Endoscopic Excision of Symptomatic Os Trigonum in Professional - PowerPoint PPT Presentation

Endoscopic Excision of Symptomatic Os Trigonum in Professional Dancers

NO DISCLOSURES

Objectives Understand Posterior Ankle Impingement • Syndrome (PAIS) Differential causes of Posterior ankle pain • Describe surgical technique • • Demonstrate a retrospective study to show results • of excision of symptomatic Os Trigonum using an endoscopic procedure Discuss result of study • Concluding remarks •

Os Trigonum Facts Os trigonum syndrome is result of an overuse injury caused • by repetitive plantar flexion stress. Predominantly seen in ballet dancers and soccer players. • Primarily a clinical diagnosis of exacerbated posterior ankle • pain while dancing on point or demi point or while doing push off maneuvers Symptoms may improve with rest or activity modification • Imaging studies include lateral radiographic view of the • ankle in maximal plantarflexion, will typically reveal the Os Trigonum Located in the posterior lip and calcaneous • If Os Trigonum is absent on radiography, a MRI may reveal • scar tissue behind the posterior talus

Differential Diagnosis Os Trigonum Syndrome often associated with • pathology of: FHL Tendonitis • Achilles tendinopathy • Retrocalcaneal bursitis • Tarsal coalition • Prominent posterior talar process • Soft tissue or bone impingement • Rear foot fracture •

Treatment Conservative vs Surgical Conservative Treatment: Non surgical means, including physical therapy • Ice compression and elevation • NSAIDS • Surgical Treatment: • Open Technique: medial or lateral approach • Endoscopic Technique

Patients and Methods 2016- Morelli et. al., published results of endoscopic excision of symptomatic Os Trigonum in professional ballet dancers Posterior Ankle Impingement Syndrome (PAIS) is a clinical • disorder characterized by chronic posterior ankle pain during plantarflexion From January 2010 to December 2015, 14 professional dancers • underwent excision of a symptomatic os trigonum for os trigonum syndrome using a posterior endoscopic technique. Of the 14 patients, 2 were excluded, because of the presence of • a combined osteochondral lesion of the talus.

Methodology • Inclusion Criteria: • Patients in the present study were: A professional level in dance • • The absence of any previous surgical procedures on the same or contralateral ankle • Unsatisfactory improvement after a rehabilitative protocol lasting 6 months.

All the patients had experienced posterior ankle pain for 6 • months that was unresolved by conservative treatment. On physical examination, the main signs were tenderness over • the posterolateral or posteromedial aspect of the ankle joint anteriorly of the Achilles tendon and pain at maximum plantarflexion of the ankle on the hyper-plantarflexion test passive forced. Plantarflexion movements of the ankle are performed with the • patient sitting with a 90 flexed knee.

Clinical and Radiologic Assessment The patients were evaluated pre- and postoperatively using the American • Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale score, Tegner activity scale and visual analog scale. All ankles were evaluated preoperatively using standard and forced • plantarflexion radiographs and magnetic resonance imaging.

Surgical Technique With the patient under general or regional anesthesia, the patient was placed • in a prone position. A tourniquet was placed proximal to the knee. • The ankle was located at the distal end of the operating table, with a padded • support under the distal tibia, allowing the ankle and foot to hang over the end of the table such that the ankle and hallux could be passively dorsiflexed during the procedure.

A 4.5-mm, 30 arthroscope was used with standard • posterolateral and posteromedial arthroscopic hindfoot portals on either side of the Achilles tendon at approximately the level of the fibula tip.

Fluoroscopy was used to localize the Os Trigonum.

After localization of the Os Trigonum laterally to the flexor hallucis longus tendon, it was debrided by tethering the soft tissue and then integrally removed. • A final inspection and dynamic visualization were completed to confirm that bony posterior impingement was no longer present. • Postoperative radiographs were completed for all the patients.

Postoperative Protocol • After surgery, a compressive bandage was applied, and patients were not allowed weight-bearing. • After 2 days, they were instructed to actively dorsiflex the ankle. • At 2 weeks postoperatively, they were allowed to walk with weight bearing and to increase their physical therapy exercises, swimming, and cycling. • At 4 weeks postoperatively, the patients were allowed to return to running, and at 6 weeks postoperatively, specific training for dance was allowed .

Results All the data for the clinical results are listed in Table 2. The mean • age of the patients at the final follow-up visit was 26.3 9.0 (range 15 to 47) years. The average postoperative follow-up duration was 38.9 20.6 (range 12 to 72) • months. The mean Tegner scale score increased from 4.3 0.8 (range 3 to 5) preoperatively to • 9 0.2 at the final follow-up visit (p < .05) The mean AOFAS scale score increased from 67.8 6.0 (range 58-76) preoperatively • to 96 5.1 (range 87 to 100) at the final follow-up visit, with 7 of 12 patients (58.3%) reporting the maximum score of 100 points (p < .05) At physical examination, no patient showed signs of local tenderness or swelling, • and the forced plantarflexion test findings were negative. No intraoperative complications were recorded. • Postoperatively, 1 patient (8.3%) developed local swelling for a period of 8 weeks. • No cases of superficial or deep infection or deep vein thrombosis were • detected. All the patients declared they would elect to undergo the • surgery again.

Discussion The most important finding of the present study was the excellent • functional and clinical outcomes at a mean follow-up period of 39 months after excision of a symptomatic Os Trigonum for PAIS using a posterior endoscopic technique. Although Burman and Lapidus in 1931 regarded the ankle joint as unsuitable • for arthroscopy because of its anatomy, the development of endoscopic techniques in the ankle has allowed for better outcomes and decreased the incidence of complications. Posterior hindfoot endoscopy was first introduced by van Dijk et al they • described 1 case of arthroscopic treatment of an Os Trigonum with an excellent result. Abramowitz et al reported similar clinical outcomes between • open and arthroscopic excision of a symptomatic Os Trigonum in a series of 41 cases. With open techniques, the time to full recovery averaged 5 (range 1 to 12) • months, and sural nerve palsy occurred in 8 cases. Jerosch described the results of arthroscopic resection of a • symptomatic Os Trigonum by way of 2 posterior portals in 10 cases. The average AOFAS ankle/hindfoot scale score increased from 43 • preoperatively to 87 postoperatively.

Conclusion • The major limitations of the present study were that it was retrospective, the small number of patients treated because of the strict selection criteria, and the absence of a case-control series. • In conclusion, the results of the present study have demonstrated that endoscopic excision of a symptomatic Os Trigonum using a 2- portal technique after failure of conservative treatment is characterized by excellent results with low morbidity. • These factors resulted in a quick return to a full preoperative level of activity, even for professional dancers who must train repetitively with the ankle in a forced plantarflexed position. • Posterior endoscopic excision of the Os Trigonum would be safe and effective in treating PAIS related to the Os Trigonum.

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