Why We Should Consider Arthroscopic Treatment For The Chronically Diseased Sesamoid
A Closer Look At The Authors’ Experience
Between 1988 and 2008, 432 patients (252 female, 180 male) had a diagnosis of sesamoid disorders at the Foot and Ankle Institute of Illinois, excluding acute fracture. The most common diagnosis was sesamoiditis (57 percent), followed by avascular necrosis (13 percent), arthritis (13 percent), non-union fracture (10 percent) and exostoses (7 percent). Of these patients, offloading (accommodative orthoses) was successful in 72 percent of these cases. This is a reminder that most sesamoid disease will respond well without patients entering the operating room.
Of the 122 (28 percent) patients who were non-responsive to conservative care, the majority consisted of those who had avascular necrosis or non-union of a fracture. Offloading was unsuccessful in only 10 to 20 percent of those diagnosed with exostoses, sesamoiditis and arthritis.
Thirty-nine of 122 patients had excision of the affected sesamoid. After six months, only 34 (28 percent) were pain-free and performing desired activity. Twelve patients (31 percent) had continued pain that kept them from performing desired activities. In fact, four of 12 patients had unsuccessful removal of the other sesamoid, requiring arthrodesis in two, a successful metatarsal head resection in one and the other refusing surgery. Two of 12 patients had a successful metatarsal head resection and two patients had an elevating osteotomy, which relieved pain in one patient. The remaining four patients refused surgery.
Four patients had sesamoid planing and after six months, three were pain-free and able to perform desired activity. We performed this treatment specifically for those with exostoses or notably hypertrophic sesamoids.
Two patients had arthrodesis, both of whom were neither pain-free nor able to perform desired activity. Three of 12 patients had joint replacement, which was successful in only one patient. Two patients had metatarsal head resection, which was successful regarding pain and function after six months. After one year, however, one developed second metatarsalgia and had a subsequent resection.
Twenty-nine patients had an elevating osteotomy, which was 31 percent effective in achieving desirable pain and function levels.
Most interesting is that 13 patients had arthroscopy and all but one were pain-free and able to perform desired activities after six months with the one failure carrying the diagnosis of sesamoiditis. We performed these arthroscopic debridements on those with chronic non-unions, exostoses and partial avascular necrosis.
While clinicians can often relieve sesamoiditis by conservative measures, the condition may remain persistent and cause significant pain and loss of desired activity, especially for those with avascular necrosis and non-unions of one or both sesamoids. The aforementioned case report highlights the fact that sesamoid removal is not without complication. The apparatus and sesamoid no longer function as designed, taking on more weightbearing forces and being subject to altered joint mechanics.6
As specialists of the foot and ankle, podiatrists must seek a more refined, proficient way to treat these disorders rather than succumb to the less advanced and destructive removal of the affected bone. Surgeons should attempt to salvage and restore the function of the joint. Arthroscopy offers the unique advantage of accomplishing these goals. We encourage the foot and ankle surgeon to consider this in his or her armamentarium for an often disabling disease.
Dr. Grady is the Director of The Foot and Ankle Institute of Illinois. He is the Chief of the Podiatry Section of the Jesse Brown Veterans Affairs Medical Center and the Director of the Podiatric Surgical Residency Program at the Westside Division of the Veterans Administration Chicago Healthcare System. He is board-certified by the American Board of Podiatric Surgery, the American Board of Podiatric Medicine and the American Board of Wound Management. Dr. Grady is a Fellow of the American Society of Podiatric Surgeons and is the Scientific Chairman of the Midwest Podiatry Conference.
Dr. Trotter is a second-year resident at the Jesse Brown Veterans Affairs Medical Center. in Chicago.