Ultrasound-guided injections in the treatment

of stress fractures of the hallucal sesamoids

1. Panagiotis Symeonidis, MD, PhD Orthopaedic Surgeon

St Luke’s Hospital, Thessaloniki, Greece

2. Dimitrios Zikoudis, MD Radiologist, Musculoskeletal Specialist

Evroiatriki Diagnostic Centre www.foot-ankle.gr

Disclosures. The authors declare:

• No financial disclosures / support

• No potential conflict of interest

Sesamoid stress fractures Panos Symeonidis

Medial (tibial) sesamoid

Lateral (fibular) sesamoid

3D CT (left foot, frontal view)

Sesamoid stress fractures

Treatment options

• Rest (how long?)

• Modification of activities

• ? plaster - taping

• Non-steroidal anti inflammatory drugs “A prolonged period of non weight bearing does not have

predictable results and has to weighed against the adverse

effects of immobilization.”

W. Hamilton

• Surgery (mixed results)

Sesamoid stress fractures Panos Symeonidis

“On many occasions in older dancers, the sesamoids appeared as if they had been smashed with a hammer. During questioning, the dancers invariably stated that they had experienced pain in the area for a year or more, but it eventually went away. Most of the time, they had been unaware of the nature of the problem and just continued dancing with the pain.

The sesamoids eventually healed by asymptomatic fibrous union.”

W. Hamilton

Foot & Ankle Injuries in Dancers

Natural history of sesamoid fractures?

John Lowe 91 years old

(in 2011)

Sesamoid stress fractures Panos Symeonidis

Rationale of treatment with an injection

To covert a symptomatic fracture to an

asymptomatic (+/- fibrous) union with:

• low risk

• quick return to activities

• low cost

• not precluding later surgery, if necessary

Sesamoid stress fractures Panos Symeonidis

• Single injection, 2 ml

betamethasone

• Entry point: depending on the

fracture location and

comminution

• Local anaesthesia

• 23-25G needle

• Localization of the fracture /

needle with ultrasound

Technique

Sesamoid stress fractures Panos Symeonidis

Why ultrasound guidance?

Accurate localization

of injection at the

fracture level

Inexpensive

Repeatable

No radiation

Dynamic

Evaluation of

coexisting pathology Sesamoid injection

Sesamoid stress fractures Panos Symeonidis

Patient series 11 patients (5 ♀, 6 ♂)

5 right - 6 left feet

8 tibial, 3 fibular sesamoids

>3 months of symptoms before diagnosis

Average:10 months

Post – injection: 2 days rest, return to activities as pain allowed

In 2 patients: repeat injection after 2-3 months

Tibial sesamoid injection

Sesamoid stress fractures Panos Symeonidis

Evaluation

Visual Analog Scale for pain

Foot Function Index

AOFAS Hallux Metatarsophalangeal –

Interphalangeal Scale

Follow up: min. 6 months, average 9.8 months

Independent observer scoring the patients

Sesamoid stress fractures Panos Symeonidis

Results

VAS (pain) Foot Function Index AOFAS score

Before After Before After Before After

6.5 2.7 54.9 12.3 68.6 88.2

p= 0.00015 p= 0.00016 p= 0.00081

No adverse effects

All but one patient had pain improvement

Four patients still use insole orthotics

Sesamoid stress fractures Panos Symeonidis

• Platelet Rich Plasma

• Stem cells from fatty tissue

• Osteomorphogenic Proteins

• Bone marrow concentrate

Alternatives

The future?

Sesamoid stress fractures Panos Symeonidis

- One patient failed

injection treatment

and required surgery

- Comminuted fibular

fracture – 2 injections

Intraoperative picture

Medial (tibial) sesamoid

Lateral (fibular) sesamoid

Sesamoidectomy

via medial approach

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416, 1998. 2. Bichara DA, Henn RF 3rd, Theodore GH. Sesamoidectomy for hallux sesamoid

fracturesFoot Ankle Int. 2012 Sep;33(9):704-6. 3. Blundell, CM; Nicholson, P; Blackney, MW: Percutaneous screw fixation for fractures

of the sesamoid bones of the hallux. J Bone Joint Surg Br. 84:1138 –1141, 2002. 4. Cohen BE Hallux sesamoid disorders. Foot Ankle Clin. 2009 Mar;14(1):91-104 5. Coughlin MJ. Sesamoids and accessory bones of the foot. In: Surgery of the foot and

ankle. 8th ed. Edited by Coughlin MJ, Mann RA, Saltzman CL. Philadelphia, PA. Mosby. 2007, pp 566-7.

6. Grace DL. Sesamoid problems. Foot Ankle Clin 2000;5(3):609–27. 7. Hamilton W, Bauman PA. Foot ans Ankle Injuries in dancers In: Surgery of the foot

and ankle. 8th ed. Edited by Coughlin MJ, Mann RA, Saltzman CL. Philadelphia, PA. Mosby. 2007, pp 1611-1612

8. Kaiman, ME; Piccora, R: Tibial sesamoidectomy: a review of the literature and retrospective study. J. Foot Surg. 22:286 –289, 1983.

9. Lee S, James WC, Cohen BE, Davis WH, Anderson RB. Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int. 2005;26:803–809.

10. Richardson, EG: Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg. 7:270 –278, 1999.

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

12. Taylor CF, Butler M, Parsons SW. Problems associated with the excision of the hallux sesamoids. Foot Ankle Clin. 2014 Sep;19(3):425-36

Sesamoid stress fractures Panos Symeonidis