of the SL and it is safe with respect to injury to the
medial plantar nerve.
2. Methods
Twelve foot and ankle specimens from 6 fresh frozen cadavers
(4 male and 2 female) were used. The average age of death was 80.5
year old (6790). None of the cadavers had deformity, trauma or
any surgery of their foot and ankle regions. The feet were dissected
to expose the posterior tibial tendon, exor digitorum longus
tendon, exor hallucis longus tendon and the medial tibial nerve. A
3 mm metal rod was inserted into the plantar recess of the
talonavicular joint just plantar to the insertion of the posterior
tibial tendon and above the brous septum between the posterior
tibial and the exor digitorum longus tendons (Fig. 2). This was the
proposed accessory medial portal (Fig. 3). In vivo, this deep portal
can be established under tendoscopic guide. With the proximal
portal of the posterior tibial tendoscopy as the viewing portal, the
tibialis posterior tendon insertion can be seen. A needle can be
inserted via the distal skin portal, plantar to the tbialis posterior
tendon, into the plantar recess of the talonavicular joint. This
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
tendons and the insertion point of the metal rod.
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
Fig. 3. Photo of the midtarsal joint of a right foot specimen showing the
accessibility of the spring ligament through the medial and accessory medial portal.
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
portal allows deep reach of the spring ligament (SL) while the medial portal can
approach the medial part of the ligament.
conrms the location of the deeply seated accessory navicular. The
deep portal can be created by an arthroscopic knife or shaver under
tendoscopic visualization. The distance between the insertion
point of the rod and the medial plantar nerve was measured
(Fig. 4). The plantar span of the spring ligament was divided into
3 equal zones. Zone A was the lateral third of the ligament. Zone B
was the middle third of the ligament and zone C was the medial
third of the ligament (Fig. 5). The zone where the medial plantar
nerve located was recorded (Fig. 6). The zone that can be reached
by the tip of the rod was also recorded.
3. Results
The results of the cadaver study were summarized in Table 1.
The average distance between the insertion point of the rod at the
medial capsuloligamentous complex of the talonavicular joint and
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. 4. Measurement of the shortest distance between the accessory medial portal
and the medial plantar nerve in a right foot specimen.
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Fig. 5. Photo showed the the plantar side of a right foot specimen. The plantar span
of the spring ligament was divided into 3 equal zones. Zone A is the lateral third of
the ligament. Zone B is the middle third of the ligament and Zone C is the medial
third of the ligament.
4. Discussion
In this study, the accessory medial portal wound is shown to be
safe with respect to injury to the medial plantar nerve. The whole
span of the SL can be accessed through this portal. There was no
safe zone of the SL allowing repair of the ligament by the inside out
method.
The arthroscope can be introduced through the accessory
medial portal which is usually within the open reconstruction
wound. Arthroscopic assisted repair of the ligament can be
attractive in case of isolated tear of the SL with normal tibialis
posterior tendon or during endoscopic assisted reconstruction of
the tibialis posterior tendon. This accessory medial portal shares
the same skin incision of the standard distal tibialis posterior
portal of the endoscopic reconstruction approach. This study
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
3
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.
In order to avoid this injury, it is important to ensure that the
instrument remains inside the talonavicular joint during the
introduction of the instrument. First metatarsal plantarexion will
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:
http://dx.doi.org/10.1016/j.fas.2017.02.012). Moreover, dorsiexion
of the great toe besides plantarexing the rst metatarsal can
tension the exor hallucis longus tendon which may push the
medial plantar nerve plantarly as the nerve crosses the tendon
plantarly [30]. The portal can also be made a bit more plantar
(closer to the brous septum than the tibialis posterior tendon) so
that the instrument would point dorsally during the introduction.
This may allow easier entrance into the plantar recess of the
talonavicular joint.
Clinical relevance of this report is that it conrmed the
feasibility of arthroscopic approach to the whole span of the SL
and alerted the potential risk of injury to the medial plantar nerve
during arthroscopic assisted repair of the ligament.
The main limitation of this study is the small number of
specimens. Moreover, the dissection of the medial plantar nerve
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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.

and the exor tendons can affect the mobility and relationship
between the medial plantar nerve and the spring ligament.
5. Conclusions
Arthroscopic approach and repair of the spring ligament can
injure the medial plantar nerve.
Conict of interest
No nancial and personal relationships with other people or
organizations that could inappropriately inuence (bias) the
preparation of this manuscript.
Acknowledgment
Thanks to James W.M. Ting, Directing Laboratory Manager of
Chinese University of Hong Kong, to arrange the cadaveric
dissection.
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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