Treatment Options

Activity restrictions, short-term immobilization, and/or use of nonsteroidal anti-inflammatory medications are cornerstones of conservative management. Commonly, the correct diagnosis is missed or delayed. As previously described, if the diagnosis is uncertain, an injection with a local anesthetic may confirm the diagnosis; an injection with steroid preparation may be thera-peutic.12,13 In a series of 19 athletes with OTS, Mouhsine et al13 reported a 84% success rate using one or two fluoroscopically guided steroid injections at 2-year follow-up. The recalcitrant cases were managed with surgical excision with complete relief of symptoms.

Abramowitz et al11 reported the outcomes of open surgical resection in 41 symptomatic os trigona. Excellent pain relief and restoration of function was reported at 44-month follow-up; the patients scored an average of 87.6 points on the American Orthopaedic Foot and Ankle Society test (range, 0 to 100). Therefore, resection was recommended if symptoms persisted following 3 months of conservative management. Abramowitz et al observed a trend toward a lower success rate when symptoms had been present for more than 3 years. Finally, iatrogenic sural nerve injury was documented in nearly 20% of their series.11

Marrotta and Micheli14 reported on 16 athletes who underwent open excision of a painful os trigonum. Their series included 12 ballet dancers. Surgical excision was undertaken following failure of conservative management. All patients undergoing excision noted significant improvement of impingement symptoms. All professional dancers returned to full activity; however, two thirds reported occasional discomfort with athletic endeavors.

In addition to open resection, an alternative form of ablation, arthroscopic resection, has been performed. In a series of 11 patients, Marumoto and Ferkel15 reported on results following arthroscopic os trigonum excision. At mean follow-up of 35 months, the average American Orthopaedic Foot and Ankle Society score increased from 45 to 86 points. Therefore, this technique may produce superior outcomes due to minimization of scar tissue and shorter recovery times. However, this is a technically demanding procedure; therefore, only surgeons familiar with subtalar arthroscopic techniques should consider this form of minimally invasive excision.

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