Review Question - QID 218823

Despite different complication profiles, there is no difference in clinical or functional outcomes following medial versus lateral sesamoidectomy. Patients generally experience good results with reliable pain relief and return to function.

Hallux sesamoid pathology is diverse and often challenging to treat. Stress fractures are the most common entity, and the medial or tibial sesamoid is most commonly involved. Radiographs are often initially negative, therefore diagnosis relies on a careful history and physical exam. Surgery is indicated only after a minimum of 3 months of failed conservative management. Sesamoidectomy has been found to be an effective treatment, albeit with a moderate rate of complications to include pain, nerve injury, infection, and deformity. Hallux valgus is the most commonly reported deformity after tibial sesamoid excision and may result from inadequate medial capsular repair and reefing.

Kane et al. reviewed the radiographic outcomes and clinical results following sesamoidectomy for fracture. The authors found that patients with medial sesamoidal pathology had greater pre-existing hallux valgus and intermetatarsal angles and this increased post-operatively to a statistically but not clinically significant degree. Conversely, patients who underwent lateral sesamoidectomy had a net decreased in both radiographic parameters. However patient outcomes did not significantly differ between the two cohorts.

Bichara et al. evaluated the outcomes following sesamoidectomy for hallucal sesamoid fractures in athletes. At an average follow-up of 3 years, the authors found that 92% of patients were able to return to activities by an average of 12 weeks. They noted a significant improvement in pain and function with the development of a postoperative hallux valgus deformity in 4% of cases. They advocated for meticulous surgical repair following excision to mitigate this risk.

Figure A shows an AP radiograph of the left foot with no obvious osseous pathology. Figure B shows a postoperative AP radiograph of the left foot demonstrating tibial sesamoidectomy.

Incorrect answers:
Answer 2: Patients undergoing medial tibial sesamoidectomy for chronic sesamoid pathology have been found to have greater pre-operative hallux valgus and intermetatarsal angles.
Answer 3: After medial tibial sesamoidectomy, hallux valgus and intermetatarsal angle have been shown to increase to a statistically significant degree. However this is reported to be of little clinical significance.
Answer 4: The most commonly cited reason for post-operative deformity is secondary to inadequate medial capsular repair and reefing following sesamoidectomy.
Answer 5: The proper branch of the medial plantar nerve is at greatest risk of injury during tibial sesamoidectomy.