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 1.Sarrafian SK: Osteology, in Sarrafian SK (ed): Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Philadelphia: JB Lippincott, 1983, pp 85-87. 2.Van Hal ME, Keene JS, Lange TA, Clancy WG Jr: Stress fractures of the great toe sesamoids. Am J Sports Med 1982;10:122-128. 3.Richardson EG, Donley BG: Disorders of hallux, in Canale ST, Daugherty K, Jones L (eds): CampbellÕs Operative Orthopaedics, 9th ed. St Louis: Mosby- Year Book, 1998, vol 2, pp 1701-1706. 4.Prieskorn D, Graves SC, Smith RA: Morphometric analysis of the plantar plate apparatus of the first metatar- sophalangeal joint. Foot Ankle1993;14: 204-207. 5.Weil LS, Hill M: Bipartite tibial sesamoid and hallux abducto valgus deformity: A previously unreported correlation. J Foot Surg1992;31: 104-111. 6.Chisin R, Peyser A, Milgrom C: Bone scintigraphy in the assessment of the hallucal sesamoids. Foot Ankle Int 1995;16:291-294. 7.Taylor JAM, Sartoris DJ, Huang GS, Resnick DL: Painful conditions affect- ing the first metatarsal sesamoid bones. Radiographics1993;13:817-830. 8.Frankel JP, Harrington J: Sympto- matic bipartite sesamoids. J Foot Surg 1990;29:318-323. 9.Biedert R: Which investigations are required in stress fracture of the great toe sesamoids? Arch Orthop Trauma Surg1993;112:94-95. 10.Coughlin MJ: Sesamoid pain: Causes and surgical treatment. Instr Course Lect1990;39:23-35. 11.Hulkko A, Orava S: Diagnosis and treatment of delayed and non-union stress fractures in athletes. Ann Chir Gynaecol1991;80:177-184. 12.Anderson RB, McBryde AM Jr: Autogenous bone grafting of hallux . (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. 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. 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,