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Anastasio AT, Baumann AN, Walley KC, Curtis DP, Johns WL, Amendola A. The Utilization of Minimally Invasive Surgery for Os Trigonum Syndrome: A Systematic Review. Am J Sports Med 2024; 52:2168-2177. [PMID: 38348483 DOI: 10.1177/03635465231198425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND A symptomatic os trigonum is a common cause of posterior ankle pain that has been traditionally managed with open excision. Minimally invasive surgery (MIS) has been proposed as an alternative to open excision for improved outcomes and decreased complication rates; however, no systematic review to date has examined the utilization of MIS for a symptomatic os trigonum. PURPOSE To examine patient outcomes, return to sport, and complications associated with MIS for a symptomatic os trigonum. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review was performed on February 22, 2023, using the PubMed, CINAHL, MEDLINE, and Web of Science databases from database inception until February 22, 2023, on the topic of MIS for a symptomatic os trigonum. RESULTS Of 885 articles retrieved from an initial search, 17 articles (N = 435 patients) met full inclusion criteria. The mean age of the cohort was 26.01 ± 4.68 years, with a mean follow-up time of 34.63 ± 18.20 months. For patients treated with MIS, the mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 55.85 ± 12.75, the mean final postoperative AOFAS score was 94.88 ± 4.04, the mean preoperative visual analog scale pain score was 7.20 ± 0.43, and the mean final postoperative visual analog scale score was 0.71 ± 0.48. The mean time to return to sport for patients undergoing MIS was 7.76 ± 1.42 weeks. MIS had an overall complication rate of 5.0%, the majority of which consisted of transient neurapraxia of the sural or superficial peroneal nerve. CONCLUSION Minimally invasive management of a symptomatic os trigonum appears to be a viable alternative to open surgery in terms of outcomes, return to sport, and complication rates. More high-quality evidence will be required to definitely recommend minimally invasive approaches as the standard of care over open surgery.
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Affiliation(s)
- Albert T Anastasio
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Anthony N Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Deven P Curtis
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
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Ulrich GL, Meyers AL, Marquart MJ. Os Trigonum Syndrome: A Cause of Posterior Ankle Pain. Orthopedics 2024; 47:e67-e72. [PMID: 38285552 DOI: 10.3928/01477447-20240122-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Os trigonum syndrome represents a cause of posterior ankle pain that is predominantly seen in athletes. The os trigonum ossicle forms from a secondary ossification center of the talus and is located at its posterior aspect in an interval between the posterior lip of the tibial plafond and calcaneus. The os trigonum ossicle is often an incidental finding and asymptomatic. However, repetitive plantarflexion and push-off maneuvers can cause symptoms and lead a patient to pursue orthopedic care. MATERIALS AND METHODS A review of the literature was conducted using the PubMed search engine with the following keywords: "os trigonum", "os trigonum ossicle", "os trigonum syndrome", "posterior ankle impingement", and "Stieda process". RESULTS The pertinent anatomy, clinical presentation, diagnostic evaluation, and treatment of os trigonum syndrome were reviewed in the literature and are extensively discussed in this article. CONCLUSION Os trigonum syndrome represents a potential cause of posterior ankle pain that needs thorough evaluation regarding history, physical examination, and imaging. Once diagnosed, treatment ranges from conservative to surgical interventions depending on surgeon preference and specific case presentation. [Orthopedics. 2024;47(2):e67-e72.].
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Anastasio AT, Kutzer K, Giambelluca L, Strasser NL, Amendola A. Posterior Ankle and Hindfoot Arthroscopy: A Contemporary Review. Foot Ankle Int 2024; 45:86-98. [PMID: 37905829 DOI: 10.1177/10711007231204882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Albert T Anastasio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham NC, USA
| | | | - Lacey Giambelluca
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham NC, USA
| | | | - Annunziato Amendola
- Virginia Flowers Baker Distinguished Professor of Orthopaedic Surgery
- Sports Medicine, Division Chief, Duke University Medical Center, Department of Orthopaedic Surgery, Durham, NC, USA
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Rui Xiang T, Zhen Ning Y, Oon Thien Kevin K. Two-Year Outcomes of Posterior Ankle Arthroscopy: A Case Series. Foot Ankle Spec 2022; 15:556-562. [PMID: 33435736 DOI: 10.1177/1938640020985822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to investigate the outcomes and complications after posterior ankle arthroscopy for the treatment of posterior ankle impingement syndrome, in a local population with a single surgeon series. Two-portal posterior ankle or hindfoot arthroscopy is an alternative option to open surgery in cases of posterior ankle impingement, that showed similar results but with less morbidity and faster recovery. There has been increasing interest in minimally invasive surgical techniques. Indications include extra- and intra-articular conditions and range from bony, cartilaginous to soft tissue pathology. Posterior ankle arthroscopy has been shown to be a good option in cases that are refractory to a period of conservative therapy. Posterior ankle arthroscopy also has known complications of sural nerve damage laterally and neurovascular bundle injury medially and also a steep learning curve that has been studied in the context of os trigonum excision. There have been few or no studies on the local Singaporean population and this article seeks to describe the various indications, results, and complications in the local Singaporean population by a single surgeon.Levels of Evidence: Level IV: Case series.
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Affiliation(s)
| | - Yeo Zhen Ning
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Zwiers R, Miedema T, Wiegerinck JI, Blankevoort L, van Dijk CN. Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement: A Meta-analysis. Am J Sports Med 2022; 50:563-575. [PMID: 34048272 DOI: 10.1177/03635465211004977] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical treatment of symptomatic posterior ankle impingement consists of resection of the bony impediment and/or debridement of soft tissue. Historically, open techniques were used to perform surgery with good results. However, since the introduction of endoscopic techniques, advantages attributed to these techniques are shorter recovery time, fewer complications, and less pain. PURPOSE The primary purpose was to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcome (American Orthopaedic Foot & Ankle Society [AOFAS] score). The secondary aim was to determine differences in return to full activity, patient satisfaction, and complications. STUDY DESIGN Systematic review and meta-analysis. METHODS MEDLINE, EMBASE (Classic), and CINAHL databases were searched. Publication characteristics, patient characteristics, surgical techniques, AOFAS scores, time to return to full activity, patient satisfaction, and complication rates were extracted. The AOFAS score was the primary outcome measure. Data were synthesized, and continuous outcome measures (postoperative AOFAS score and time to return to full activity) were pooled using a random-effects inverse variance method. Random-effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients who were satisfied and who experienced complications. RESULTS A total of 32 studies were included in this review. No statistically significant difference was found in postoperative AOFAS scores between open surgery (88.0; 95% CI, 82.1-94.4) and endoscopic surgery (94.4; 95% CI, 93.1-95.7). There was no difference in the proportion of patients who rated their satisfaction as good or excellent, 0.91 (95% CI, 0.86-0.96) versus 0.86 (95% CI, 0.79-0.94), respectively. No significant difference in time to return to activity was found, 10.8 weeks (95% CI, 7.4-15.9 weeks) versus 8.9 weeks (95% CI, 7.6-10.4 weeks), respectively. Pooled proportions of patients with postoperative complications were 0.15 (95% CI, 0.11-0.19) for open surgery versus 0.08 (95% CI, 0.05-0.14) for endoscopic surgery. Without the poor-quality studies, this difference was statistically significant for both total and minor complications, 0.24 (95% CI, 0.14-0.35) versus 0.02 (95% CI, 0.00-0.06) and 0.14 (95% CI, 0.09-0.20) versus 0.03 (95% CI, 0.01-0.05), respectively. CONCLUSION We found no statistically significant difference in postoperative AOFAS scores, patient satisfaction, and return to preinjury level of activity between open and endoscopic techniques. The proportion of patients who experienced a minor complication was significantly lower with endoscopic treatment when studies of poor methodological quality were excluded.
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Affiliation(s)
- Ruben Zwiers
- Department of Orthopaedic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands.,Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, the Netherlands.,Amsterdam Collaboration on Health & Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
| | - Thymen Miedema
- Department of Orthopaedic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Johannes I Wiegerinck
- Department of Orthopaedic Surgery, Bergman Clinics, Naarden, Amsterdam, the Netherlands
| | - Leendert Blankevoort
- Department of Orthopaedic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands.,Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, the Netherlands.,Amsterdam Collaboration on Health & Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
| | - C Niek van Dijk
- FIFA Medical Centre of Excellence Ripoll-dePrado-vanDijk SportClinic Madrid, Spain.,FIFA Medical Centre of Excellence Clinica do Dragao Porto, Portugal
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Arthroscopic Treatment of Posterior Ankle Impingement Syndrome: Mid-Term Clinical Results and a Learning Curve. Arthrosc Sports Med Rehabil 2021; 3:e1077-e1086. [PMID: 34430887 PMCID: PMC8365197 DOI: 10.1016/j.asmr.2021.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 03/30/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose To report mid-term clinical results of posterior ankle arthroscopy in the treatment of posterior ankle impingement syndrome (PAIS) and to assess the learning curve and its influence on the results. Methods This was a retrospective evaluation of the clinical outcomes of posterior ankle arthroscopy and its learning curve in a series of patients with PAIS. Demographic and clinical data, surgical time, the American Orthopaedic Foot Ankle Society (AOFAS) ankle/hindfoot scores, and time to resumption of sports were recorded. Results Fifty-nine patients with 72 posterior ankle arthroscopies were evaluated at a mean follow-up period of 60 months (24-133 months). Causes of PAIS were an os trigonum (50), a large posterior talar process (14), and soft-tissue impingement (8). There were 29 male and 30 female patients. The average age was 21.8 years (12-74 years). The average preoperative AOFAS score improved significantly from 79.6 to 97.6 postoperatively (P < .0001). The average time taken to resume training was 5.3 weeks, and the time to return to a competitive condition was 13.4 weeks. The times to resumption of training were shorter in elite athletes than local competitive athletes. The learning curve of the posterior ankle arthroscopy was detected and determined by a logarithmic trendline and moving averages. An experience of 26 cases was required to be proficient in posterior arthroscopies. The postoperative AOFAS scores were not statistically different between the initial and the latest 10 series each. Conclusions The mid-term follow-up results of endoscopic treatment for the PAIS were good, with a high success rate in returning to sports activities. Although a learning curve effect was detected in our series of arthroscopic treatment for the PAIS due to os trigonum, a low volume of experience did not affect the results. Level of Evidence Level IV, therapeutic case series.
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Abstract
Ankle impingement presents with painful and limited range of motion with dorsiflexion or plantar flexion, originating from pathological contact between bone and/or soft-tissue structures. Diagnosis is made primarily through clinical examination with adjunct radiographs and magnetic resonance imaging, with care taken to rule out a plethora of similarly presenting pathologies. Arthroscopic surgical approaches bring satisfactory short, mid, and long-term outcomes, with the current body of evidence dominated by Level-IV studies. Minimally invasive techniques offer improvements in time to return to play and complication rates relative to open approaches. Recent advances in the arthroscopic management of ankle impingement include long-term outcome studies, novel prognostic classification systems, and strategies for concomitant lesion management.
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Thompson JM, Langan TM, Hyer CF. Posterior Ankle Scope Approach to Symptomatic Os Trigonum Removal. Foot Ankle Spec 2021; 14:266-270. [PMID: 33435740 DOI: 10.1177/1938640020984304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Os trigonum can become symptomatic following acute or chronic repetitive compression of the posterior ankle. Following conservative treatment failure, removal is often warranted. Current surgical options include traditional open resection and endoscopic removal. The purpose of this article is to review a population of patients who underwent endoscopic excision of symptomatic accessory os trigonum through a posterior approach and evaluate the outcomes of the procedure. METHODS From May 2009 to September 2018, all patients who underwent excision of a symptomatic os trigonum were reviewed. Outcomes of interest were major and minor complications and time to return to full weight-bearing activities. Postoperative protocol included 5 to 7 days non-weight-bearing and 1 to 2 weeks of protected weight-bearing followed by full release to weight-bearing activities. RESULTS Twelve patients who met the inclusion criteria were studied. Mean follow-up was 10.2 (±7.4) months with no major complications and 1 minor wound complication. Average advancement to protected weight-bearing was 7.1 days. Average return to full weight-bearing activities without restriction was 24.4 days. CONCLUSION The current study describes the technique and results to minimally invasive os trigonum removal with favorable postoperative outcomes. Results demonstrated minimal complications and postoperative pain, also quick return to weight-bearing and full activity. LEVEL OF EVIDENCE Therapeutic, Level IV: Case series.
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Affiliation(s)
| | | | - Christopher F Hyer
- Grant Medical Center, Columbus, Ohio
- Orthopedic Foot and Ankle Center, Worthington, Ohio
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Abstract
This article offers an overview of os trigonum syndrome, complications, operative techniques, and the authors' preferred protocol. Os trigonum is an ossicle like many other ossicles in the foot and ankle. Individuals who require repetitive plantarflexion of the ankle for activity may develop symptoms of an enlarged os trigonum. Usually, symptoms will be isolated to the posteriolateral aspect of the ankle. Because of the normal anatomic route of the flexor hallucis longus tendon, its range of motion may also elicit pain to the posterolateral ankle. Conservative, as well as surgical including both endoscopic and open excision, has been described.
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Affiliation(s)
- Jeffrey E McAlister
- Phoenix Foot and Ankle Institute, 7301 East 2nd Street, Suite 206, Scottsdale, AZ 85251, USA.
| | - Usman Urooj
- Department of Surgery-Podiatry, Carl T. Hayden Medical Center, 650 East Indian School Road, Phoenix, AZ 85012, USA
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10
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Szaro P, Ghali Gataa K, Polaczek M. Ligaments of the os trigonum: an anatomical study. Surg Radiol Anat 2021; 43:1083-1090. [PMID: 33554290 PMCID: PMC8273053 DOI: 10.1007/s00276-021-02694-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/20/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of the study was to examine the ligaments of the os trigonum. METHODS The ankle joint magnetic resonance imaging (MRI) of 104 patients with the os trigonum (experimental group) and 104 patients without the os trigonum (control group) were re-reviewed. The connections of the os trigonum and posterior talofibular ligament (PTFL), the fibulotalocalcaneal ligament (FTCL), the paratenon of the Achilles tendon, the posterior talocalcaneal ligament (PTCL), the osteofibrous tunnel of the flexor hallucis longus (OF-FHL) and the flexor retinaculum (FR) were studied. RESULTS The os trigonum is connected to structures. The posterior part of the PTFL inserted on the os trigonum in 85.6% of patients, whereas in all patients in the control group, the posterior part of the PTFL inserted on the posterior talar process (p < 0.05). The connection of the PTCL was seen in 94.2% of patients in the experimental group, while it was seen in 90.4% of patients in the control group (p > 0.05). The connection to the FTCL in the experimental group was 89.4%, while in the control group, it was 91.3% (p > 0.05). The communication with the paratenon was seen more often in the control group compared to that in the experimental group (31.7% vs. 63.8%, p < 0.001). The FTCL was prolonged medially into the FR in 85.6% of patients in the experimental group and in 87.5% of patients in the control group (p > 0.05). The flexor hallucis longus (FHL) run at the level of articulation between the os trigonum 63.5% and the posterior process of the talus 25% and less often on the os trigonum 11.5%. CONCLUSION The os trigonum is connected with all posterior ankle structures and more connections than previously reported.
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Affiliation(s)
- Paweł Szaro
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Descriptive and Clinical Anatomy, Medical University of Warsaw, Warsaw, Poland. .,Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Gothenburg, Sweden.
| | - Khaldun Ghali Gataa
- Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Gothenburg, Sweden
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Nikolopoulos D, Safos G, Moustakas K, Sergides N, Safos P, Siderakis A, Kalpaxis D, Moutsios-Rentzos A. Endoscopic Treatment of Posterior Ankle Impingement Secondary to Os Trigonum in Recreational Athletes. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420945330. [PMID: 35097403 PMCID: PMC8697201 DOI: 10.1177/2473011420945330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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.
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Affiliation(s)
- Dimitrios Nikolopoulos
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - George Safos
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - Konstantinos Moustakas
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - Neoptolemos Sergides
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - Petros Safos
- Orthopaedic Research Institute for Education and Training, Athens, Greece
- Ikaria General Hospital, Orthopaedic, Ikaria, Greece
| | | | - Dimitrios Kalpaxis
- Orthopaedic Research Institute for Education and Training, Athens, Greece
- Physiotherapist; Rehabilitation Center of Central Clinic of Athens, Greece
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12
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Carreira DS, Garden SR, Ueland T. Operative Approaches to Ankle and Hindfoot Arthroscopy. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011419894968. [PMID: 35097358 PMCID: PMC8564949 DOI: 10.1177/2473011419894968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The role of arthroscopy in the management of ankle and hindfoot pathology management has increased greatly in recent years with the potential for lower complication rates, faster recovery, improved access, and improved outcomes when compared to open techniques. Procedural variations exist as techniques aim to optimize lesion access, decrease operative time, and improve patient safety. Our goal is to summarize the described approaches and patient positionings common in minimally invasive arthroscopic surgery for anterior, lateral, and posterior ankle pathologies. A survey of pathology organized by arthroscopic approach and a review of recent advances in concomitant lesion management may be useful when planning arthroscopic foot and ankle surgery. LEVEL OF EVIDENCE Level V, expert opinion.
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13
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Yammine K, Assi C. Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies. Surg Radiol Anat 2018; 40:489-497. [PMID: 29700593 DOI: 10.1007/s00276-018-2013-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 04/03/2018] [Indexed: 01/16/2023]
Abstract
Neurovascular and tendon structures are considered at risk when performing ankle arthroscopy. Injury rate and distance from portals to such structures varied in the literature. The aim of this meta-analysis is to evaluate the injury risk of these structures in terms of proximity and injury prevalence. Thirteen studies including 184 cadaveric ankle arthroscopy procedures met the inclusion criteria. The antero-central portal exhibited the highest frequencies of nerve/vessel proximity and nerve/vessel missed injuries. Weighted mean distances were as follows: 2.76 ± 2.37 mm for the superficial fibular nerve (SFN) to the antero-lateral portal, 8.13 ± 2.45 mm for the saphenous nerve to the antero-medial portal, 2.1 ± 1.7 mm for the dorsalis pedis artery (DPA) to the antero-central (AC) portal, 6.84 ± 2.59 mm for the sural nerve to the postero-lateral portal. Distances to the postero-medial portal were 7.82 ± 2.98 and 11.03 ± 3.2 mm for the posterior tibial nerve and the posterior tibial artery, respectively. A total of 14 (10.3%) nerve injuries and 17 (12.5%) missed nerve injuries with a cumulative frequency of 22.8% of nerve structure at high risk. The SFN was the most vulnerable (10.3% of injury/missed injury), and it was the closest nerve to a portal. Vascular involvement consisted of 2 (1.5%) injuries and 12 (8.8%) missed injuries with the DPA being the most vulnerable (20%) through the AC portal. Tendon injuries were found in 8.7% procedure acts. The injury rates of extra-articular structures were found to be higher than previously reported in clinical literature. Apart from clinical studies, distance to portals and missed injuries of these structures could be evaluated. This cadaveric meta-analysis yielded more accurate results over the proximity and potential injury risk of ankle noble structure and should incite surgeons for more attention during portal placement. Such anatomical meta-analyses could offer an excellent statistical model of evidence synthesis when assessing injury risk in mini-invasive surgeries.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedics, Lebanese American University-Rizk Hospital, Achrafieh, P. O. Box: 11-3288, Beirut, Lebanon. .,Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.
| | - Chahine Assi
- Department of Orthopedics, Lebanese American University-Rizk Hospital, Achrafieh, P. O. Box: 11-3288, Beirut, Lebanon
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Ankle MRI and Arthroscopy Correlation With Cartilaginous Defects and Symptomatic Os Trigonum. Sports Med Arthrosc Rev 2017; 25:237-245. [DOI: 10.1097/jsa.0000000000000169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Painful stress reaction in the posterior subtalar joint after resection of os trigonum or posterior talar process. INTERNATIONAL ORTHOPAEDICS 2017; 41:1585-1592. [DOI: 10.1007/s00264-017-3489-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 04/18/2017] [Indexed: 12/18/2022]
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Morelli F, Mazza D, Serlorenzi P, Guidi M, Camerucci E, Calderaro C, Iorio R, Guzzini M, Ferretti A. Endoscopic Excision of Symptomatic Os Trigonum in Professional Dancers. J Foot Ankle Surg 2017; 56:22-25. [PMID: 27989340 DOI: 10.1053/j.jfas.2016.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Indexed: 02/03/2023]
Abstract
The present study reports the clinical results of excision of a symptomatic os trigonum using an endoscopic procedure in professional ballet dancers. The hypothesis was that posterior endoscopic excision of the os trigonum would be safe and effective in treating posterior ankle impingement syndrome related to the os trigonum. Twelve professional dancers underwent excision of a symptomatic os trigonum for PAIS using a posterior endoscopic technique after failure of conservative treatment. The patients were evaluated pre- and postoperatively according to the American Orthopaedic Foot and Ankle Society hindfoot scale score, the Tegner activity scale score, and the visual analog scale score. The surgical time, timing of a return to sports, patient satisfaction, and any complications related to the procedure were recorded. The average postoperative follow-up duration was 38.9 ± 20.6 (range 12 to 72) months. The mean Tegner activity scale score increased from 4.3 ± 0.8 (range 3 to 5) preoperatively to 9 ± 0.2 postoperatively (p < .05). The mean American Orthopaedic Foot and Ankle Society scale score increased from 67.8 ± 6.0 (range 58 to 76) preoperatively to 96 ± 5.1 (range 87 to 100) postoperatively, with 7 of 12 patients (58.3%) reporting the maximum score of 100 points (p < .05). The return to sports was 8.7 ± 0.7 (range 8 to 10) weeks. No major complications were recorded. The results of the present study demonstrate that the endoscopic excision of symptomatic os trigonum using a 2-portal technique after failure of conservative treatment is characterized by excellent results with low morbidity.
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Affiliation(s)
- Federico Morelli
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Daniele Mazza
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Pierluigi Serlorenzi
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Marco Guidi
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Emanuela Camerucci
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Cosma Calderaro
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Raffaele Iorio
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Matteo Guzzini
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Andrea Ferretti
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Kudaş S, Dönmez G, Işık Ç, Çelebi M, Çay N, Bozkurt M. Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:649-654. [PMID: 27919560 PMCID: PMC6197591 DOI: 10.1016/j.aott.2016.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/27/2016] [Accepted: 03/12/2016] [Indexed: 12/12/2022]
Abstract
Objective To describe a clinical treatment algorithm for posterior ankle impingement (PAI) syndrome in professional football players. Material and methods A case series of 26 elite professional football players diagnosed and treated for posterior ankle impingement syndrome were included for the study. All of the athletes received conservative treatment with physical therapy modalities initially. If the first line medical treatment and rehabilitation was ineffective to alleviate the symptoms, ultrasound-guided corticosteroid injection was proposed and thereafter the patients underwent posterior ankle arthroscopy if the complaints are still unresolved. The pain scores (AOFAS, VAS), and time to return to play were the main outcome measures. Results The complaints of 18 (69.2%) players were subsided with non-surgical treatment whereas three of acute cases and five of the chronic cases did not respond to medical treatment and arthroscopic surgery was performed for eight athletes. Eighteen players returned to training for a mean time of 36.3 days (24–42 days) after conservative treatment. The patients who underwent arthroscopic surgery returned to training for a mean time of 49.8 days (42–56 days) after the surgery. All athletes returned to their previous level of competition after treatment without any complications or recurrence in a mean follow-up 36.5 months (19–77 months). Conclusion Non-surgical treatment modalities were effective in 2/3 of posterior ankle impingement syndrome in elite football players. On the other hand, posterior ankle arthroscopy is safe and effective treatment option for posterior ankle impingement syndrome if the conservative treatment fails. Level of evidence Level IV, Therapeutic study
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Yasui Y, Hannon CP, Hurley E, Kennedy JG. Posterior ankle impingement syndrome: A systematic four-stage approach. World J Orthop 2016; 7:657-663. [PMID: 27795947 PMCID: PMC5065672 DOI: 10.5312/wjo.v7.i10.657] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/15/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Posterior ankle impingement syndrome (PAIS) is a common injury in athletes engaging in repetitive plantarflexion, particularly ballet dancers and soccer players. Despite the increase in popularity of the posterior two-portal hindfoot approach, concerns with the technique remain, including; the technical difficulty, relatively steep learning curve, and difficulty performing simultaneous anterior ankle arthroscopy. The purpose of the current literature review is to provide comprehensive knowledge about PAIS, and to describe a systematic four-stage approach of the posterior two-portal arthroscopy. The etiology, clinical presentation, diagnostic strategies are first introduced followed by options in conservative and surgical management. A detailed systematic approach to posterior hindfoot arthroscopy is then described. This technique allows for systematic review of the anatomic structures and treatment of the bony and/or soft tissue lesions in four regions of interest in the hindfoot (superolateral, superomedial, inferomedial, and inferolateral). The review then discusses biological adjuncts and postoperative rehabilitation and ends with a discussion on the most recent clinical outcomes after posterior hindfoot arthroscopy for PAIS. Although clinical evidence suggests high success rates following posterior hindfoot arthroscopy in the short- and mid-term it may be limited in the pathology that can be addressed due to the technical skills required, but the systematic four-stage approach of the posterior two-portal arthroscopy may improve upon this problem.
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Ferkel RD. Editorial Commentary: Ankle Arthroscopy: Correct Portals and Distraction Are the Keys to Success. Arthroscopy 2016; 32:1375-6. [PMID: 27373182 DOI: 10.1016/j.arthro.2016.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 05/12/2016] [Indexed: 02/02/2023]
Abstract
Access to all areas of the ankle during arthroscopy is always problematic. The use of the correct portals and distraction increases access in both the supine and prone positions. Noninvasive distraction up to 30 pounds is safe and effective to perform arthroscopy in the supine position, and avoids the potential complications of pin distraction.
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Song B, Li C, Chen Z, Yang R, Hou J, Tan W, Li W. Combined Anterior and Dual Posterolateral Approaches for Ankle Arthroscopy for Posterior and Anterior Ankle Impingement Syndrome. Foot Ankle Int 2016; 37:605-10. [PMID: 26892889 DOI: 10.1177/1071100716632042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We introduce a novel method of combining the standard anteromedial and anterolateral approaches and dual posterolateral approaches in the arthroscopic treatment of posterior and anterior ankle impingement syndrome and compare the postoperative outcomes with conventional anteromedial/anterolateral and posteromedial/posterolateral approaches. METHODS From January 2013 to January 2015, we treated 28 patients with posterior and anterior ankle impingement syndrome by arthroscopy. The patients were divided into the conventional group (n = 13) and the modified group (n = 15) according to the surgical approaches used in the operation. Preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score, range of ankle motion, and operation time were recorded. The average follow-up was 16 months (range 6-24 months). RESULTS Posterior and anterior ankle impingement syndrome was confirmed arthroscopically in all patients. After the operation, the range of ankle motion in all patients was restored. There was no significant difference in postoperative AOFAS score, VAS score, dorsiflexion, and plantarflexion between the conventional group and the modified group. Moreover, the operation time was significantly reduced in the modified group compared with the conventional group. There was no recurrence of osteophyte and no complications such as infection, neurovascular injury, or delayed healing of surgical incision in the modified group. CONCLUSIONS Dual posterolateral approaches combined with standard anteromedial and anterolateral approaches was a novel method for arthroscopic treatment of posterior and anterior ankle impingement syndrome. It proved to be safe and effective, and significantly reduced the operation time. Reposition, repeated prep and drape, and limb distraction were avoided. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Bin Song
- Department of Sports Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Changchuan Li
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Zhong Chen
- Department of Sports Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Rui Yang
- Department of Sports Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Jingyi Hou
- Department of Sports Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Weiquan Tan
- Department of Sports Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
| | - Weiping Li
- Department of Sports Medicine, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, China
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Evidence-based indications for hindfoot endoscopy. Knee Surg Sports Traumatol Arthrosc 2016; 24:1386-95. [PMID: 26744282 DOI: 10.1007/s00167-015-3965-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/23/2015] [Indexed: 01/25/2023]
Abstract
PURPOSE The 2-portal hindfoot endoscopic technique with the patient in prone position, first introduced by van Dijk et al. (Arthroscopy 16:871-876, 2000), is currently the most used by foot and ankle surgeons to address endoscopically pathologies located in the hindfoot. This article aims to review the literature to provide a comprehensive description of the level of evidence available to support the use of the 2-portal hindfoot endoscopy technique for the current generally accepted indications. METHODS A comprehensive review was performed by use of the PubMed database to isolate literature that described therapeutic studies investigating the results of different hindfoot endoscopy treatment techniques. All articles were reviewed and assigned a classification (I-V) of level of evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for hindfoot endoscopy. A subscale was used to further describe the evidence base for indications receiving a grade of recommendation indicating poor-quality evidence. RESULTS On the basis on the available evidence, posterior ankle impingement syndrome, subtalar arthritis and retrocalcaneal bursitis have the strongest recommendation in favour of treatment (grade Cf). CONCLUSION Although a low level of evidence of the included studies, the review showed that adequate literature to support the use of the 2-portal endoscopic techniques for most currently accepted indications exists. Future "higher quality" evidence could strengthen current recommendations and further help surgeons in evidence-based practice. LEVEL OF EVIDENCE Level V, Review of Level III, IV and V studies.
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Endoscopic treatment of the posterior ankle impingement syndrome on amateur and professional athletes. Knee Surg Sports Traumatol Arthrosc 2016; 24:1396-401. [PMID: 26264381 DOI: 10.1007/s00167-015-3747-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/30/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine whether professional and amateur athletes showed differences in ankle function when treated with endoscopic technique for posterior ankle impingement syndrome, to verify the impact of the presence of associated lesions in clinical evolution and to assess time to return to sport (we hypothesize that time will be the only difference between groups). METHODS Thirty-two athletes with a diagnosis of posterior impingement syndrome underwent surgery endoscopically. The American Orthopaedics Foot and Ankle Society (AOFAS) scale was used to compare functional results between amateur (15) and professional athletes (17). The satisfaction, time to return to sport, operative time, intraoperative findings and complications were evaluated, and the presence of associated injuries interfering in these results was verified. RESULTS The preoperative AOFAS score range for the professional group was 62.9 ± 14 preoperatively and 92.3 ± 7.7 postoperatively, and for the amateur group was 67.9 ± 19.7 and 94 ± 9.3. The satisfaction was excellent or good in 94 % of all cases and fair in 6%. The average time of surgery was 48.3 + 25 min. Bone involvement was present in 100% of cases and complications in three cases. Time to return to sports was similar (n.s.) in both groups, and the mean time was 15.6 ± 13.7 and 16.3 ± 9 weeks, respectively. CONCLUSION No significant difference regarding functional results and time to return to sports between professionals and amateur athletes operated was found. Athletes showed mainly good and excellent results and low complication rate. The presence of associated injuries did not significantly influence the results. With these results, the high-level athlete can better programme their surgeries so they can fully recover and perform better in the most important competitions. LEVEL OF EVIDENCE Level III.
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Arthroscopic Excision of a Symptomatic Os Trigonum. Arthroscopy 2015; 31:2082-8. [PMID: 26076662 DOI: 10.1016/j.arthro.2015.04.086] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the clinical outcomes of arthroscopic excision for a symptomatic os trigonum initially viewing through the posteromedial ankle portal with the motorized instrument in the posterolateral portal. METHODS A retrospective review of a consecutive series of patients with symptomatic os trigonum failing nonoperative management and treated with arthroscopic excision was performed. Demographic data, clinical data, American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scores, and Single Assessment Numeric Evaluation scores were obtained. Any complications and the time required to return to sports or full activities were recorded. RESULTS Twenty-four patients with an arthroscopic excision of a symptomatic os trigonum were included. There were 13 male and 11 female patients. The average age was 36.7 ± 17 years. Twenty-one isolated os trigonum excisions and 3 excisions combined with other procedures were studied. At a mean follow-up of 26 months (range, 24 to 31 months), average preoperative AOFAS scores significantly improved from 55.3 to 92.3 postoperatively (P < .0001). The preoperative AOFAS function component improved from 17.1 to 33.8 (P < .0001). The mean postoperative Single Assessment Numeric Evaluation score was 90. Patients reported full activity at an average of 1.5 months with no limitations at an average of 7.8 months after surgery. The only complication was a posterior tibial nerve calcaneal branch neurapraxia. CONCLUSIONS Arthroscopic excision in the prone position without traction of a symptomatic os trigonum viewing initially through the posteromedial portal with a high-speed burr in the posterolateral portal resulted in significantly improved AOFAS scores with a single transient neurapraxia in 24 patients. Patients returned to their normal daily activities without limitations at an average of 1.5 months. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Rungprai C, Tennant JN, Phisitkul P. Disorders of the Flexor Hallucis Longus and Os Trigonum. Clin Sports Med 2015; 34:741-59. [PMID: 26409593 DOI: 10.1016/j.csm.2015.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Os trigonum syndrome with disease of the flexor hallucis longus tendon, so-called stenosing flexor tenosynovitis, is a common cause of posterior ankle impingement. Conservative treatment is the recommended first line of treatment, with secondary treatment options of either open or arthroscopic os trigonum excision with flexor hallucis longus retinaculum release. The arthroscopic approaches have gained popularity in the past decade because of less scarring, less postoperative pain, minimal overall morbidity, and earlier return to activities. However, comprehensive understanding of the anatomy of the posterior ankle is crucial to warrant successful outcomes and minimizing complications.
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Affiliation(s)
- Chamnanni Rungprai
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Ratchawithi Road, Bangkok 10400, Thailand
| | - Joshua N Tennant
- Department of Orthopaedics, University of North Carolina School of Medicine, 3147 Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC 27514, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Ribbans WJ, Ribbans HA, Cruickshank JA, Wood EV. The management of posterior ankle impingement syndrome in sport: a review. Foot Ankle Surg 2015; 21:1-10. [PMID: 25682399 DOI: 10.1016/j.fas.2014.08.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 06/29/2014] [Accepted: 08/11/2014] [Indexed: 02/04/2023]
Abstract
A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Forty-seven papers have reported on the surgical outcomes of 905 procedures involving both open and artho-endoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers.
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Affiliation(s)
- William J Ribbans
- University of Northampton, Boughton Green Road, Northampton, NN2 7AL, United Kingdom.
| | - Hannah A Ribbans
- Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
| | - James A Cruickshank
- Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
| | - Edward V Wood
- Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
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López Valerio V, Seijas R, Alvarez P, Ares O, Steinbacher G, Sallent A, Cugat R. Endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players. Foot Ankle Int 2015; 36:70-4. [PMID: 25249322 DOI: 10.1177/1071100714552078] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND An os trigonum may cause posterior ankle impingement syndrome (PAIS), which may lead to poor sports performance, especially in soccer players. The aim of the present study was to analyze the outcomes of endoscopic repaired posterior ankle impingement (PAI) secondary to os trigonum syndrome within a group of soccer players as well as their return to play time. METHODS A retrospective review of 20 soccer players with Tegner activity level 9 was performed. All players were diagnosed of PAIS due to os trigonum. Chief complaint was pain produced with forced plantarflexion when kicking the ball. Conservative treatment was first performed during a 6-week rehabilitation program. When conservative treatment failed, arthroscopic surgical resection of the os trigonum was proposed. Visual analogue scale (VAS) was used to measure pain before and after surgery as well as time until their return to previous sports level. RESULTS VAS showed a mean preoperative pain score of 7.5 (SD = 0.9), whereas postoperative VAS at 1 month after surgery decreased to 0.8 (SD = 1.36). Mean symptomatic period was 8.5 months (SD = 4.3), from the beginning of symptoms up to the surgery day. Once patients had undergone surgery, mean time until their return to previous level of sports was 46.9 days (SD = 25.96), reaching the same pre-lesion Tegner level. CONCLUSIONS Endoscopic treatment of posterior ankle impingement syndrome due to os trigonum showed excellent results. Hindfoot endoscopy with a posterior approach was an effective treatment and allowed for a prompt return to play in soccer players with a high activity level. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
| | - Roberto Seijas
- Orthopedic Surgery, Fundación García Cugat Hospital Quirón Barcelona, Spain Professor Basic Science Department, Universitat Internacional Catalunya, Spain
| | - Pedro Alvarez
- Orthopedic Surgery, Fundación García Cugat Hospital Quirón Barcelona, Spain Professor Medicine Department, Universitat Internacional Catalunya, Spain
| | - Oscar Ares
- Orthopedic Surgery, Fundación García Cugat Hospital Quirón Barcelona, Spain Professor Basic Science Department, Universitat Internacional Catalunya, Spain Professor Medicine Department, Universitat Internacional Catalunya, Spain Orthopedic Department, Hospital Clínic Barcelona, Spain
| | | | - Andrea Sallent
- Orthopedic Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Ramón Cugat
- Orthopedic Surgery, Fundación García Cugat Hospital Quirón Barcelona, Spain
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Abstract
There are multiple causes of pediatric foot and ankle pain. Although conservative measures are appropriate for initial management, patients with refractory pain should be given consideration for further intervention. This review highlights some of the most common causes of foot and ankle pain in the child, with specific attention to demographics, etiologies, diagnostic workup, and treatment options.
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Affiliation(s)
- Amiethab Aiyer
- Department of Orthopaedic Surgery, Penn State College of Medicine, 30 Hope Drive, Hershey, PA 17033, USA
| | - William Hennrikus
- Department of Orthopaedic Surgery, Penn State College of Medicine, 30 Hope Drive, Hershey, PA 17033, USA.
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The posterior impingement view: an alternative conventional projection to detect bony posterior ankle impingement. Arthroscopy 2014; 30:1311-6. [PMID: 25023737 DOI: 10.1016/j.arthro.2014.05.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 04/15/2014] [Accepted: 05/16/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of the current study was to clinically evaluate the diagnostic value of the new posterior impingement (PIM) view in the detection of an os trigonum, compared with the standard lateral view, using computed tomography (CT) as a reference standard. METHODS Three observers, 2 experienced (orthopaedic surgeon and radiologist) and one inexperienced (resident), independently scored 142 radiographic images for the presence of an os trigonum. The diagnostic performance was assessed using the computed tomographic scan as the reference standard. Accuracy, sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) were calculated. RESULTS The PIM view had significantly superior accuracy compared with the lateral view for each observer: orthopaedic surgeon, PIM view = 90 versus lateral view = 75 (P = .013); radiologist, PIM view = 80 versus lateral view = 64 (P = .019); resident, PIM view = 90 versus lateral view = 79 (P = .039). The mean sensitivity and specificity of the lateral view for all observers was 50% and 81%, respectively. For the PIM view, this was 78% and 89%, respectively. The PPV was 50% for the lateral view and 70% for the PIM view. The NPV was 84% for the lateral view and 93% for the PIM view. CONCLUSIONS The PIM view has significantly superior diagnostic accuracy compared with the conventional lateral view in the detection of an os trigonum. In cases of symptomatic posterior ankle impingement, we advise that a PIM view be used instead of or in addition to the standard lateral view for detection of posterior talar pathologic conditions. LEVEL OF EVIDENCE Level II, development of diagnostic criteria on basis of consecutive patients with universally applied reference gold standard.
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Hindfoot endoscopy for the treatment of posterior ankle impingement syndrome: a safe and reproducible technique. Foot Ankle Surg 2014; 20:174-9. [PMID: 25103704 DOI: 10.1016/j.fas.2014.03.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 02/03/2014] [Accepted: 03/13/2014] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Posterior ankle impingement is a clinical syndrome characterized by posterior ankle pain that is mainly presented on plantar flexion. The aim of this study is to compare and evaluate the results of posterior ankle impingement treated by endoscopic hindfoot posterior portals. MATERIALS AND METHODS Between 2004 and 2009, a total of 38 endoscopic hindfoot procedures were performed to treat posterior ankle impingement. The indication for procedure was posterior ankle impingement syndrome in all cases. There were 38 patients, 17 females and 21 males. Mean age was 27.6 years (16-59 years). Mean follow-up was 27.6 months (12.5-52 months). The results were evaluated following the AOFAS score. Data statistical analysis was performed using the Student's t-test. RESULTS The main preoperative AOFAS score increased from 67.42 (range 41-91) to 97.13 (range 84-100) at follow-up. No complications were reported in any case. CONCLUSION Hindfoot endoscopy is a reproducible and safe procedure which offers excellent outcomes in posterior ankle impingement syndrome.
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Rückfußarthroskopie als Revisionseingriff. ARTHROSKOPIE 2014. [DOI: 10.1007/s00142-013-0787-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, Kennedy JG. Posterior hindfoot arthroscopy: a review. Am J Sports Med 2014; 42:225-34. [PMID: 23868522 DOI: 10.1177/0363546513491213] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In recent years, minimally invasive surgery has developed and progressed the standard of care in orthopaedics and sports medicine. In particular, the use of posterior hindfoot arthroscopy in the treatment of posterior ankle and hindfoot injury is increasing rapidly as a means of reducing pain, infection rates, and blood loss postoperatively compared with traditional open procedures. In athletes, hindfoot arthroscopy has been used effectively in expediting rehabilitation and ultimately in minimizing the time lost from competition at previous levels. Van Dijk et al were the first to describe the original 2-portal technique, which remains the most commonly used by surgeons today and forms the basis for this review. The current evidence in the literature supports the use of 2-portal hindfoot arthroscopy as a safe, primary treatment strategy for symptoms of posterior ankle impingement, including resection of os trigonum, treatment of flexor hallucis longus and peroneal tendon injury, treatment of osteochondral lesions of the ankle, and the resection of subtalar coalitions. In this review, we present where possible an evidence-based literature review on the arthroscopic treatment of posterior ankle and hindfoot abnormalities. Causes, diagnosis, surgical technique, outcomes, and complications are each discussed in turn.
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Affiliation(s)
- Niall A Smyth
- Niall A. Smyth, Hospital for Special Surgery, 523 East 72nd Street, Ste 507, New York, NY 10021.
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The incidence of complications after posterior hindfoot endoscopy. Arthroscopy 2013; 29:2049-54. [PMID: 24286803 DOI: 10.1016/j.arthro.2013.08.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review was to determine the incidence of complications after posterior hindfoot endoscopy. METHODS Ovid/Medline and Google Scholar were systematically searched for pertinent references to be included. In addition, we hand-searched common American and European orthopaedic and podiatric surgical journals for relevant articles. Articles considered for inclusion were published in peer-reviewed journals, described complications after posterior hindfoot endoscopy using a standard 2-portal technique, and involved 25 or more patients treated. RESULTS We identified 335 potentially relevant publications, of which 5 met our inclusion criteria. A total of 452 ankles (452 patients) were included in this study. Overall, 17 complications (3.8%) occurred, with only 8 (1.8%) requiring additional treatment or operative intervention. CONCLUSIONS The endoscopic approach for the treatment of hindfoot and ankle pathology is safe with a low incidence of complications. However, additional studies with prospective designs should be undertaken to determine the long-term patient outcomes using validated scoring systems. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
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Surgical treatment for posterior ankle impingement. Arthroscopy 2013; 29:1263-70. [PMID: 23541613 DOI: 10.1016/j.arthro.2013.01.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 01/24/2013] [Accepted: 01/25/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aims to provide an overview of both the open and endoscopic procedures used to treat posterior ankle impingement, as well as an analysis, evaluation, and comparison of their outcomes. METHODS A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases and the Cochrane Database of Clinical and Randomized Controlled Trials was performed. Quality of included studies was assessed by use of the Downs and Black scale. RESULTS After we reviewed 783 studies, 16 trials met the inclusion criteria. Of these trials, 6 reported on open surgical techniques and 10 evaluated endoscopic techniques. The complication rate (15.9% v 7.2%) and time to return to full activity (16.0 weeks v 11.3 weeks) differed between the 2 groups, both favoring endoscopic surgery. CONCLUSIONS Although the level of evidence of the included studies is relatively low, it can be concluded that the endoscopic technique is superior to the open procedure. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.
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Ahn JH, Kim YC, Kim HY. Arthroscopic versus posterior endoscopic excision of a symptomatic os trigonum: a retrospective cohort study. Am J Sports Med 2013; 41:1082-9. [PMID: 23514703 DOI: 10.1177/0363546513480614] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both subtalar arthroscopic and posterior endoscopic techniques are used to treat posterior ankle impingement syndrome (PAIS). However, there have been no studies comparing the 2 procedures. HYPOTHESIS Both arthroscopic and endoscopic excisions of the os trigonum are safe and effective in treating PAIS. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Twenty-eight patients were treated with excision of the os trigonum either by an arthroscopic (16 patients) or endoscopic (12 patients) technique. The mean patient age was 29.8 years (range, 17-55 years), and the mean follow-up period was 30 months (range, 18-58 months). Preoperative and postoperative visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Maryland Foot Score (MFS) were used to analyze the functional results. Duration of surgery, time to return to sports (RTS), and patient satisfaction were evaluated as well. The size of the os trigonum was measured using T1-weighted sagittal magnetic resonance imaging (MRI). The clinical and MRI results were compared between the 2 groups. RESULTS The VAS score, AOFAS score, and MFS for both the arthroscopic group (preoperative: 6.3, 63.8, and 61.5, respectively; postoperative: 1.2, 89.9, and 89.6, respectively) and endoscopic group (preoperative: 6.7, 64.8, and 62.5, respectively; postoperative: 1.2, 89.9, and 88.4, respectively) improved significantly (P < .01). The mean surgery and RTS times were 39.4 minutes and 7.5 weeks in the arthroscopic group and 34.8 minutes and 8.0 weeks in the endoscopic group, respectively (P > .05). All patients were satisfied with the results. There were no significant differences between the 2 groups in the preoperative and postoperative VAS score, AOFAS score, or MFS (P > .05). The mean size of the os trigonum was 11.1 × 8.8 mm(2) in the arthroscopic group and 12.6 × 10.4 mm(2) in the endoscopic group, and the difference was significant (P < .05). Two patients underwent both arthroscopic and endoscopic procedures because of technical difficulty in removing the large os trigonum arthroscopically. CONCLUSION Both arthroscopic and posterior endoscopic excisions of the os trigonum were safe and effective in treating PAIS. The arthroscopic procedure was more demanding, especially in cases of a large os trigonum. The posterior endoscopic approach had the advantage of addressing problems in the posterior ankle joint and allowed a more extensive release of the flexor hallucis longus.
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Affiliation(s)
- Jae Hoon Ahn
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul, 137-040, Korea.
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Yoshimura I, Naito M, Kanazawa K, Ida T, Muraoka K, Hagio T. Assessing the safe direction of instruments during posterior ankle arthroscopy using an MRI model. Foot Ankle Int 2013; 34:434-8. [PMID: 23520302 DOI: 10.1177/1071100712468563] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The safety of posterior ankle arthroscopy is still the subject of debate. The purpose of this study was to evaluate the anatomical relationship between the posterior portals and the neurovascular structures using magnetic resonance imaging (MRI) to determine the safety of posterior portals in posterior ankle arthroscopy. METHODS Forty ankles from 38 patients who had undergone MRI scanning for ankle disorders were assessed (18 males, 20 females). For each ankle, the angles of the presumed position of the portals to the posterior neurovascular structures and the malleoli were measured on 4-mm proximal slices from the anterior tip of the fibula. The shortest distance from the sural nerve and the tibialis posterior neurovascular bundle to the position of the posterior portals was measured. RESULTS The average distance between the posteromedial portal and the tibialis posterior neurovascular bundle was 18 ± 3 mm, whereas the average distance between the posterolateral portal and the sural nerve was 15 ± 3 mm. In 100% of ankles, there were no neurovascular structures lying within the region between the anterior tip of fibula and the posteromedial portal or between the posterior tip of fibula and the posteromedial portal. In 32 ankles (80%), the medial neurovascular structures were present on the medial side of the line running between the anterior tip of medial malleolus and the posteromedial portal. CONCLUSION The posterior neurovascular structures were not in immediate proximity to where we estimated the posteromedial and posterolateral portals to be located. CLINICAL RELEVANCE The findings of the present MRI-based study suggest that arthroscopic instruments oriented toward the fibula may be safely introduced into the posterior ankle without injuring the neurovascular structures.
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Affiliation(s)
- Ichiro Yoshimura
- Department of Orthopaedic Surgery, Fukuoka University, Fukuoka, Japan.
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Heck J, Mendicino RW, Stasko P, Shadrick D, Catanzariti AR. An anatomic safe zone for posterior ankle arthroscopy: a cadaver study. J Foot Ankle Surg 2012; 51:753-6. [PMID: 22999969 DOI: 10.1053/j.jfas.2012.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Indexed: 02/03/2023]
Abstract
Posterior ankle arthroscopy has traditionally been associated with concern for injury to the posterior tibial nerve and vessels, and this concern is greatest when the patient is positioned supine. Positioning the patient prone could be a safer method for posterior ankle arthroscopy. The purpose of this cadaver study was to determine the anatomic safe zone devoid of vital structures relative to the posteromedial and posterolateral arthroscopic portals created. In addition, exposure of the posterior ankle was evaluated by direct visualization and fluoroscopy to determine the relative utility of these portals. Based on our findings, which are consistent with other previously reported results, we believe that a wide range of ankle pathology can be suited to treatment by means of posterior arthroscopy with the patient in the prone position.
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Affiliation(s)
- Jacob Heck
- Division of Foot and Ankle Surgery, The Western Pennsylvania Hospital, Pittsburgh, PA, USA
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Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul P, Femino JE, Amendola A. Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Joint Surg Am 2012; 94:439-46. [PMID: 22398738 DOI: 10.2106/jbjs.k.00069] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Posterior ankle and hindfoot arthroscopy, performed with use of posteromedial and posterolateral portals with the patient in the prone position, has been utilized for the treatment of various disorders. However, there is limited literature addressing the postoperative complications of this procedure. In this study, the postoperative complications in patients treated with posterior ankle and hindfoot arthroscopy were analyzed to determine the type, rate, and severity of complications. METHODS The study included 189 ankles in 186 patients (eighty-two male and 104 female; mean age, 37.1 ± 16.4 years). The minimum duration of follow-up was six months, and the mean was 17 ± 13 months. The most common preoperative intra-articular diagnoses were subtalar osteoarthritis (forty-six ankles), an osteochondral lesion of the talus (forty-two), posterior ankle impingement (thirty-four), ankle osteoarthritis (twenty), and subtalar coalition (five). The most common extra-articular diagnoses were painful os trigonum (forty-six), flexor hallucis longus tendinitis (thirty-two), and insertional Achilles tendinitis (five). RESULTS The most common intra-articular procedures were osteochondral lesion debridement (forty-four ankles), subtalar debridement (thirty-eight), subtalar fusion (thirty-three), ankle debridement (thirty), and partial talectomy (nine). The most common extra-articular procedures were os trigonum excision (forty-eight), tenolysis of the flexor hallucis longus tendon (thirty-eight), and endoscopic partial calcanectomy (five). Complications were noted following sixteen procedures (8.5%); four patients had plantar numbness, three had sural nerve dysesthesia, four had Achilles tendon tightness, two had complex regional pain syndrome, two had an infection, and one had a cyst at the posteromedial portal. One case of plantar numbness and one case of sural nerve dysesthesia failed to resolve. CONCLUSIONS Our experience demonstrated that posterior ankle and hindfoot arthroscopy can be performed with a low rate of major postoperative complications.
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Affiliation(s)
- Florian Nickisch
- Department of Orthopaedics, University of Utah Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA
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Galla M, Lobenhoffer P. Technique and results of arthroscopic treatment of posterior ankle impingement. Foot Ankle Surg 2011; 17:79-84. [PMID: 21549977 DOI: 10.1016/j.fas.2010.01.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Revised: 12/24/2009] [Accepted: 01/22/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to investigate the outcome after arthroscopic procedures for treatment of posterior ankle impingement. METHODS From June 2006 to April 2009 36 patients were treated by hindfoot arthroscopy. Indication was posterior ankle impingement due to symptomatic os trigonum or osteophytes. Pain on the VAS was evaluated pre- and postoperatively. Minimum follow-up was 6 months. RESULTS 30 patients were available for follow-up. Follow-up averaged 9.7 months (range 6-14 months). Pain measured on the VAS improved significantly from 7.2 points to 1.3 points. One superficial (3.3%) and one deep wound infection (3.3%) occurred, 6.6% of our patients complained about impaired sensitivity of the sural nerve, and 6.6% required resurgery. CONCLUSIONS Hindfoot arthroscopy is an elegant surgical technique in treatment of posterior ankle impingement. The minimally invasive procedure allows for low complication rates.
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Affiliation(s)
- Mellany Galla
- Chirurgie im Medicinum, Goslarsche Landstrasse 19, 31135 Hildesheim, Germany.
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Noguchi H, Ishii Y, Takeda M, Hasegawa A, Monden S, Takagishi K. Arthroscopic excision of posterior ankle bony impingement for early return to the field: short-term results. Foot Ankle Int 2010; 31:398-403. [PMID: 20460066 DOI: 10.3113/fai.2010.0398] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We treated 12 cases of posterior ankle bony impingement in 12 athletes arthroscopically, and examined the operating methods, findings, and postoperative physical therapy and overall results. MATERIALS AND METHODS The patients' average age was 21.4 years. The mean duration of postoperative followup was 33.8 months. A 2.7-mm, 30 degree arthroscope was inserted into the subtalar joint using posterolateral and accessory posterolateral portals. When the impinged fragment was visualized, it was carefully excised from the surrounding soft tissues. The operation was completed once the entire flexor hallucis longus tendon was seen. No cast immobilization was applied postoperatively, and physical therapy including limited weight bearing and range-of-motion exercises commenced within 24 hours after surgery. Beginning 3 weeks after surgery, the patients were permitted to gradually resume sports under the guidance of a physiotherapist. The AOFAS ankle-hindfoot score, the postoperative range of motion of the ankle and the time to recover were determined. RESULTS The average postoperative AOFAS ankle-hindfoot score improved from 68.0 to 98.3 points. The mean preoperative range of motion of the ankle joint was improved from 59.2 degree to 68.4 degree. The average period to return to sports was 5.9 weeks. All patients reached full activity within 13 weeks after surgery. The surgical time ranged from 40 minutes to over 2 hours and was affected by the impingement condition. CONCLUSION Arthroscopic treatment for posterior ankle bony impingement syndrome was minimally invasive and suitable for athletes who desire an early return to sports activity.
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Affiliation(s)
- Hideo Noguchi
- Ishii Orthopaedic and Rehabilitation Clinic, Orthopaedic Surgery, Gyoda, Saitama 361-0037, Japan.
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Hampton CB, Shawen SB, Keeling JJ. Positioning technique for combined anterior, lateral, and posterior ankle and hindfoot procedures: technique tip. Foot Ankle Int 2010; 31:348-50. [PMID: 20371025 DOI: 10.3113/fai.2010.0348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Expert Opinion
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Affiliation(s)
- Chadwick B Hampton
- Orthopaedic Surgery, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
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Guo QW, Hu YL, Jiao C, Ao YF, Tian DX. Open versus endoscopic excision of a symptomatic os trigonum: a comparative study of 41 cases. Arthroscopy 2010; 26:384-90. [PMID: 20206049 DOI: 10.1016/j.arthro.2009.08.029] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 07/02/2009] [Accepted: 08/21/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical results of a consecutive series of 43 cases of excision of a symptomatic os trigonum performed with an open versus hindfoot endoscopic technique. METHODS From 1994 to 2007, 43 patients underwent a symptomatic os trigonum excision. A subjective satisfaction questionnaire and a visual analog scale score for pain were obtained, and the American Orthopaedic Foot & Ankle Society ankle and hindfoot score and the time to return to previous sports level were determined in 41 of 43 patients at follow up. Of the ankles, 16 had an open os trigonum excision and 25 had hindfoot endoscopic surgery. Group A (16 ankles, open surgery) and group B (25 ankles, endoscopic excision) were comparable concerning age, sex, profession, and concomitant injury of the ankle. RESULTS At follow-up evaluation (12 to 86 months after surgery), group B had a significantly shorter mean time to return to previous sports level. There was no difference in postoperative visual analog scale score, American Orthopaedic Foot & Ankle Society score, subjective satisfaction rating, or rating of sensory nerve loss between the 2 groups. CONCLUSIONS Both open surgery and hindfoot endoscopic excision of a symptomatic os trigonum were effective and safe. Patients with an endoscopic excision had a shorter time to return to previous sports level. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Qin Wei Guo
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, China
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Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP. Evidence-based indications for ankle arthroscopy. Arthroscopy 2009; 25:1478-90. [PMID: 19962076 DOI: 10.1016/j.arthro.2009.05.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Accepted: 05/05/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence available to support the surgical technique of ankle arthroscopy for the current generally accepted indications and assign a grade of recommendation for each of them. METHODS A comprehensive review of the literature was performed (in August 2008) by use of the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of different ankle arthroscopic treatment techniques. All articles were reviewed and assigned a classification (I-IV) of Level of Evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for ankle arthroscopy. RESULTS There exists fair evidence-based literature (grade B) to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement and osteochondral lesions and for ankle arthrodesis. Ankle arthroscopy for ankle instability, septic arthritis, arthrofibrosis, and removal of loose bodies is supported with only poor-quality evidence (grade C). Treatment of ankle arthritis, excluding isolated bony impingement, is not effective and therefore this indication is not recommended (grade C against). Finally, there is insufficient evidence-based literature to support or refute the benefit of arthroscopy for the management of synovitis and fractures (grade I). CONCLUSIONS There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications; however, further studies in this area are needed. LEVEL OF EVIDENCE Level IV, systematic review.
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Affiliation(s)
- Mark A Glazebrook
- Department of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
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Glard Y, Jacopin S, de Landevoisin ES, Launay F, Jouve JL, Bollini G. Symptomatic os trigonum in children. Foot Ankle Surg 2009; 15:82-5. [PMID: 19410174 DOI: 10.1016/j.fas.2008.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Accepted: 08/06/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Symptomatic os trigonum is a rare condition well described in adults responsible for chronic ankle pain. To date there is no published case of successfully managed symptomatic os trigonum in children. METHODS We retrospectively reviewed 4 paediatric patients (11-17) successfully operated on for a symptomatic os trigonum through a postero medial approach. One case was bilateral. RESULTS Pain relief was postoperatively obtained in all cases. All of the patients were able to return to physical activities after 3 months. The mean follow up was 12 months. CONCLUSION Symptomatic os trigonum may be responsible for chronic ankle pain in children and adolescents as well as in adults. The surgical treatment is effective in children.
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Affiliation(s)
- Yann Glard
- Department of Pediatric Orthopaedics, Timone Children's Hospital, 264, Rue St Pierre, Marseille 13385, France.
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Rückfußarthroskopie. ARTHROSKOPIE 2009. [DOI: 10.1007/s00142-008-0493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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de Landevoisin ES, Jacopin S, Glard Y, Launay F, Jouve JL, Bollini G. Surgical treatment of the symptomatic os trigonum in children. Orthop Traumatol Surg Res 2009; 95:159-63. [PMID: 19346178 DOI: 10.1016/j.otsr.2008.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 10/08/2008] [Indexed: 02/02/2023]
Abstract
Symptomatic os trigonum is a rare condition, well described in adults, that causes chronic ankle pain. To date there are no reported cases of successfully managed symptomatic os trigonum in the children population. We retrospectively reviewed four paediatric patients (11-17 years of age) successfully operated for a symptomatic os trigonum using an open excision through a posteromedial approach. One case was bilateral. Postoperative pain relief was obtained in all cases. All of the patients were able to return to unrestricted physical activities after three months. The average follow-up was 12 months. Symptomatic os trigonum may be held responsible for chronic ankle pain in children and adolescents as well as in adults. The surgical treatment is effective in children.
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Affiliation(s)
- E Soucanye de Landevoisin
- Paediatric Orthopaedic Surgery Department, La Timone Children Hospital, 13005 Marseille cedex 5, France.
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Scholten PE, Sierevelt IN, van Dijk CN. Hindfoot endoscopy for posterior ankle impingement. J Bone Joint Surg Am 2008; 90:2665-72. [PMID: 19047712 DOI: 10.2106/jbjs.f.00188] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The surgical treatment of posterior ankle impingement is associated with a high rate of complications and a substantial time to recover. An endoscopic approach to the posterior ankle (hindfoot endoscopy) may lack these disadvantages. We hypothesized that hindfoot endoscopy causes less morbidity and facilitates a quick recovery compared with open surgery. METHODS Fifty-five consecutive patients with posterior ankle impingement were treated with an endoscopic removal of bone fragments and/or scar tissue. The symptoms were caused by trauma (65%) or overuse (35%). All patients were enrolled in a prospective protocol. At baseline, the age, sex, work and sports activities, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and preinjury Tegner scores were determined for all patients. At the time of follow-up, AOFAS hindfoot scores and Tegner scores were assessed and the time to return to work and sports activities was determined. Complications were recorded. Patients scored the overall result as poor, fair, good, or excellent by means of a 4-point Likert scale. RESULTS The median duration of follow-up was thirty-six months, and no patient was lost to follow-up. The median AOFAS hindfoot score increased from 75 points preoperatively to 90 points at the time of final follow-up. The median time to return to work and sports activities was two and eight weeks, respectively. At the time of follow-up, patients in the overuse group were more satisfied than those in the posttraumatic group, and the AOFAS hindfoot scores were higher in patients in the overuse group (median, 100 points) compared with patients in the posttraumatic group (median, 90 points). A complication occurred in one patient who had a temporary loss of sensation of the posteromedial aspect of the heel. CONCLUSIONS The outcome after endoscopic treatment of posterior ankle impingement compares favorably with the results of open surgery reported in the literature. Hindfoot endoscopy appears to cause less morbidity than open ankle surgery and facilitates a quick recovery. Patients treated for posterior ankle impingement caused by overuse have better results than those treated following trauma.
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Affiliation(s)
- P E Scholten
- Department of Orthopaedic Surgery, Kliniek Klein Rosendael, Rosendaalselaan 30, 6891 DG Rozendaal, The Netherlands.
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Willits K, Sonneveld H, Amendola A, Giffin JR, Griffin S, Fowler PJ. Outcome of posterior ankle arthroscopy for hindfoot impingement. Arthroscopy 2008; 24:196-202. [PMID: 18237704 DOI: 10.1016/j.arthro.2007.08.025] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Revised: 07/17/2007] [Accepted: 08/20/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To provide short-term clinical results of posterior ankle arthroscopy in the treatment of posterior ankle impingement. METHODS This was a retrospective evaluation of the clinical outcomes of posterior ankle arthroscopy in a series of patients with posterior ankle pain. RESULTS Of 23 patients who underwent 24 posterior ankle arthroscopies between July 1998 and February 2004, 15 patients (mean age, 25 years) with 16 posterior ankle arthroscopies were evaluated at a mean follow-up time of 32 months (range, 6 to 74). Procedures carried out were: excision of os trigonum (11); decompression of prominent posterior talar process (5); tenolysis of flexor hallucis longus (5); removal of loose body (1); osteochondritis dissecans lesion debridement (1); and arthrotomy (1). The average time to return to work was 1 month (range, 0 to 3) and to sports, 5.8 months (range, 1 to 24). Fourteen patients returned to their preinjury level of athletics. Mean Health Survey Short Form (SF-12) scores were 51.80 for the mental component (range, 30.77 to 60.53) and 55.80 for the physical component (range, 44.26 to 63.33). Mean score on the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale was 91 (range, 77 to 100) and on the Lower Extremity Functional Scale was 75 (range, 65 to 80). Documented complications included temporary numbness in the region of the scar in 5 patients and temporary ankle stiffness in 1 patient. There were no permanent neurovascular injuries. All subjects reported significant improvement and indicated that they would undergo the surgery again if needed. CONCLUSIONS Functional and clinical evaluations following posterior ankle arthroscopy revealed that all patients were very satisfied. They reported good to excellent health-related quality of life scores, satisfactory functional outcomes, and a high rate of return to sporting activities. Most importantly, no significant complications were encountered. This review suggests that posterior ankle arthroscopy is a safe and effective surgical procedure in the treatment of posterior ankle impingement. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Kevin Willits
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, Canada.
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Horibe S, Kita K, Natsu-ume T, Hamada M, Mae T, Shino K. A novel technique of arthroscopic excision of a symptomatic os trigonum. Arthroscopy 2008; 24:121.e1-4. [PMID: 18182212 DOI: 10.1016/j.arthro.2007.04.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Revised: 03/30/2007] [Accepted: 04/19/2007] [Indexed: 02/02/2023]
Abstract
We describe a new arthroscopic excision technique for a symptomatic os trigonum. With the patient lying in a prone position, a posterolateral portal just lateral to the Achilles tendon, at the 5-mm level proximal to the tip of the fibula, is used for the arthroscope and an accessory posterolateral portal just posterior to the peroneal tendon at the same level is used for instruments. The synovial tissues are then debrided with a power shaver through the accessory posterolateral portal for better visualization. An elevator is used to release the fibrous tissue between the os trigonum and the talus. The os trigonum is completely excised with a grasper to visualize the flexor hallucis longus tendon. Radiographic control is helpful to check the position of the arthroscope if it happens to be inserted into the ankle joint as a result of the reduced subtalar joint space. Postoperatively, no immobilization is necessary, and full weight-bearing is allowed as tolerated. Three of us have performed 11 procedures with excellent results and no cases of complications. This arthroscopic excision technique for the symptomatic os trigonum is a safe and effective procedure.
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