Hallucal sesamoid Pain: Nguyên nhân và điều trị phẫu thuật pot

Journal of the American Academy of Orthopaedic Surgeons
270
Although small and seemingly in-
consequential, the hallucal sesa-
moids can cause disabling pain
when injured. Activities such as
racket sports, football, soccer, basket-
ball, volleyball, running, and sprint-
ing may result in overuse injury to
the sesamoids from repetitive stress.
Inflammation from arthrosis, chon-
dromalacia, flexor hallucis brevis
tendinitis, osteochondritis dissecans,
and fracture can all affect the
sesamoids and must be considered
when there is persistent pain in the
first metatarsophalangeal joint.
Anatomy
Three sesamoids may be present in
the great toe; two (one medial and
one lateral) are almost always pres-
ent on the plantar aspect of the
metatarsophalangeal joint, and one
may be present at the level of the
plantar aspect of the interpha-
langeal joint. The sesamoids at the
metatarsophalangeal joint are by
far the most clinically pertinent.
The two sesamoids of the meta-
tarsophalangeal joint are embedded
in the tendons of the short flexor of

the great toe. They are held together
by the intersesamoid ligament and
the plantar plate, which inserts on
the base of the proximal phalanx of
the hallux (Fig. 1, A).
1
The medial
(tibial) sesamoid, which usually is
larger than the lateral (fibular)
sesamoid, rests in the medial facet
(sulcus) of the first metatarsal head
and is more impacted by weight
bearing than the lateral, which rests
in the lateral facet (Fig. 1, B). This
anatomic arrangement leads to a
higher incidence of traumatic in-
juries to the tibial sesamoid.
The hallucal sesamoids function
to absorb weight-bearing pressure,
reduce friction, and protect ten-
dons. They are important to the
dynamic function of the great toe
and act as a fulcrum to increase the
mechanical force of the flexor hal-
lucis brevis tendon.
2
Ossification of the hallucal sesa-
moids occurs between the 7th and
10th years of life, often from multi-
ple ossification centers, which may

result in bipartite and tripartite
sesamoids. The fibular sesamoid is
rarely bipartite, whereas a bipartite
tibial sesamoid is present in about
10% of the population. In 25% of
those with a bipartite tibial sesa-
moid, the condition is bilateral.
3
Prieskorn et al
4
reported slightly
higher percentages in the 200 feet
they studied. Weil and Hill
5
re-
ported a statistically significant
association between a bipartite tib-
ial sesamoid and hallux valgus
deformity, which they attributed to
incomplete fusion of the separate
ossification centers and the resul-
tant imbalance of intrinsic muscle
control of the first metatarsopha-
langeal joint.
Dr. Richardson is Professor, Department of Or-
thopaedic Surgery, University of Tennessee/
Campbell Clinic, Memphis.
Reprint requests: Dr. Richardson, Campbell
Foundation, Suite 500, 910 Madison Avenue,
Memphis, TN 38103.

Copyright 1999 by the American Academy of
Orthopaedic Surgeons.
Abstract
The hallucal sesamoids, although small and seemingly insignificant, play an
important role in the function of the great toe by absorbing weight-bearing pres-
sure, reducing friction, and protecting tendons. However, the functional com-
plexity and anatomic location of these small bones make them vulnerable to
injury from shear and loading forces. Injury to the hallucal sesamoids can
cause incapacitating pain, which can be devastating to an athlete. Although
traumatic injuries usually can be diagnosed easily, other pathologic conditions
may be overlooked. Careful physical and radiologic examinations are necessary
to determine the cause of pain and allow a recommendation of the optimal treat-
ment. Surgical treatment may include partial or complete resection of the
sesamoid, shaving of a prominent tibial sesamoid, or autogenous bone grafting
for nonunion. Excision of both sesamoids should be avoided if possible.
J Am Acad Orthop Surg 1999;7:270-278
Hallucal Sesamoid Pain:
Causes and Surgical Treatment
E. Greer Richardson, MD
E. Greer Richardson, MD
Vol 7, No 4, July/August 1999
271
Clinical Evaluation
Symptoms
Patients with conditions involv-
ing the sesamoids may not always
present with symptoms directly
referable to the sesamoid bones.
The patient may complain of gen-
eralized pain around the big toe or

may describe pain after a sudden
pop or snap during running.
Generally, however, patients com-
plain of pain as the hallux extends
in the terminal part of the stance
phase of gait. If the first metatarsal
is plantar-flexed, an intractable
plantar keratosis may have devel-
oped. Neuritic symptoms and
numbness also may occur if a digi-
tal nerve is compressed by edema,
inflammation, or displacement of a
bipartite or fractured sesamoid.
Physical Examination
Patients with pain around the
first metatarsophalangeal joint
should undergo a thorough exami-
nation that includes evaluation of
the sesamoids. On physical exami-
nation, swelling, diminished strength
in plantar flexion, and loss of active
and passive dorsiflexion may be
present. Direct palpation over the
sesamoids will identify localized
tenderness; tenderness in other
areas of the joint may suggest reac-
tive synovitis of the first metatarso-
phalangeal joint. If nerve compres-
sion is present, a positive Tinel
sign, particularly along the medial

branch of the plantar digital nerve,
will be elicited. The foot should be
inspected for a cavus deformity,
which is often associated with an
abnormally plantar-flexed or less
mobile first ray; such a deformity
places more axial load on the sesa-
moids, especially the tibial sesamoid.
Imaging
The standard lateral x-ray view
of the foot usually is not useful in
evaluating a sesamoid-related dis-
order. Anteroposterior, medial
oblique, and lateral oblique views
may be more revealing. The medi-
al oblique sesamoid view (Fig. 2, A)
is helpful in evaluating the tibial
sesamoid. The lateral oblique view
(Fig. 2, B) is helpful in evaluating
the fibular sesamoid. An axial
sesamoid view should always be
obtained if a pathologic condition
is suspected (Fig. 2, C and D).
If radiographs are normal, a
bone scan may be helpful; how-
ever, the projection of the bone
scan is important in differentiating
pathologic conditions attributable
to the sesamoids from intra-articular
conditions affecting the metatarso-

phalangeal joint (Fig. 3). On an
anteroposterior bone scan, a sesa-
moid abnormality may be ob-
scured if there are degenerative or
posttraumatic articular changes in
the first metatarsophalangeal joint.
A posteroanterior or oblique view
with collimation will distinguish
the sesamoid apparatus from the
articular component of the first
metatarsophalangeal joint. Chisin
et al
6
recommend caution in inter-
preting increased scintigraphic
activity, because they found that
26% to 29% of asymptomatic per-
sons had some increased activity.
A marked difference in uptake
between the sesamoids of one foot
and those of the other is signifi-
cant.
Magnetic resonance imaging
may be helpful if osteomyelitis is
suspected.
7
Computed tomogra-
phy (CT) is particularly useful in
delineating posttraumatic changes,
because comparisons with the

sesamoids of the opposite foot can
be made.
Cord portion of medial
capsular ligament
Accessory portion of
medial capsular ligament
(ligament of medial sesamoid)
Plantar plate and
sesamoids
Abductor hallucis
Medial sesamoid
Intersesamoid
ligament
Plantar plate
Crista
Capsule
Deep transverse
metatarsal ligament
Transverse
head of
adductor
hallucis
Lateral sesamoid
Oblique head of
adductor hallucis
Lateral head of
flexor hallucis brevis
Medial head of
flexor hallucis brevis
Fig. 1 Anatomy of the hallux. Above, Components of the medial

capsular ligament. Right, Drawing shows the intrinsic muscles
about sesamoids cut and reflected distally, opening the plantar
aspect of the metatarsophalangeal joint. (Adapted with permission
from Richardson EG: Injuries to the hallucal sesamoids in the ath-
lete. Foot Ankle 1987;7:229-244.)
Hallucal Sesamoid Pain
Journal of the American Academy of Orthopaedic Surgeons
272
Causes of Sesamoid Pain
Traumatic injuries to the sesamoids
are easily recognized, but chronic
inflammatory conditions, infec-
tions, and arthritis may be less ob-
vious. Inflamed bursae, intractable
plantar keratoses, or diffuse callus
may indicate an underlying condi-
tion. In addition, chondromalacia,
flexor hallucis brevis tendinitis,
osteochondritis dissecans, and frac-
ture must all be ruled out.
3
Sesamoid Fracture
Because bipartite tibial sesamoids
are present in about 10% of the pop-
ulation, the physician must be cer-
tain that a tender sesamoid with a
division through it, as seen on a
radiograph, is indeed a fracture
(Fig. 4). A tibial sesamoid may be
divided into two, three, or four

parts. It is often difficult to distin-
guish between a symptomatic
bipartite or multipartite sesamoid
and a fractured sesamoid, especially
if there is a fracture through a bipar-
tite sesamoid. If a fracture is pres-
ent, radiographs may show an
irregular radiolucent line, but it may
be necessary to obtain serial radio-
graphs or CT scans to compare the
distance between fragments.
8
Be-
cause bipartite sesamoids occur
bilaterally in 25% of persons with
this condition,
3
radiographs of the
opposite foot should be obtained for
comparison. Magnetic resonance
imaging and pin-hole collimated
bone scanning are methods for early
diagnosis of fracture of a bipartite
sesamoid.
9
Initially, nonsurgical treatment
is recommended, with use of or-
thoses, modified footwear, or cast-
ing.
10

A dancerÕs pad or a molded
orthosis with a well, combined
with a metatarsal pad, should be
utilized first (Fig. 5). In nonath-
letes, a metatarsal bar is frequently
used in place of a molded orthosis
to simplify treatment and reduce
expense. If orthotic management
fails, a short-leg walking cast with
a toe plate should be worn for 6
weeks. If tenderness persists, a
removable short-leg cast should be
applied. If there is no tenderness,
an orthosis can be worn.
Stress fractures, which frequently
occur in athletes, usually heal ade-
quately with rest and nonoperative
treatment. A cast should be ap-
plied, and the patient should not
bear weight for 6 to 8 weeks until
the fracture heals. A molded ortho-
sis with a pad and a well beneath
the first metatarsal head can then be
used for comfort.
Delayed union and nonunion of
the sesamoids have been reported
in patients with stress fractures,
and may result from a delay in
diagnosis or an inadequate period
of immobilization.

11
If symptoms
continue in spite of 6 to 8 weeks of
nonoperative treatment, surgical
A B
C D
Fig. 2 Radiographic imaging of the sesamoids. A, Medial oblique view. B, Lateral oblique
view depicts sesamoids (arrow). C, Technique for axial view. X-ray beam is directed from
posterior to anterior. D, Axial view demonstrates mottling of tibial sesamoid.
Fig. 3 Bone scan shows asymmetry of the
two sesamoid regions. Patient had a frac-
tured tibial sesamoid associated with cap-
suloligamentous disruption.
E. Greer Richardson, MD
Vol 7, No 4, July/August 1999
273
intervention may be indicated,
especially if instillation of a small
amount (1 to 2 mL) of a short-acting
local anesthetic over the sesamoid
relieves the pain of weight bearing.
Excision of the most comminuted
fragment or the entire sesamoid is
preferred over bone grafting in
most cases. Bone grafting for
chronic symptomatic displaced
sesamoid fractures has been advo-
cated for high-performance ath-
letes, in whom any decrease in the
strength of the capsulosesamoid

apparatus is undesirable.
12
Osteochondritis
Osteochondritis of the sesa-
moids occurs infrequently, and its
cause is unknown. Although trau-
ma probably is the most frequent
cause, osteonecrosis with subse-
quent regeneration and excessive
calcification may be present. Typi-
cally, the patient has pain and ten-
derness on palpation. An axial
radiograph or CT scan may show
an enlarged or deformed sesamoid
with irregular areas of increased
bone density, mottling, and frag-
mentation (Fig. 6). The appearance
of the symptomatic foot should be
compared with that of the opposite
foot. All nonsurgical treatment
modalities should be exhausted
before surgical resection of the
involved sesamoid is considered.
13
Infection
Infection rarely occurs in the
sesamoids, except in patients with
diabetic peripheral neuropathy. In
a review of the literature regarding
osteomyelitis of the sesamoid bones

after a puncture wound of the foot,
Rahn and Jacobson
14
found that
Pseudomonas was the infecting
organism in 7 of 22 patients. Be-
cause the hallux valgus deformity
that occurred with osteomyelitis
was worsened by sesamoid exci-
sion, they recommended preserving
the surrounding structures (medial
and lateral bands of the flexor hal-
lucis brevis tendons traversing to
the base of the proximal phalanx)
during sesamoid excision to pre-
vent intrinsic-minus deformity of
the hallux.
14
Patients with diabetic neuropa-
thy in the lower extremities are
especially susceptible to infection
from skin breakdown and ulcera-
tion. If the infection is refractory to
medical treatment or if osteo-
myelitis is present, excision of one
or both sesamoids may be neces-
sary. Thorough irrigation and
debridement should be carried out,
and antibiotic therapy started. A
localized subperiosteal resection,

combined with preservation of the
tendons of the abductor and
adductor flexor hallucis muscles,
Fig. 4 A, Radiograph depicting a fractured tibial sesamoid. B, Note the asymmetry of the
two sesamoid regions on a bone scan.
A B
Fig. 5 Above, DancerÕs pad. Right,
Molded orthosis with a well under the first
metatarsal head and metatarsal pad.
Hallucal Sesamoid Pain
Journal of the American Academy of Orthopaedic Surgeons
274
may maintain hallucal flexion or at
least prevent the cock-up deformity
that occurs after bilateral sesamoid
resection. Holding the metatar-
sophalangeal joint in 20 to 30 de-
grees of plantar flexion with an
obliquely placed Kirschner wire for
3 to 4 weeks is even more likely to
prevent intrinsic-minus hallux de-
formity.
Sesamoiditis
Sesamoiditis often occurs after
repetitive trauma and is most com-
mon in young adults and teen-
agers. Pain on weight bearing,
local tenderness over the sesa-
moids, and inflammation or bursal
thickening on the plantar aspect of

the sesamoid mechanism may be
present. Even if the radiographic
evaluation includes an axial
sesamoid view, it is usually unre-
vealing.
15
This entity should be
treated conservatively, with ortho-
ses, shoe modifications, reduced
weight bearing, and cast immobi-
lization for lengthy periods before
excision of the symptomatic sesa-
moid is considered.
Arthritis
Arthritis of the metatarsal sesa-
moid articulation may be the result
of chronic sesamoiditis, chondro-
malacia, or trauma. Hallux rigidus
(osteoarthritis), gouty arthropathy,
or rheumatoid arthritis may be
present. Characteristic findings of
arthritis include swelling, erythe-
ma, restricted motion of the meta-
tarsophalangeal joint, and localized
pain on palpation and forced dorsi-
flexion. Nonsteroidal anti-inflam-
matory medication, a stiff-soled or
rocker-bottom shoe, and a metatar-
sal pad usually help to lessen pain.
Although sesamoidectomy may

decrease pain, motion at the meta-
tarsophalangeal joint is often re-
stricted. The medial and lateral
sesamoids should not both be re-
moved, because this may lead to
clawing of the hallux.
10
Intractable Plantar Keratoses
A localized plantar keratosis
usually is caused by the presence
of a sesamoid with a plantarly
located osseous prominence or a
first metatarsal with reduced dorsi-
flexion (Fig. 7). However, a more
diffuse callosity beneath the meta-
tarsal head may be attributable to
an enlarged sesamoid or an imbal-
ance between the tibialis anterior
and peroneus longus tendons or
between the tibialis posterior and
peroneus brevis tendons. A meta-
tarsal pad placed proximal to the
keratotic lesion and intermittent
paring may be all that is necessary.
For intractable lesions, sesamoid
shaving and occasionally resection
may be necessary. However, sesa-
moid shaving should be avoided
when a plantar-flexion deformity of
the first metatarsal is present. If the

plantar-flexed metatarsal is fixed
and not translatable or is level with
the second metatarsal head or is
slightly dorsiflexed in relation to it,
excision is contraindicated because
the lesion is likely to recur. A basilar-
dorsiflexion metatarsal osteotomy is
preferable in these situations.
A localized plantar keratosis
beneath the first metatarsal head in a
patient with profound sensory neu-
ropathy (e.g., due to diabetes melli-
tus) is potentially devastating. If the
keratosis ulcerates from the pressure
of the sesamoid, deep infection,
including pyarthrosis and osteo-
myelitis of the adjacent phalanx or
first metatarsal, may develop.
Nerve Impingement
Pain over the tibial sesamoid
may be caused by impingement of
the medial branch of the plantar
digital nerve by the medial side of
the hallux. Symptoms include
radiating pain and decreased sen-
sation. Padding with moleskin or
other adhesive friction-relief mater-
ial, shoes with a wide toe-box, and
gentle massage usually are suffi-
cient treatment. If symptoms per-

sist, partial or complete excision of
the tibial sesamoid and release of
the fascial capsular restraints about
the nerve are indicated. However,
the patient must be informed that
sesamoid pain associated with neu-
ritic symptoms may require a
lengthy period of recovery and that
autonomic nervous system dys-
function (reflex sympathetic dys-
trophy) may occur.
Occasionally, an enlarged, dis-
placed, or inflamed fibular sesamoid
may produce neuritic symptoms in
the first web space, particularly on
the lateral aspect of the hallux. The
nerve branch travels adjacent to the
lateral border of the fibular sesa-
moid on its course to the pulp of the
Fig. 6 Osteochondritis of the right lateral sesamoid (arrow) with fragmentation and
increased density compared with normal left side.
E. Greer Richardson, MD
Vol 7, No 4, July/August 1999
275
hallux. If there are neuritic symp-
toms on the medial side of the hal-
lux, padding, shoes with a wide
toe-box, and massage should be
used for an extended period before
surgical excision of the sesamoid is

considered.
Surgical Treatment
Surgical treatment should not be
considered until all conservative
options have been exhausted,
including orthotic management,
shoe modifications, decreased
weight bearing or avoidance of
weight bearing, and cast immobi-
lization. Surgical treatment of
painful hallucal sesamoid disorders
involves partial or complete resec-
tion of one or both sesamoids.
Excision of both sesamoids should
be avoided because of the high post-
operative incidence of hallux valgus
or cock-up deformity of the toe.
However, occasionally a young man
may require resection of both
sesamoids because of unrelenting
symptoms of inflammatory arthritis.
Sesamoidectomy
Total sesamoidectomy produces
a mechanical defect in the flexor hal-
lucis brevis muscle-tendon unit by
reducing the flexion moment arm of
the muscle at the metatarsopha-
langeal joint.
16
Two thirds of either

sesamoid can be removed without
disturbing the ligamentous attach-
ments. This may relieve pain while
avoiding total sesamoidectomy.
17
The surgical approach depends on
which sesamoid is to be resected. For
tibial sesamoidectomy, a longitudinal
medial incision or plantar medial
incision can be used. The fibular
sesamoid can be approached through
a dorsal or plantar incision. The dor-
sal approach is technically demand-
ing because of the depth of the sesa-
moids; however, with the plantar ap-
proach, the proximity of the neuro-
vascular bundle to the first web space
and the presence of the flexor hallucis
longus tendon between the sesa-
moids make excision difficult.
Technique for Tibial Sesamoidectomy
A 3-cm plantar medial incision
is made (Fig. 8, A). The medial
branch of the plantar digital nerve
is identified and retracted to avoid
injury (Fig. 8, B). The sesamoid is
located by palpation and differenti-
ated from the metatarsal head.
With the great toe flexed 20 to 30
degrees and the flexor hallucis

longus retracted, the intersesamoid
ligament is incised, and the tibial
sesamoid is pulled medially. The
sesamoid is shelled out of the cap-
sule and plantar plate by sharp dis-
section with a small-blade knife.
Excision is accomplished by proxi-
mal release of the medial head of
the flexor hallucis brevis and its
continuation distally to the base of
the proximal phalanx of the hallux
(Fig. 8, C). The medial side of the
capsule is closed with absorbable
sutures, and the skin is closed with
nonabsorbable sutures (Fig. 8, D).
Technique for Fibular
Sesamoidectomy
The fibular sesamoid is ap-
proached through a dorsal incision
in the first intermetatarsal space.
The incision is begun 2 to 3 cm
proximal to the apex of the web
space and is extended proximally 5
to 7 cm. The branches of the deep
peroneal nerve are identified and
protected. The interval between the
adductor hallucis longus and the
joint capsule is opened. The tendon
of the adductor hallucis longus is
reflected from the lateral sesamoid,

and the lateral capsulosesamoid lig-
ament is incised. The sesamoid is
grasped firmly and displaced later-
ally, and the intersesamoid liga-
ment is severed. The fibular sesa-
moid is displaced farther laterally,
released proximally and distally,
and then removed. The depth of
the wound should be inspected to
ensure that the flexor hallucis
longus tendon has not been severed
and the neurovascular bundle to
the first web has been preserved.
Repair of the capsular tissue is not
possible. The skin is closed with
interrupted sutures.
Fig. 7 A, Intractable plantar keratosis. B, Osseous nodule (arrow) on tibial sesamoid.
A B
Hallucal Sesamoid Pain
Journal of the American Academy of Orthopaedic Surgeons
276
Technique for Plantar Removal of the
Fibular Sesamoid
The fibular sesamoid can be re-
moved through a plantar approach
(Fig. 9, A). With the ankle held in
dorsiflexion, the hallux is flexed
and extended to locate the sesa-
moid. A longitudinal incision is
made, beginning 1.0 to 1.5 cm dis-

tal to the metatarsophalangeal joint
and extending proximally 3.5 to 4.0
cm between the first and second
metatarsals. Once the skin and fas-
cial septa within the forefoot pad
have been separated, a small self-
retaining retractor is inserted.
With use of a small, blunt-tip dis-
secting scissors, the neurovascular
bundle to the first web space is
retracted laterally or medially,
depending on the position of the
sesamoid. The sesamoids are pal-
pated, and the hallux is flexed and
extended to locate the flexor hallu-
cis longus tendon. The pulley over
the flexor hallucis longus tendon is
opened, and the tendon is retracted
medially. This is made easier by
holding the foot in dorsiflexion at
the arch with one hand and flexing
the metatarsophalangeal joint to
relax the flexor hallucis longus ten-
don with the opposite hand.
At this point, the intersesamoid
ligament will come into view and
should be divided completely.
This may require moving the
scalpel 1 or 2 mm laterally or medi-
ally to find the groove between the

sesamoids. The cleavage plane
between the two sesamoids is
incised while the flexor hallucis
longus muscle is retracted medially
and the neurovascular bundle is
retracted laterally. The fibular
sesamoid is grasped with a strong
pick-up or small Kocher clamp,
and the lateral head insertion of the
flexor hallucis brevis muscle is
removed from the proximal end of
the sesamoid under direct vision.
Once the medial and proximal
restraints of the sesamoid have
been released, the attachment of
the adductor hallucis muscle to its
lateral distal edge close to the bone
is severed. The last attachment of
A B
C D
Fig. 8 Tibial sesamoidectomy. A, Incision. B, Identification of the digital nerve. C, Tibial sesamoid excised. D, Capsular closure.
E. Greer Richardson, MD
Vol 7, No 4, July/August 1999
277
the sesamoid is severed distally
where the plantar plate continues
its distal insertion into the proxi-
mal phalanx. Once the sesamoid
has been removed, the wound is
carefully inspected for bleeding

(Fig. 9, B).
The cuff of residual tendon of
the flexor hallucis brevis, as well as
any intersesamoid ligament left by
the dissection, is retracted to pas-
sively flex the hallux. If the hallux
does not flex, the defect should be
repaired with 2-0 absorbable suture
while holding the hallux in 15 to 20
degrees of plantar flexion. A 0.062-
inch Kirschner wire is passed
obliquely across the first metatar-
sophalangeal joint and cut off
under the skin. At follow-up, if the
repair is under tension, the wire can
be removed in the office. Pressing
on the edges of the wound is help-
ful in identifying bleeding vessels,
which should be cauterized. The
skin is closed with interrupted 4-0
nylon suture, with care being taken
to evert the skin edges to minimize
scarring.
Tibial Shaving
For a prominent tibial sesamoid
that has caused an intractable plan-
tar keratotic lesion, sesamoid shav-
ing is an alternative to sesamoid
excision if there is normal mobility
of the first metatarsal. Mann and

Wapner
18
believe shaving to be
superior to excision because post-
operative morbidity is less. They
describe removing the plantar half
of the sesamoid and smoothing the
sharp edges with a rongeur.
The technique for tibial shaving
begins with a longitudinal plantar-
medial incision. The medial branch
of the plantar digital nerve is care-
fully retracted. The sesamoid is ex-
posed, and the metatarsophalangeal
joint is flexed 10 to 20 degrees. The
plantar fat pad is retracted, and the
plantar half of the tibial sesamoid is
resected with a sagittal saw. Be-
cause the articular surface of the
sesamoid is concave, gradual shav-
ing of the sesamoid to the desired
thickness is recommended to avoid
damage to the articular surface.
The flexor hallucis longus tendon
lies lateral to the tibial sesamoid
and should be protected. The sharp
edges of the sesamoid are smoothed
with a rongeur. The wound is
closed in routine fashion, as de-
scribed in the preceding section.

Postoperatively, a compressive
forefoot dressing is used, and a
rigid-sole shoe is worn for approxi-
mately 2 weeks. Weight bearing is
allowed to tolerance with or with-
out crutches. Sutures are removed,
and the patient is allowed to wear a
wide, deep shoe. If the patient
wants to be more active during the
first 2 to 3 weeks after surgery, a
short-leg walking cast can be ap-
plied.
Autogenous Bone Grafting for
Nonunion of the Sesamoid
Autogenous bone grafting of the
hallucal sesamoid may be an alter-
native to sesamoid excision in
selected patients with established
nonunions (usually high-perfor-
mance athletes). Anderson and
McBryde
12
reported union in 19 of
21 patients who underwent this
procedure for symptomatic tibial
hallucal sesamoid nonunions.
This procedure is done through
a 5-cm longitudinal plantar medial
skin incision centered over the
metatarsophalangeal joint. The

capsule and abductor hallucis ten-
don are divided in line with the
skin incision, and the joint is
entered dorsal to the tibial sesa-
moid. Dissection plantar to the
abductor hallucis tendon provides
extra-articular exposure of the tib-
ial sesamoid. Care is taken to
avoid injury to the medial branch
of the plantar digital nerve.
After sharp periosteal reflection,
a transverse lesion within the mid-
portion of the sesamoid can be
identified, and gross motion at the
A B
Fig. 9 A, Plantar incision for removal of lateral sesamoid. The flexor hallucis longus ten-
don and neurovascular bundle must be protected. B, After removal of lateral sesamoid.
sesamoid nonunions. Foot Ankle Int
1997;18:293-296.
13.Velkes S, Pritsch M, Horoszowski H:
Osteochondritis of the first metatarsal
sesamoids. Arch Orthop Trauma Surg
1988;107:369-371.
14.Rahn KA, Jacobson FS: Pseudomonas
osteomyelitis of the metatarsal sesamoid
bones. Am J Orthop1997;26:365-367.
15.Kliman ME, Gross AE, Pritzker KPH,
Greyson ND: Osteochondritis of the
hallux sesamoid bones. Foot Ankle
1983;3:220-223.

16.Aper RL, Saltzman CL, Brown TD:
The effect of hallux sesamoid excision
on the flexor hallucis longus moment
arm. Clin Orthop1996;325:209-217.
17.Quirk R: Common foot and ankle
injuries in dance. Orthop Clin North
Am1994;25:123-133.
18.Mann RA, Wapner KL: Tibial sesa-
moid shaving for treatment of intrac-
table plantar keratosis. Foot Ankle
1992;13:196-198.
Hallucal Sesamoid Pain
Journal of the American Academy of Orthopaedic Surgeons
278
nonunion site may be appreciated.
Taking care to avoid disruption of
the articular surface, fibrous and
necrotic tissue is curetted with a
small dental curette. The defect is
then packed with autogenous bone
graft harvested locally through a
cortical window in the medial emi-
nence of the first metatarsal head.
As a result of the tendinous expan-
sion that surrounds the sesamoid,
the proximal and distal fragments
will remain in close apposition.
The capsule is carefully closed with
absorbable sutures, and the skin is
closed with a nonabsorbable suture.

Postoperatively, the patient is
immobilized in a short-leg plas-
ter cast, which is worn for 3 to 4
weeks. At that time, a new short-
leg walking cast is applied,
which is worn for 8 weeks.
Active exercises are begun, fol-
lowed by gentle passive range-
of-motion exercises as tolerated.
At 10 to 12 weeks, tomograms are
obtained to evaluate union. Plain
radiographs may remain equivo-
cal for several weeks or months,
but serial tomograms are helpful
in documenting progression of
union.
Summary
The hallucal sesamoid bones can be
the cause of disabling pain when
injured, especially in athletes.
Traumatic injuries to the sesamoids
are easily recognized, but other
conditions may not be immediately
apparent. Appropriate imaging
techniques and a thorough physical
examination are necessary to accu-
rately diagnose and treat these
problems. Initially, conservative
treatment is recommended; howev-
er, if symptoms continue, surgical

intervention is indicated.
References
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