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I have a patient, 47 y/o w/f with hx of herniated lumbar discs but otherwise in good health. She has a painful bunion of a few years duration but getting progressively worse. Radiograph shows 1st IM=10 degrees, MAA=22 degrees, HAA=35 degrees, tibial sesamoid position around 5. She also has some restriction of motion at !st MPJ with pain on end range dorsiflection

She has a relatively short window of time that she has for recovery/rehab. She is also a smoker. For these reasons I'm considering an Austin/Youngswick type procedure (hopefully quicker time to recovery and no need for immobilization). She's aware that this may not fully correct the problem.

My question has to do with fibular sesamoidectomy. It's been a long time since I removed a fibular sesamoid but I was considering it now to help reduce the HAA. Is there any consensus on sesamoidectomy vs. aggresive lateral release?

Any advice would be appreciated. Feel free to comment on any other aspect of my thought process regarding this case.

Thanks in advance.

 

I have a patient, 47 y/o w/f with hx of herniated lumbar discs but otherwise in good health. She has a painful bunion of a few years duration but getting progressively worse. Radiograph shows 1st IM=10 degrees, MAA=22 degrees, HAA=35 degrees, tibial sesamoid position around 5. She also has some restriction of motion at !st MPJ with pain on end range dorsiflection

She has a relatively short window of time that she has for recovery/rehab. She is also a smoker. For these reasons I'm considering an Austin/Youngswick type procedure (hopefully quicker time to recovery and no need for immobilization). She's aware that this may not fully correct the problem.

My question has to do with fibular sesamoidectomy. It's been a long time since I removed a fibular sesamoid but I was considering it now to help reduce the HAA. Is there any consensus on sesamoidectomy vs. aggresive lateral release?

Any advice would be appreciated. Feel free to comment on any other aspect of my thought process regarding this case.


Remove the fib sesmoid as an aggressive lat release with attachment of the conjoined adductor tendon to the tib sesmoid ligament probably will not help although a hallux distraction test will give you idea of stiffness of first ray in transverse plane.

I would be concerned with pain at End ROM. Opening up the joint would probably reveal osteochondral lesions or thinning of cartilage due to compression along lateral first met head. You would want to make sure you pick the proper procedures to address this and ensure you are decompressing and plantarflexing the first met head to decrease compression forces.

Review pathomechanics of the first ray and practice the dissection if your rusty. I always had access to a cadaver lab. You do not want to be experiementing on live patients.

Steven

 

Please do not remove the fibular sesamoid. It's an archaic procedure that should be left for surgical historians.

I would suggest the Austin osteotomy coupled with a prox. phalangeal osteotomy of your choice. These are very quick healing, 2 (or 3 weeks tops) in a post operative shoe. My routine for these is to put them into a short CAM boot for 2 weeks, not crutches needed.

Good luck

Steve