Dorsolateral Excision of the Fibular Sesamoid: Technique ...

Dorsolateral Excision of the Fibular Sesamoid:Technique and Results

Jason Kurian, MD,* David A. McCall, MD,w and Richard D. Ferkel, MDz

Background: Injuries to the hallucal sesamoid complex are uncom-mon, but they can cause significant pain. The medial sesamoid is themost common site of pain, but the fibular sesamoid can also becomesymptomatic. The most common clinical entities that lead to chronicfibular sesamoid pain are fracture nonunion and osteonecrosis. Thepurpose of this study was to describe the technique and determine theresults of the dorsolateral approach for fibular sesamoid excision.

Methods: During an 11-year span, 8 patients underwent fibular ses-amoidectomy using a dorsolateral approach after a minimum of 6 monthsof nonoperative treatment. The mean age was 33 years (range, 22 to 43 y).The average follow-up was 97 months (range, 24 to 167 mo). Patients wereassessed using the AOFAS forefoot grading scale and a subjective ratingfor walking, pain, and overall satisfaction.

Results: Fibular sesamoidectomy was performed for osteonecrosis in 3patients and for nonunion in 5 patients. Four patients had work-relatedinjuries. Two injuries were due to trauma and the rest were chronic,without a known cause. The average length of nonoperative care was107 weeks and included rest, injections, physiotherapy, bracing, cast-ing, NSAIDs, and orthotics. Overall, the patient subjective satisfactionwas 5 excellent and 3 good. The mean AOFAS forefoot score was 91and average time to return to activity was 15 weeks. The mean painrating was 1.3/5, and the mean subjective walking score was 4.625/5.

Discussion: Compared with previously published reports, our resultsfor isolated fibular sesamoidectomy show similar satisfaction rateswith equivalent time to return to activities and a low complication ratewhile avoiding a plantar incision.

Level of Evidence: Diagnostic Level 3. See Instructions for Authorsfor a complete description of levels of evidence.

Key Words: dorsolateral fibular sesamoid excision, hallux, sesamoid

fractures

(Tech Foot & Ankle 2014;13: 226–235)

After participating in this CME activity, physicians should bebetter able to:1. Diagram the anatomy of the great toe MTP joint and

sesamoid complex.2. Evaluate a chronically painful sesamoid clinically as well as

radiologically to assess the treatment alternatives.3. Explain the dorsal surgical approach to removing the lateral

sesamoid to improve patient function.

HISTORICAL PERSPECTIVEThe sesamoid bones of the hallux have long been recognizedas an essential component of human anatomy. Named after theancient Greek word for sesame seed, “sesamoedes,” theancient Hebrews believed the sesamoids were indestructibleand thus the center of individual resurrection.1 More recently ithas become apparent that these structures are far from“indestructible,” and, in fact, play an important role in themechanics of the hallux.1

The sesamoid complex is centered over the plantar aspectof the metatarsal phalangeal (MTP) joint of the great toe. Theossification of the hallucal sesamoids begins in the eighth yearof life from multiple ossification centers.2 Bipartite and tri-partite sesamoids form if the ossification process is not com-pleted. Imbedded in the flexor hallucis brevis (FHB) andsupported medially and laterally by the abductor and adductorhallucis tendons, the sesamoid complex transmits up to 50% ofbody weight during stance, and as much as 300% body weightwith push off.3 The larger tibial sesamoid is within the medialhead of the FHB and the smaller fibular sesamoid is within thelateral head. The average size of the tibial sesamoid is 12 to15 mm and fibular is 10 to 12 mm.4 The tibial and fibularsesamoids are connected by a thick intersesamoid ligament,

*Orthopedic Surgeon, Summa Health System, Portland, OR; wOrthopedic Surgeon, Palo Alto Medical Foundation, Mountain View, CA; and zProgramDirector, Southern California Orthopedic Institute, Van Nuys, CA.Richard D. Ferkel has served as a consultant for Smith & Nephew Inc.; has received royalties from Smith & Nephew Inc. and Lippincott Williams & Wilkins;

and received institutional support from Smith & Nephew, DePuy Mitek, and Ossur Medical. His spouse/life partner, if any, have disclosed that they haveno relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.

The remaining authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they haveno relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. Lippincott CME Institute hasidentified and resolved all conflicts of interest concerning this educational activity.

Address correspondence and reprint requests to Richard D. Ferkel, MD, Southern California Orthopedic Institute, 6815 Noble Ave., Van Nuys, CA 91405.E-mail: [email protected].

INSTRUCTIONS FOR OBTAINING AMA PRA CATEGORY 1 CREDITtTechniques in Foot & Ankle Surgery includes CME-certified content that is designed to meet the educational needs of its readers. This activity is available for

credit through December 31, 2015.Earn CME credit by completing a quiz about this article. You may read the article here, on the TFAS website, or in the TFAS iPad app, and then complete the

quiz, answering at least 80 percent of the questions correctly to earn CME credit. The cost of the CME exam is $10. The payment covers processing andcertificate fees. If you wish to submit the test by mail, send the completed quiz with a check or money order for the $10.00 processing fee to theLippincott CME Institute, Inc., Wolters Kluwer Health, Two Commerce Square, 2001 Market Street, 3rd Floor, Philadelphia, PA 19103. Only the firstentry will be considered for credit, and must be postmarked by the expiration date. Answer sheets will be graded and certificates will be mailed to eachparticipant within 6 to 8 weeks of participation.

Need CME STAT? Visit http://cme.lww.com for immediate results, other CME activities, and your personalized CME planner tool.Accreditation StatementLippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing

medical education for physicians.Credit Designation StatementLippincott Continuing Medical Education Institute, Inc., designates this journal-based CME activity for a maximum of 1 (one) AMA PRA Category 1

Creditt. Physicians should only claim credit commensurate with the extent of their participation in the activity.Copyright r 2014 by Lippincott Williams & Wilkins

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which is the central component of the plantar plate of the firstMTP joint.5 There are also medial and lateral phalangeosesa-moid and metatarsosesamoid ligaments which attach to thetibial and fibular sesamoids, respectively, and will form aportion of the plantar plate as well. The flexor hallucis longus(FHL) tendon courses between the sesamoids, dorsal to theintersesamoid ligament (Fig. 1). This anatomy can causeconfusion when attempting to ascertain the source of hallucalpain. Fortunately, patients with FHL pathology can be dis-tinguished from those with purely sesamoidal pain using thePassive Axial Compression test6 as well as clinical findings ofpain throughout the entire course of the FHL.7 This maneuvershould be specific for the sesamoids as all other soft tissuesabout the plantar aspect of the first metatarsophalangeal jointare in a relaxed position. The Passive Axial Compression testis performed with the patient in a seated position with theaffected leg extended. After the sesamoids are carefully pal-pated, the hallux is maximally dorsiflexed at the MTP joint,which will cause distal migration of the sesamoids. The indexfinger of the examiner is then used to apply compression justproximal to the sesamoids. If the test is positive, the patient’ssymptoms are reproduced with passive plantar flexion of theMTP joint.

The primary extraosseous blood supply of the sesamoidsis derived from the posterior tibial artery. At its distal extent,the posterior tibial artery divides to form the medial plantarartery and a contributing vessel to the plantar arch. The plantararch directly provides the main blood supply to the sesamoidsin 25% of the population.8 The medial plantar artery is theprimary supply in another 25%, whereas 50% receive theirsupply from both.9 Regardless of the vessel or vessels thatenter the sesamoids, there is further division of the branchesafter they enter the sesamoid from its proximal pole.10 Theintraosseous blood supply is 3-fold. The main contribution isfrom the sesamoid arteries that enter both sesamoids from theproximal pole through a single vessel. Usually, a single ses-amoid artery supplies each sesamoid, although 2 or 3 havebeen described in some patients.8 The second contributors are

nonarticular vessels that enter the sesamoids from a plantardirection. Small vessels from the medial and lateral capsularattachments provide the third source of circulation.10 In sum-mary, the majority of the blood supply comes from a proximalplantar direction, with little collateral flow, potentially leadingto chronic nonunion or osteonecrosis if this system isdisrupted.11

The medial plantar digital nerve courses over the medialborder of the tibial sesamoid12 and the common digital nerveof the first web space lies beneath the transverse inter-metatarsal ligament, near the fibular sesamoid.12 Both of thesestructures can be involved in pain-generating nerve impinge-ments and must be avoided during surgery involving thesesamoids.13

The sesamoids function to increase the moment arm ofthe great toe flexors8 and cushion the MTP joint, dispersing theimpact on the metatarsal head.14 The majority of the impactseems to be taken by the larger tibial sesamoid as it is more ofteninjured.14 Because of their function as a “shock absorber” as wellas a force transducer, they are prone to both impact and chronicoveruse injury. The hallucal sesamoid complex is involved in 9%of foot injuries and 1.2% of all running injuries.1

Indications and ContraindicationsDisorders of the sesamoid include: congenital variations,pathology involving hallux valgus and metatarsus primusvarus, systemic disorders, infection, trauma (acute fracture andchronic nonunion), osteochondritis, and osteonecrosis.15–17

Partition of the sesamoid occurs in 7.8% to 33.5% of thepopulation (medial 10� more common than lateral).1 Eighty-fivepercent are bilateral. Fracture of a bipartite sesamoid can gounnoticed and lead to chronic pain/nonunion. Fractures can becaused by a fall from a height1 or forceful dorsiflexion of the MTPjoint resulting in a transverse fracture pattern.18 Most fractures/chronic overuse injuries are treated conservatively, but chronic,painful, nonunion/osteonecrosis can occur, leading to the need forexcision versus open reduction internal fixation.2,16,19–23

Preoperative PlanningConfirming the sesamoid as the source of pain requires acomplete history, physical examination, x-ray, and often othermodalities to include magnetic resonance imaging (MRI),computed tomography (CT), or bone scan24 (Fig. 2).

As the majority of pathology is in the tibial sesamoid,20

there are few series of fibular sesamoidectomies, the largest ofwhich involves 10 cases.2,4,20–23 Many of these are in combi-nation with tibial sesamoidectomies.2,4,20–23 In addition, someauthors advocate a plantar approach for lateral sesamoidexcision, but Coughlin et al12 cautioned about a painful scar.Because of our concern for a persistently painful postoperativescar, we have used the dorsolateral approach. The purpose ofthis study was to describe the technique and determine theresults of the dorsolateral approach for fibular sesamoidexcision.

Our hypothesis was that the dorsal approach for excisionof a lateral sesamoid provided excellent results with fewcomplications.

MATERIALS AND METHODSDuring an 11-year span, 8 patients underwent fibular sesamoi-dectomy by a single surgeon through a dorsolateral approach. Allpatients failed a prolonged period of nonoperative treatment(at least 6 mo) including rest, injections, bracing, casting,physical therapy, NSAIDs, and orthoses. The mean age atsurgery was 33 years (range, 22 to 43 y). There were 4 females

FIGURE 1. Plantar view of the right great toe anatomy(Copyright, Richard D. Ferkel).

Techniques in Foot & Ankle Surgery � Volume 13, Number 4, December 2014 Dorsolateral Excision of the Fibular Sesamoid

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and 4 males (mean age 32 and 34 y, respectively). The meanfollow-up range was 97 months (range, 24 to 167 mo). Theincidence of pain and neurological symptoms as well as MTPflexion strength loss was noted before surgery.

At a minimum of 24 months postoperatively, all patientswere evaluated using 3 subjective rating scores including sub-jective evaluations of: pain, walking ability, and overall sat-isfaction. Pain was rated on a 1 to 5 scale; 1 being no pain

FIGURE 2. Imaging studies of the right foot. A, Bilateral sesamoid views indicate flattening of the lateral sesamoid of the right foot withsclerosis. B, Bone scan of both feet with increased activity over the MTP joint and specifically over the lateral sesamoid, indicatingabnormal activity in the lateral sesamoid. C, Coronal view of the lateral right sesamoid showing fragmentation of the sesamoid. D, AxialCT scan of the lateral right sesamoid demonstrating a sagittal fracture within the sesamoid. E, Coronal T1 MRI showing decreased signalover the lateral sesamoid.

TABLE 1. Overall Patient Subjective Satisfaction

Rating (Points) Specifications

Excellent (5) Without problems, very satisfied, mild or no pain, walk without difficultyGood (4) A few problems, satisfied, mild pain, walks without difficulty, would still have had surgeryFair (3) Moderate pain, limited walking, reservations about success of surgeryPoor (2) Continued pain, little improvement in walking ability, regrets surgery

Patients were asked to evaluate their overall satisfaction as: poor, fair, good, or excellent based on the criteria in the table. Points were assigned as indicated inparentheses.

Kurian et al Techniques in Foot & Ankle Surgery � Volume 13, Number 4, December 2014

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and 5 being severe pain. Walking ability was also rated on a 1 to5 scale. A patient that was housebound was awarded 1 point,whereas patients with significant, moderate, mild, and nolimitation were given 2, 3, 4, and 5 points, respectively. Thesubjective overall satisfaction rating is outlined in Table 1.Patients were also evaluated postoperatively with the AOFAShallux/great toe rating system.25 Mean scores for all 3 subjectivescoring systems and the AOFAS rating system for all patientswere calculated using a 2-tailed Student t test. The workers’compensation and nonworkers’ compensation for the 3 sub-jective ratings were then compared. Postoperative radiographs(AP and lateral weight bearing, oblique, and sesamoid views)were also obtained at this time to ascertain overall halluxalignment and alignment of the sesamoid complex.

Surgical TechniqueA 3 cm incision was made dorsally in the first intermetatarsalweb space. Soft-tissue retraction was provided using suturesand hemostats to avoid excessive force on the fragile dorsalskin of the foot (Fig. 3). After careful dissection through thesubcutaneous tissue, a laminar spreader was placed to spreadthe first and second metatarsals. Care was taken to avoiddamage to the common digital nerve below the intermetatarsalligament. The adductor tendon/joint capsule complex wasdetached subperiosteally from the metatarsal and the base ofthe proximal phalanx (midway between the dorsal and plantaraspects of the MTP joint) exposing the MTP joint and fibularsesamoid (Fig. 4). A cuff of tissue was left on the metatarsaland the proximal phalanx for later reattachment.

A stitch was then placed in the lateral capsule to retract itlaterally to assist in exposure of the fibular sesamoid. A Beaverblade (ref. 376900) was used to first release the intersesamoidligament from the medial side of the fibular sesamoid beforereleasing the lateral proximal and distal attachments (Fig. 5). It iscritical to avoid releasing the lateral attachment first to preventretraction of the lateral sesamoid under the metatarsal head.

The sesamoid was fully excised using extreme caution toavoid injuring the FHL. Often this requires a “shelling out” of thebed in which the sesamoid lays as it may be crushed into severalpieces (Fig. 6). An x-ray was then taken to verify toe alignmentand complete excision of the fibular sesamoid. The image inten-sifier was brought in from the contralateral side and 25 degrees ofaxial tilt toward the foot was used to recreate the sesamoid view.The surgeon used a freer elevator to dorsiflex the great toe whileleaving the foot in approximately 30 degrees of plantar flexion(Fig. 7). This axial view (Walter-Muller view), in conjunction withstandard AP and oblique views of the foot, was used to confirmcomplete excision of the sesamoid.12 Following resection, thedeep, plantar portion of the wound must be inspected to ensure theFHL has not been damaged. A stitch was used to close the fibularsesamoid defect if possible, with 3-0 absorbable suture. Theadductor hallucis tendon/joint capsule complex was then

FIGURE 3. The dorsolateral incision is made in the first webspace of a right foot. Notice sutures and hemostats are used forsoft-tissue retraction to avoid excessive force on the skin and softtissues.

FIGURE 4. Dorsal approach for a fibular sesamoid excision in a right great toe. A, Care must be taken during dissection to avoid damageto the common digital nerve below the intermetatarsal ligament. B, The adductor tendon/joint capsule complex is detachedsubperiosteally exposing the MTP joint and fibular sesamoid (Copyright, Richard D. Ferkel).



reapproximated to the previously left cuff of tissue at the base ofthe proximal phalanx and distal metatarsal with 2-0 absorbablesuture. Skin closure was accomplished with 5-0 interrupted nylonsuture.

Postoperative ManagementThe foot was bandaged carefully to provide good compressionand to prevent varus drift. Postoperatively, the patients wereimmobilized in a short leg cast that completely covered thegreat toe, with limited weight bearing for the first 2 weeks andthen placed in a walking cast for an additional 2 weeks. At 4weeks, they were placed into a controlled active motionwalking boot. At 6 weeks, they were placed into a stiff-soledshoe with a full-length semirigid orthotic with a Mortonextension, and began physical therapy. All activities, includingsports, are resumed after the patient completes phases 1 to 4rehabilitation and the orthotic is worn at all times.26 Phase 1includes immediate postoperative care, phase 2 is direct footand ankle intervention, phase 3 is restoration of activities ofdaily living, and phase 4 is sports-specific or work-specifictraining.

RESULTSOur patient population included 4 males and 4 females. Fibularsesamoidectomy was performed for osteonecrosis in 3 patientsand fracture nonunion in 5 patients. Four patients (2 male and 2female) had work-related injuries. Two injuries were due totrauma and all others were chronic in nature without a knowncause. All patients underwent nonoperative treatment beforesurgery. The average length of nonoperative care was 107weeks for both males and females (time from first presentationto surgery) and included: physiotherapy (1 patient), boots/casts(4 patients), NSAIDS (6 patients), injections (1 patient), andorthotics (6 patients).

Preoperative examination revealed 1 male and 1 femalehad some MTP flexion strength loss and 3 females experiencednerve symptoms of tingling on the lateral toe from the commondigital nerve. All patients had plantar pain with walking andactivities. Only 1 female patient had dorsal pain, whereas 3females and 1 male had start-up pain. Only 1 female had dorsal

FIGURE 5. Fibular sesamoid excision, right great toe. A, A Beaver blade is used to release the intermetatarsal ligament from the medialborder of the lateral sesamoid. Retracting the lateral sesamoid facilitates safe excision while avoiding injury to the FHL and neurovascularstructures. B, After lateral sesamoid excision, the FHL, FHB, and soft tissues are carefully inspected for injury and residual bony fragments(Copyright, Richard D. Ferkel).

FIGURE 6. The excised fibular sesamoid and associatedfragments. Notice the longitudinal fracture of the sesamoid.



tenderness to palpation (TTP) on physical examination, theremainder had only plantar TTP. Three patients had a positiveTinel sign over the first web space, whereas 4 had MTP motionloss. The number and positive findings of x-rays, bone scans,MRIs, and CT scans are shown in Table 2. Not all patientsreceived all tests. Fewer bone scans have been performed inrecent years. CT is performed to further delineate possiblefractures and MRI is performed to assess edema and sesamoidcirculation.

Postoperatively, in all patients, MTP flexion strength wasnormal and nerve symptoms resolved. The preoperativestrength deficit was due to pain at the MTP joint. The meanAOFAS hallux/MTP score was similar in males and females(90 and 92, respectively). The overall mean AOFAS score was91. Workers’ compensation claims had no effect on AOFASscore (92 for workers compensation; 90 for nonworkerscompensation). Two males and 1 female rated their satisfactionlevel as good, whereas a total of 5 individuals (2 males and 3females) rated their satisfaction level as excellent with a fullreturn to function. According to the 3 subjective rating scales,pain was rated at a mean of 1.3 of 5, and mean walking andoverall satisfaction scores were both 4.63 of 5 (Table 3). Therewere no differences between workers’ compensation andnonworkers’ compensation patients with regard to walking andoverall satisfaction. Pain scores were lower for workers’compensation patients than for nonworkers’ compensation

patients (P = 0.02) (Table 3). The average return to activity was15 weeks (12 wk in males and 17 wk in females). The x-rayfindings postoperatively showed no varus or valgus drift andanatomic positioning of the remaining tibial sesamoid in allpatients. No patients underwent additional surgery, and no onehad complaints of pain in the tibial sesamoid.

ComplicationsNo complications occurred in any of our patients in this study.There were no cases of loss of motion, delayed wound healing,varus drift, or nerve symptoms.

DISCUSSIONThere are very few studies that examine sesamoidectomy forchronic sesamoid pain, and even fewer that documentsignificant numbers of fibular sesamoidectomies.2,4,10,19–23

To the best of our knowledge, this is the first paper to studyisolated fibular sesamoidectomy through a dorsolateralapproach. As we have previously described, Mann et al,21 atthe 1985 AOFAS meeting, reported on 13 tibial and 8 fibularsesamoidectomies. Fifty percent of all patients (tibial andfibular) had complete pain relief. Of the remaining 50%, threefourths of those had only occasional or mild symptoms. Plantar

FIGURE 7. Intraoperative imaging of the right great toe MTP joint. A, After the lateral sesamoid is excised, the image intensifier is brought infrom the contralateral side, utilizing 25 degrees of axial tilt toward the foot. This view is helpful when evaluating for complete excision of thelateral sesamoid. B, Intraoperative fluoroscopic image demonstrating complete excision of the lateral sesamoid in a right great toe.

TABLE 2. The Incidence of Imaging Studies Performed on the 8Patients in the Study is Listed Along With the Incidence ofSignificant Findings in the Studies Performed

Patient

X-rayFindings/

#Done

CTFindings/

#Done

Bone ScanFindings/

#Done

MRIFindings/

#Done

Male 3/4 2/2 2/2 3/3Female 3/4 3/3 1/1 1/1Total 6/8 5/5 3/3 4/4

TABLE 3. Mean Values Obtained From the 3 Subjective RatingScales Separated Into Workers’ Compensation Patients andNonworkers’ Compensation Patients

Pain (1-5)Walking

(1-5)Outcome

(2-5)

Total 1.30 4.63 4.63Work compensation 1.00 4.50 4.50Nonwork compensation 1.75 4.75 4.75P 0.02 0.52 0.52

P-values for workers’ compensation versus non-workers’ compensation inthe 3 categories are also displayed.



flexion weakness was seen in 60% and 10% had drift into varusor valgus. We had no plantar flexion weakness and no drift intovarus or valgus. Our overall satisfaction, however, was similarto Mann’s findings, with 5/8 being completely satisfied and theremaining 3 with only mild or occasional symptoms.

Saxena et al22 reported on 26 sesamoidectomies in 24athletic and active individuals. Ten patients had excision of thelateral sesamoid with the approach dorsolateral in 7 and plantarin 3. All patients returned to their previous level of activity.Athletes returned in 7.5 weeks and active patients in 12 weeks.Although only 5/8 of our patients returned to full activity and didso at a later date than patients in Saxena and colleagues’ study,the remaining 3 would have the surgery again, and there were nocomplications. Complications in Saxena and colleagues’ studyincluded 2 cases of postoperative scarring with neuroma-likesymptoms and 1 case of hallux varus in fibular sesamoidec-tomies. One case of hallux valgus occurred after tibial ses-amoidectomy. Interestingly, complications were higher with thedorsal than the plantar approach for fibular sesamoidectomy.More recently, Waizy et al4 reported on 2 patients with at least2-year follow-up after fibular sesamoid excision using a plantarapproach with excellent clinical and radiologic results.

Whereas Mann et al,21 and classically, Inge and Furguson,2

noted loss of both flexion strength and cock-up deformity, VanHal et al23 noted no loss of strength and no cock-up deformity.Reportedly, Van Hal and colleagues’ results were due to carefulreapproximation of the adductor/abductor as well as maintenanceof the joint capsule. As an attempt to further preserve the“normal” anatomy, Biedert24 did only a partial sesamoid exci-sion for chronic stress fractures in athletes. The 5 athletes treatedall returned to their previous level of activity by 6 months, andthe average AOFAS score was 95.3 of 100. Our AOFAS scoreswere slightly lower (91/100), but we had a slightly faster returnto activity (average of 14 wk) with all dorsal approaches. In ourseries we had 2 professional dancers treated with dorsolateralsesamoid excision. One dancer returned to her previous level, butis now limited after a shoulder injury that led to chronic insta-bility. The remaining dancer was much improved and canfunction well with activities of daily living, but was unable toreturn to professional dancing and thus made a career change.

Another option for fibular sesamoidectomy is the medialapproach described by Pinto and colleagues in 2010. Thisapproach has the advantage of being familiar to most foot andankle surgeons, as well as allowing the incorporation of amedial capsulorrhaphy, which can combat the development ofpostoperative hallux varus deformity.27

Alternatively, the fibular sesamoid can be approachedthrough a plantar incision. To help avoid painful scar for-mation, the plantar approach is made through the inter-metatarsal space rather than directly plantar to either themetatarsal head or the sesamoid. The incision is made slightlycurvilinear on the border of the hallux metatarsal fat pad,beginning distally near the tibial side of the second toe and thedistal extent of the metatarsal fat pad. The lateral plantardigital nerve of the hallux is found on the fibular side of thefibular sesamoid or directly over the fibular sesamoid. Thisnerve should be identified and protected to avoid injury.5

Even with meticulous surgical technique, postoperativescarring or keloid formation can still occur directly beneath themetatarsal or sesamoid which can cause intractable pain. Theskin incision may heal, but the underlying fatty tissue canatrophy over a short period and leaves the patient with inad-equate cushioning on the plantar aspect of the foot.12 Thiscomplication can be easily avoided with an alternate incisionfor excision of the sesamoid.

Although all of our patients felt they were improved, andno complications occurred, the total number of those whoreturned to their former activity level was only 5 of 8. Apossible explanation for the lack of total satisfaction of allpatients could be the extensive length of nonoperative treat-ment, especially for those with nonunions. This may havemanifested as altered biomechanics that subsequently led tochronic pain following surgery.

Chronic pain at the surgical incision site is a potentialcomplication of this surgery. This can also occur with the plantarapproach to the sesamoids, particularly when the incision iscentered directly under the sesamoids or the metatarsophalangealjoint. We believe the dorsolateral approach allows for access tothe fibular sesamoid without the risk of a potentially painfulplantar incision which can lead to chronic pain after surgery. Thecommon digital nerve of the first and second intermetatarsalspace can be injured with the dorsolateral approach to the fibularsesamoid. Care must be taken during dissection to ensure thatthese neurovascular structures are seen and protected to preventpainful neuromas in the postoperative period.

CONCLUSIONSFibular sesamoid pain is usually successfully treated non-operatively using a combination of physical therapy, NSAIDs,orthotics, and activity/shoe modifications. When pain persists,a fibular sesamoidectomy through a dorsolateral approach canyield a high percentage of excellent-good results with minimalcomplications. However, patients should be cautioned aboutresidual pain, development of hallux varus deformity, stiffness,and an inability to return to their preoperative activities.

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Dorsolateral Excision of the Fibular Sesamoid: Technique ...

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