Sesamoidectomy for Hallux Sesamoid Disorders: A Systematic Review

Arthroscopic Sesamoidectomy and Plantar Metatarsal Head Bone Shaving in Management of First Metatarsal Head Metatarsalgia After First Metatarsophalangeal Fusion

First metatarsophalangeal arthrodesis has been used to treat end-stage arthritis of the great toe (e.g., gout, post-traumatic, infection), severe hallux valgus deformity, hallux valgus caused by neuromuscular disorders, rheumatoid forefoot deformity, primary hallux varus, and rigid plantarflexion deformities, as well as a salvage procedure for failed previous operation of the great toe. As with any arthrodesis procedure, proper positioning of the hallux in first metatarsophalangeal arthrodesis is of utmost importance for good clinical outcome. The chief problem tends to be sagittal alignment. In case of the significant dorsiflexion malunion of the fusion site with excessive plantar pressure of the first metatarsophalangeal joint and abutment of the hallux to the shoebox, corrective osteotomy is indicated. If there is isolated excessive plantar pressure of the first metatarsophalangeal joint without hallux problem, arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head is another surgical option. The purpose of this technical note is to describe the details of arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head.

A Systematic Review of Intramedullary Fixation in Midfoot Charcot Neuroarthropathy

Charcot neuroarthropathy can cause severe deformity of the midfoot, and intramedullary use of beams and bolts has been utilized as a method of definitive stabilization. This systematic review evaluated the outcomes of intramedullary beaming in patients with Charcot neuroarthropathy and determined the methodological quality of the studies. Four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). To assess the methodological quality of the studies, the Coleman Methodology Score was used. The data was pooled into 2 outcomes groups for comparison: (1) Studies that reported on the outcomes of Charcot specific implants (study group). (2) Studies that reported on the outcomes using non-Charcot specific implants (control group). After screening, 16 studies were included. Compared to our control group, our study group had significantly higher rates of overall hardware complications, hardware migration, surgical site infection, reoperation, and nonunion. The study group had significantly lower rates of limb salvage compared to the control group. Our study and control groups did not differ in the rates of hardware breakage, wound healing complications, or mortality. The limb salvage rate was 92% and 97% of patients were still alive at a mean follow-up of 25 months. The mean Coleman Methodology Score indicated the quality of the studies was poor and consistent with methodologic limitations. The quality of published studies on intramedullary implants for Charcot reconstruction is low. Complications when utilizing intramedullary fixation for Charcot reconstruction are high, whether or not Charcot specific implants are used.

Arthroscopic Autologous Bone Grafting for Hallux Sesamoid Fracture Nonunion Results in a High Rate of Complete Resolution

Purpose

To review the outcomes of patients with hallux sesamoid fracture nonunion who underwent arthroscopic autologous bone grafting.

Methods

Medical records of patients who underwent surgery between July 2017 and April 2020 were reviewed. The inclusion criterion was 2 years or more of follow-up. The exclusion criterion was less than 2 years of follow-up. Outcomes were assessed using the visual analog scale (VAS) for pain and the Japanese Society for Surgery of the Foot (JSSF) score. Improvements after surgery were analyzed using the Wilcoxon signed-rank test.

Results

Eleven patients (3 women and 8 men) were enrolled. The mean age was 18.6 years (standard deviation [SD] ± 10.3 years), and the mean body mass index was 21.9 kg/m² (SD ± 2.5 kg/m²). The mean follow-up duration was 3.2 years (SD ± 0.8 years). One patient had fracture nonunion in the fibular sesamoid and a hypoplastic tibial sesamoid. Another patient had fracture nonunion in the distal part of the congenital bipartite sesamoid. The other patients had fracture nonunion in the normal tibial sesamoids. The mean duration until bone union was 2.9 months (SD ± 0.8 months). The mean duration until returning to sports was 5.3 months (SD ± 3.6 months). The VAS score improved from 72.1 (SD ± 15.2) preoperatively to 12.0 (SD ± 26.7) postoperatively. The JSSF score improved from 58.7 (SD ± 15.8) preoperatively to 95.0 (SD ± 11.0) postoperatively (P < 0.01, respectively). All patients except the two previously described achieved a VAS score of 0 and a JSSF score of 100 postoperatively. The remaining 2 patients with congenitally distinct sesamoids and fractures had poor outcomes. No complications were observed.

Conclusions

Nine of the 11 patients reported complete resolution. The remaining two patients with congenitally distinct sesamoids and fractures had poor outcomes.

Concentrated Bone Marrow Aspirate Injection for Hallux Sesamoid Disorders

Concentrated bone marrow aspirate (CBMA) offers an alternative to sesamoid resection in end stage sesamoid pathology. CBMA potentiates the anti-inflammatory effect, stimulates local tissue regeneration and osteogenesis, when injected into bone. The purpose of this study is to evaluate the functional outcomes in a cohort of athletes following CBMA injection for the treatment of hallux sesamoid disorders. A retrospective case series of consecutive patients treated with CBMA injection for hallux sesamoid disorders were identified. Radiographs, Foot and Ankle Outcome Scores (FAOS), and Visual Analogue Scale (VAS) score were collected pre- and postinjections. Descriptive statistics were presented as the mean and standard deviation for continuous variables and frequency as percentages for categorical variables. Fifteen consecutive patients with were included with a mean follow-up time of 20.1 (range 12-34) months. Significant improvement in all scoring subscales of the FAOS and VAS score was noted preinjection compared to final follow-up postinjection (p < .001). Eight of 11 patients that were involved in sports prior to the CBMA injection returned to play, with 7 successfully returning to preinjury level status. Three patients required further treatment (20%). The case series suggests that CBMA injection is a safe and effective treatment option for hallux sesamoid disorders with a high rate of return to play.

Sesamoid Avascular Necrosis and Stress Fracture Treated with Core Decompression and Biologic Augmentation

Sesamoid bone disorders are disabling conditions with limited treatment options. This case report describes a 17-year-old football player with avascular necrosis (AVN) in both the tibial and fibular hallux sesamoids with a concomitant non-displaced stress fracture of the tibial hallux sesamoid. After a short period of conservative management, the patient underwent open sesamoid core decompression with an application of concentrated bone marrow aspirate and amnion matrix. After postoperative physical therapy, the patient achieved a painless range of motion of the first metatarsophalangeal joint. He returned to full athletic activities by 6 months postoperatively. Core decompression with biologic augmentation is a viable treatment option for sesamoid AVN. Earlier surgical intervention for sesamoid AVN can also be considered, particularly in younger active patients.

Arthroscopic Sesamoidectomy for Hallux Sesamoid Disorders

In this retrospective case series, we aimed to study arthroscopic sesamoidectomy, including surgical methods, clinical outcomes, and complications. We retrospectively reviewed the medical records of patients with hallux sesamoid disorders who underwent arthroscopic sesamoidectomy from July 2015 to July 2017. The visual analog scale for rating pain, Japanese Society for Surgery of the Foot scale scores, number of days taken to return to normal daily living, number of months taken to return to playing sports, and complications were analyzed. The mean follow-up duration was 3.2 years. Among 14 patients, there were 8 females and 6 males (median age: 39 years). The mean visual analog scale score improved from 75.4 to 14.3 mm; the mean Japanese Society for Surgery of the Foot score improved from 55.2 to 88.0 points. The mean time to return to activities of daily living was 5.3 days. Among the 5 patients who played sports, 3 and 2 patients resumed playing sports at 3 and 12 postoperative months, respectively. Complications included wound pain (n = 4), discomfort in severe weather (n = 4), numbness (n = 3), pain in the sole other than in the ball of the foot (n = 2), pain during hallux dorsiflexion (n = 2), residual sesamoid discomfort (n = 1), swelling (n = 1), toe-in gait (n = 1), and metatarsal head bone marrow edema (n = 1). Despite good clinical outcomes of arthroscopic sesamoidectomy, patients should be made aware of the many potential complications of this procedure prior to surgery.

Efficacy, Outcomes, and Alignment Following Isolated Fibular Sesamoidectomy via a Plantar Approach

BACKGROUND

The purpose of this study was to evaluate patients for intermediate-term pain relief, functional outcome, and changes in hallux alignment following isolated, complete fibular sesamoidectomy via a plantar approach for sesamoid-related pain recalcitrant to conservative treatment.

METHODS

A retrospective query of a tertiary referral center administrative database was performed using the Current Procedural Terminology code 28135 for sesamoidectomy between 2005 and 2016. Patients who underwent an isolated fibular sesamoidectomy were identified and contacted to return for an office visit. The primary outcome measure was change in visual analog pain score at final follow-up. Secondary measures included satisfaction, hallux flexion strength, hallux alignment, pedobarographic assessment, and postoperative functional outcome scores. Patients who met the 2-year clinical or radiographic follow-up minimum were included. Ninety fibular sesamoidectomies were identified. Thirty-six sesamoidectomies met inclusion criteria (median 60-month follow-up). The average patient was 36 years old and underwent sesamoidectomy 1.1 years after initial diagnosis.

RESULTS

Median visual analog scale scores improved 5 (6 to 1) points at final follow-up (P < .001). Final postoperative mean hallux valgus angle did not differ from preoperative values (10.5 degrees/8.5 degrees, P = .12); similarly, the intermetatarsal angle did not differ (8.0 degrees/7.9 degrees, P = .53). Eighty-eight percent of patients would have surgery again and 70% were "very satisfied" with their result. Hallux flexion strength (mean 14.7 pounds) did not differ relative to the contralateral foot (mean 16.1 pounds) (P = .23). Among the full 92 case cohort, 3 patients underwent 4 known reoperations.

CONCLUSION

Fibular sesamoidectomy effectively provided pain relief (median 5-year follow-up) for patients with sesamoid pathology without affecting hallux alignment.

LEVEL OF EVIDENCE

Level IV, retrospective case series.