FOOT & ANKLE INTERNATIONAL Copyright 2012 by the American Orthopaedic Foot & Ankle Society DOI: 10.3113/FAI.2012.

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Sesamoidectomy for Hallux Sesamoid Fractures

David A. Bichara, MD; R. Frank Henn III, MD; George H. Theodore, MD
Boston, MA

ABSTRACT Background: Hallux sesamoid fractures are challenging to treat. Symptomatic nonunion is a common problem after nonoperative treatment. Surgical xation of the fracture can result in successful union, but is technically challenging and can be associated with prolonged return to activities (RTA). Sesamoidectomy is an alternative surgical option that may provide reliable outcomes and allow an earlier RTA in athletes. The purpose of this case-series study was to evaluate a cohort of athletic patients with a hallucal sesamoid fracture treated with sesamoidectomy. Methods: A total of 24 patients with 24 sesamoid fractures that failed to respond to nonoperative measures were treated surgically with sesamoidectomy. Patients age, level of activity, fractured bone, surgical approach, time required to RTA, and postoperative complications were recorded. Pre- and postoperative pain was assessed with a visual analog scale ranging from zero (no pain) to 10 (intense pain). Five patients were classied as elite athletes playing at an intercollegiate level and 19 were classied as active individuals performing an athletic activity at least three times per week. The mean patient age was 32.2 10.4 (range, 17 to 54) years. The 24 patients were reviewed at a mean follow-up of 35 21 (range, 8 to 70) months. Results: A total of 22/24 patients (91.6%) returned to activities at a mean time of 11.6 3.87 (range, 8 to 24) weeks. Mean preoperative pain level was 6.2 1.4 and the pain level improved after treatment to a mean of 0.7 1. One patient developed a symptomatic hallux valgus deformity after the resection of the medial sesamoid. Conclusions: This case series demonstrates good results after sesamoidectomy for sesamoid fractures in athletic individuals with reliable pain relief and RTA within 11.6 weeks. Progressive hallux valgus remains a
Massachusetts General Hospital, Harvard Medical School, Boston, MA. No benets in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding Author: George H. Theodore, MD Massachusetts General Hospital 175 Cambridge Street, 4th Floor Boston, MA 02114 E-mail: GTheodore@Partners.org For information on pricings and availability of reprints, e-mail reprints@datatrace.com or call 410-494-4994, x232.

concern after medial sesamoidectomy, with an incidence of 1 in 24 cases in this study.

Level of Evidence: IV, Retrospective Case Series

Key Words: Sesamoidectomy; Hallucal Sesamoid Fracture; Athletic Patients INTRODUCTION

Sesamoid bones perform a crucial role in the function of the rst metatarsophalangeal joint. Located within the tendons of the exor hallucis brevis, the hallux sesamoid bones aid in the transmission of a majority of force of the rst ray. Because of their anatomical location, these accessory bones are predisposed to repeated stress and trauma, making them susceptible to fractures, which are characterized by pain that is worsened by passive dorsiexion, ambulation, and running. Patients sometimes tolerate fractures by ambulating on the lateral aspect of the foot. Delay in diagnosis is common and may lead to prolonged symptoms and decreased function. Nonoperative treatment is the initial management for hallux sesamoid fractures. Activity modication, immobilization in a cast, orthotics, and anti-inammatory medications may all be considered as initial measures.2,7,8 Symptomatic nonunion may occur after nonoperative treatment.4 Surgical xation of the fracture, with possible bone grafting,1 can result in successful union but is technically challenging. If the screw is not inserted perpendicular to the fracture line, the insertion may cause fracture displacement.6 Improper screw placement can also fail to deliver the required compression to achieve fracture healing. Additionally, xation can be associated with prolonged return to activities (RTA) and screws may cause mechanical pain when patients exercise.6 Sesamoidectomy is an alternative surgical option for symptomatic hallucal fractures that fail to respond to conservative treatment. Sesamoidectomy, when combined with early weightbearing and functional rehabilitation, can result in successful and timely RTA. The purpose of this study was to
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report a cohort of 24 athletes with a hallucal sesamoid fracture treated with sesamoidectomy after failed nonoperative treatment.
MATERIALS AND METHODS

The study was approved by the Institutional Review Board of the Massachusetts General Hospital. This was a retrospective study of patients who underwent surgical treatment for a sesamoid nonunion by the senior author from 2006 to 2010. Written informed consent was collected from each patient. Twenty-four patients with 24 sesamoid fractures were included in this study and a review of available medical records was performed. The patients age, level of activity, fractured sesamoid bone, surgical approach, time required to RTA, and postoperative complications were recorded. Pre- and postoperative pain was assessed with a visual analog scale ranging from zero (no pain) to 10 (intense pain). Patients were classied as elite athletes (playing in a professional or college level) or athletically active individuals (performing an athletic activity at least three times per week). All patients underwent uoroscopically guided diagnostic injection with 0.5% bupivacaine hydrochloride and 10 mg of triamcinolone acetonide into the affected metatarsalsesamoid articulation to conrm relief of painful symptoms before consideration of surgical excision. All patients included in this study failed to respond to conservative measures and underwent sesamoidectomy as a therapeutic treatment. Twenty-four patients were reviewed at a mean follow-up of 35 21 (range, 8 to 70) months. Five patients were classied as elite athletes playing at an intercollegiate level and 19 were classied as athletically active individuals. Twenty-three patients sustained a fracture while performing an athletic activity, including a police ofcer who sustained a fracture while on duty. One patient sustained a fracture after trauma (direct blow from a heavy box). The mean patient age was 32.2 10.4 (range, 17 to 54) years. There were 15 medial sesamoid fractures and nine lateral fractures. A medial sesamoid resection was done through a medial approach in which the plantar digital nerve was retracted. A capsulotomy was done, and the sesamoid was dissected from the exor hallucis brevis, which was preserved. Meticulous closure of the capsule was performed with multiple
Table 1: Results Summary

interrupted sutures. For the dorsal approach to the lateral sesamoid, an incision was created in the rst interdigital space and deepened to the sesamoid-rst metatarsal articulation. The sesamoid was excised, and the adductor tendon and capsule were anatomically repaired. Postoperatively, patients were instructed to begin weightbearing as tolerated in a postoperative shoe with crutches for 7 to 10 days. Some patients used a removable walking boot for an additional 2 weeks.
RESULTS

A total of 22/24 patients (91.6%) RTA at a mean time of 11.6 3.9 (range, 8 to 24) weeks. Patients with a lateral sesamoid excision RTA at a mean time of 10.2 2.9 (range, 8 to 16) weeks, whereas those with a medial sesamoid excision RTA at 12.7 4.3 (range, 8 to 24) weeks. With the numbers available, no signicant difference could be detected between the excised sesamoid bone and the time required to RTA (p value = 0.155). Additionally, no signicant difference was found on the time required to RTA between elite athletes (n = 5) and athletically active (n = 19) individuals (p value = 1.0). Mean preoperative pain level was 6.2 1.4, and improved after treatment to a mean of 0.7 1. Histological evaluation of the 24 excised specimens conrmed a chronic fracture in all cases. One of the specimens also contained negatively birefringent crystals, consistent with a diagnosis of gout. Although no cases required revision surgery, one patient developed a symptomatic hallux valgus deformity after the resection of the medial sesamoid. This was one out of two patients who did not RTA. The results of this study are summarized in Table 1.
DISCUSSION

Limited peer-reviewed reports describing case series after sesamoidectomy for hallux sesamoid fractures exist in the literature. In this case series, we report good overall results after sesamoidectomy in athletes with a hallucal sesamoid fracture that failed to respond to conservative measures. Patients experienced excellent pain relief postoperatively and 22/24 (91.6%) were able to RTA, on average, within 11.6

Medial Lateral Patients Fractures sesamoids sesamoids

24 24 15 9

Surgical approach
Medial incision: 15 medial sesamoids; Dorsal incision: 9 lateral sesamoids

Mean Mean Mean RTA preoperative postoperative (weeks) pain level pain level
11.6 6.2 0.69

Complications
Hallux valgus in one patient after medial sesamoid resection.

Copyright 2012 by the American Orthopaedic Foot & Ankle Society

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weeks. The RTA in our study is comparable with other results. Saxena and Krisdakumtorn reported 26 sesamoid excisions in 24 patients that were resected due to intractable symptoms despite conservative treatment. After sesamoidectomy, patients had a mean RTA after a 12-week period, while some of the athletically active individuals included in the study returned to activities as early as seven and a half weeks.9 Two patients in this series were unable to RTA; one patient developed a symptomatic hallux valgus deformity after excision of the medial sesamoid, and the second patient reported pain attributable to associated right foot metatarsalgia and exor hallucis tenosynovitis after resection of the lateral sesamoid through a dorsal incision. Both of these patients were classied as athletically active individuals. Although surgical excision of a sesamoid is recommended when nonoperative care has proven unsuccessful, postoperative complications need to be considered. Complications may include disruption of the anatomy of the hallucal sesamoid complex, great toe stiffness, injury to the cutaneous nerves, or persistent pain. One patient developed a hallux valgus deformity after resection of the medial sesamoid. No hallux varus deformities were encountered. An alternative treatment includes screw xation of the nonunion. Blundell et al. reported a case-series study of nine high-performance athletes in which hallucal sesamoid fractures were treated by percutaneous screw xation.3 No complications were reported and patients went back to their same level of activity at the 12-week time point. Pagenstert et al. reported the same time to RTA in a study involving percutaneous screw xation of sesamoid fractures in eight athletic patients. Both of these studies reported a time required to RTA similar to the one in our study. Although the authors stated that the sesamoids are critical for the

preservation of the function of the great toe, particularly in high-performance athletes,5 we have demonstrated results comparable to cases treated by percutaneous screw xation in regards to time required for patients to RTA.
CONCLUSION

This retrospective case series demonstrates good results after sesamoidectomy for sesamoid nonunions in athletic individuals with reliable pain relief and RTA at a mean of 11.6 weeks. Progressive hallux valgus remains a concern after medial sesamoidectomy.
REFERENCES
1. Anderson, RB; McBryde, AM, Jr.: Autogenous bone grafting of hallux sesamoid nonunions. Foot Ankle Int. 18:293 296, 1997. 2. Axe, MJ; Ray, RL: Orthotic treatment of sesamoid pain. Am J Sports Med. 16:411 416, 1998. 3. Blundell, CM; Nicholson, P; Blackney, MW: Percutaneous screw xation for fractures of the sesamoid bones of the hallux. J Bone Joint Surg Br. 84:1138 1141, 2002. http://dx.doi.org/10.1302/0301620X.84B8.13064 4. Hulkko, A; Orava, S: Diagnosis and treatment of delayed and non-union stress fractures in athletes. Ann Chir Gynaecol. 80:177 184, 1991. 5. Oloff, LM; Schulhofer, SD: Sesamoid complex disorders. Clin Podiatr Med Surg. 13:497 513, 1996. 6. Pagenstert, G, Hintermann B, Valderrabano V: Percutaneous xation of hallux sesamoid fractures. Tech Foot Ankle Surg. 7:107 114, 2008. http://dx.doi.org/10.1097/BTF.0b013e318165dda7 7. Richardson, EG: Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg. 7:270 278, 1999. 8. Richardson, EG: Injuries to the hallucal sesamoids in the athlete. Foot Ankle. 7:229 244, 1987. 9. Saxena, A; Krisdakumtorn, T: Return to activity after sesamoidectomy in athletically active individuals. Foot Ankle Int. 24:415 419, 2003.

Copyright 2012 by the American Orthopaedic Foot & Ankle Society