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Arthroscopic Medial Bipartite Sesamoidectomy of the Great Toe
Case Report
Arthroscopic Medial Bipartite Sesamoidectomy of the Great Toe L. Perez Carro, M.D., Ph.D., J.I. Echevarria Llata, M.D., and J.A. Martinez Agueros, M.D.
Summary This is the first report of a successful first metatarsophalangeal joint medial bipartite sesamoidectomy using great toe arthroscopy. The surgical trauma associated with open operative sesamoidectomy can be minimized using minimally invasive techniques under arthroscopic control. The authors describe the surgical principles and discuss the advantages compared with traditional surgery. Key Words: Arthroscopy—Sesamoid—Great toe.
T
he traditional treatment method for sesamoidectomy of the first metatarsophalangeal joint sesamoids requires a global exposure with direct visualization through an arthrotomy. Recent advances in great toe arthroscopy for visualization and instrumentation allow access to all areas of metatarsophalangeal joint. In this report, we describe a first metatarsophalangeal joint medial bipartite sesamoidectomy through arthroscopic control using a minimally invasive technique resulting in little surgical morbidity. The advantages of this alternative treatment are excellent intra-articular visualization, decreased soft tissue dissection, and shortened postoperative recovery with excellent cosmetic and functional results. To our knowledge this is the first report of arthroscopic sesamoidectomy of the great toe.
CASE REPORT A 20-year-old woman was referred to our clinic for a 6-month history of severe pain and tenderness under
From Servicio de Traumatologia, Hospital de Laredo, Laredo, Cantabria, Spain. Address correspondence and reprint requests to L. Perez Carro, M.D., Ph.D., Servico de Traumatologia, Hospital de Laredo, Laredo, Cantabria, Spain. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1503-1977$3.00/0
the first metatarsal head of the left foot, particularly medially in association with walking, that had failed to respond to conservative treatment with low-heeled shoes, molded insole, and local steroids. Radiographs showed a medial bipartite sesamoid with no changes or fragmentation (Fig 1). Magnetic resonance imaging was performed showing no alteration of the signal on both sesamoids. On examination, a specific local tenderness on palpation of the medial sesamoid was elicited. Under the diagnosis of medial sesamoiditis, we decided this was a feasible case for performing sesamoidectomy under arthroscopic control. After induction of epidural anesthesia, the patient was placed in the supine position with 4 kg of traction using a toe-finger trap. Under torniquet control, an incision was made in the dorsolateral portal and a 2.7-mm 30° oblique arthroscope was inserted into the joint. Then the dorsomedial portal was established under direct visualization and the joint was inspected. Debridement of all hyaline cartilage of both parts of the sesamoid was performed using a 2-mm burr through a medial portal and then the bone was removed from distal to proximal until soft tissue was found, being careful so as not to disrupt the flexor brevis attachments and the rest of the sesamoid complex (Fig 2). A bulky dressing was applied for comfort and the patient was discharged from the hospital the same day and was encouraged to begin early metatarsophalangeal joint motion. The
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 3 (April), 1999: pp 321–323
321
322
L.P. CARRO ET AL. ectomy is a well-established procedure for sesamoiditis and osteochondritis refractory to conservative treatment. It can also be performed in cases of infection secondary to diabetic neuropathy and in nonunion of sesamoid fractures.1 The traditional treatment method uses a standard medial approach, opening up the capsule and retracting it plantarward until the articular surface of the sesamoid can be visualized. Open surgical exposure increases and introduces additional potential for complications. Adjunctive use of the arthroscope for excisions has been used in other joints such as the wrist2,3 and elbow.4 Arthroscopic excision methods appear to allow a shorter hospital stay, resulting in less severity and duration of postoperative pain and stiffness, better cosmetic results, reduction of the period of postoperative rehabilitation, diminished morbidity, and an earlier return to work.3 Similar application of arthroscopic surgery to the first metatarsophalangeal joint would involve the same potential advantages. Ferkel and Scranton5 reported on the details of a technique for great toe arthroscopy making feasible the arthroscopic exploration of the metatarsophalangeal joint. As far as we know, arthroscopic sesamoidectomy of the great toe has never been reported.
FIGURE 1.
hallux was strapped into slight varus for 3 weeks to prevent hallux valgus deformity. Postoperatively, the vasculo-nervous status was normal. Radiographs confirmed the successful excision of the bipartite sesamoid (Fig 3). At 1-year follow-up, no deformity was present in the great toe and the patient is currently asymptomatic. DISCUSSION The sesamoids of the great toe are rather constant bones that ossify in the eighth year for girls and the 12th year for boys. First metatarsophalangeal sesamoid-
FIGURE 2. Arthroscopic view during the procedure. The arthroscope is in the dorsolateral portal and the burr in the medial portal removing the proximal part of the
ARTHROSCOPIC SESAMOIDECTOMY
323 REFERENCES
1. Leventen EO. Sesamoid disorders and treatment. Clin Orthop 1991;269:236-240. 2. Roth JH, Poehling GG. Arthroscopic ‘‘ectomy’’ surgery of the wrist. Arthroscopy 1990;6:141-147. 3. Menon J. Arthroscopic management of trapeziometacarpal joint arthritis of the thumb. Arthroscopy 1996;12:581-587. 4. Lo IKY, King GJW. Arthroscopic radial head excision. Arthroscopy 1994;10:689-692. 5. Ferkel RD, Scranton PE. Arthroscopy of the ankle and foot. J Bone Joint Surg Am 1993;75:1233-1242.
FIGURE 3. Anteroposterior radiograph showing the successful excision of the bipartite sesamoid.
Arthroscopic Medial Bipartite Sesamoidectomy of the Great Toe L. Perez Carro, M.D., Ph.D., J.I. Echevarria Llata, M.D., and J.A. Martinez Agueros, M.D.
Summary This is the first report of a successful first metatarsophalangeal joint medial bipartite sesamoidectomy using great toe arthroscopy. The surgical trauma associated with open operative sesamoidectomy can be minimized using minimally invasive techniques under arthroscopic control. The authors describe the surgical principles and discuss the advantages compared with traditional surgery. Key Words: Arthroscopy—Sesamoid—Great toe.
T
he traditional treatment method for sesamoidectomy of the first metatarsophalangeal joint sesamoids requires a global exposure with direct visualization through an arthrotomy. Recent advances in great toe arthroscopy for visualization and instrumentation allow access to all areas of metatarsophalangeal joint. In this report, we describe a first metatarsophalangeal joint medial bipartite sesamoidectomy through arthroscopic control using a minimally invasive technique resulting in little surgical morbidity. The advantages of this alternative treatment are excellent intra-articular visualization, decreased soft tissue dissection, and shortened postoperative recovery with excellent cosmetic and functional results. To our knowledge this is the first report of arthroscopic sesamoidectomy of the great toe.
CASE REPORT A 20-year-old woman was referred to our clinic for a 6-month history of severe pain and tenderness under
From Servicio de Traumatologia, Hospital de Laredo, Laredo, Cantabria, Spain. Address correspondence and reprint requests to L. Perez Carro, M.D., Ph.D., Servico de Traumatologia, Hospital de Laredo, Laredo, Cantabria, Spain. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1503-1977$3.00/0
the first metatarsal head of the left foot, particularly medially in association with walking, that had failed to respond to conservative treatment with low-heeled shoes, molded insole, and local steroids. Radiographs showed a medial bipartite sesamoid with no changes or fragmentation (Fig 1). Magnetic resonance imaging was performed showing no alteration of the signal on both sesamoids. On examination, a specific local tenderness on palpation of the medial sesamoid was elicited. Under the diagnosis of medial sesamoiditis, we decided this was a feasible case for performing sesamoidectomy under arthroscopic control. After induction of epidural anesthesia, the patient was placed in the supine position with 4 kg of traction using a toe-finger trap. Under torniquet control, an incision was made in the dorsolateral portal and a 2.7-mm 30° oblique arthroscope was inserted into the joint. Then the dorsomedial portal was established under direct visualization and the joint was inspected. Debridement of all hyaline cartilage of both parts of the sesamoid was performed using a 2-mm burr through a medial portal and then the bone was removed from distal to proximal until soft tissue was found, being careful so as not to disrupt the flexor brevis attachments and the rest of the sesamoid complex (Fig 2). A bulky dressing was applied for comfort and the patient was discharged from the hospital the same day and was encouraged to begin early metatarsophalangeal joint motion. The
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 3 (April), 1999: pp 321–323
321
322
L.P. CARRO ET AL. ectomy is a well-established procedure for sesamoiditis and osteochondritis refractory to conservative treatment. It can also be performed in cases of infection secondary to diabetic neuropathy and in nonunion of sesamoid fractures.1 The traditional treatment method uses a standard medial approach, opening up the capsule and retracting it plantarward until the articular surface of the sesamoid can be visualized. Open surgical exposure increases and introduces additional potential for complications. Adjunctive use of the arthroscope for excisions has been used in other joints such as the wrist2,3 and elbow.4 Arthroscopic excision methods appear to allow a shorter hospital stay, resulting in less severity and duration of postoperative pain and stiffness, better cosmetic results, reduction of the period of postoperative rehabilitation, diminished morbidity, and an earlier return to work.3 Similar application of arthroscopic surgery to the first metatarsophalangeal joint would involve the same potential advantages. Ferkel and Scranton5 reported on the details of a technique for great toe arthroscopy making feasible the arthroscopic exploration of the metatarsophalangeal joint. As far as we know, arthroscopic sesamoidectomy of the great toe has never been reported.
FIGURE 1.
hallux was strapped into slight varus for 3 weeks to prevent hallux valgus deformity. Postoperatively, the vasculo-nervous status was normal. Radiographs confirmed the successful excision of the bipartite sesamoid (Fig 3). At 1-year follow-up, no deformity was present in the great toe and the patient is currently asymptomatic. DISCUSSION The sesamoids of the great toe are rather constant bones that ossify in the eighth year for girls and the 12th year for boys. First metatarsophalangeal sesamoid-
FIGURE 2. Arthroscopic view during the procedure. The arthroscope is in the dorsolateral portal and the burr in the medial portal removing the proximal part of the
ARTHROSCOPIC SESAMOIDECTOMY
323 REFERENCES
1. Leventen EO. Sesamoid disorders and treatment. Clin Orthop 1991;269:236-240. 2. Roth JH, Poehling GG. Arthroscopic ‘‘ectomy’’ surgery of the wrist. Arthroscopy 1990;6:141-147. 3. Menon J. Arthroscopic management of trapeziometacarpal joint arthritis of the thumb. Arthroscopy 1996;12:581-587. 4. Lo IKY, King GJW. Arthroscopic radial head excision. Arthroscopy 1994;10:689-692. 5. Ferkel RD, Scranton PE. Arthroscopy of the ankle and foot. J Bone Joint Surg Am 1993;75:1233-1242.
FIGURE 3. Anteroposterior radiograph showing the successful excision of the bipartite sesamoid.