Complications and Outcomes of Sesamoidectomy: What Surgeons Need to Know

Introduction to Sesamoidectomy

Sesamoidectomy is a surgical procedure involving the removal of one or both sesamoid bones, typically from the foot. The sesamoid bones are small, pea-shaped bones embedded within tendons, most commonly located under the big toe joint (first metatarsophalangeal joint). These bones play a critical role in bearing weight, absorbing impact, and facilitating movement. However, when these bones become fractured, inflamed, or suffer from avascular necrosis, surgical intervention in the form of a sesamoidectomy may be required.

Indications for Sesamoidectomy

Sesamoidectomy is indicated in several conditions where conservative treatments fail to alleviate symptoms:

1. Fractures: Chronic or acute fractures of the sesamoid bones can cause significant pain and dysfunction, often necessitating surgical removal.
2. Sesamoiditis: Chronic inflammation of the sesamoid bones, often due to overuse, can lead to persistent pain unresponsive to non-surgical treatment.
3. Avascular Necrosis: A lack of blood supply to the sesamoid bones can result in avascular necrosis, leading to bone death and the need for surgical removal.
4. Osteoarthritis: Degeneration of the sesamoid bones and surrounding joints can cause pain and reduced mobility, making sesamoidectomy a viable option.
5. Turf Toe: This condition, often seen in athletes, involves hyperextension of the big toe, which can damage the sesamoid bones and require their removal.
6. Hallux Valgus and Rigidus: In cases where these deformities lead to sesamoid involvement, sesamoidectomy may be part of the corrective surgical plan.

Preoperative Evaluation

A thorough preoperative evaluation is essential to determine the appropriateness of sesamoidectomy and to plan the surgical approach. The evaluation typically includes:

1. Clinical Examination: A detailed examination of the foot to assess pain, range of motion, and the exact location of symptoms. Special attention is paid to gait analysis and the presence of deformities.
2. Imaging:
   • X-rays: Standard anteroposterior, lateral, and axial views of the foot help identify fractures, arthritis, and alignment issues.
   • MRI: Magnetic Resonance Imaging is crucial for assessing soft tissue involvement, the integrity of tendons, and the presence of avascular necrosis.
   • CT Scan: Computed Tomography provides detailed bone imaging and is particularly useful in complex cases or where MRI is contraindicated.
3. Non-Surgical Treatments: Prior to considering surgery, conservative measures such as orthotics, physical therapy, anti-inflammatory medications, and steroid injections should be attempted.
4. Patient Consultation: A detailed discussion with the patient regarding the risks, benefits, and expected outcomes of the surgery. The patient’s lifestyle, activity level, and expectations are crucial factors in the decision-making process.

Contraindications

Sesamoidectomy is contraindicated in certain situations, and surgeons must weigh these factors before proceeding:

1. Infection: Active infection in the foot or systemic infection is a contraindication to elective surgery.
2. Poor Vascular Supply: Patients with compromised blood flow, such as those with peripheral arterial disease, may be at increased risk of non-healing wounds and should be carefully evaluated.
3. Severe Osteoporosis: Weak bones may not support surgical intervention, leading to complications in healing.
4. Advanced Age and Comorbidities: Elderly patients with significant comorbidities may not be good candidates for surgery due to the increased risk of complications.
5. Non-compliance: Patients who are unlikely to adhere to postoperative care and restrictions should be carefully considered, as non-compliance can lead to poor outcomes.

Surgical Techniques and Steps

There are two primary approaches to sesamoidectomy: medial and plantar. The choice of approach depends on the specific sesamoid bone involved and the surgeon's preference.

1. Medial Approach:
   • Incision: A longitudinal incision is made along the medial side of the foot, over the first metatarsophalangeal joint.
   • Exposure: The soft tissues are carefully retracted to expose the sesamoid complex without damaging the surrounding structures, particularly the flexor hallucis longus tendon.
   • Resection: The sesamoid bone is isolated, and care is taken to preserve as much of the surrounding soft tissue as possible. The bone is excised with appropriate tools.
   • Closure: The wound is closed in layers, ensuring proper alignment and tension to promote healing.
2. Plantar Approach:
   • Incision: A transverse or longitudinal incision is made on the plantar surface of the foot, directly over the sesamoid bone.
   • Exposure: The plantar fascia is incised, and the sesamoid bone is identified.
   • Resection: The bone is excised with attention to preserving the integrity of the flexor tendons.
   • Closure: The plantar fascia and skin are closed meticulously to prevent complications such as wound dehiscence.

Important Considerations During Surgery:

• Preservation of the Flexor Hallucis Longus Tendon: Great care is taken to avoid injury to the flexor hallucis longus tendon, as damage can lead to significant postoperative complications.
• Bone Preservation: Whenever possible, partial resection of the sesamoid bone is preferred to preserve function and reduce the risk of complications.

Postoperative Care

Postoperative management is crucial for successful recovery:

1. Immobilization: The foot is typically immobilized in a walking boot or cast for several weeks to protect the surgical site and allow healing.
2. Weight-Bearing: Weight-bearing is generally restricted for the first few weeks, with gradual progression based on healing and pain levels.
3. Physical Therapy: Rehabilitation begins after immobilization, focusing on restoring range of motion, strength, and gait training. Therapy is tailored to the patient’s specific needs and goals.
4. Pain Management: Postoperative pain is managed with a combination of medications, including NSAIDs, acetaminophen, and occasionally opioids.
5. Wound Care: Regular follow-up appointments are necessary to monitor wound healing, check for signs of infection, and assess the overall progress.

Possible Complications

As with any surgical procedure, sesamoidectomy carries potential risks and complications:

1. Infection: Although rare, infection can occur, requiring antibiotics or, in severe cases, additional surgery.
2. Nonunion or Delayed Healing: The bone or soft tissues may heal more slowly than expected, prolonging recovery time.
3. Nerve Injury: Injury to the digital nerves during surgery can lead to numbness, tingling, or chronic pain in the toe.
4. Residual Pain: Some patients may continue to experience pain after surgery, often due to incomplete resection or scar tissue formation.
5. Altered Gait: Changes in foot biomechanics after sesamoidectomy can lead to an altered gait, sometimes requiring orthotic support.
6. Recurrence of Symptoms: In some cases, symptoms may recur if the underlying issue is not fully addressed, necessitating further intervention.

Different Techniques

Various techniques have been developed and refined to optimize outcomes and reduce complications:

1. Partial Sesamoidectomy: Instead of removing the entire sesamoid bone, only the affected portion is excised. This technique aims to preserve foot function while alleviating symptoms.
2. Endoscopic Sesamoidectomy: A minimally invasive approach where small incisions and an endoscope are used to remove the sesamoid bone, resulting in faster recovery and less scarring.
3. Arthroscopic-Assisted Sesamoidectomy: This technique combines arthroscopy with traditional surgical methods to provide better visualization and precision during the procedure.

Prognosis and Outcome

The prognosis after sesamoidectomy is generally favorable, with most patients experiencing significant pain relief and improved function. However, outcomes can vary based on several factors:

1. Patient Selection: Proper patient selection, including a thorough preoperative evaluation, is critical to achieving the best outcomes.
2. Surgical Technique: The skill and experience of the surgeon, along with the chosen technique, play a significant role in the success of the procedure.
3. Postoperative Care: Adherence to postoperative care instructions, including physical therapy and weight-bearing restrictions, is essential for optimal recovery.
4. Complication Management: Prompt identification and management of complications can prevent long-term issues and improve overall results.

Alternative Options

For patients who are not good candidates for sesamoidectomy or prefer non-surgical options, several alternatives exist:

1. Orthotics: Custom-made orthotics can help redistribute pressure away from the sesamoid bones, alleviating pain and preventing further damage.
2. Physical Therapy: A structured physical therapy program focusing on strengthening and stretching can improve symptoms in some patients.
3. Medications: Anti-inflammatory medications, corticosteroid injections, and pain relievers can be used to manage symptoms non-surgically.
4. Activity Modification: Avoiding activities that exacerbate symptoms, such as running or jumping, can provide relief and reduce the need for surgery.

Average Cost

The cost of sesamoidectomy can vary depending on several factors, including geographic location, the complexity of the procedure, and the healthcare facility. On average, the cost ranges from $5,000 to $10,000, which may include the surgeon’s fee, anesthesia, and hospital or surgical center charges. It is important for patients to discuss costs with their healthcare provider and insurance company to understand coverage and out-of-pocket expenses.

Recent Advances

Recent advances in sesamoidectomy techniques and technologies have focused on improving patient outcomes and reducing recovery time:

1. Minimally Invasive Techniques: The development of endoscopic and arthroscopic techniques has revolutionized sesamoidectomy, allowing for smaller incisions, less pain, and quicker recovery.
2. Biomaterials: The use of advanced biomaterials in postoperative care, such as collagen dressings and bioactive wound dressings, has improved healing rates and reduced complications.
3. Regenerative Medicine: The application of platelet-rich plasma (PRP) and stem cell therapy in conjunction with sesamoidectomy is being explored to enhance tissue repair and recovery.
4. Enhanced Imaging: Advances in imaging techniques, such as high-resolution MRI and CT scans, have improved preoperative planning and intraoperative precision.