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
Trang 1Although small and seemingly
in-consequential, the hallucal
sesa-moids can cause disabling pain
when injured Activities such as
racket sports, football, soccer,
basket-ball, volleybasket-ball, 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 al4 reported slightly higher percentages in the 200 feet they studied Weil and Hill5 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
Causes and Surgical Treatment
E Greer Richardson, MD
Trang 2Clinical 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 al6 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.)
Trang 3Causes 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,3radiographs 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
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.
Trang 4intervention 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 Jacobson14 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.
Fig 5 Above, DancerÕs pad Right,
Molded orthosis with a well under the first metatarsal head and metatarsal pad.
Trang 5may 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 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.
Trang 6hallux 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.
Trang 7Technique 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
Fig 8 Tibial sesamoidectomy A, Incision B, Identification of the digital nerve C, Tibial sesamoid excised D, Capsular closure.
Trang 8the 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 Wapner18 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 plantar-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 McBryde12 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
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.
Trang 9sesamoid 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 Orthop 1997;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 Orthop 1996;325:209-217.
17 Quirk R: Common foot and ankle injuries in dance. Orthop Clin North
Am 1994;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.
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-l e g w a short-l k i n g c a s t i s a p p short-l i e d ,
w h i c h i s w o r n f o r 8 w e e k s 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
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Autogenous bone grafting of hallux