When is surgical intervention recommended for a medial great toe sesamoid condition?

Surgical Intervention for Medial Great Toe Sesamoid Conditions

Surgical intervention for medial great toe sesamoid pathology is recommended after failure of 2-6 months of conservative management, with sesamoidectomy (particularly partial excision of the proximal fragment) providing excellent outcomes in athletes and active individuals who have persistent pain despite non-operative treatment. 1, 2

Conservative Management First-Line Approach

Before considering surgery, attempt conservative treatment for 2-6 months including: 2

• Activity modification and rest from aggravating activities 2
• Analgesia for pain control 2
• Orthotic devices with proper fitting to offload the sesamoid 2
• Physiotherapy and rehabilitation 2

Conservative management should be exhausted before proceeding to surgery, as this represents the standard treatment algorithm. 2

Indications for Surgical Intervention

Surgery is indicated when: 1, 2

• Persistent activity-related pain after 2-6 months of conservative treatment 1, 2
• Pain that increases with forced dorsiflexion of the great toe 1
• Symptoms that significantly limit athletic or daily activities 1, 3
• Confirmed stress fracture or sesamoiditis on imaging (bone scan, CT, or MRI) 1

Surgical Technique Selection

Partial Sesamoidectomy (Preferred for Stress Fractures)

For stress fractures of the medial sesamoid, surgical excision of the proximal fragment alone is sufficient and provides excellent results. 1

• This approach achieved good/excellent clinical results in all patients with stress fractures 1
• Mean AOFAS-Hallux Score of 95.3 points (range 75-100) 1
• Return to full sports activity within 2.5-6 months 1
• No complications reported with this technique 1

Complete Sesamoidectomy Options

Two modern approaches are available: 3, 4

Medial approach using a burr (increasingly preferred): 3

• Provides adequate exposure while avoiding plantar scar formation 3
• Does not disrupt plantar plate, flexor hallucis brevis tendon, or ligamentous structures 3
• Familiar approach to foot and ankle surgeons 3
• Achieved 80% patient satisfaction with significant functional improvement 3
• VR-12 physical component improved from 35.98 to 51.34 (P < .001) 3
• FAAM ADL scores improved from 58.33 to 83.27 (P < .001) 3

Arthroscopic sesamoidectomy: 4

• Minimally invasive technique under arthroscopic control 4
• Reduces surgical trauma compared to open approaches 4
• Particularly useful for bipartite sesamoids 4

Internal Fixation (For Specific Cases)

Internal fixation shows the best return to full-level sport rates with low complication rates when appropriate. 2

• Consider for acute fractures in high-level athletes 2
• Preserves sesamoid function 2
• Optimal for patients requiring maximal functional restoration 2

Expected Outcomes and Complications

Positive Outcomes

With appropriate surgical technique: 1, 3

• Pain-free status achieved in majority of patients 1
• Return to full sports activity within 6 months 1
• Significant improvement in functional scores (FAAM, VR-12) 3
• Long-term satisfaction maintained at mean 50.6 months follow-up 1

Potential Complications

Be aware of: 3

• Overall complication rate approximately 38% with medial burr approach 3
• Persistent pain in approximately 20% of cases 3
• Arthrofibrosis (rare) 3
• Flexor hallucis longus injury (rare) 3
• Reoperation rate approximately 14% 3
• No sesamoid excision revisions required 3

Special Diagnostic Considerations

When stress fracture is suspected: 1

• Bone scan and CT (axial and sagittal views) are most reliable for diagnosis 1
• Plain X-rays show fragmentation but may be insufficient 1
• MRI does not always confirm the diagnosis 1
• Frontal plane CT alone may miss the pathology 1

Clinical Pitfalls to Avoid

• Do not proceed to surgery before adequate conservative trial (2-6 months minimum) 2
• Avoid traditional plantar approaches that create painful plantar scars 3
• Do not disrupt the plantar plate or flexor hallucis brevis unnecessarily 3
• Recognize that stress fractures occur more commonly in the medial sesamoid and predominantly affect females 1
• Be aware that bipartite sesamoids can develop sesamoiditis and should not be automatically dismissed as normal variants 5