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Advice for sesamoiditis surgery

Discussion in 'Foot Surgery' started by LynneB, Jul 24, 2009.

  1. LynneB

    LynneB Welcome New Poster

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    Hi, I am a Physiotherapist from New Zealand. I have encoutered some sesamoiditis in my practice but most have resolved with conservative treatment including padding and activity modification.

    I am currently struggling with a case, my own. I know this forum is not meant for personal use, however I wish to gain a greater knowledge of the stabilizing structures of the first MTPJ. If possible could respondents please provide references to direct me.

    Female 27, I have extremely cavus feet and a history of recurrent ankle sprains on my left (injured side). Previously very active before my foot gave out on me. Now I am an aquatic creature yearning to run on land again.

    It all started when I was 22 when I started getting pain under the ball of my left foot. Unfortunately I was one of those people that played (competitive soccer and triathlons) through the pain. During soccer training involving jumping drills… my sesamoid gave out.

    I was diagnosis with a fibular sesamoid fracture (left) and after spending months in a POP and moon boot the fracture did not heal. The pain was localised to the plantar aspect of my foot fibular sesamoid location.

    The surgeon was concerned about the other sesamoid giving out and so performed a dorsiflextory wedge osteotomy along with a plantar approach excision of my fibular sesamoid.

    The recovery went well, although the end result was worse because of the angle alteration of the metatarsal. After 16 long months of walking the speed of a tortoise the dorsiflextory wedge osteotomy was reversed using a calcaneal bone graft (ouch).

    The recovery from the second surgery went well and I am now able to walk 30 minutes at a medium pace without significant pain if I use my good (right) foot to provide the main propulsion (push off) I am also suffering from medial knee pain on my left (bad) side as a result of the sesamoid removal. How does the removal of a sesamoid (fibular) affect the biomechanics of the lower limb?

    Aggravating/Easing Behaviours
    Agg = Well.. walking (pushing off) on my forefoot. Sore with movement – lingers for about 30 minutes after forced extension
    Uphill and downhill
    Ease = nil (not moving it)

    24 Hour Pattern
    No AM pain. Mechanical based.

    Main Area of Pain
    Plantar Aspect joint line and medial aspect of MTP joint.

    Subjective/Objective Measures
    Joint feels “looser” there is actually GREATER range of movement (extension) on the operated side (left). I am able sublux the MTP joint dorsally and laterally. I can sublux the joint by flex/ext occasionally and also by applying a miniscule amount of force directed post-anteriorly and pressing laterally. Also I am unable to “crack” my left MTP. I used to be able to crack both MTPJs. Also when flexing both MTPs the biomechanics are not symmetrical. For example in my good (right) foot it seems as though the MTP pops up (dorsally) whereas in my bad foot (left) the MTP does not.

    Diagnostic/Clinical Tests
    An MRI performed last year (before surgery 2) confirmed that the plantar plate is intact
    Positive Anterior Drawer (instability) Test of the MTP
    Films – there is joint space and no osteophytes seen. Tibial sesamoid intact. Position ?

    Conservative Treatments
    I have tried countless orthotics in consultation with my Podiatrist, but he does not believe any orthotics can fix my lose, subluxing MTP joint.

    Running (my ultimate goal) occasionally is attempted but never for greater than 2 minutes and followed by 2 days of pain in the MTP joint.

    My Interpretation
    My MTP joint in loose due to the disruption of the capsuloligamentous structures while excising the fibular sesamoid. The adaptive way to walk without causing pain is putting more pressure on the medial aspect of my MTP and also causing medial knee pain.

    Proposed 3rd Surgery
    My orthopaedic surgeon is proposing that an hallucis adductor tendon transposition might provide my toe with some stability. He can also tighten up the lateral capsule at the same time.

    My Question
    1. How would transferring the Hallux Add tendon help provide stability to the joint? This has been reported in the literature with Hallux Abd and Medial sesamoidectomy (McCormick and Anderson, 2009) but I could not find anywhere in the literature regarding isolated hallux add tendon transposition post fibular sesamoidectomy. Please help.

    Thank you very much for reading. I look forward to some insight.

    McCormick and Anderson. 2009. The Great Toe: Failed Turf Toe, Chronic Turf toe, and complicated sesamoid injuries. Foot and Ankle clinics of North America.
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Re: MTP dynamic and static structures that provide stability


    Interesting case, pity its you though!:eek:

    Honestly (from the information supplied)...I think the 3rd surgery will not assist you.

    The dynamic forces are too great, your foot type (cavus) is too complex, and the only reliable procedure for 1st MTPJ instability post sesamoidectomy is a 1st MTPJ fusion.

    From a physiotherapy perspective this sounds horrible. From a podiatry perspective it is not so bad. People run marathons with 1st MTPJ fusions.

    Yes, sagittal plane movement is compromised, but you tend to compensate for this adequately through the IP joint of the hallux over time.

    I would seek further surgical opinions, perhaps podiatric and orthopaedic, before making a decision.

  3. Re: MTP dynamic and static structures that provide stability

    A fibular sesamoidectomy done by a competent foot surgeon is the only surgical procedure you needed in the first place. I have never seen a fibular sesamoidectomy cause the problems you describe and no foot surgeons that I know would peform a dorsiflexion osteotomy of the first metatarsal while also performing a fibular sesamoidectomy. Like LL, I agree that you now you need an arthrodesis procedure of the 1st metatarsophalangeal joint. I have a patient who is 60+ years old doing iron-man triathlons (Hawaii, etc) that I did an arthrodesis on a few years ago. Don't worry, contrary to what sagittal plane theorists believe, a restriction of hallux dorsiflexion motion will not produce a flat foot deformity. Have the surgery done by someone (probably by someone other than your current surgeon) that does them routinely and you should have no problem. Good luck!!
  4. Admin2

    Admin2 Administrator Staff Member

    Related threads:
    Other threads tagged with sesamoiditis
  5. drsarbes

    drsarbes Well-Known Member

    Hi Lynne:
    I agree with Kevin, in retrospect the DFWO on the first Met was unnecessary.
    The angle and length of the first met is rather important. In a young active athlete like yourself the Dorsal wedge was a tricky proposition.

    Your overall length of the first met, even after a graft, is most likely shorter than you started with, causing laxity in the 1st MTPJ.

    Was the Fibular sesamoid removed through a dorsal or plantar incision?
    Why do you feel the capsular elements of the first MTPJ were disrupted by this procedure?
    How is the strength of the FHL?
    Does your hallux purchase the ground on static stance?
    What is your activity level now?
    What actually hurts when you are running?



    Don't let anyone remove your remaining sesamoid!
  6. LynneB

    LynneB Welcome New Poster

    Thank you DrSArbes for your reply

    To answer some of your questions:

    -The fibular sesamoidectomy was performed with a plantar incision (for better exposure) has healed very well.

    -I feel the lateral structures MAY have been disrupted because of the varus instability of the MTP joint. The capsulo-ligamentous structure MAY have also become lax due to chronic synovitis after the first surgery (sesamoidectomy & DFWO)

    -The strength of the FHL is pretty good, however not symetrical. The EHL COULD be unmatched by weaker FHL contributing to the dorsal subluxation.

    -My hallux purchases "slightly" off the ground. I can only tell looking closely at pictures I have taken, therefor minor.

    -Activity Level - I have turned into an aquatic creature. I swim for fitness. I can go for walks but do not fully push off on my left. I compensate by predominantly using the strength of my right for main propulsion. This is tolerable currently.

    -Area of Pain -the plantar aspect underneath the MTP is the main source of pain. It feels as though it is pain on the joint line more distal (towards the phalanx) than the tibial sesamoid.

    In retrospect, yes, the DFWO was unnecessary, as evidenced by the huge improvement after it reversed. I think it is amazing the difference 1 or 2 mm has on MTP function. I did have several independent orthopods examine my foot and both recommended a sesamoidectomy and DFWO. I believe it was because my extremely cavus foot was always recorded as a "deformity" instead of an extreme variant of normal.

    My next port of call would be to get some lateral weight bearing films taken to see if the metatarsal is back to its original length and angle and then go from there.
    Pinning the lax structures (like a shoulder) with an adductor transfer MAY help to tighten the structures that have been “loosened” by the change in the angle and length of the metatarsal.

    If is doesn't work... there is always fusion. How successful is fusion with an extremely cavus foot?

    Thank you for your interest.

  7. anthonywhitty

    anthonywhitty Member

    Hi I am a exercise physiologist and health practioner in Australia and confused with advice about a patient.

    This is the history

    1. June 09 pain in ball of foot due to overuse running injury x ray found large medial bipartite sesamoid bone, MRI SCAN IN July 09 showed sesamoiditis, edema and chronic stress.
    2. Referred to surgeon in nov 09 and he said that it was the bursa that was the problem and recommended cortisone injection and if that didn’t work surgery to remove it.
    3. Feb 10 surgery to remove bursa and planned the sesamoid protrusion that was not seen on scan.
    4. 2 months post surgery no pain walking and began running on it as per surgeons advice. After 5 runs pain in the ball of the foot again but different pain and have had that pain for over 6 months cant walk properly. Had another MRI in july 10.
    5. Surgeon unsure as to the cause of the pain and thought it was just inflamed scar tissue but said he couldn’t help any more
    6. Scans viewed by another doctor and he compared the 09 to the 10 MRI and said that he thought that the tibial sesamoid was worse that pre surgery and that it was “ sick” large and irregular.
    7. Referred on to another surgeon who has recommended excision of the tibial sesamoid. His only concern was why the first surgeon did not want to do this. Also did a bone sacn which revealed both tibial sesamoids were stressed by the left (foot in question) was worse than right

    I am concerned about two issues

    The runner has ver slight valgus due to being a pronator and years of running.

    My question is how do I know if

    1) The tibial sesamoid is the cause of the pain
    2) Removing it could cause hallux valgus issues
  8. Anthony:

    My first concern for this patient is that sesamoiditis typically is not a surgical problem. Sesamoiditis in runners may be treated quite effectively in 90% of cases with a properly made custom foot orthosis along with other therapeutic conservative modaliites. However, you have not made any mention of even attempting to use custom foot orthoses. Why not consider referral to a sports podiatrist who may be able to treat this patient conservatively without surgery?

    I will not consider excision of a "sick" sesamoid until 6 months of conservative treatment is attempted utilizing ice, custom foot orthoses, braces, possible non-weigthbearing casts and cortisone injections, depending on the case. Medial sesamoidectomy may result in hallux valgus deformity post-operatively, but this is not always the case. In my community, if a runner had a medial sesamoid excision, developed hallux valgus as a result, but had never been offered custom foot orthoses for treatment, I would consider this to be below the standard of medical care for the medical community.
  9. anthonywhitty

    anthonywhitty Member

    Thanks for the advice Kevin.

    The patient has custom made orthotics (albeit 12 months ago) to unload the medial sesamoid and has had 2 cortisone injections, as well as 6 weeks in the cam boot. There was no improvement with these treatments. However there has been improvement when releasing FHL and taping the foot to assist in unloading the joint. Hopefully this will allow the condition to improve. I will recommend another visit to the podiatrist and more time before surgery is considered.

    Cheers Anthony
  10. drsarbes

    drsarbes Well-Known Member

    12 months!
    You should take the sesamoid out before he's too old to have the surgery!!!

  11. I tend to agree with Steve. Have you considered the possibility that the long term negative consequences of gait compensation for a painful sesamoid may be more harmful to the patient than simply excising the painful sesamoid?
  12. anthonywhitty

    anthonywhitty Member

    Thanks for the advice Kevin and Steve.

    The patient has been booked in to have the sesamoid removed in Jannuary.

    Kevin I think you are right about compensation problems as he now has a similar pain on the right foot which a previous bone scan as have similar issues to the left foot.

    He has an intermetatarsal angle of 7 degrees and tibial sesamoid is in position 1. My understanding is with this type of foot a hallux valgus deformity is unlikely but still a consideration.

    Again thanks for the advice in this matter.

    Cheers Anthony
  13. anthonywhitty

    anthonywhitty Member

    Thought this might be of interest.

    The same patient returned today for treatment on his right foot with news that his Sports GP had sent him for another surgical opinion before removing the medial sesamoid. This surgeon said that although the bone was not dead or crumbling there was oedema throughout both modalities of the bi partite sesamoid. Because this patient is a long distance runner he suggested that a dorsal wedge osteotomy may be more appropriate due to the patients plantar flexed first ray. This kind of procedure is way out of my depths of knowledge. I advised him to go with the medial sesamoidectomy or at least discuss the success rates and pros and cons of the osteotomy which I could not assist with at all.

    Any opnions on this matter would be apprecited
  14. The dorsiflexion base wedge osteotomy might be a good idea if the medial sesamoid wasn't so affected by edema and chronic pain. The dorsiflexion osteotomy would preserve both sesamoids, would eliminate the risk of hallux valgus deformity that is present with medial sesamoidectomy but, unfortunately, may still not be sufficient to relieve the pain from a medial sesamoid that has a chronic stress reaction and bone edema. I would choose the medial sesamoidectomy. (In addition, the medial sesamoidectomy would reduce the time away from sports by approximately half compared to the base wedge osteotomy.)

    Hope this helps.
  15. anthonywhitty

    anthonywhitty Member

    Thanks for the advice Kevin I will pass it on and advise him to go for the sesamoidectomy.

    I have also suggested that he should not expect to run ultra marathons after a sesamoidectomy due to the disruption of the stability of the first MTP joint which may occur.

    The surgeon advised him that he could still do long distance running. I wasnt being negative towards the patient just realistic and what I thought the joint could handle post such a procedure. Also I have seen other patients after such a surgery attempt to do too much too soon and hence incur a lengthier delay from activity than they should have.

    Thanks again and Happy holidays

    Cheers Anthony
  16. anthonywhitty

    anthonywhitty Member

    Thought this may be of interest and possible advice would be helpful.

    Same case presented here over 12 months ago went ahead with tibial sesamoidectomy.

    Pain and function was improving until 3 months after surgery began to get pain at the medial aspect of metatarsal head described as a deep bone ache.

    He now has constant pain even at rest at the mdeial aspect of met head very localised however he has no pain at all where the sesamoid previously was.

    Clinically there is a slight drift of the hallux and localised swelling at the medial aspect of the met head where the pain is.

    He recently underwent an MRI and has an appointment with his surgeon again in 2 weeks who up until now is unsure what is the cause of the pain.

    Here are his MR results.

    "Previous rsection of the mdeial sesamoid of the great toe noted. Partial thickness chrondal loss in the lateral sesamoid and in the first MTP joint with a small joint effusion. Partial tear to the medial collateral ligament at its metatarsal attachment site with adjacent minor bone edema. Mild intermetatarsal bursitis in the first second and third web spaces"

    My only thought was that the sesamoidectomy may of caused a biomechanical change in the first mtp joint or a weakening of the ligament.

    He has been to a sports podiatrist recently who has strapped the big toe and also implemendted the use of a toe spacer.

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