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Research Article

Masaragian et al., Clin Res Foot Ankle 2020, 8:2 Open Access

Endoscopic Spring Ligament Repair: Classification and Surgical Technique

H?ctor Jos? Masaragian*, Leonel Rega, Fernando Perin and Nicolas Ameriso Foot and Ankle Surgeon, Buenos Aires, Argentina

Abstract

Background: Spring ligament lesions have been proposed as a cause of adult flatfoot deformities. Series of isolated injuries have been published in the literature. An alternative endoscopic surgical technique and a classification related to treatment for spring ligament injuries is proposed.

Methods: A cadaveric study with 6 feet was performed, recreating a spring ligament lesion with a bipolar radio frequency probe and subsequent endoscopic repair of the injury. Specimens were dissected to assess correct repair.

Results: Spring ligament anatomy was restored after endoscopic procedure in all feet. Accessory portal was needed only in one foot.

Conclusion: Spring Ligament endoscopic repair is an effective technique for diagnosis and treatment. It allows direct visualization of the ligament and posterior tibialis tendon, as well as treatment in the same procedure. We also present an endoscopic classification, related to our treatment of choice.

Keywords: Spring ligament; Flatfoot deformity; Tibialis posterior

tendon dysfunction; Endoscopic repair; Tendoscopy

Introduction

The spring ligament (SL) complex includes the superomedial and inferior calcaneonavicular ligaments. Anatomy has been studied and described in detail in the past [1-3]. The superomedial ligament has a quadrangular shape and it merges with the inferior ligament. It also fuses with components of the deltoid as well as the talonavicular ligament. It has a fibrocartilage surface that supports the head of the talus. The inferior ligament is trapezoidal and supports the inferior aspect of the head of the talus, with a triangular dorsal fibrocartilage surface [1] Taniguchi et al. described a third bundle of fibers running independently from the other two ligaments, also known as the medio plantar oblique ligament. Their origin is in the notch between the anterior and middle facets of the calcaneus and goes to the insertion in the navicular beak [2].

Adult-acquired flat foot deformity develops when dynamic and static stabilizers of the hindfoot fail. The structures supporting the arch of the foot are the Spring, Deltoid, talocalcaneal interosseous ligaments, the plantar fascia, and Tibialis Posterior Tendon [4].

The consequences of spring ligament injury have been studied [4,5]. In chronic injuries, it?s still not clear whether the initial injuries that develop flat foot deformity takes place on the posterior tibial tendon (PTT), the spring (SL) or Deltoid ligament. The loss of function of the PTT could lead to stress to the Deltoid or SL, which attenuates and eventually ruptures. On the other hand, an initial injury to the SL increases strain on the PTT, developing PTT insufficiency [5]. Usually, spring ligament injuries were casual findings during exploration of the tibialis posterior tendon due to tenosynovitis or tibialis Posterior Tibial Tendon Dysfunction (PTTD) with extensive soft tissue dissection. Lui et. al described an endoscopic treatment of spring ligament lesions using classic tibialis posterior tendon tendoscopy and an accessory portal. We describe an endoscopic repair technique using modified PTT tendoscopy portals and a Miniscorpion? (Arthrex, Inc. ? Naples, Florida, USA) suture passer.

Clinical suspicion is essential for diagnosis. Prior trauma history may or may not be present, as well as hindfoot deformity. Patients usually have palpatory pain, immediately plantar to the tibialis posterior

tendon, approximately 1 cm proximal to its insertion on the navicular, with tenderness along the tendon?s trajectory. Imaging studies include radiographs (weightbearing AP, lateral and long axis view), ultrasound and MRI with micro-coil (Figure 1A-D). These studies may be negative

Figure 1: MRI imaging of the Spring Ligament. A and B: Coronal views. Note arrows showing superomedial bundle of the spring ligament and PTT thickness. C and D: Axial views. Arrows show inferior bundle of the spring ligament with the presence in left arrow of the medio plantar oblique ligament described by Taniguchi et al. [2].

*Corresponding author: H?ctor Jos? Masaragian, Foot and Ankle Surgeon, Buenos Aires, Argentina, Tel: +54 9115249 4685; E-mail: masa@ Received June 29, 2020; Accepted July 14, 2020; Published July 21, 2020 Citation: Masaragian HJ, Rega L, Perin F, Ameriso N (2020) Endoscopic Spring Ligament Repair: Classification and Surgical Technique. Clin Res Foot Ankle 8: 296 Copyright: ? 2020 Masaragian HJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Clin Res Foot Ankle, an open access journal ISSN: 2329-910X CRFA

Volume 8 ? Issue 2 ? 1000296

Citation: Masaragian HJ, Rega L, Perin F, Ameriso N (2020) Endoscopic Spring Ligament Repair: Classification and Surgical Technique. Clin Res Foot Ankle 8: 296

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and, when symptoms persist despite adequate medical treatment, tendoscopy and eventual repair is indicated. The objective of this paper is to describe an endoscopic surgical technique and a classification for SL injuries related to our treatment of choice.

Materials and Methods

A cadaveric specimen study was performed with 6 feet, four left and two right, all included the knee. Portals were placed as described in the surgical technique presented below. After the spring ligament was identified, a transverse (coronal) cut was made to the superomedial bundle of the SL with a bipolar radio frequency ablation probe. Next, the spring ligament was repaired with a suture passer. The dorsal accessory portal was needed in only one foot. The procedure was recorded for future study.

Surgical technique

Equipment: We perform the procedure with a 4 mm scope since the field of view is much wider, and allow us to move the tendon medially to achieve a better view of the SL. A 2.7 mm probe with a 3.0 / 3.5 shaver blade are necessary. We will describe the surgical technique using a suture passer (Miniscorpion?).

Setup: In this manuscript, all procedures were done on cadaveric specimens. When the procedure is done on patients, they should be placed supine, with the knee flexed and external rotation of the hip. The foot is placed over a soft cushion. This allows hindfoot varusvalgus mobilization, if necessary, during the procedure and prevents scope movement restriction by the leg. A contralateral hip elevation could be used, and a thigh tourniquet should be applied. The medial malleolus, the navicular and the tendon trajectory are marked as well as the Tendoscopy portals. The procedure can be performed under peripheral popliteal block and sedation (Figure 2 A-C).

Portal placement: First, saline is injected into the tendon sheath to create space and prevent tendon damage when going through the sheath. The first portal is placed just behind the tip of the medial malleolus. Portal is made with a #15 scalpel, only through the skin, and a Mosquito clamp is used to open the tendon sheath. The 4 mm scope is placed. It is important at this point to check if the scope is in the correct sheath since it could happen that the mosquito clamp slips into the Flexor Digitorum Longus (FDL) tendon sheath. Moving the toes

is a simple maneuver to check the correct placement of the scope. The second portal is placed 0.5 cm proximal to the tendon insertion guided by transillumination of the previously placed portal (Figure 3A). We use a 21 Gauge needle to locate the correct placement of the distal portal with the endoscopic view (Figure 3B).

Exploration: The tibialis posterior tendon should be easily identified (Figure 4A). Injuries of the tendon can be searched with the probe at both sides. Any areas of the tendon with neovascularization should be specifically noted since those areas are usually surrounding an injured zone (Figure 4B). Then, the tendon is pulled down with a probe allowing to visualize the superomedial calcaneonavicular ligament from inside the PTT sheath. After that, the scope should be located between the tendon and the medial malleolus, to obtain a good view of the Spring ligament.

Assessing the injury: Once the Spring ligament is visualized (Figure 5A), the presence and type of injury is determined. We use an intraoperative classification that is related to our treatment choice for the spring ligament (Table 1).

Type A - Lax ligament or superficial injury (frayed ligament) (Figure 5B).

Type B - Partial rupture.

B1 - Less than 5 mm (Figure 5C).

Figure 3: Portal placement. A: Distal portal placement aided by transillumination. Note Needle for endoscopic guidance to place this portal. B: Proximal portal placement. Note right hand positioning to provide a more stable grip for the scope.

Figure 2: Set up and patient positioning. A: Popliteal nerve block under ultrasound assistance used for de procedure. B: Leg positioning. Note right hip with gentle cushioning to allow some external rotation of the left side. C: Classic portal placing (Crosses) and recommended portal placement for spring ligament endoscopic repair (dots).

Clin Res Foot Ankle, an open access journal ISSN: 2329-910X CRFA

Figure 4: Tibialis posterior tendon and spring ligament endoscopic view. A: SL - Spring ligament. PTT ? Posterior tibial tendon. B: PTT - Posterior Tibial Tendon. Probe and arrows showing tendon tear.

Volume 8 ? Issue 2 ? 1000296

Citation: Masaragian HJ, Rega L, Perin F, Ameriso N (2020) Endoscopic Spring Ligament Repair: Classification and Surgical Technique. Clin Res Foot Ankle 8: 296

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Type A B I B II

C

Description Lax ligament or superficial injury (frayed ligament) Partial rupture less than 5 mm Partial rupture, more than 5mm with clear access to the talonavicular joint Complete rupture or no ligament to repair

Treatment

Tibialis posterior tendon synovectomy. Debridement with shaver if SL lesion present

Debridement and endoscopic suture if possible

Debridement and endoscopic suture is indicated. Bone anchor if ligament needs to be reattached. Hindfoot and midfoot deformities should be treated

Open procedures are necessary. Tendoscopy conversion to open procedure with FCD transfer to the navicular and augmentation with Internal Brace?

Table 1: Endoscopic classification for Spring ligament injuries. In all cases, we suggest that any foot deformity should be addressed at the time of tendoscopy.

Figure 5: Spring ligament assessment. A: Normal SL: spring ligament, TP: tibialis posterior tendon. Probe is located between the tendon and healthy spring ligament. B: Type A injury: lax or frayed ligament. SL: spring ligament. PTT: tibialis posterior tendon. Arrow: tendon lesion. C: Type B injury (subtype B1): Partial SL tear, (less than 5 mm). SL: Spring Ligament. PTT: tibialis posterior Tendon. Arrows: showing stumps of torn Spring ligament. Probe is used to measure injury size. D: Subtype B2 injury: Partial SL tear, (more than 5mm). Probe or shaver blade could be used for measurement. Note both stumps and probe traction to evidence the head of the talus. D: Type C injury: massive tear of superomedial bundle. Probe is holding inferior part of the injury, with no possibility for endoscopic repair. Open procedure should be considered.

B2 - More than 5 mm with clear access to the talonavicular joint (Figure 5D).

Type C - Complete rupture or no ligament to repair (Figure 5E).

Treatment of choice

If no lesions are seen or there is a frayed ligament (Type A), a SL debridement and tibialis posterior tendon synovectomy are enough. If a tendon injury is observed, debridement with shaver is also performed.

In partial lesions (type B) If it's smaller than 5 mm (subtype B1) (Figure 5C), debridement and endoscopic suture should be done if possible.

In partial lesions larger than 5mm, (subtype B2) (Figure 5D), we suggest debridement and endoscopic suture according to the surgeon preferred technique. The size is established with the probe or the shaver width as we are using a 3.0- or 3.5-mm blade. In all cases, if any hindfoot or midfoot deformity is present, they should be addressed in the procedure. If the Spring ligament is detached from navicular insertion, it may be reattached with a bone anchor.

Complete or massive injury (type C) (Figure 5E) is usually associated with hindfoot malalignment and open procedures could be necessary. In those cases, extra open procedures are mandatory. According to radiographic and clinical deformities, a combination of procedures should be performed: flexor digitorium longus (FDL) transfer, augmentation with internal brace? (Arthrex, inc.?Naples, Florida, USA), calcaneal osteotomies (lateral column lenghtening/ medializing calcaneal osteotomy), subtalar arthroereisis and/or first metatarsal osteotomies.

Endoscopic Repair of SL: (Miniscorpion?): once the lesion is identified, a number zero FiberWire? (Arthrex, inc.?Naples, Florida, USA) suture is passed through the distal stump of the spring ligament with the suture passer (Figure 6A-C) using the distal portal. Sutures are recovered through the same portal, and the distal thread is loaded again to the Miniscorpion?. Suture is passed through the proximal stump (Figure 6D and E), recovered through the distal portal and a sliding blocked knot is made (Figure 7A and B). An arthroscopic suture cutter is then used (Figure 7C and D). In case there is some limitation using the distal portal, it can be switched to the proximal one. Is important to keep the foot inverted during this part of the procedure to facilitate the endoscopic suture. In some cases, an extra alternative portal could be used

Use of alternative portal: If the ligament lesion is difficult to repair or maneuvering with the Miniscorpion? inside the tendon sheath is not possible, an accessory portal can be placed immediately dorsal to the tendon trajectory, half-way to the already placed portals to facilitate suture with the suture passer (Figure 8).

Portal closure: 4-0 nylon is used to close the portals.

Results

In this cadaveric study 6 fresh frozen feet were used. In all specimens the endoscopic spring ligament repair was achieved. The proximal and distal portals were used in all procedures as described in the surgical technique. A transverse (coronal) SL lesion was made using the same technique (bipolar radio frequency ablation probe) in all specimens in the same location of the spring ligament. In one foot the dorsal accessory portal was needed to complete the suture, aiding in the plantar displacement of the posterior tibial tendon. Both, the SL lesion and the surgical procedure, were carried out by the senior surgeon.

Once the endoscopic repair procedure was accomplished in all spring ligaments, the feet were dissected. The reestablished continuity of the spring ligament was confirmed, and portal safety evaluated. When placing the portals in the described positions, no risk of neurovascular lesions was observed. A clinical article is being developed for publication.

Pearls and pitfalls

Placing the proximal portal close to the medial malleolus and to the PTT insertion to the navicular will prevent mosquito clamp to slip through the FDL tendon sheath.

Clin Res Foot Ankle, an open access journal ISSN: 2329-910X CRFA

Volume 8 ? Issue 2 ? 1000296

Citation: Masaragian HJ, Rega L, Perin F, Ameriso N (2020) Endoscopic Spring Ligament Repair: Classification and Surgical Technique. Clin Res Foot Ankle 8: 296

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Figure 6: Spring ligament endoscopic suture. A: Suture passer (SP) positioning through distal portal. B: Arthroscopic view of SP. C: Suture passed through proximal spring ligament (SL) stump. D: SP through SL lesion (arrows), loaded with distal suture thread. Note proximal suture thread passed through proximal stump. E: suture through proximal and distal SL stumps. Arrows: SL lesion.

Figure 7: Endoscopic suture knot. SL: Spring ligament. PTT: tibialis posterior tendon. A: Duncan knot. B: knot tightening (AKP: arthroscopic knot pusher). C: Knot cutting (ESC: Endoscopic suture cutter). D: final view (arrow: final knot).

Figure 8: Accessory portal placement. Just superior to PTT tendon sheath. Probe through portal.

Move the toes once the tendon is identified to make sure that the scope is not placed inside the flexor digitorum longus sheath.

Vascularization of the tendon is usually a sign of tendon injury and should be searched for.

Once the tibialis posterior tendon is identified, using the probe to move and maintain the tendon plantar or medial may be useful for a clearer view of the spring ligament and also to be able to place the scope between PTT and the medial malleolus.

Care should be taken when placing the suture passer. The needle must always be directed into the tendons sheath, avoiding the talus head to prevent breakage of the tip.

Avoid tangles inside the spring ligament?s lesion when passing the sutures through the proximal stump.

Discussion

Acquired flatfoot deformity is a progressive disease, which in advanced stages may produce severe deformity and disability. Recent studies have proposed that spring ligament lesions may be a precursor injury to the complete pathology [4?7]. With new imaging techniques and a clearer clinical presentation, these injuries may be detected and early diagnosed.

Isolated spring ligament injuries have been described in the past. Jennings et al. performed a cadaveric study in 2008 to determine the effects of SL isolated lesion. After sectioning the superomedial bundle of the SL, they observed a talar displacement with hindfoot valgus, loss of high in the longitudinal arch and an increased stress on the PTT. They still were able to invert the calcaneus but with a decrease in its function. They recommend inspecting and repair of the SL in conjunction with other flat foot deformities procedures [5].

In 2008 Tryfonidis et al. [6] presented a series of 9 patients with acute flatfoot deformity due to spring ligament insufficiency. They didn?t observe a direct relation with trauma. Patients consulted for pain after long walks or a severe ankle sprain during sports. All patients had pain, tenderness, and certain degree of flat foot, with partial correction of the medial arch height when performing single heel rise test. Treatment was addressed according to the patient. initially conservative, with exception of patients regularly involved in sports who underwent surgery as the first line of treatment. In the remaining 8 patients, 2 had conservative treatment failure and had surgical procedures. They had more complex surgeries due to delayed diagnosis and more severe deformities.

We presented a case report and review of the literature in 2013 were we performed an open repair of an acute injury with excellent results and a follow up of 8 years (14 years up to now) without hindfoot deformities [8].

In 2013 Orr et al. [4] a series of 6 patients with isolated spring ligament injuries, treated with extensive medial approaches, direct spring ligament repair and adjunctive flatfoot procedures (medial calcaneal osteotomy, lateral column lengthening) to all patients but one, who was treated with direct SL repair alone. Patients had no residual pain, complete satisfaction, and no recurrence of deformities with exception of one who continued with pain after 6 months

Tibialis posterior tendon tendoscopy has been described in 2016 by Lui et al. [9,10]. They presented the surgical technique for an endoscopic spring ligament repair by adding an accessory portal and a CPR Viper suture passer? (Arthrex, Inc. Naples, Florida, USA).

Lui et al. published a paper concerning the security of the portals, using in addition to the classic portals, an accessory one placed plantar to the sheath. The only main structure at risk was the medial planar

Clin Res Foot Ankle, an open access journal ISSN: 2329-910X CRFA

Volume 8 ? Issue 2 ? 1000296

Citation: Masaragian HJ, Rega L, Perin F, Ameriso N (2020) Endoscopic Spring Ligament Repair: Classification and Surgical Technique. Clin Res Foot Ankle 8: 296

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nerve, which can be avoided as he reported by doing plantar flexion of the first metatarsal head along with dorsiflexion of the hallux [9].

Portals placed as we describe in our technique, minimize nerve injuries as we do not use any portal placed plantar to PTT. Since early stages of flatfoot deformity is difficult to diagnose, tendoscopy for suspected spring ligament lesions is not frequent currently. The aim of this procedure is to stop or delay progressive deformity. It is proved to be less effective as it evolves to final stages. We are completing a case series (with short to mid-term follow up) that will be published shortly, in which no complications have been found.

When treating patients for suspected spring ligament lesions, hindfoot and midfoot deformities should be always addressed at the same time of tendoscopy. When these findings are clinically or radiographically present, osteotomies should be carried out as described in Myerson's classification of posterior tibial tendon disfunction. Acute medial pain has got more relevance lately, allowing early diagnose in the initial stages of adult flatfoot deformity. Posterior tibial tendon and spring ligament repair can be performed and thus avoiding or minimizing foot deformity, but, if they are already present, they should be addressed with bony corrections, in addition to the endoscopic procedure. Each patient should be assessed for pain and deformities, supplemented with imaging studies to evaluate tendon and ligament condition.

Conclusion

Endoscopy is an effective technique for diagnosis and treatment of Tibialis posterior tendon and Spring ligament injuries. It allows direct visualization of the tendon and the ligament, as well as treatment in the same procedure, according to the severity of the injury.

We present an endoscopic classification, related to our treatment of choice. We remark that all extra deformities should be addressed at the same time of endoscopy for optimal correction of foot alignment.

This technique may be done by any orthopedic surgeon with arthroscopic training, we suggest this procedure for advanced foot and ankle surgeons, as it has a medium learning curve and needs specific instrumentation.

The limits of this study include the limited number of specimens used and that the lesion was produced artificially by the senior surgeon.

On the other hand, we could not perform a bio mechanical testing of the suture in the lab to corroborate its resistance.

Although this study proves endoscopy as a valid alternative for spring ligament repair, further high-level, randomized, prospective and comparative studies should be conducted.

Funding

This research did not receive any specific grant for funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

Corresponding author acknowledges to be consultant and speaker for Arthrex ? and Wright?.

References

1. Golano P, Fari?as O, S?enz I (2004) The anatomy of the navicular and periarticular structures. Foot Ankle Clin 9: 1-23.

2. Taniguchi A, Tanaka Y, Takakura Y, Kadono K, Maeda M, et al. (2003) Anatomy of the spring ligament. J Bone Joint Surg Am 85: 2174-2178.

3. Acevedo J, Vora A (2013) Anatomical reconstruction of the spring ligament complex. Foot Ankle Spec 6: 441-645.

4. Orr JD, Nunley JA (2013) Isolated spring ligament failure as a cause of adultacquired flatfoot deformity. Foot Ankle Int 34: 818-23.

5. Jennings MM, Christensen JC (2008) The effects of sectioning the spring ligament on rearfoot stability and posterior tibial tendon efficiency. J Foot Ankle Surg 47: 219-224.

6. Tryfonidis M, Jackson W, Mansour R, Cooke PH, Teh J, et al. (2008) Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normal tibialis posterior tendon. Foot Ankle Surg 14:89? 95.

7. Masaragian HJ, Massetti S, Perin F, Rega L, Mizdraji L, et al. (2020) Flatfoot deformity due to isolated spring ligament injury. J Foot Ankle Surg 59: 469-478.

8. Masaragian HJ, Ricchetti HO, Testa C (2013) Acute isolated rupture of the spring ligament: A case report and review of the literature. Foot Ankle Int 34: 150-154.

9. Lui TH, Mak CYD (2018) Arthroscopic approach to the spring (calcaneonavicular) ligament. Foot Ankle Surg 24: 242-245.

10. Lui TH (2016) Endoscopic repair of the superficial deltoid ligament and spring ligament. Arthrosc Tech 5: 621-625.

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