DEFINITION

Sesamoiditis is a general term that indicates an injury to the sesamoid bone. There are multiple possible causes, such as trauma (fracture, contusion, repetitive stress), infection, arthrosis, osteonecrosis, and osteochondritis dissecans.3,5,12,13,15

There are two sesamoid bones located plantar to the metatarsal head of the hallux: the lateral or fibular and the medial or tibial sesamoid.

 

 

ANATOMY

 

The two sesamoid bones are located plantar to the metatarsal head within the tendon of the flexor hallucis brevis (FHB). They are held together by the intersesamoid ligament and plantar plate. Their dorsal surfaces articulate with the head of the first metatarsal articular facets, and they are separated by a crista. The sesamoids absorb the weight-bearing stress across the medial ray and protect the flexor hallucis longus (FHL) tendon that passes between them. The tibial sesamoid is typically larger and located slightly more distal than the fibular sesamoid (FIG 1).

 

During the stance phase of gait, the sesamoids are slightly proximal to the metatarsal head, but with dorsiflexion of the hallux, the sesamoids are pulled distally, protecting the exposed surface of the metatarsal head (FIG 2A). During the act of heel raising, the sesamoids bear a significant amount of stress. This stress is typically concentrated more medially over the tibial sesamoid, thus accounting for the increased incidence of tibial

sesamoid injuries.13

 

 

 

FIG 1 • A. Medial view of relevant anatomy with special note of the adductor hallucis brevis and the relationship to the plantar cutaneous nerve. B. Plantar view of the sesamoid complex and the investing structures.

 

 

Biomechanically, the sesamoids function as a fulcrum for the FHB tendon during metatarsal phalangeal joint plantarflexion.7

 

Ossification of the sesamoids typically occurs from multiple centers and occurs during the 7th to 10th years of life. The multiple ossification centers may account for the incidence of bipartite and tripartite sesamoids.5

 

The bipartite tibial sesamoid occurs in about 19% of the population and is bilateral in 25% (FIG 2B).6

 

PATHOGENESIS

 

Symptoms can arise from a single acute traumatic event, or more commonly, there is a history of minor or repetitive trauma.

 

Acute injuries typically occur with acute hyperextension to the hallux metatarsophalangeal (MTP) joint or a direct contusion to the sesamoid region of the forefoot. This can also result in a fracture or an injury to a bipartite sesamoid.

 

 

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FIG 2 • A. Sagittal MRI of the sesamoid-MTP complex showing the increased stress across the tibial sesamoid in MTP dorsiflexion. B. AP view of the foot showing a bipartite sesamoid. (B: From Lee S. Technique of isolated tibial sesamoidectomy. Tech Foot Ankle Surg 2004;3:85-90, with permission.)

 

 

In nonacute injuries, the patient often cannot remember a specific incident or injury and can only initially recall activity-related discomfort to the forefoot. This history is typically noted in cases of repetitive stress, osteochondritis dissecans, and arthrosis. A bipartite sesamoid can similarly be injured in this case.

 

Neuritic pain has also been described with compression to the plantar medial cutaneous nerve underlying the tibial sesamoid.

 

NATURAL HISTORY

 

Most sesamoid injuries resolve with appropriate nonoperative treatment.

 

Sesamoiditis that does not resolve with conservative treatment is unlikely to improve significantly after 3 to 12 months.

 

As a result, patients often have pain that prevents them from participating in everyday activities that involve a dorsiflexed MTP joint and in athletic activities.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Most patients cannot remember a specific incident or injury, unless it was acute, and can only recall a gradual onset of discomfort to their forefoot. This pain is often generalized and localized to the great toe region. It is localized more plantarward and is worse with weight-bearing activity. Patients will often prefer cushioned shoe wear versus barefooted activity.

 

Performing activities that require a dorsiflexed MTP joint such as running, jumping, toe raising, or stair climbing can become very irritating to this region.

 

Gait can be antalgic, specifically in the toe-off phase, and can also reveal evidence of medial offloading and lateral foot overload as the patient walks with the foot externally rotated.

 

Clinical inspection will reveal swelling over the plantar aspect of the hallux MTP joint.

 

In acute injuries or in patients with a bipartite sesamoid, a drawer test of the hallux MTP joint may also reveal laxity, indicating a fracture of the sesamoid or disruption of the synchondrosis of a bipartite sesamoid.

 

Direct palpation over the tibial sesamoid may also reveal a positive Tinel sign or paresthesia distally, indicating a compression over the plantar medial cutaneous nerve.

 

Assessment of hallux alignment is critical, as concomitant procedures may be necessary in those with hallux valgus or a cavus foot to prevent further migration after tibial sesamoidectomy.

 

 

Augmenting a tibial sesamoidectomy with a lateral capsular release, medial capsular reefing, or metatarsal or phalangeal osteotomy may be considered to prevent progressive deformity.15

 

Methods for examining the tibial sesamoid include the following:

 

 

Direct palpation under the tibial sesamoid with the foot in neutral and with dorsiflexion of the MTP joint

 

Range of motion (ROM): One hand should be placed on the proximal phalanx with the other stabilizing the metatarsal. Dorsiflexion and plantarflexion ROM should be assessed. Symmetry between the right and left side should be noted.

 

Drawer test: The examiner grasps the proximal phalanx in one hand and the metatarsal head in the other and performs a dorsal to plantar stress of the MTP joint.

 

Toe raise: The patient is asked to do double-limb and single-limb toe raises.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Routine radiographs should consist of standing anteroposterior (AP), lateral, oblique, and axial sesamoid views.

 

 

Plain radiographs will often be diagnostic in cases of arthrosis and osteochondritis dissecans if fragmentation is present (FIG 3A).

 

A bipartite tibial sesamoid may be distinguished from a fractured sesamoid in that an acutely injured sesamoid may have a sharp radiolucent line (irregular trabecular pattern) that may assist in differentiation.

 

AP radiographs in neutral and dorsiflexion may assist in evaluating separation of the sesamoid segments.

 

A triple-phase bone scan or magnetic resonance imaging (MRI) is often required to confirm the diagnosis.

 

 

A triple-phase bone scan, with collimated views of the MTP joint, is very sensitive and may demonstrate increased uptake before radiographic changes become present (FIG 3B,C).

 

MRI allows the examiner to identify most causes of hallux MTP pathology in addition to sesamoiditis (FIG 3D,E).

 

 

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FIG 3 • A. A sesamoid view of the foot. Note the significant fragmentation of the tibial sesamoid. B. Triple-phase bone scan showing increased uptake of the tibial sesamoid region in an AP view of bilateral feet. C. Collimated view showing the increased uptake of the tibial sesamoid. D. Coronal MRI view highlighting the signal change of the tibial sesamoid, and reactive plantar bursitis, compared to the fibular sesamoid, indicating tibial sesamoid avascular necrosis. E. Sagittal MRI view of a tibial sesamoid fracture and subsequent reactive plantar bursitis. (From Lee S. Technique of isolated tibial sesamoidectomy. Tech Foot Ankle Surg 2004;3:85-90, with permission.)

 

DIFFERENTIAL DIAGNOSIS

Infection, sesamoid-metatarsal or MTP arthrosis or chondromalacia, bursitis, flexor tendinosis, fracture, osteochondritis dissecans, intractable plantar keratosis, nerve compression, bi- or tripartite sesamoid, turf toe injury

 

 

NONOPERATIVE MANAGEMENT

 

Most patients respond to conservative therapy. This consists of nonsteroidal anti-inflammatory medication, rest or immobilization for 2 to 4 weeks, followed by protected weight bearing with an orthotic, walker boot, or cast for an additional 4 to 6 weeks.

 

 

 

FIG 4 • A. Dancer's pad with sesamoid cutout. B. Example of a Morton extension in an orthotic.

 

 

Typically, a hard-soled shoe decreases the dorsiflexion stresses across the MTP joint and a negative heel shoe will decrease forefoot loading.

 

An orthosis such as a turf toe plate or dancer's pad with a medial longitudinal arch support will decrease the stresses across the sesamoids (FIG 4).

 

 

 

In athletes, taping the MTP joint to prevent dorsiflexion may allow continued participation. The judicious use of steroid injections for chronic sesamoiditis is also indicated.

 

SURGICAL MANAGEMENT

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Pain under the tibial sesamoid unresponsive to conservative treatment is the main indication for operative intervention. The presence of hallux MTP malalignment, a cavus foot, or stiffness requires careful evaluation and may require additional surgical procedures to improve clinical results.

 

Previous excision of the fibular sesamoid or absence of the fibular sesamoid is the main contraindication to a tibial sesamoidectomy.1,2 A history of peripheral vascular disease, soft tissue or wound healing problems, diabetes mellitus, and smoking are also relative contraindications that require proper evaluation and discussion

with the patient before operative intervention.

 

Preoperative Planning

 

The initial evaluation of hallux alignment is of utmost importance, as failure of reconstruction of the tibial FHB complex or failure to address preexisting hallux malalignment will compromise patient outcome.

 

In general, any patient whose hallux alignment would be considered for surgical realignment without tibial sesamoiditis should have the malalignment corrected during the tibial sesamoidectomy.

 

Positioning

 

Anesthesia should be similar to a bunion procedure.

 

An ankle block with some mild sedation is typically well tolerated.

 

The patient should be placed on the operating table in a supine position.

 

A well-padded supramalleolar Esmarch tourniquet is applied.

 

The natural external rotation of the lower extremity allows excellent exposure to the medial aspect of the forefoot (FIG 5).

 

Approach

 

Dorsomedial, straight medial, and plantar medial incisions to approach the tibial sesamoid have been described. The most commonly used incision is a longitudinal medial skin incision that is slightly plantar to the standard incision for a bunion excision (see FIG 5).

 

With the dorsomedial incision, it is difficult to obtain adequate exposure of the plantar aspect of the foot, whereas the plantar medial incision is typically directly over the plantar cutaneous nerve and near the weight-bearing surface of the foot, increasing wound complications.

 

 

 

FIG 5 • Patient positioning including the slightly plantar planned incision and the natural externally rotated view of the foot.

 

TECHNIQUES

• Exposure

The most commonly used incision is a 3-cm longitudinal medial skin incision that is slightly plantar to the standard incision for a bunion excision. The incision is started at the midshaft of the proximal phalanx and ends at the metatarsal metaphyseal flare.

The plantar cutaneous nerve must be identified and mobilized inferiorly for protection during the procedure (TECH FIG 1A).

The nerve can usually be found along the inferior border of the abductor hallucis brevis tendon alongside the MTP joint.

 

 

A vessel loop can also be placed around the nerve to protect it.

 

 

 

TECH FIG 1 • A. The Freer elevator is underneath the plantar cutaneous nerve. B. Intracapsular view showing the articulation of the tibial sesamoid and the metatarsal head. (B: From Lee S. Technique of isolated tibial sesamoidectomy. Tech Foot Ankle Surg 2004;3:85-90, with permission.)

 

 

Make a longitudinal incision in the capsule in line with the skin incision in order to evaluate the MTP joint.

 

This incision is usually dorsal to the fibers of the insertion of the abductor hallucis tendon.

 

 

Assess the sesamoid articular surface for significant displacement or step-off in acute fractures or bipartite sesamoids. In chronic cases, assess the sesamoid-metatarsal articular cartilage that may be damaged by osteonecrosis, osteochondritis dissecans, or arthrosis (TECH FIG 1B).

 

• Tibial Sesamoidectomy

  54

   

  Outline the tibial sesamoid with a Beaver blade from the intraarticular approach, as it will assist in its later removal.

   

  In an acute fracture or a bipartite sesamoid without articular damage, consider bone grafting of the defect and repair as opposed to performing a sesamoidectomy. This bone graft may come from the distal portion of the first metatarsal.

   

  At this time, a repair of the capsulotomy with a 2-0 nonabsorbable suture before proceeding with the sesamoidectomy exposure can be performed or deferred for visualization of the sesamoid from an intraarticular or plantar vantage point (TECH FIG 2A).

   

  Expose the tibial sesamoid through an extra-articular plantar medial incision in line with the FHB fibers.

   

  The sesamoid is embedded within a dense fibrous sheath, and careful dissection out of the FHB and its soft tissue attachments is required (TECH FIG 2B).

   

   

   

  TECH FIG 2 • A. The tip of the Freer elevator is underneath the tibial sesamoid before dissection of the FHB complex. Also note the longitudinal capsulotomy and repair. B. After the initial incision to separate the FHB in line with its fibers. C. Note the FHL tendon deep to the operative incision as well as the subsequent purse-string repair of the FHB complex.

   

   

  This can be facilitated by the use of a Beaver mini-blade, using a pushing technique rather than a cutting motion, as well as grasping the sesamoid with a small towel clamp or Kocher clamp for stability.

   

  Take utmost care to protect the nerve medially as well as the FHL laterally to prevent injury.

   

  Once the sesamoid is removed, carefully assess the continuity of the FHB complex, as there are usually some remaining fibers of the FHB complex.

   

  Repair the plantar capsule defect with a 2-0 nonabsorbable suture in a triangular, figure-8, or purse-string fashion, with careful reapproximation of the FHB complex (TECH FIG 2C). The use of a UCL taper needle is recommended because it is noncutting and has a smaller radius of curvature, allowing easier manipulation.

   

  Assess the FHL tendon at this time.

   

  Once the FHB complex is reapproximated, take the hallux through a ROM to confirm that the FHB is intact and that the FHL tendon has not been inadvertently sutured.

• Wound Closure

   

  Complete the closure in standard fashion for a bunion procedure.

   

  Reapproximate the skin edges with a 3-0 nylon suture and dress the wound with a bunion dressing, with the hallux protected in plantarflexion and in mild varus.

   

  55

• Case Example (Courtesy of Mark E. Easley, MD)

Background and Imaging

 

A 34-year-old man with 1-year history of right plantar first metatarsal pain

 

 

Pain/ache with weight bearing and push-off during gait Physical examination

 

 

 

Tender under medial (tibial) sesamoid Plantar pain with hallux MTP joint dorsiflexion Negative first MTP joint Lachman test

 

 

Radiographs suggest lateral (fibular) sesamoid fracture (TECH FIG 3A,B). Sesamoid view suggests some irregularity to lateral sesamoid (TECH FIG 3C).

 

Computed tomography (CT) scan demonstrates transverse fracture line with a subacute/chronic appearance (TECH FIG 3D).

 

T2-weighted MRI scan demonstrates signal change in lateral (fibular) sesamoid (TECH FIG 3E).

Positioning and Exposure

 

Prone position typically improves exposure and visualization (TECH FIG 4A).

 

 

Longitudinal plantar incision between lateral sesamoid and second metatarsal head (TECH FIG 4B-E) Plantar lateral sensory nerve to the hallux identified and protected (TECH FIG 4F)

 

 

Longitudinal sharp division in periosteum over lateral sesamoid (TECH FIG 4G-I) FHL tendon identified and protected

 

 

 

TECH FIG 3 • A-C. Weight-bearing AP, lateral, and sesamoid radiographs, respectively, of a 34-year-old man with 1-year history of right lateral sesamoid fracture/nonunion. D. CT demonstrating fracture/nonunion and fragmentation of proximal pole of sesamoid. E. T2-weighted MRI demonstrates signal change in lateral sesamoid and dorsal first MTP joint effusion.

Lateral Sesamoidectomy

 

Fractured/nonunited area of lateral sesamoid identified (TECH FIG 5A)

 

Distal pole of lateral sesamoid enucleated from surrounding flexor mechanism/residual sesamoid complex (TECH FIG 5B-D)

 

Proximal of lateral sesamoid enucleated from surrounding flexor mechanism/residual sesamoid complex (TECH FIG 5E,F)

 

Excised sesamoid is inspected; in this case, cartilage degeneration, fragmentation, and suggestion of avascular necrosis (AVN) noted (TECH FIG 5G).

Flexor Mechanism/Residual Sesamoid Complex Repair

 

Preserving the flexor mechanism/residual sesamoid complex allows for its optimal repair, improves hallux MTP joint plantarflexion, and limits risk of hallux varus developing.

 

While protecting the FHL tendon, the residual intersesamoidal ligament (TECH FIG 6A-C) and periosteum (TECH FIG 6D-F) are reapproximated in layers to close the defect left by sesamoidectomy.

 

Intraoperative fluoroscopy confirms complete lateral sesamoidectomy and satisfactory hallux MTP joint alignment (TECH FIG 6G).

 

In this case, because the patient was placed in prone position, the fluoroscopic image appears to be a left foot.

 

Hallux MTP ROM is evaluated to make sure that the repair is not too tight (TECH FIG 6H,I).

 

Hallux interphalangeal (IP) joint ROM is checked to ensure that the FHL tendon has not been trapped in the repair (TECH FIG 6J,K).

 

The plantar wound is closed carefully to make sure the wound margins are congruent (TECH FIG 6L,M).

 

 

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TECH FIG 4 • A. Prone position is used to facilitate visualization and exposure. B,C. Planned longitudinal plantar incision between lateral sesamoid and second metatarsal head. B. Lateral sesamoid is medial. C. Second metatarsal head is lateral. D. Careful congruent longitudinal incision made. E. Careful soft tissue dissection to lateral sesamoid. F. The plantar lateral sensory nerve to the hallux identified and protected. It typically courses immediately plantar to the lateral sesamoid. For lateral sesamoid exposure, the fascial layer is divided longitudinally (G) and the periosteum is divided longitudinally (H).

 

 

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TECH FIG 5 • A. Fracture/nonunion site identified. Note scalpel blade in the fracture/nonunion site. B. Careful elevation of periosteum from plantar lateral sesamoid. C. Distal pole gradually being separated from intersesamoidal ligament. D. Distal pole extracted. E. Proximal pole separated from sesamoid complex. F. Proximal pole extracted. G. Excised sesamoid inspected. Note fragmentation and degeneration of sesamoid, particularly the proximal pole, suggestive of AVN.

 

 

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TECH FIG 6 • A-C. Reapproximation of residual sesamoid complex. A. Defect left by excised lateral sesamoid assessed. B. With FHL tendon protected, intersesamoidal ligament reapproximated to lateral periosteum. C. Defect being closed. D-F. Plantar fascial layer reapproximation. D. Suture passed through lateral tissue. E. Suture passed through medial tissue while protecting the plantar lateral sensory nerve to the hallux. F. Layer closed. G. Intraoperative fluoroscopy confirms complete lateral sesamoidectomy and satisfactory hallux MTP joint alignment. In this case, because the patient was placed in prone position, the fluoroscopic image appears to be a left foot. Passive MTP joint motion confirms that the repair is not overtightened: neutral position (H) and dorsiflexion (I). (continued)

 

 

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TECH FIG 6 • (continued) Passive IP joint motion confirms that the FHL tendon is not trapped in the repair: neutral position (J) and dorsiflexion (K). L. Careful subcutaneous layer repair. M. Congruent plantar skin reapproximation.

Postoperative Care

 

A bunion dressing is placed to protect the lateral soft tissue repair and limit the risk of developing hallux varus; a lower profile bunion dressing should continue for 4 to 6 weeks (TECH FIG 7A).

 

Protected weight bearing on heel for 4 to 6 weeks

 

Return to full activities limited for 8 to 10 weeks from surgery

 

With careful lateral flexor mechanism, closure and protected weight bearing postoperatively with bunion strapping, alignment, ROM, and push-off strength typically well maintained (TECH FIG 7B-D)

 

Plantar incision typically heals well, especially if it was performed between the weight-bearing surfaces (TECH FIG 7E).

 

 

 

TECH FIG 7 • Bunion dressing applied to limit risk of hallux varus developing.

 

 

 

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PEARLS AND PITFALLS
	Hallux ▪ The presence of a cavus foot, hallux valgus, claw toe, cock-up deformity, or malalignment stiffness requires careful evaluation and may require additional surgical procedures to improve clinical results.     Plantar ▪ The nerve is most commonly located plantar to the inferior border of the abductor cutaneous hallucis brevis tendon. This nerve should be visualized and protected throughout nerve the case.     FHB repair ▪ A UCL taper needle is easier to use in the limited surgical field. Careful and

 

	meticulous repair of the FHB complex is required to prevent the development of malalignment.

 

 

POSTOPERATIVE CARE

 

The patient is provided with a firm-soled postoperative shoe or a short walker boot and allowed immediate heel weight bearing.

 

 

Patients are limited to heel weight bearing for 2 weeks.

 

At the 2-week follow-up visit, stitches are removed, a toe spacer is placed, and patients are allowed to bear weight as tolerated in a postoperative shoe or a short walker boot.

 

 

Standing radiographs should be performed to confirm maintenance of hallux alignment.

 

The toe spacer should remain in place for 6 to 8 weeks postoperatively to prevent hallux valgus deformity.

 

If a hallux realignment procedure was also performed, we use a taping technique for 4 to 6 weeks similar to a bunion procedure.

 

Patients are encouraged to begin active and passive ROM exercises for the hallux MTP joint after stitches are removed.

 

In active patients, formal physical therapy is warranted to monitor patient progress and to assist in ROM and soft tissue modalities.

 

Patients return at 6 weeks postoperatively and are then allowed to progress to accommodative shoe wear and activity as tolerated.

 

 

 

FIG 6 • Six-month follow-up of the patient in TECH FIGS 3, 4, 5, 6, 7. A. Although hallux with neutral position compared to contralateral hallux, alignment satisfactory without suggestion of hallux varus. B. Weight-bearing

AP radiograph demonstrating lateral sesamoid excision and satisfactory alignment. (continued)

 

 

Patients may occasionally require continued short-term use of a sesamoid relief orthotic while returning to activity.

 

OUTCOMES

 

FIG 6 shows the case example at 6-month follow-up.

 

Hallux malalignment with resultant claw toe and cock-up and hallux valgus deformity after tibial sesamoid excision have been described.8,9,11

 

Historical studies have found a 10% to 42% incidence of hallux valgus and a 33% to 60% incidence of loss of motion on follow-up.8,11

 

Kaiman and Piccora9 also reviewed tibial sesamoidectomies and concluded that assessment of the osseous relationship was crucial to prevent hallux valgus deformity. Their average follow-up was only

13.2 months and they found no evidence of valgus drift, but they recommended tendon balancing or capsulorrhaphy in conjunction with the tibial sesamoidectomy.

 

Lee et al10 reported on 20 patients without preoperative malalignment and noted no significant difference in postoperative ROM or the development of subsequent hallux malalignment.

 

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FIG 6 • (continued) C. Dorsiflexion function well preserved. D. Plantar incision is well healed without thickened scar or symptoms.

 

 

Saxena and Krisdakumtorn13 reported on active individuals who had isolated tibial sesamoidectomies.

 

One patient developed loss of hallux flexion after surgery.

 

Two patients with hallux valgus deformity were identified before surgery. One patient had a concomitant distal metatarsal osteotomy with no further drift, whereas the other patient did not have a concomitant procedure at the same time and went on to a bunion correction at a later date.

Inge and Ferguson8 found that 41% of their patients continued to have mild to severe pain after a tibial sesamoidectomy. More recently, however, Van Hal et al,15 Saxena and Krisdakumtorn,13 and Lee et al10 have reported excellent pain relief in the majority of their patients with tibial sesamoidectomies in their

athletic population.

Aper et al2 showed in two cadaveric studies that the FHB effective tendon moment arms are significantly decreased with the excision of both hallux sesamoids. However, FHL effective tendon moment arms are

noted to be diminished with isolated sesamoid excisions as well.1 However, Van Hal et al15 and Saxena

and Krisdakumtorn13 did not find functional weakness of plantarflexion in any of their patients. Their patients were also able to return to their previous level of athletic participation with no functional deficit.

Lee et al10 also reported that 30% of their patients could not do a single-limb toe raise, indicating some plantarflexion weakness, but this did not affect any subsequent athletic activity.

Tagoe et al14 described 36 feet that underwent total sesamoidectomy for the management of hallux rigidus or limitus. No significant functional impairment or malalignment were found postoperatively. There were no patients with transfer metatarsalgia or pain with metatarsal compression. Postoperatively, the patients had a statistically significant improvement in their American Orthopaedic Foot and Ankle Society (AOFAS) scores.

Bichara et al4 reported on 24 athletic patients (5 elite athletes) with sesamoid fractures that failed conservative management were treated surgically with an isolated sesamoidectomy. Twenty-two out of 24 patients (91.6%) returned to athletic activities at a mean of 11.6 weeks. Mean preoperative pain level decreased from 6.2 to a mean of 0.7 postoperatively. One patient developed a symptomatic hallux valgus deformity after tibial sesamoidectomy.

 

 

COMPLICATIONS

Complications related to tibial sesamoid excisions can be separated into intraoperative complications, insufficient pain relief, functional weakness, and hallux malalignment.

The most common intraoperative complication reported is injury to the plantar digital nerve.

Patients typically complain of nerve irritation postoperatively. This generally responds well to observation or localized steroid injections. It occurs more commonly with fibular sesamoid excisions.

Complete laceration of the nerve has never been reported, and this nerve irritation appears to be the result of aggressive retraction during surgery. This can be avoided by using meticulous technique with identification and protection of the plantar digital nerve during surgery.

Isolated complete sesamoidectomies are thought to alter the mechanical balance of the hallux MTP joint. Clinical studies have described stiffness, functional loss, cock-up deformity, claw toe deformity, and the development of a hallux valgus deformity after isolated tibial sesamoidectomies.8,9,10

As noted earlier, identifying and addressing any significant malalignment of the hallux MTP can decrease the rate of future deformities.

The loss of single-limb toe raise has also been reported and may be related to the decreased moment arm and inadequate repair of the FHB complex.10

 

 

 

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REFERENCES

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2. Aper RL, Saltzman CL, Brown TD. The effect of hallux sesamoid resection on the effective moment of the flexor hallucis brevis. Foot Ankle Int 1994;15:462-470.

    

    

3. Beaman DN, Nigo LJ. Hallucal sesamoid injury. Oper Tech Sports Med 1999;7:7-13.

    

    

4. Bichara DA, Henn RF III, Theodore GH. Sesamoidectomy for hallux sesamoid fractures. Foot Ankle Int 2012;33:704-706.

    

    

5. Coughlin MJ. Sesamoid pain: causes and surgical treatment. Instr Course Lect 1990;39:23-35.

    

    

6. Dobas DC, Silvers MD. The frequency of partite sesamoids of the first metatarsophalangeal joint. J Am Podiatry Assoc 1977;67:880-882.

    

    

7. Helal B. The great toe sesamoid bones: the lus or lost souls of Ushaia. Clin Orthop Relat Res 1981; (157):82-87.

    

    

8. Inge GAL, Ferguson AB. Surgery of the sesamoid bones of the great toe: an anatomic and clinical study, with a report of forty-one cases. Arch Surg 1933;27:466-489.

    

    

9. Kaiman ME, Piccora R. Tibial sesamoidectomy: a review of the literature and retrospective study. J Foot Surg 1983;22:286-289.

    

    

10. Lee S, James WC, Cohen BE, et al. Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int 2005;26:803-809.

     

     

11. Nayfa TM, Sorto LA Jr. The incidence of hallux abductus following tibial sesamoidectomy. J Am Podiatry Assoc 1982;72: 617-620.

     

     

12. Richardson EG. Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg 1999;7:270-278.

     

     

13. Saxena A, Krisdakumtorn T. Return to activity after sesamoidectomy in athletically active individuals. Foot Ankle Int 2003;24: 415-419.

     

     

14. Tagoe M, Brown HA, Rees SM. Total sesamoidectomy for painful hallux rigidus: a medium-term outcome study. Foot Ankle Int 2009;30: 640-646.

     

     

15. Van Hal ME, Keene JS, Lange TA, et al. Stress fractures of the great toe sesamoids. Am J Sports Med

1982;10:122-128.