Disclosures. 20 year old Female 2/23/2018. Sesamoid Disorders: Painful for Everyone

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1 Sesamoid Disorders: Painful for Everyone Gregory C Berlet, MD FRCS(C), FAOA Orthopedic Foot and Ankle Columbus, Ohio Robert B Anderson MD Titletown Sports Medicine and Orthopedics Green Bay Wisconsin Columbus, Ohio orthofootankle.com Disclosures Consultant/Speaker Bureau/Royalties/ Stock: Wright Medical, Stryker, ZimmerBiomet, DJO, Plasmology 4, Amniox Medical, United Orthopedic Group, Paragon 28, CrossRoads, Ossio 20 year old Female Colleagiate soccer athlete 6 month history of pain in the ball of her foot Swelling, pain and inability to run 1

2 Clinical Findings Pain localized to tibial sesamoid Some local swelling Good ROM and stability Fracture or Bi Partite? Bipartite: 20 40% incidence Bilateral 60 80% Fracture: Tibial >Fibular Larger and more prone to injury Fracture vs Bi Partite Fracture tends to be at the waist, jagged edges Bipartite often rounded sclerotic edges and may be distal or proximal 1/3 Comparison views helpful 2

3 MRI / Bone Scan / CT Cold and No Edema = Bipartite Tibial Sesamoid Stress Fracture Young athlete Fairly profound disability despite 6 months non operative care: Boot walker x 2 months Orthotic with mortons extension Attempt to return to sport failed Audience Poll: Recommendations for Tx 1. Further immobilization 2. Sesamoid ORIF 3. Sesamoid bone grafting 4. Partial sesamoidectomy 5. Medial sesamoidectomy 3

4 Operative Treatment Indications Failure of conservative treatment Pain/tenderness localized to one sesamoid Diagnostic studies identify abnormality that correlates with pain Partial Sesamoidectomy Biedert et al (2003): 5 pts with proximal pole sesamoidectomy for non union 100% good to excellent, one with restriction of sports activities Anderson ( personal communication): Perform for fractures <25% of total Bierdert R, Hintermann B: FAI 24(2), 2003 Our Choice: Sesamoid Bone Grafting Why? Sesamoid stress fracture nonunion Fragments healthy Minimal diastasis Young patient 4

5 Sesamoid Bone Grafting Medial approach Fracture identified on plantar surface after plantar shaving Articular surface intact Local bone graft No internal fixation Sesamoid Bone Grafting Tips and Tricks: Plantar shaving to decrease plantar load and expose the fracture Local bone graft from metatarsal head Sesamoid Bone Grafting Anderson/McBryde (1997): 21 tibial hallux sesamoid stress fracture nonunions 19 radiographically healed Avg. 12 weeks to union 20/21 returned to athletics Anderson RB and McBryde A: FAI 18(5),

6 Sesamoid Bone Grafting Example Postop CT Union at 16 weeks Our Patient Healed CT at 12 months But continued pain RBA: majority of patients received concomitant relief of symptoms Anderson RB and McBryde A: FAI 18(5), 1997 Our Patient Healed CT at 12 months But continued pain RBA: majority of patients received concomitant relief of symptoms Anderson RB and McBryde A: FAI 18(5),

7 Persistent Pain Differential Diagnosis: Plantar plate ligament instability Sesamoid arthritis Sesamoid instability / Bunion Lateral sesamoiditis / fracture Back to Some Imaging Pre bone grafting Now My Plan Medial sesamoidectomy Remove the pain generator DSTP Balance the lateral sesamoid back into the cristae Reconstruct the medial plantar plate 7

8 Consequences! Effect of sesamoid resection on FHB pushoff strength Tibial: 10% Fibular: 16% Both: 30% Apner RL, Saltzman DL, Brown TD: FAI 15(9), 1994 Sesamoidectomy Approach Goal: Preserve or restore the anatomy Tibial: medial approach Fibular: plantar approach Medial Sesamoidectomy Medial approach Identify and protect medial plantar nerve Protect FHL centrally Shell out from plantar 8

9 Reconstruct the Defect Abductor Hallucis Tendon Transfer Transfer into defect Secure to the proximal phalanx base Indications for Abd Transfer Large defect that cannot be primarily closed Concern about hallux valgus Need for flexion power Surgical Technique 9

10 Good not Great Operation Sesamoidectomy Results: Mann et al, 1985 Leventen, 1991 Brodsky, 1991/1999 Mann and Coughlin, 1993 Lee et al, 2005 Athletes and Sesamoidectomy Bichara et al (2012): 24 medial sesamoidectomies Avg f/u of 35 months 22/24 returned to sporting activities Average of 11.4 months Mean pain improvement from 6.2 to 0.7 One patient developed hallux valgus Bichara DA, Henn RF, Theodore GH: FAI 33(9), 2012 Deformity after Sesamoidectomy Nayfa et al ( 1982): 19 tibial sesamoidectomies 8 of 19 (42.1%) developed a hallux valgus deformity (post-operative Δ of HVA >8 ) Recommended an adjunctive procedure when performing a tibial sesamoidectomy Nayfa TM, Sorto LS: JAPA 72(112),

11 Postop sesamoidectomy Non WB x 2 weeks Maintain hallux alignment/protect in boot for 6 8 weeks 3 months orthosis/tape protection for recreation Our Patient Pain reduction is significant Bunion is improved Return to sport at 6 months Sesamoid Fractures CONCLUSIONS Take Home Points: Imaging helps distinguish between bipartite and fracture Don t be quick to operate Partial sesamoidectomy only for small proximal pieces (<25%) 11

12 Sesamoid Fractures CONCLUSIONS Take Home Points: FHB must be restored for power and balance In medial sesamoidectomy consider abd hallicus transfer Do not overpromise with sesamoids a good operation, not a great one! 12