Why We Should Consider Arthroscopic Treatment For The Chronically Diseased Sesamoid

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

   Since that time, she developed stiffness and pain that was worse than before the initial surgery. Her physical exam on the first visit was notable for 15 degrees of dorsiflexion and plantarflexion of the first MPJ. The patient demonstrated an antalgic gait, walking with the hallux completely off the ground of the affected foot.

   Radiographs at this visit were notable for significant erosion, narrowing and asymmetry of the sesamoid-metatarsal articulation with hypertrophy, sclerosis and erosions present on the tibial sesamoid. An ultrasound scan using an 8 mHz probe demonstrated degeneration within the sesamoid-metatarsal articulation.

   Offloading started at this first visit.There was minimal relief with aggressive offloading and the patient subsequently received steroid injections, a prescription for physical therapy and even visited a pain control specialist over the course of the next six months.

   The patient returned in May 2008, continuing to complain of 10/10 pain while standing and ambulating. At this point, atrophy was visible under the sesamoid and we thought the patient might benefit from a sesamoidectomy as no other options existed. However, in order to preserve the remaining sesamoid, we decided to perform arthroscopic debridement of the sesamoid, including osteochondral defects and loose fragments.

   We performed the surgery in May 2008. We marked portals using the typical dorsomedial, dorsolateral and straight medial arthroscopy portals of the first MPJ.5 Appreciating the anatomy, we took care to avoid branches of the deep peroneal, medial dorsal cutaneous and saphenous nerves. Palpating the joint line helped identify the medial and lateral border of the extensor hallucis longus. We then inserted a 19 gauge spinal needle into the joint and inflated the joint with 5 mL of normal saline. We made skin incisions and bluntly dissected subcutaneous tissue with a hemostat to reach the deep capsule. We inserted an obturator and cannula into the joint followed by a 2.7 mm (one can use 1.9 mm), 30 degree arthroscope. Plantarflexion of the hallux facilitates exposure.

   When visualizing the dorsomedial portal, the first metatarsal head is proximal, the tibial sesamoid is central and the proximal phalanx base is visible at the top. In the corresponding arthroscopic view, the tibial sesamoid is to the left and the metatarsal articulation is above. The abnormal cartilaginous defect is visible centrally on the sesamoid and appears walled off as a partial avascular necrosis. The procedure involved removal of the lateral portion of the tibial sesamoid along with debridement of this defect.

   From the first postoperative visit forward, the patient had a drastic reduction in pain and no pain on her last visit in September 2008. She had achieved 65 degrees of dorsiflexion and 32 degrees of plantarflexion, and was returning to all desired sporting activities. A subsequent ultrasound of the joint revealed a reduction in fluid within the apparatus and smooth edges of the sesamoid metatarsal articulation with unrestricted motion.

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