Posterior Tibial Tendoscopy: Endoscopic Synovectomy and Assessment of the Spring (Calcaneonavicular) Ligament

Abstract

A tear of the spring ligament is frequently associated with posterior tibial tendon dysfunction. Repair of the damaged spring ligament is an important component of surgical reconstruction in the treatment of posterior tibial tendon dysfunction because it is a major anatomic contributor to the integrity of the medial longitudinal arch, particularly if the dynamic support of the posterior tibial tendon is compromised. Extensive dissection is required for exposure and repair of the ligament because it is a deep-seated structure. It is beneficial to confirm the presence of ligament tears before surgical exploration to avoid unnecessary dissection. Preoperative magnetic resonance imaging and ultrasound studies have moderate sensitivity in the detection of these tears. We report an arthroscopic technique for assessment of the integrity of the spring ligament during endoscopic or open reconstruction of the posterior tibial tendon. This allows the surgeon to confirm the presence of a ligament tear before additional dissection to explore and repair the ligament.

Arthroscopic Repair of Superomedial Spring Ligament by Talonavicular Arthroscopy

“…[9][10][11] A high distal portal that is dorsal to the posterior tibial tendon insertion and close to the equator of the talar head has been proposed as the working portal for repair of the spring ligament. The medial midtarsal portal used in this technical approach has a similar location to the high distal portal and allows proper orientation of the Viper suture passer for repair of the spring ligament.…”

“…9,10 This is performed by posterior tibial tendoscopy. The technique can be incorporated with endoscopy-assisted reconstruction of the tibialis posterior tendon to treat posterior tibial tendon deficiency.…”

Endoscopic Repair of the Superficial Deltoid Ligament and Spring Ligament

“…Endoscopic assessment of the integrity before open exploration has been proposed to avoid unnecessary soft-tissue dissection. 9 The technique of endoscopic repair of the spring ligament is an advancement in the field and, together with the endoscopically assisted reconstruction of the tibialis posterior tendon, 8 allows complete endoscopic treatment of stage 2 posterior tibial tendon deficiency ( Table 1).…”

“…If the superficial deltoid ligament is not torn, an accessory distal portal can be made at the medial wall of the tibialis posterior tendon sheath just above the septum between the tibialis posterior tendon and the flexor digitorum longus tendon. 9 The arthroscope can be inserted into the plantar gutter of the talonavicular joint through the distal and accessory distal portals. The integrity of the spring ligament can then be examined.…”

Endoscopically Assisted Reconstruction of Posterior Tibial Tendon for Stage 2 Posterior Tibial Tendon Dysfunction

“… 12 However, tendoscopy is more effective than magnetic resonance imaging for detection of a spring ligament tear. 12 , 14 …”