FOOT & ANKLE INTERNATIONAL

Copyright 2012 by the American Orthopaedic Foot & Ankle SocietyDOI: 10.3113/FAI.2012.0704

Sesamoidectomy for Hallux Sesamoid Fractures

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

ABSTRACT

Background: Hallux sesamoid fractures are challenging to treat.Symptomatic nonunion is a common problem after nonopera-tive treatment. Surgical fixation of the fracture can result insuccessful union, but is technically challenging and can be asso-ciated with prolonged return to activities (RTA). Sesamoidec-tomy is an alternative surgical option that may provide reliableoutcomes and allow an earlier RTA in athletes. The purpose ofthis case-series study was to evaluate a cohort of athletic patientswith a hallucal sesamoid fracture treated with sesamoidectomy.Methods: A total of 24 patients with 24 sesamoid fracturesthat failed to respond to nonoperative measures were treatedsurgically with sesamoidectomy. Patients’ age, level of activity,fractured bone, surgical approach, time required to RTA, andpostoperative complications were recorded. Pre- and postop-erative pain was assessed with a visual analog scale rangingfrom zero (no pain) to 10 (intense pain). Five patients wereclassified as elite athletes playing at an intercollegiate level and19 were classified as active individuals performing an athleticactivity at least three times per week. The mean patient agewas 32.2 ± 10.4 (range, 17 to 54) years. The 24 patients werereviewed at a mean follow-up of 35 ± 21 (range, 8 to 70) months.Results: A total of 22/24 patients (91.6%) returned to activ-ities 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 levelimproved after treatment to a mean of 0.7 ± 1. One patientdeveloped a symptomatic hallux valgus deformity after theresection of the medial sesamoid. Conclusions: This case seriesdemonstrates good results after sesamoidectomy for sesamoidfractures in athletic individuals with reliable pain relief andRTA within 11.6 weeks. Progressive hallux valgus remains a

Massachusetts General Hospital, Harvard Medical School, Boston, MA.

No benefits in any form have been received or will be received from a commercialparty related directly or indirectly to the subject of this article.

Corresponding Author:George H. Theodore, MDMassachusetts General Hospital175 Cambridge Street, 4th FloorBoston, MA 02114E-mail: GTheodore@Partners.org

For information on pricings and availability of reprints, e-mail reprints@datatrace.comor call 410-494-4994, x232.

concern after medial sesamoidectomy, with an incidence of 1 in24 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 functionof the first metatarsophalangeal joint. Located within thetendons of the flexor hallucis brevis, the hallux sesamoidbones aid in the transmission of a majority of force of the firstray. Because of their anatomical location, these accessorybones are predisposed to repeated stress and trauma, makingthem susceptible to fractures, which are characterized by painthat is worsened by passive dorsiflexion, ambulation, andrunning. Patients sometimes tolerate fractures by ambulatingon the lateral aspect of the foot. Delay in diagnosis iscommon and may lead to prolonged symptoms and decreasedfunction.

Nonoperative treatment is the initial management forhallux sesamoid fractures. Activity modification, immobiliza-tion in a cast, orthotics, and anti-inflammatory medicationsmay all be considered as initial measures.2,7,8 Symptomaticnonunion may occur after nonoperative treatment.4 Surgicalfixation of the fracture, with possible bone grafting,1 canresult in successful union but is technically challenging. Ifthe screw is not inserted perpendicular to the fracture line, theinsertion may cause fracture displacement.6 Improper screwplacement can also fail to deliver the required compression toachieve fracture healing. Additionally, fixation can be asso-ciated with prolonged return to activities (RTA) and screwsmay cause mechanical pain when patients exercise.6

Sesamoidectomy is an alternative surgical option for symp-tomatic hallucal fractures that fail to respond to conserva-tive treatment. Sesamoidectomy, when combined with earlyweightbearing and functional rehabilitation, can result insuccessful and timely RTA. The purpose of this study was to

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Foot & Ankle International/Vol. 33, No. 9/September 2012 HALLUX SESAMOID FRACTURES 705

report a cohort of 24 athletes with a hallucal sesamoid frac-ture treated with sesamoidectomy after failed nonoperativetreatment.

MATERIALS AND METHODS

The study was approved by the Institutional Review Boardof the Massachusetts General Hospital. This was a retro-spective study of patients who underwent surgical treatmentfor a sesamoid nonunion by the senior author from 2006to 2010. Written informed consent was collected from eachpatient. Twenty-four patients with 24 sesamoid fractures wereincluded in this study and a review of available medicalrecords was performed. The patients’ age, level of activity,fractured sesamoid bone, surgical approach, time requiredto RTA, and postoperative complications were recorded.Pre- and postoperative pain was assessed with a visualanalog scale ranging from zero (no pain) to 10 (intensepain). Patients were classified as elite athletes (playing ina professional or college level) or athletically active individ-uals (performing an athletic activity at least three times perweek). All patients underwent fluoroscopically guided diag-nostic injection with 0.5% bupivacaine hydrochloride and 10mg of triamcinolone acetonide into the affected metatarsal-sesamoid articulation to confirm relief of painful symp-toms before consideration of surgical excision. All patientsincluded in this study failed to respond to conservativemeasures and underwent sesamoidectomy as a therapeutictreatment. Twenty-four patients were reviewed at a meanfollow-up of 35 ± 21 (range, 8 to 70) months. Five patientswere classified as elite athletes playing at an intercollegiatelevel and 19 were classified as athletically active individuals.Twenty-three patients sustained a fracture while performingan athletic activity, including a police officer who sustained afracture while on duty. One patient sustained a fracture aftertrauma (direct blow from a heavy box). The mean patientage was 32.2 ± 10.4 (range, 17 to 54) years. There were 15medial sesamoid fractures and nine lateral fractures.

A medial sesamoid resection was done through a medialapproach in which the plantar digital nerve was retracted.A capsulotomy was done, and the sesamoid was dissectedfrom the flexor hallucis brevis, which was preserved. Metic-ulous closure of the capsule was performed with multiple

interrupted sutures. For the dorsal approach to the lateralsesamoid, an incision was created in the first interdigitalspace and deepened to the sesamoid-first metatarsal articula-tion. The sesamoid was excised, and the adductor tendon andcapsule were anatomically repaired. Postoperatively, patientswere instructed to begin weightbearing as tolerated in a post-operative shoe with crutches for 7 to 10 days. Some patientsused a removable walking boot for an additional 2 weeks.

RESULTS

A total of 22/24 patients (91.6%) RTA at a mean timeof 11.6 ± 3.9 (range, 8 to 24) weeks. Patients with alateral sesamoid excision RTA at a mean time of 10.2 ±2.9 (range, 8 to 16) weeks, whereas those with a medialsesamoid excision RTA at 12.7 ± 4.3 (range, 8 to 24) weeks.With the numbers available, no significant difference couldbe detected between the excised sesamoid bone and thetime required to RTA (p value = 0.155). Additionally, nosignificant difference was found on the time required toRTA between elite athletes (n = 5) and athletically active(n = 19) individuals (p value = 1.0). Mean preoperativepain level was 6.2 ± 1.4, and improved after treatmentto a mean of 0.7 ± 1. Histological evaluation of the 24excised specimens confirmed a chronic fracture in all cases.One of the specimens also contained negatively birefringentcrystals, consistent with a diagnosis of gout. Although nocases required revision surgery, one patient developed asymptomatic hallux valgus deformity after the resection ofthe medial sesamoid. This was one out of two patients whodid not RTA. The results of this study are summarized inTable 1.

DISCUSSION

Limited peer-reviewed reports describing case series aftersesamoidectomy for hallux sesamoid fractures exist in theliterature. In this case series, we report good overall resultsafter sesamoidectomy in athletes with a hallucal sesamoidfracture that failed to respond to conservative measures.Patients experienced excellent pain relief postoperatively and22/24 (91.6%) were able to RTA, on average, within 11.6

Table 1: Results Summary

Patients FracturesMedial

sesamoidsLateral

sesamoidsSurgicalapproach

MeanRTA

(weeks)

Meanpreoperative

pain level

Meanpostoperative

pain level Complications

24 24 15 9 Medial incision: 15medial sesamoids;

11.6 6.2 0.69 Hallux valgus in onepatient after medialsesamoid resection.

Dorsal incision: 9lateral sesamoids

Copyright 2012 by the American Orthopaedic Foot & Ankle Society

706 BICHARA ET AL. Foot & Ankle International/Vol. 33, No. 9/September 2012

weeks. The RTA in our study is comparable with otherresults. Saxena and Krisdakumtorn reported 26 sesamoidexcisions in 24 patients that were resected due to intractablesymptoms despite conservative treatment. After sesamoidec-tomy, patients had a mean RTA after a 12-week period,while some of the athletically active individuals included inthe study returned to activities as early as seven and a halfweeks.9

Two patients in this series were unable to RTA; one patientdeveloped a symptomatic hallux valgus deformity after exci-sion of the medial sesamoid, and the second patient reportedpain attributable to associated right foot metatarsalgia andflexor hallucis tenosynovitis after resection of the lateralsesamoid through a dorsal incision. Both of these patientswere classified as athletically active individuals.

Although surgical excision of a sesamoid is recommendedwhen nonoperative care has proven unsuccessful, postopera-tive complications need to be considered. Complications mayinclude disruption of the anatomy of the hallucal sesamoidcomplex, great toe stiffness, injury to the cutaneous nerves,or persistent pain. One patient developed a hallux valgusdeformity after resection of the medial sesamoid. No halluxvarus deformities were encountered.

An alternative treatment includes screw fixation of thenonunion. Blundell et al. reported a case-series study ofnine high-performance athletes in which hallucal sesamoidfractures were treated by percutaneous screw fixation.3 Nocomplications were reported and patients went back to theirsame level of activity at the 12-week time point. Pagenstertet al. reported the same time to RTA in a study involvingpercutaneous screw fixation of sesamoid fractures in eightathletic patients. Both of these studies reported a timerequired to RTA similar to the one in our study. Althoughthe authors stated that the sesamoids are critical for the

preservation of the function of the great toe, particularlyin high-performance athletes,5 we have demonstrated resultscomparable to cases treated by percutaneous screw fixationin regards to time required for patients to RTA.

CONCLUSION

This retrospective case series demonstrates good resultsafter sesamoidectomy for sesamoid nonunions in athleticindividuals with reliable pain relief and RTA at a mean of11.6 weeks. Progressive hallux valgus remains a concernafter medial sesamoidectomy.

REFERENCES

1. Anderson, RB; McBryde, AM, Jr.: Autogenous bone grafting of halluxsesamoid nonunions. Foot Ankle Int. 18:293–296, 1997.

2. Axe, MJ; Ray, RL: Orthotic treatment of sesamoid pain. Am J SportsMed. 16:411–416, 1998.

3. Blundell, CM; Nicholson, P; Blackney, MW: Percutaneous screwfixation for fractures of the sesamoid bones of the hallux. J BoneJoint Surg Br. 84:1138–1141, 2002. http://dx.doi.org/10.1302/0301-620X.84B8.13064

4. Hulkko, A; Orava, S: Diagnosis and treatment of delayed and non-unionstress fractures in athletes. Ann Chir Gynaecol. 80:177–184, 1991.

5. Oloff, LM; Schulhofer, SD: Sesamoid complex disorders. Clin PodiatrMed Surg. 13:497–513, 1996.

6. Pagenstert, G, Hintermann B, Valderrabano V: Percutaneous fixationof 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. FootAnkle. 7:229–244, 1987.

9. Saxena, A; Krisdakumtorn, T: Return to activity after sesamoidectomyin athletically active individuals. Foot Ankle Int. 24:415–419, 2003.

Copyright 2012 by the American Orthopaedic Foot & Ankle Society