SUBTALAR ARTHROSCOPIC EXCISION OF A SYMPTOMATIC OS TRIGONUM:
DOES SIZE MATTER?
Peter Bellezza DPM, MS; Midori Higashi DPM; Jeffrey Christensen, DPM, FACFAS
Statement of Purpose
Arthroscopic surgery of the subtalar joint (STJ) is a relatively new technique that can be
used to diagnose and treat multiple conditions including os trigonum syndrome (1-3).
However, the techniques published have run into complications with removal of larger os
trigonums (4). Although an open approach can be used for resection of large painful os
trigonums, there are many complications including sural nerve palsies and longer recovery
times (5). We improve upon this technique with unique portal placement and describe a
modification that allows for removal of large, symptomatic os trigonums.
Our Technique
The patient is placed in a lateral decubitus position. The subtalar joint is insufflated with
6 mL of a mixture of 40 mL of lactated ringer, 10 mL of ropivacaine, and 0.2 mL of
epinephrine. A standard 4 mm 30 degree or small joint arthroscope can be utilized. Our
portals are placed 180 degrees along the posterior facet. The anterolateral portal is located
at the floor of the sinus tarsi, 1 cm anterior to the tip of fibula (Fig A). The posterolateral
portal is located adjacent to Achilles tendon, at the level of or 0.5 cm proximal to the tip of
the fibula, which avoids injury to the sural nerve (Fig A). Attention is first directed through
the anterior portal, the trocar is advanced to the posterior aspect of the ankle and the skin
is gently tented lateral to the border of the Achilles tendon where the posterolateral portal
is later created.
Fig A Fig B
Fig C Fig D
PTFL
Os Trigonum
Calcaneus
The arthroscope is entered through this posterolateral portal in retrograde
fashion, allowing for easy visualization of the subtalar joint (Fig B). The key landmark
is the posterior talofibular ligament (Fig C). We seek to identify this ligament and
follow it to the os trigonum. A key modification we have made is the utilization of a
power burr with low speed oscillation to debride the os trigonum (Fig D). This allows
for removal of os trigonums of various sizes without difficulty. Remnants are removed
with a synovial rongeur.
Discussion and Literature Review
Arthroscopic excision of a symptomatic os trigonum is an established technique
with various portal approaches described. As far as we know, our posterolateral
portal coupled with an anterolateral portal for removal of a symptomatic os
trigonum has not been described.
The most common approach was originally described by Van Dijk (6) and uses a
posterolateral and posteromedial portal (7). This procedure was performed with the
patient in the prone position, and a change to supine position is necessary for
examination of the anterior ankle.
Discussion and Literature Review, continued
Although it has been reported that the posteromedial portal is safe with
regard to injury of the tibial nerve or posterior tibial vessels (8-10), it has been
described that the distance between the portal and neurovascular structures
ranges from 0 to 16.2 mm (9).
Other described approaches include the use of a posterolateral portal coupled
with either an accessory or stacked posterolateral portal. Use of these stacked
portals creates a problem of instrument crowding. A trans-Achilles tendon portal
with a standard posterolateral portal has also been described but carries the risk
of damage to the Achilles tendon.
Advantages of our technique is that our described posterolateral and
anterolateral portals avoid vital anatomical structures. Utilizing a small low-speed
burr gives the surgeon good control of the burr and will debride most os
trigonums in a predicable manner. Utilizing the burr also helps avoid repeated
tissue trauma which is typically seen while using a grasper.
Conclusion
Compared with an open surgical resection requiring extensive exposure with
the risk of infection or sural nerve injury, arthroscopic resection of the
symptomatic os trigonum is a less invasive surgical technique with a reduced risk
of complications, shorter recovery period, and better clinical outcome. Our
described arthroscopic technique using a posterolateral portal for visualization
and our anterolateral portal for instrumentation as well as use of a burr for
debridement, is a safe and effective procedure.
References
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