Why We Should Consider Arthroscopic Treatment For The Chronically Diseased Sesamoid

John F. Grady, DPM, FASPS, FACFAOM, and Katy Trotter, DPM

Although hallux valgus and hallux limitus comprise the majority of first ray pathology, sesamoid disorders are not uncommon and may even carry greater morbidity that demands attention. A generic diagnosis of sesamoiditis may encompass several etiologies including fracture, symptomatic nonunion, avascular necrosis, osteoarthritis, dislocation, infection and symptomatic bipartite sesamoids.1

   Upon diagnosis, conservative care begins and includes offloading with accommodative padding, rest and anti-inflammatory medication. Further conservative care for those unresponsive to initial therapies includes steroid injections, below-knee cast/boot immobilization, bone stimulation and radial extracorporeal shockwave therapy.1,2

   When isolated sesamoid disease becomes refractory to conservative treatments, physicians face what seems to be a last resort: removal of the painful sesamoid. While this is seemingly a benign procedure, an isolated sesamoidectomy is not without complications. Accordingly, one must weigh the benefits of pain relief against the postoperative complications. Complications may include continued pain, painful scars, wound dehiscence, infection, hallux stiffness, hallux hammertoe, hallux varus, hallux valgus, neuritis, injury to the remaining sesamoid and the inability to resume desired activity.1,2

   Saxena and colleagues sought to determine the time to return to activity, particularly in athletically active individuals, when they performed 26 sesamoidectomies in 24 patients.1 Prior to the surgery, the patients in the study had between three and 48 months of unsuccessful treatment consisting of offloading orthotics, injections, non-steroidal anti-inflammatory drugs and physical therapy. Overall, 20 of 24 patients were able to return to their desired level of activity with no patients developing injury to the remaining sesamoid at an average follow-up of seven years. Complications included two patients with nerve entrapment, two patients with hallux valgus, one patient with hallux varus and one with a loss of hallux flexion, requiring fusion. Patients returned to activity as early as seven weeks. Others have reported the incidence of hallux valgus following tibial sesamoidectomy at 42 percent.3

   The sesamoid apparatus has four functions: aiding shock absorption; increasing plantarflexion power at the first metatarsophalangeal joint (MPJ); maintaining an equal and smooth arc of motion of the first MPJ; and protecting the flexor hallucis longus as it courses distally.4,7 The sesamoid bones and apparatus inherently serve these valuable functions. The reported complications give credence to this fact and one should attempt to maintain and salvage as much of the apparatus as possible. Physicians, therefore, should not be quick to settle for the less than desirable sesamoid removal and consider a minimally invasive, more technically demanding and less practiced surgical intervention in arthroscopic debridement, drilling and removal of loose fragments to restore and salvage the sesamoid.

Case Study: How Arthroscopic Debridement Can Preserve The Remaining Sesamoid

The following case study highlights not only the fact that isolated sesamoid removal can and often does cause morbidity to the remaining sesamoid, it also demonstrates the drastic and impressive recovery of the remaining sesamoid for which surgeons had heavily contemplated removal.

   A 34-year-old female first presented to the office in 2007 for evaluation of a painful tibial sesamoid of her left foot. She had previous removal of the fibular sesamoid and received a diagnosis of avascular necrosis.

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