No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
An Unusual Os Trigonum Syndrome Case Secondary to Car Accident: A Case Report
Abstract
Introduction: The os trigonum syndrome is a common cause of posterior ankle pain, often affecting ballet dancers, soccer players, runners and gymnasts who frequently force the ankle into plantar flexion. In rare cases, onset of the os trigonum syndrome followed an acute injury.
Case Presentation: A 62-year-old female patient was admitted with load depended ankle pain and swelling, lasting for five years which promptly started after a car accident. We incidentally discovered os trigonum on plain radiography on a lateral view of the right ankle.
Conclusions: The os trigonum syndrome should take in consideration in elderly subject who had posterior ankle pain starting after a car accident.
... It frequently occurs bilateral being common in soccer players, runners, and gymnasts, due to repeated plantar flexion of the ankle. 6,[8][9][10][11][12] It is predominantly symptomatic in men compared to women. 3 Repetitive dorsiflexion of the foots, metatarsophalangeal joint, and plantarflexion of the ankle, can result in FHL tendonitis, tenosynovitis. ...
... 3 Repetitive dorsiflexion of the foots, metatarsophalangeal joint, and plantarflexion of the ankle, can result in FHL tendonitis, tenosynovitis. 9,12 OST resulting from failed fusion of secondary ossification center of lateral tubercle of the talus can be differentiated from avulsion fractures of the talus, by remarkably sharp edges and discontinuity of the cortical lining. Hyper plantarflexion of the ankle may result in posterior ankle fractures, which are commonly misdiagnosed and treated as simple ankle sprains, which can present with nutcracker sign. ...
Background: Os trigonum (OST) is commonly located on the posterior aspect of the talus. It occurs as a result of secondary ossification center failing to fuse with the lateral tubercle of the posterior process of the talus; its incidence varies between 2 and 25%, and is more often bilateral. It occurs as an intra-articular Os, which is most often securely rooted to the lateral tubercle of the talus by a fibrocartilaginous synchondrosis.
Aims and Objective: To determine the incidence, morphology, and distribution of Os Trigonum (OST).
Materials and Methods: Retrospective 500 lateral foot radiographs view were studied to determine the incidence, morphology, and distribution of OST.
Results: Incidence of OST in the present study was 6.6%, with predominantly round or ovoid in shape. OST was located on the posterolateral aspect of the talus.
Conclusion: OST can be one of the causative factor responsible for Flexor hallucis longus tendonitis, OST syndrome, which occur in plantarflexion of the ankle, leading to compression of the OST between the distal tibia and the calcaneus. Hence, knowledge regarding the incidence, morphology, and distribution of OST is important for the radiologist, orthopedic surgeons to arrive at a correct diagnosis, which aids in the management of cases presenting with complaints of posterior ankle pain.
... It is believed to arise from the failure of fusion between the lateral tubercle of the posterior process of the talus and the surrounding bone during development [7]. The os trigonum can cause pain and limited range of motion in the ankle joint, particularly in athletes and dancers who place increased stress on this area [8]. MRI is commonly used to diagnose and evaluate os trigonum, as it allows for visualization of the bony structure and surrounding soft tissues. ...
This study aimed to investigate the dimensions and types of the os trigonum and evaluate their relationship with various pathologic conditions on the posterior ankle using ankle MRI images. A total of 124 non-contrast-enhanced ankle and foot MR images of 123 consecutive patients were included in this retrospective study. The images were presented randomly, and they contained no patient information. The MR images were retrospectively and independently reviewed by two reviewers with a fellowship-trained musculoskeletal radiologist. The images were classified as type I and II based on the ossicle’s medial border overlying the talus’s posterior process and the groove for the flexor hallucis longus tendon (FHL). The study revealed that patients with type II os trigonum had a longer transverse diameter of the ossicle than type I, and there were statistically significant differences. Detachment status tended to be less in type I than in type II os trigonum, and the differences between the groups were statistically significant. There were no significant differences between type I and II os trigonum regarding posterior talofibular ligament (PTFL) abnormality, bone marrow edema, FHL tenosynovitis, and posterior synovitis. The study concluded that the os trigonum is a common cause of posterior ankle impingement, and type II os trigonum has a longer transverse diameter of the ossicle than type I.
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.
Sesamoids and accessory ossicles seen in the foot vary widely in their prevalence and appearance. Occasionally, these bones may be associated with painful syndromes, due to various pathologies, including trauma, infection, inflammation, degeneration and others. However, symptomatic accessory and sesamoid bones are rare, and search for additional pathology should be performed. Although the clinical significance of these osseous structures is probably minor, clinicians very commonly ask about these bones, which may originate an unnecessary work-up. Therefore, knowledge of their presence and morphological variations is important to prevent misinterpreting them as fractures—a common error. Finally, it may be very difficult to distinguish between incidental variants and truly symptomatic ones. Radiological studies provide insight regarding the presence and pathology involving these bones. This review describes an overview of the anatomy of sesamoids and accessory ossicles in the foot, and provides a pictorial review of their pathological conditions, including trauma, sesamoiditis, osteomyelitis, osteoarthritis and pain syndromes. Radiological studies including radiography, ultrasound, scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI) provide useful information which should be used in concert with clinical findings to guide patient management.
Teaching points
• Sesamoids and accessory ossicles seen in the foot vary widely in their prevalence and appearance.
• Pathology of these bones includes trauma, sesamoiditis, infection, osteoarthritis and pain syndromes.
• Radiography, ultrasound, scintigraphy, CT and MRI provide information regarding the pathology of these bones.
Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.
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.
The os trigonum syndrome is a rare entity with scant evidence in the literature regarding diagnosis and treatment. The current literature concerning the clinical presentation, diagnostic techniques and treatment options are reviewed.
Os trigonum syndrome is the result of an overuse injury of the posterior ankle caused by repetitive plantar flexion stress. It is predominantly seen in ballet dancers and soccer players and is primarily a clinical diagnosis of exacerbated posterior ankle pain while dancing on pointe or demi-pointe or while doing push-off maneuvers. Symptoms may improve with rest or activity modification. Imaging studies, including a lateral radiographic view of the ankle in maximal plantar flexion, will typically reveal the os trigonum between the posterior tibial lip and calcaneus. If an os trigonum is absent on radiography, an MRI may reveal scar tissue behind the posterior talus, a condition associated with similar symptoms. Os trigonum syndrome is often associated with pathology of the flexor hallucis longus tendon. Treatment begins with nonsurgical measures. In addition to physical therapy, symptomatic athletes may need surgical excision of os trigonum secondary to unavoidable plantar flexion associated with their sport. This surgery can be performed using open or arthroscopic approaches.
While an os trigonum at the posterolateral aspect of the talus is usually asymptomatic, this inconsistently present accessory bone has been associated with persistent posterior ankle pain, which has been described as the os trigonum syndrome. We present the clinical results of excision of the os trigonum through a posterolateral approach and report several factors affecting the clinical outcome.
During a five-year period from 1994 through 1999, forty-one patients had a failure of nonoperative treatment of os trigonum syndrome and underwent excision of a symptomatic os trigonum. In all cases, the os trigonum syndrome was diagnosed on the basis of the history, physical examination, and radiographs. Postoperatively, the patients were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. A questionnaire was used to evaluate the effect of several factors on the clinical outcome.
The average duration of follow-up was forty-four months. The postoperative AOFAS score averaged 87.6 points. The thirty-three patients who had had symptoms for two years or less prior to the surgery had an average postoperative score of 90 points compared with 78 points for the eight patients who had had preoperative symptoms for more than two years (p = 0.011). Eight patients had sural nerve sensory loss, which was temporary in four and permanent in four. A superficial wound infection developed in one patient, and reflex sympathetic dystrophy developed in another.
An os trigonum that is persistently symptomatic after a minimum three-month trial of nonoperative treatment can be excised through a posterolateral approach with highly satisfactory results. The main complication of this procedure is sural nerve injury.
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.
De nonnullis musculorum corporis humani varietatibus. Klaubarth; 1804
- J Rosenmüller
Rosenmüller J. De nonnullis musculorum corporis humani varietatibus. Klaubarth; 1804.