| | Tibial sesamoidectomy of the great toe in heavy manual workersAbstract BackgroundThe sesamoids of the great toe play an integral part of the dynamic function of the foot and any disorder affecting them leads to significant disability. ObjectivesThe purpose of this study was to evaluate the clinical and radiological results of tibial sesamoidectomy in heavy manual workers. Material and methodsThirteen cases of tibial (medial) sesamoiditis underwent surgical excision after failure of conservative treatment. All patients were males and were heavy manual workers in steel company. The age ranged from 20 to 38 years. All cases were unilateral; six left and seven right. Patients were evaluated clinically and radiologically; pre- and post-operatively. Post-operative evaluation included time to return to work, pain, range of motion, deformity, subluxation of lateral sesamoid and any complication. The average follow-up period was 3.6 years (range 2–5). ResultsAll patients were able to return to their heavy work at a mean time of 12.5 weeks. Twelve patients had no pain and 1 had mild pain on standing on tip toe. Two patients had limitation of motion of the great toe. ConclusionMedial sesamoidectomy is a successful operation in manual workers who can return to work as early as 9 weeks. 1. Introduction  The sesamoids of the great toe, although small and seemingly insignificant, play an important role in the function of the foot by absorbing weight bearing pressure, reducing friction, protecting tendons and increasing the mechanical advantage of flexor hallucis brevis [1]. The medial (tibial) sesamoid, due to functional complexity and anatomic location, is more vulnerable to injury from shear and loading forces [2], [3]. Many of these injuries can be avoided in vulnerable populations by wearing low-heeled shoes with shock absorbing moulded insoles, task re-design to eliminate overuse elements in operations, work or training place changes and worker re-training [1], [4]. Any disorder affecting the medial sesamoid can cause incapacitating pain, which can be devastating to heavy manual workers who depend on their feet to perform their work which is usually the only source of their income. These workers do heavy work while they are standing or walking for at least 8 h every day for years. They have to wear safety shoes which are usually heavy, rigid and with hard insoles. Foot disorders such as plantar fasciitis, metatarsalgia and sesamoiditis are common problems in these workers. Sesamoidectomy of the tibial sesamoid may be indicated in cases of chronic sesamoiditis resistant to non-surgical care [3], [4], [5], [6], [7], [8], [9], [10]. Painful scar, hallux deviation and delayed return to work are all potential complications [3], [6], [9], [11], [12]. These need to be considered, especially when performing surgery in the heavy manual workers who need to return to work as early and as efficiently as possible to keep their only income. This study evaluates the results of tibial sesamoidectomy in a group of heavy manual workers, especially the time to return to work, pain relief, hallux deviation, range of motion and any complications. 2. Material and methods From January 1999 to March 2004, tibial sesamoidectomy was performed in 13 patients with sesamoiditis after failure of conservative treatment for at least 6 months. All patients were males. They were heavy workers in a group of steel factories. They were walking or standing for at least 8h every day for many years ranging from 5 to 8 years. Medial sesamoiditis was defined as a painful inflammatory condition of the medial sesamoid which is characterized clinically with a history of repetitive injury to the forefoot, pain in the toe-off phase of gait, local tenderness which increased with forced dorsiflexion of the hallux metatarso-phalangeal joint (MTP), and radiologically with degenerative arthritis of the metatarsal sesamoid articulation with sclerosis, fragmentation and/or disintegration. Patients with a diagnosis of peripheral neuropathy, diabetes mellitus, inflammatory arthropathy or previous foot surgery were excluded as were patients who had concomitant joint realignment procedures. The average age was 31.4 years (range 20–38 years). All cases were unilateral; six left, seven right. All cases were evaluated clinically and radiologically pre- and post-operatively. Clinical evaluation included pain in the toe-off phase of gait, tenderness on direct pressure under the tibial sesamoid which increased with forced dorsiflexion of the hallux metatarso-phalangeal joint (MTP), swelling of the MTP joint, range of motion (ROM) and hallux alignment (valgus or varus). Radiological evaluation included AP, oblique and axial or tangential views [4], [6]. We applied an initial conservative treatment program for at least 6 months that included reduction of activities and casting for 2–3 weeks, followed by use of an orthotic device incorporating a steel shank extension and a U-shaped pad to unload the sesamoid [13]. This was in addition to use of non-steroidal anti-inflammatory medications. Sesamoidectomy had been performed after failure of conservative treatment for at least 6 months and after counselling the patient regarding the expectations of the outcome and the rehabilitation requirements. 2.1. Technique of surgical excision of the tibial sesamoid The tibial sesamoid was approached through a plantar–medial incision [5], [10]. The medial–plantar cutaneous nerve was identified and retracted with the plantar skin flap. The sesamoid was identified on the plantar border of the abductor hallucis tendon. Care was taken not to interrupt the tendinous insertion of the abductor hallucis into the base of the proximal phalanx. The sesamoid was grasped with a small towel clamp or Kocher clamp and was carefully sharply dissected from the flexor hallucis brevis (FHB) and its soft tissue attachments. Once the sesamoid was removed, careful assessment was made for the continuity of the FHB complex. Any defect was repaired with a 2–0 non-absorbable suture in a figure eight with careful re-approximation of the FHB complex. The tendon of the flexor hallucis longus (FHL) was then inspected to make sure that it had not been violated by the dissection. The hallux was taken through a range of motion to confirm that the FHB was intact and to be sure that FHL tendon was not inadvertently sutured. Closure in layers was done and the wound was wrapped in a compression dressing with the hallux slightly planter flexed and in mild varus. 2.2. Post-operative care and follow-up Post-operatively patients were limited to heel weight bearing for 2 weeks. The patients were then allowed to weight bear as tolerated, wearing a wooden-soled shoe and having a toe spacer for 6–8 weeks post-operatively. Patients were followed up clinically and radiologically at 3 and 6 months and yearly thereafter. The follow-up period ranged from 2 to 5 years (average 3.6 years). 3. Results All patients were able to return to their heavy work with a mean time to return to work of 12.5 weeks (range 9–16). Of the 13 cases, 12 had no pain or tenderness and one patient had mild pain on standing on tip toe. Eleven patients had normal ROM, while 2 had mild limitation. Preoperative and post-operative comparison radiographs did not reveal significant differences in the hallux valgus (HV) angle, or sesamoid alignment (sesamoid station) (Fig. 1). All patients were satisfied and found significant relief of pain and improved functional outcome. As regard complications, one patient had neuralgia of the planter digital nerve and responded well to local steroid injection. 4. Discussion With more than 50% of body weight transmitted through the great toe complex, the sesamoids are subjected to significant forces of impact loading and shear [4], [10], [14]. The tibial sesamoid receives most of this weight and is, therefore, more commonly affected [2], [14]. Surgical excision of the chronically painful sesamoid is advocated when conservative treatment has failed [3], [4], [5], [6], [7], [8], [9], [10]. Older reports on tibial sesamoidectomy have shown unfavorable results [3], [9], [12]. Inge and Ferguson [3], reported on 15 tibial sesamoidectomies and found a 17% incidence of claw toe deformity, 59.5% incidence of impaired range of motion and only 41.5% of patients reported normal function and complete relief of pain. Also, Mann et al. [12] reported on surgical excision of 13 tibial sesamoids and found plantar-flexion weakness in 60% of patients, restricted range of motion in 33%, mild drift of the hallux in 10%; only 50% of patients noted complete relief of pain. More recently, the literature would support significant pain relief with minimal functional deficits and minimal deformities with tibial sesamoidectomy. Van Hal et al. [10], Saxena and Krisdakumtorn [15] and Lee et al. [16] have reported no evidence of hallux drift or functional weakness of plantar flexion in any of their patients. Their patients were also noted to return to their previous sports in 7.5–12 weeks [15]. All these researchers reported on sesamoidectomy mainly in runners and ballet dancers; they related this to overuse syndrome, training errors, the running surface and to footwear of the athlete [13], [17]. Our study reported on a different group of patients, who are heavy manual workers in steel factories. The sesamoids of these patients are exposed to marked repetitive stresses and overuse syndrome for about 8h every day and for many years. The results of tibial sesamoidectomy in these patients are similar to those of athletes in recent reports, except the longer time to return to work (sports in athletes). This may be due to more overuse and repetitive stresses of the feet of heavy manual workers. They cannot work half time or decrease their work as the athletes can do especially in the early recovery period. However, careful preoperative planning is needed to minimize dissection and maintain the integrity of the remaining intrinsic complex, thereby optimizing the chance of a return to the heavy work as early and as efficiently as possible. At the same time, a period of 2–3 months for conservative treatment would be better than 6 months if the operation could relieve the symptoms better and sooner. References [1]. [1]Richardson EG. Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg. 1999;7(4):270–278. [2]. [2]Bizarro AH. On the traumatology of the sesamoid structures. Ann Surg. 1921;74:783–791. [3]. [3]Inge GAL, Ferguson AB. Surgery of the sesamoid bones of the great toe: An anatomic and clinical study, with a report of forty-one cases. Arch Surg. 1933;27:466–489. [4]. [4]Coughlin MJ. Sesamoid pain: causes and surgical treatment. Instr Course Lect. 1990;39:23–35. MEDLINE [5]. [5]Helal B. The great toe sesamoid bones: The lus or lost souls of Ushaia. Clin Orthop. 1981;157:82–87. [6]. [6]Jahss MH. The sesamoids of the hallux. Clin Orthop. 1981;157:88–97. [7]. [7]Kaiman ME, Piccora R. Tibial sesamoidectomy: a review of the literature and retrospective study. J Foot Surgery. 1983;22:286–289. [8]. [8]Kliman ME, Gross AE, Pritzker KP, et al. Osteochondritis of the hallux sesamoid bones. Foot Ankle. 1983;3:220–223. [9]. [9]Nayfa TM, Sorto LA. The incidence of hallus abductus following tibial sesamoidectomy. J Am Podiatry Assoc. 1982;72:617–620. MEDLINE [10]. [10]Van Hal ME, Keene JS, Lange TA, et al. Stress fractures of the great toe sesamoids. Am J Sports Med. 1982;10:122–128. MEDLINE |
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[11]. [11]Mann RA, Coughlin MJ. Hallux valgus: etiology, anatomy, treatment and surgical considerations. Clin Orthop. 1981;157:31–41. [12]. [12]Mann RA, Coughlin MJ, Baxter D, et al. Sesamoidectomy of the great toe. In: Presented at the 15th Annual Meeting of the American Orthopaedic Foot and Ankle Society. Las Vegas. 1985;. [13]. [13]Baxter DE, Zingas C. The foot in running. J Am Acad Orthop Surg. 1995;3:136–145. [14]. [14]Shereff MJ, Bejjani FJ, Kummer FJ. Kinematics of the first metatarso-phalangeal joint. J Bone Joint Surg. 1986;68:392–395. MEDLINE [15]. [15]Saxena A, Krisdakumtorn T. Return to activity after sesamoidectomy in athletically active individuals. Foot Ankle Int. 2003;24(5):415–419. MEDLINE [16]. [16]Lee S, James WC, Cohen BE, Davis WH, Anderson RB. Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int. 2005;26(10):803–809. MEDLINE [17]. [17]Richardson EG. Injuries to the hallucal sesamoids in the athlete. Foot Ankle. 1987;7:229–244. Department of Orthopedic Surgery, Faculty of Medicine, Menoufyia University, Menoufyia, Egypt  Correspondence address: 25 Elmohtsb St., Mohrm Bak, Alexandria, Egypt. Tel.: +20 3 3184626/12 7469041; fax: +20 3 3184626.
PII: S0958-2592(06)00099-X doi:10.1016/j.foot.2006.09.002 © 2006 Elsevier Ltd. All rights reserved. | |
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