Advertisement

Return to activity after excision of the symptomatic Os trigonum: A systematic review comparing arthroscopic versus open excision

Open AccessPublished:June 22, 2022DOI:https://doi.org/10.1016/j.fastrc.2022.100212

      Abstract

      The os trigonum, an irregular, accessory ossicle at the posterior lateral process of the talus, is known to be one of the main causes of posterior ankle impingement. It is unclear if an arthroscopic technique offers a superior outcome over an open technique when surgical excision is indicated. The purpose of this study is to better understand the outcomes and complications after os trigonum excision using an open versus arthroscopic technique. Using PRISMA guidelines, a systematic review of studies published in PubMed, Cochrane Reviews, and CINAHL databases through November 2021 was conducted to identify articles that evaluated postoperative outcomes and complications following os trigonum excision. Studies involving concurrent procedures, arthroscopic approaches varying from the technique described by Van Dijk et. al (2000), and case studies (where n ≤ 2) were excluded 1996 unique articles were identified. 18 studies were included representing 242 patients undergoing the arthroscopic technique and 217 undergoing the open technique. The arthroscopic group returned to activity sooner than the open group (9.86 weeks versus 13.074 weeks, respectively; p-value <0.001). Sural nerve damage occurred in 11 patients in the open group (5.07%), while the arthroscopic group reported 1 complication (0.41%). Arthroscopic os trigonum excision may offer a quicker return to activity. Further data is required to compare additional clinical outcome measures of these two surgical strategies.

      Keywords

      Introduction

      A secondary center of ossification at the lateral tubercle of the posterior process of the talus typically appears between the ages of 8 and 13 and usually fuses with the talus within 1 year, forming the trigonal (Stieda) process.
      • Peace K.A.L.
      • Hillier J.C.
      • Hulme A
      • Healy J.C.
      MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases.
      If unfused, the accessory ossicle is known as an os trigonum, which has a prevalence ranging from 1.7% to 7%.
      • Guo Q.W.
      • Hu Y.L.
      • Jiao C
      • Ao Y.F.
      Open versus endoscopic excision of a symptom atic os trigonum: a comparative study of 41 cases.
      This accessory bone is not symptomatic under normal circumstances, however in some circumstances may cause posterior ankle impingement syndrome (PAIS). This often is due to forced plantarflexion of the foot and is thus most common in dancers and soccer players.
      • Georgiannos D.
      • Bisbinas I.
      Endoscopic versus open excision of os trigonum for the treatment of posterior ankle impingement syndrome in an athletic population: a randomized controlled study with 5-year follow-up.
      While conservative options such as activity modification, rest, ice, anti-inflammatory drugs, immobilization (bracing to limit plantarflexion), and physical therapy exist, surgical excision may be required.
      • López Valerio V.
      • Seijas R
      • Alvarez P
      • et al.
      Endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players.
      Surgical excision of the os trigonum can be completed via an open or arthroscopic excision. The open procedure is historically viewed as the gold standard and has highly satisfactory results in the literature, however is often associated with sural nerve damage.
      • Abramowitz Y.
      • Wollstein R
      • Barzilay Y
      • et al.
      Outcome of resection of a symptomatic os trigonum.
      The arthroscopic technique has become increasingly popular and offers minimal morbidity, less scarring, and the potential for faster recovery.
      • Guo Q.W.
      • Hu Y.L.
      • Jiao C
      • Ao Y.F.
      Open versus endoscopic excision of a symptom atic os trigonum: a comparative study of 41 cases.
      The most commonly used arthroscopic technique is the 2 portal hindfoot approach described by van Dijk et al. which includes the following:
      • van Dijk C.N.
      • Scholten P.E.
      • Krips R
      A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology.
      • Patient in prone position
      • Posterolateral and posteromedial portals
      • 4.0-mm 30° arthroscope
      While posterior arthroscopy has promising outcomes, it is technically demanding and believed to have a steep learning curve. Due to the high occurrence of symptomatic os trigonum in athletes, the time to return to activity is particularly of interest when selecting a surgical technique.
      A systematic review of studies published in PubMed, Cochrane Reviews, and CINAHL databases through November 2021 was conducted to identify articles that evaluated time to return to activity following an os trigonum excision either by open or arthroscopic excision. We followed standard methodology for performing a systematic review using PRISMA guidelines as demonstrated in Fig. 1.
      The following inclusion and exclusion criteria were followed:
      • Inclusion criteria:
        • Prospective and retrospective designs
        • Reported time to return to activity
        • Failed conservative treatment
        • Clear description of surgical technique
        • Minimum 6-month follow-up
      • Exclusion criteria:
        • Concurrent procedures
        • Arthroscopic approaches varying from the technique described by Van Dijk6
        • Non-English studies
        • Case studies where n ≤ 2
        • Cadaver or animal model studies
      A t-test was used to determine this p-value, representing a statistically significant difference between groups. Complications, specifically sural nerve damage, were also analyzed.

      Results

      1996 unique articles were identified. 18 studies were included representing 459 patients. 10 studies represented the open technique (n = 217), demonstrated in Table 1. 10 studies represented the arthroscopic technique (n = 242), demonstrated in Table 2. The arthroscopic group returned to activity sooner than the open group (9.86 weeks versus 13.07 weeks, p-value <0.001). Sural nerve damage occurred in 11 patients in the open group (5.07%), while the arthroscopic group reported 1 complication (0.41%).
      Table 1Identified studies utilizing the open technique.
      Open studiesMedial vs lateralNMean return to activity (weeks)Range (weeks)Sural nerve complicationComplication rate (%)
      Ballal (2016)L2214.99-2000
      Heyer (2017)M3817.76-5200
      Abramowitz (2003)L41204-52614.6
      de Landevoisin (2009)M41400
      Georgiannos (2017)L2611.54415.4
      Marotta (1992)L12126-5200
      Brodsky (1987)610.6000
      Wredmark (1991)M1375-1000
      Spicer (1999)M391100
      Guo (2010)L1611.94-2416.3
      TOTAL21713.07115.1
      Table 2Identified studies utilizing the arthroscopic technique.
      Arthroscopic studiesNMean return to activity (weeks)Range (weeks)Sural nerve complicationComplication rate (%)
      Morelli (2017)128.78-1000
      López Valerio (2015)206.700
      Jerosch (2006)10800
      Micheli (2021)542000
      Georgiannos (2017)267.1200
      Rakha (2021)289.88-1213.4
      Xiang (2021)36.700
      Sugimoto (2021)5013.64-3600
      Smyth (2013)14126-1600
      TOTAL2429.8610.41

      Discussion

      When conservative treatment fails to resolve PAIS due to the presence of an os trigonum, surgical excision of the ossicle, either by an open or arthroscopic approach, is the treatment of choice.
      • López Valerio V.
      • Seijas R
      • Alvarez P
      • et al.
      Endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players.
      Literature suggests that patients may return to activity following the arthroscopic procedures quicker compared to the open technique. This makes the arthroscopic treatment option particularly appealing for athletes who may require earlier return to activity. However, it is important to note the studies analyzed did not stratify outcomes according to age or other possible confounders, such as activity level, that is not equally distributed in the two treatment groups.
      Further outcome data is required to review other surgical outcomes variables, such as AFAOS and VAS. In a randomized controlled study of 26 subject by Georgiannos, D., & Bisbinas, I. (2017), arthroscopic excision appeared to have significant improvement of AOFAS hindfoot score compared with those who had the open technique (P < .05), whereas no statistical significance was found for the postoperative VAS-FA scores between the 2 groups.
      • Georgiannos D.
      • Bisbinas I.
      Endoscopic versus open excision of os trigonum for the treatment of posterior ankle impingement syndrome in an athletic population: a randomized controlled study with 5-year follow-up.
      Further sufficiently powered, randomized clinical trials with uniform methodology and validated outcome measures such as the study above should be initiated to compare the outcome of surgical strategies for os trigonum excision.

      Conclusion

      Arthroscopic os trigonum excision may offer a quicker return to activity. Further prospective randomized controlled trials are required to compare the outcome of these two surgical strategies for os trigonum excision.

      Disclosures and Acknowledgements

      No financial disclosures.
      Special thanks to Dr. Rachel Albright, DPM, MPH and Dr. Adam Fleischer, DPM, MPH, FACFAS for their support and guidance.

      References

        • Peace K.A.L.
        • Hillier J.C.
        • Hulme A
        • Healy J.C.
        MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases.
        Clin Radiol. 2004; 59: 1025-1033
        • Guo Q.W.
        • Hu Y.L.
        • Jiao C
        • Ao Y.F.
        Open versus endoscopic excision of a symptom atic os trigonum: a comparative study of 41 cases.
        Arthroscopy. 2010; 26: 384-390
        • Georgiannos D.
        • Bisbinas I.
        Endoscopic versus open excision of os trigonum for the treatment of posterior ankle impingement syndrome in an athletic population: a randomized controlled study with 5-year follow-up.
        Am J Sports Med. 2017; 45: 1388-1394
        • López Valerio V.
        • Seijas R
        • Alvarez P
        • et al.
        Endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players.
        Foot Ankle Int. 2015; 36: 70-74
        • Abramowitz Y.
        • Wollstein R
        • Barzilay Y
        • et al.
        Outcome of resection of a symptomatic os trigonum.
        JBJS. 2003; 85: 1051-1057
        • van Dijk C.N.
        • Scholten P.E.
        • Krips R
        A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology.
        Arthroscopy. 2000; 16: 871-876