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Saura, Ryuichi / Andoh, Yoshihiro / Fujii, Hideki / Ishikawa, Makoto / Mizuno, Kousaku Bulletin of allied medical sciences Kobe : BAMS

1 Kobe University Repository : Kernel タイトル Title 著者 Author(s) 掲載誌巻号ページ Citation 刊行日 Issue date 資源タイプ Resource Type 版区分 Resource Version 権利 Rights DOI JaLCDOI URL Osteochondritis of Hallux Sesamoid Bone : A Case Report Ishikawa, Hitoshi / Hirata, Souichirou / Saura, Ryuichi / Andoh, Yoshihiro / Fujii, Hideki / Ishikawa, Makoto / Mizuno, Kousaku Bulletin of allied medical sciences Kobe : BAMS (Kobe),13: Departmental Bulletin Paper / 紀要論文 publisher PDF issue:

2 Osteochondritis of Hallux Sesamoid Bone - A Case Report- Hitoshi Ishikawa \ Souichirou Hirata 1, Ryuichi Saura 1, Yoshihiro Andoh 2, Hideki Fujii 3, Makoto Ishikawa 2, and Kousaku Mizuno 3. A case of the osteochondritis of the tibial sesamoid bone of the first metatarsophalangeal joint following the stress fracture is described. Because of the disorders of the great toe usually have long delay between first symptoms and definitive diagnosis, physicians must consider sesamoid bone pathology when the patient complains first plantar metatarsalgia. Conservative treatment of the osteochondritis of sesamoid bone can be used for a time, however, the appearance of fragmentation in radiograph and persistent pain usually indicate the surgical resection of the involved sesamoid. Surgical excision may provide complete relief of symptoms. Key words Great toe, Sesamoid bone, Osteochondritis, Surgical excision, Stress fracture. INTRODUCTION Many conditions can cause pain and plantar swelling around the metatarsophalangeal joint of the great toe. The sesamoids are stabilized by the presence of the thick capsular intersesamoid ligament as well as their tendinous attachments. The sesamoids provide mechanical advantage of the flexor halluc is brevis tendon via the elevation of the first metatarsal head. The position of the hallux sesamoids relative to both the metatarsophalangeal joint and the weight-bearing Faculty of Health Science, Kobe University" School of Medicine!, Kobe, Ishikawa Hospital 2, Himeji, and the Department of Orthopaedic Surgery, Kobe University School of Medicine 3, Kobe, Japan. axis of the foot makes them vulnerable to injl!-ry. Possible diagnosis includes metatarsalgia, bursitis, sesamoiditis, multipartite sesamoid, nonunion of acute fractures and stress fractures. 1-4 ) The following case elucidates the difficulty in correctly diagnosing and treating the medial sesamoid osteochondritis. Early diagnosis and proper treatment are imperative to avoid the debilitating syndrome of the painful non-healing sesamoid bone. The presentation, diagnosis, and treatment of this InjUry are discussed. CASE PRESENTATION A 42-year-old man was seen in the orthopedic clinic on November 15, 1996 with a three months history of pain, swelling under the right forefoot. With increased walking, the pain worsened and swelling was noted. There was no history of trauma against the foot. He had experiences the Karate during his adolescence, but Vol.13, 1997 Bulletin of Allied Medical Sciences, Kobe 203

H. Ishikawa et al. he did not notice any discomfort since that time. He had been working on a construction laborer with rubbersoled tabi for twenty years.

3 H. Ishikawa et al. he did not notice any discomfort since that time. He had been working on a construction laborer with rubbersoled tabi for twenty years. The patient pointed to the plantar area of the first metatarsophalangeal joint as the painful region. On physical examination, hindfoot motion was within normal limits and not painful. Examination of the forefoot revealed normal range of motion of the first metatarsophalangeal joint. Deep palpation of the sesamoids revealed severe tenderness over what was thought to be the tibial sesamoid. On the A-P radiograph, the tibial sesamoid showed osseous mottling or fragmentation (Figure 1 a). This was more characterized by an axial radiograph (Figure 1 b). Other laboratory data including ESR, blood cell counts and serological tests were all within normal ranges. Old stress fracture or osteochondritis of the tibial sesamoid was suspected. Despite two months conservative care including padding or molded shoe inserts and nonsteroidal anti-inflammatory medications, the patient noted increased pain and tenderness. Repeat radiographs showed no change. Because of these symptoms, operative exploration was undertaken. The right first metatarsophalangeal (MTP) joint was explored via a longitudinal incision over the medial aspect of the joint. A l<?ngitudinal capsulotomy revealed the sesamoid bone to be contained necrotic fragments. The distal component of the sesamoid was found to be degenerative changes (Figure 2 a). The medial sesamoid bone was carefully excised (Figure 2b) and the joint capsule sutured for capsular repair. Histological examination showed Figure 1. Anteroposterior (a) and axial (b) radiographs showing the fragmentation of the medial sesamoid bone. Figure 2. a: Operative exploration of medial sesamoid bone showing degenerative articular surface and fragmentation of sesamoid bone and soft radiograph of a resected sesamoid bone (b). necrotic bone area and some lymphoid cell infiltration, indicating the possibility of the post-fracture healing process (Figure 3). DISCUSSION Al though fracture of a sesamoid IS 204 Bulletin of Allied Medical Sciences, Kobe

$5-7 ) It is generally difficult to distinguish between a symptomatic bipartite sesamoid and a fractured sesamoid.$

4 Osteochondritis of sesamoid bone Figure 3. Histological appearance of the resected sesamoid bone. relatively rare, numerous cases have been reported in the orthopaedic literature. 5-7 ) It is generally difficult to distinguish between a symptomatic bipartite sesamoid and a fractured sesamoid. The development of pain from minimal trauma in the presence of a bipartite sesamoid should make the clinician highly suspicious of a superimposed fracture of a bipartite sesamoid. As presented in this report, the fractured bone usually demonstrates a jagged dividing line and irregular outline compared to the smooth regular outline in the bipartite sesamoid in radiographic examination. 8 ) In addition to purely traumatic disorders, the great toe sesamoids are also subject to a variety of additional pathogenesis. Osteomyelitis may occur either as a primary event, or as a sequel of fracture with fragmentation as in our case. 9 ) We speculate that the patient presented here had a bipartite tibial sesamoid and attributed the patient bias to the wearing rubber-soled tabi, which directed increased stress to the first metatarsal head as mentioned by Kliman et al. Kliman and associates postulated that a stress fracture and a subsequent reparative process caused osteochondritis. 9 ) Early diagnosis of MTP pathology depends on familiarity with the joint anatomy, the spectrum of pathology and proper use of available imaging techniques. Conservative treatment can be used for a time, but the appearance of fragmentation usually indicates that sur- Vol.13,

5 H. Ishikawa et al. gical resection of the involved sesamoid would be necessary if symptoms persist as in our case. Finally it should be mentioned that the sesamoids of the first metatarsophalangeal joint play an integral part in the dynamic function of the first MTP joint. Therefore, disruption of normal function through fracture, inflammation, trauma can lead to significant disability. Thus, it seems that early recognition of this condition is very important. REFERENCES 1. Potter HG, Pavlov H, Abrahams TG. The hallux sesamoids revisited. Skel Radiology 21: , Biedert R. Which investigations are required in stress fracture of the great toe sesamoids? Arch Orthop Trauma Surg 112: 94-95, Hershman EB, Mailly T. Stress fractures. Clin Sports Med 9: , Weiss KS. Fracture of the medial sesamoid bone of the great toe: Controversies in therapy. Orthopedics 14: , Coughlin MJ. Sesamoid pain. Causes and surgical treatment. Instr Course Lect 39: 23-35, Van Hal ME, Keene JS, Lange T A, et al. Stress fractures of the great toe sesamoids. Am J Sports Med 10: , Parra G. Stress fractures of the sesamoids of the foot. Clin Orthop 18: , Feldman S, Pochaczesvsky R, Hecht H. The cause of the wandering sesamoid and other sesamoid afflictions. Radiology 96: , Kliman ME, Gross AE, Pritzker KP, et al. Osteochondritis of the hallux sesamoid bones. Foot Ankle 3: , Bulletin of Allied Medical Sciences, Kobe

Kobe University Repository : Kernel

Kobe University Repository : Kernel タイトル Title 著者 Author(s) 掲載誌巻号ページ Citation 刊行日 Issue date 資源タイプ Resource Type 版区分 Resource Version 権利 Rights DOI Treatment and Diagnosis of Panner's Disease : A Report