Endoscopic Treatment of Posterior Ankle Impingement Secondary to Os Trigonum in Recreational Athletes

Abstract

Background: The os trigonum (OT)—the most common accessory bone of the foot—although usually asymptomatic, may cause posterior ankle impingement syndrome (PAIS), which may be a severely debilitating problem for recreational or competitive athletes. The aim of the present study was to evaluate effectiveness of posterior ankle arthroscopy and to assess the outcome in the treatment of PAIS secondary to OT impingement or OT fractures within a group of young athletes and their return to previous sports level. Methods: From 2011 to 2018, a retrospective review of 81 recreational athletes of mean age 27.8 years was performed. All patients were diagnosed with PAIS due to OT pathology and were operated on endoscopically with resection of the OT. Pre- and postoperative clinical evaluation were performed at 3 months, 1 year, and 2 years based on visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the Foot & Ankle Disability Index (FADI) scores, in a follow-up of at least 2 years. Results: VAS score was significantly improved from an average of 7.5 (5-9) preoperatively to 1.9 (1-3) at 3 months postoperatively and to 0.6 (0-2) and 0.3 (0 -1) at 1 and 2 years postoperatively. Ankle ROM was significantly improved from an average of 24.8 (10-35) preoperatively to 58.0 (50-65) at 3 months postoperatively and to 64.0 (50-65) at 1 year and 64.7 (60-65) at 2 years postoperatively. AOFAS and FADI scores were significantly improved from 39.4 (18-55) and 49.7 (42.3-62.5) preoperatively to 85.2 (74-89) and 87.3 (81.7-88.5) postoperatively at 3 months to 97.7 (85-100) and 97.9 (93.3-100) postoperatively at 1 year, respectively ( P < .001). Only 5 patients dropped to a lower activity level. There were 5 complications (4 transient). Conclusion: Endoscopic treatment of PAIS due to OT pathology demonstrated excellent results. Posterior ankle arthroscopy was an effective treatment and allowed for a prompt return to a high activity level of their athletic performance. Level of Evidence: Level IV, therapeutic study / retrospective case series.

Hindfoot Pathologies

“…Softtissue impingement occurs when the tendons, ligaments, or muscles at the back of the ankle become inflamed or pinched, causing pain and discomfort. Bone impingement occurs when the bones of the ankle rub against each other or become stuck, causing pain and limited range of motion in the ankle [35,36].…”

“…It is important to seek medical treatment for posterior ankle impingement syndrome to prevent the condition from worsening and to maintain good function of the ankle. Early detection and management can help relieve the pain and avoid additional ankle damage [35][36][37].…”

Introductory Chapter: Foot and Ankle Disorders – Pathology and Surgery

“…Hindfoot pathologies can be caused by a variety of factors, including overuse, trauma, degeneration, and underlying medical conditions [9,10]. Some common hindfoot pathologies include tendinopathy of the posterior tibialis tendon or flexor hallucis longus, posterior ankle impingement syndrome (PAIS), calcaneus contusion, stress fractures of the calcaneus or talus, hindfoot rheumatoid arthritis, Paget's disease, osteomyelitis after posterior foot and ankle open fractures, and cancer metastases [9,10]. One of the most common problems of hindfoot pathology (mainly in athletes and ballet dancers) is the Posterior Ankle Impingement Syndrome (PAIS), which is usually caused by Os Trigonum (OT) or a hypertrophic posterior talar process Stieda.…”

“…Ankles' posterior arthroscopy (PA) has been improved considerably in the last 25 years and has become the gold standard procedure for different pathologies of the ankle and hindfoot, as a safe and reliable treatment option. Currently, the indications for ankles' posterior endoscopy have extended, including both intra-and extra-articular pathologies, and may involve: (1) bone (os trigonum (OT), loose bodies, posttraumatic ossifications, lateral or medial malleolus avulsion fragments, and Haglund's pathology); (2) cartilage (ankle and subtalar joint osteochondral defects, osteoarthritis, osteochondromatosis, and cystic lesions); or (3) soft tissues (tendinopathy of flexor hallucis longus, inflammation of retrocalcaneal bursa, posttraumatic synovitis, and soft-tissue impingement) [9,10].…”

Clinical and radiological results of posterior ankle endoscopy treatment for the flexor hallusis longus tenosynovitis and os trigonum syndrome

“…It is posterolateral to the talus, triangular or oval, usually single-parted, and approximately 1 cm in size. While it is often asymptomatic, symptoms may be seen in persistent posterior ankle pain and posterior impingement syndrome known as OTS [5,6].…”