Partial Sesamoidectomy for Fractured Sesamoid: Email Report from Patient

This patient and I communicated in 2013 over her fractured sesamoid and conservative treatment. 

Hi Richard,

You probably won’t remember me – we chatted quite a while back about my sesamoid stress fracture (see below) and you were a huge help to me! I still follow your blog religiously, and noticed someone had contacted you about outcomes from partial sesamoidectomy last week – a relatively new procedure. 

After a fair amount of conservative treatment failing me (and some impatience to get back to Ironman racing as well as being able to be on my feet for work 40+ hours a week), I saw one of Australia’s best lower limb surgeons Dr Ben Forster (might as well give him some credit over the internet), who operated.  He had planned to bone graft the sesamoid, but the bone fell to pieces once he got in there so he cleaned it up and did a partial sesamoidectomy instead, leaving about 2/3 of the (healthy) bone in tact.  He also did a (planned) Dorsiflexion Osteotomy of my 1^stMetatarsal at the same time, to decrease future risk of re-injury given my age, injury history and urge to return to long course racing.

Anyway long story short, the surgery was a huge success.  The rehab process was LONG (9 months back to running, including 6 weeks in plaster NWB’ing, 8 weeks in a boot, and many, many hours of rehab exercises and patience).  I got back to running 8km very comfortably before becoming pregnant, and have been able to maintain running up until 8 months pregnant – even with 11 exra kilos on board! My foot is not my limiting factor and I hardly ever think about it any more, it feels great, so I have full faith in a successful return to racing once the baby arrives.

Anyway I hope that my experience can help you and some of your patients with some hope on the situation.

Thanks again for your help and please never stop doing what you’re doing, your work is amazing!

Partial Sesamoidectomy: Email Advice

Hi Doctor Blake! 

     I have been reading your replies and not sure if you are still posting on this subject anymore but in hopes that you might I wanted to ask some questions. I actually had a partial sesamoidectomy. I think your anonymous writer is the only other person that I have found that has had this type of partial surgery. My doctor suggested this route because most of my sesamoid bone was healthy and no arthritis or any other ailiments. I had an injury many years ago that possible broke my bone in half but where it broke was nearer the bottom so it was too tiny to put a screw in. I had pain in my foot off and on for years but it was like flair ups and then the pain would reside and no big deal go on my way, however I had a cortisone shot done for my hip (which is another injury that I am facing and a couple of months after the shot that pain in my foot was back, it felt like a stabbing knife pain and this time it was not going away it was debilitating and extremely painful. I am not sure if the cortisone weakened the bone break even more but I can't really figure out what the culprit was all I know is I could not bear the pain any longer and this thing was not going way like in the past.

    So I went to see a foot and ankle specialist with an x ray he was able to see my injury to my sesamoid bone closest to the end of my foot. He could tell that it was an old break that happened a long time ago that did not heal properly. There was scar tissue between the bones where it tried to heal its self. So and every time I took a step the two bones were bending up and down, your sesamoid bone are not suppose to bend right!! Ouch! So of course I did the conservative route just like everyone else with no relief it finally came to a point that I had to make the decision to just have surgery done.

    I am 7 weeks out post op. My scar is healing great and I do deep tissue massages on it every other day. Toe strengthening and stretching. I am walking in a pair of comfortable boots, a tennis shoe with custom insoles, and some dearfoam thick comfy sleepers. I walk when I need to but I do a lot resting still and elevate my foot often. I still sleep with my foot elevated most nights. I took pain meds half dose for the first 3 days post surgery. I really didn't want to but I couldn't sleep and sleep is when we do our best healing so I took them to sleep.

    Now 7 weeks out I still have pain where the cutting took place. I think from reading this blog and the research that I have found this pain is normal and probably due to nerves being healed. My doctor said I could have this tenderness for up to 6 months, and possibly a year. I see my doctor again in 5 weeks which will be my 3 month appointment. My doctor did say however if the pain persist we may need to go in and take the other part out, but he mentioned that this is probably unlikely since the rest was healthy. If it wasn't he would have taken the whole bone in the surgery. He is under the impression the more original anatomy you have the better. I felt good with my decision to have a partial done. Now for me it just having patience and not over doing it. 

   I guess my question to you is does this sound normal at about the 7 week mark? Also I can feel that partial sesamoid bone like your other responder, and it feels tender but the super sharp pain is gone since that smaller part is out. My other question is do you think it will take longer to heal with a partial sesamoidectomy since there is still bone left and I heard that bone takes longer to heal. Or should I have just had the whole thing removed from the beginning?

Thanks
Kimberly

Dr Blake's comment:

     Kimberly, Thank you. This is such a rare procedure, that the med profession is learning on you. Everything sounds good. It is early, but I love the concept of leaving the good part in there. Please keep us in the loop with monthly or bi-monthly updates. I would think that it will take less time to heal if you leave 1/2 in, but I really do not know. Good luck my friend. Rich

Recurring Sesamoid Fractures: Email Advice

Dr Blake,
I have had 3 different sesamoid fractures in 1 1/2 years.  One on left foot, one on right foot, then this morning my podiatrist told me my left was fractured again in the same place.  I was given clearance the first time so this is a new break.  I'm thinking this is due to a very high arch putting excessive pressure through my sesamoids. 

Dr Blake's comment: Definitely high arches can place more pressure on the sesamoids due to the downward positioning of the first metatarsal (more downward than in a flat foot). Designing orthotics for sesamoid injuries is difficult at times due to this situation. Sometimes the best orthotic is more on the line of the full length Hannaford style which evens the playing field better. 

 There was not any act in which would have caused this.  It slowly began to hurt and swell.  It got worse and by the second week I was at my podiatrist receiving the news that it was fractured again. 

Dr Blake's comment: It can be very difficult to make this call. The original injury probably caused some irregularity in the appearence of the sesamoid. This irregularity can look like a separation of fragments, even though there is solid internally healing. Also, Golden Rule of Foot: It is hard to break a bone in the same place a second time. This is due to the fact that bones typically "double heal" or get twice as strong as they were originally. So, a word of caution about rushing ahead on any surgery. 

 My dr suggested removing one of the pieces as he does not feel it will heal completely or if it does that the fracture is likely to happen again given the way this one happened.  They are putting me on the schedule to have a partial sesamoidectomy.  I'm fine with this as I do not want to fight this breaking for no apparent reason for the rest of my life. 

Dr Blake's comment: I have only seen only partial sesamoidectomy in my life, so I am not a judge. It did not help the problem, but my comment is not anyway scientific. I would be thinking complete removal of the involved sesamoid, or no surgery until the biomechanics of your high arches were addressed. Without the biomechanics being adequately with inserts so that you feel you have no to minimal pressure on the sesamoids, you will have one surgery, then another, and then perhaps more. 

 I have a few questions given my story.
Is it normal to break a sesamoid in TWO DIFFERENT FEET?

Dr Blake's comment: Yes, and it points to a biomechanical predisposition that you want/need to correct. And yes, there are also surgical treatments for this predisposition, if the predisposition can be eliminated. Typically, non surgical avenues can be explored with complete success. 

Is it normal to break the same sesamoid twice?

Dr Blake's comment: No, but it may have never healed completely in the first place, or the underlying predisposition never corrected. That could be foot biomechanics, shoes, diet, Vit D deficiencies, running style, etc. We look at all causes of bone injury, attempt to reverse/correct all these factors, and this is why it is hard to break the same bone twice. That being said I do have my failures also when I did not recognize a problem, say Vit D deficiency, or the patient did not say on track at correcting the problem, or I forgot to tell the patient their need for the corrective orthotics was a life long committment, or the correction of the problem was difficult to do and we hoped the bone would not break again. 

Would you suggest a different option?

Dr Blake's comment: See above, definitely do three things:

1. Treat this sesamoid fracture conservatively like you treated the first one
2. Have the biomechanics of your high arch feet, and all causes of bone weakness addressed.
3. Get a bone stimulator to use for the next 6 months (I love Exogen since it is 20 minutes per day)

How long can I expect to be back to a normal gait, and pain level?

Dr Blake's comment: Of course this depends on surgery or no surgery.

It is extremely swollen and painful now.  How can I relieve some of the pressure?  I am in a walking boot and ice twice a day and take naproxen to help inflammation.

Dr Blake's comment: Definitely add crutches or in boot accommodations to float the sesamoid to achieve a 0-2 pain level with your protected weight bearing. You should add the Exogen bone stimulator, and do daily contrast baths for deep flushing. You should have you internist look for Vit D deficiency and perhaps a bone density test should be ordered. 

Should I get a second opinion?  I am very comfortable in the surgical route given my dr has been working with me for a year and a half.

Dr Blake's comment: Yes, I love our foot surgeon, Dr Remy Ardizzone, but I always think patients should get a 2nd opinion, and not from someone in the same group. I would look at the member list of the AAPSM (American Academy of Podiatric Sports Medicine) for a referral near you. This does not mean you have to switch. You just want another smart person to give you an opinion. I tell my patients never to tell the 2nd opinion doc what the first doc says. Make it a true 2nd opinion. Just tell them your scenario, and that you wnat there advice on what to do from here. 

I have read about pt after these surgeries on your site but should it be the same for me with a partial instead of a full? 

Dr Blake's comment: Again, I claim lack of valuable knowledge.

Could I have a deficiency causing weak bones?

Dr Blake's comment: Yes!!!!

I'm a very active 31 yr old male with a 4 year old who loves to play sports.  I just want to be back to functioning without extreme pain.

Dr Blake's comment: As a father of 2 boys, I feel your pain and understand. I hope this helps you. 
Regards,
Lawrence (Name changed due to witness protection)