SLR - February 2021 - Meghan K. Blanchet

Functional Outcome of Sesamoid Excision in Athletes

Reference: Dean RS, Coetzee JC, McGaver RS, Fritz JE, Nilsson LJ. Functional Outcome of Sesamoid Excision in Athletes. Am J Sports Med. 2020 Dec;48(14):3603-3609. doi: 10.1177/0363546520962518. Epub 2020 Oct 23. PMID: 33095661.

Level of Evidence: Level IV

Scientific Literature Review

Reviewed By: Meghan K. Blanchet, DPM
Residency Program: Inova Fairfax Medical Campus – Falls Church, VA

Podiatric Relevance: The sesamoid complex is vulnerable to injury from athletic activities including dance, running, and high-impact sports such as football. Injuries to the sesamoids become complicated very quickly due to their interconnection to plantar soft tissue structures that are vital to the function of the first metatarsophalangeal joint. There are various manifestations of sesamoid pathologies, including sesamoiditis from repetitive overuse, osteochondroses, acute fracture, or acute injury to atypical anatomy such as bipartite sesamoids. Often, these diagnoses are successfully treated with conservative treatment, however when this fails, surgical options consist of partial or complete sesamoid excision. It has previously been controversial how often athletes are able to successfully return to their previous level of activity following sesamoid excision. This article explores if sesamoid excision can produce reliable improved functional outcomes within a large patient cohort, and how successfully athletes return to sport following sesamoid excision.

Methods: This was a retrospective case series designed to evaluate the functional outcomes of patients undergoing complete sesamoid excision, differentiating between athletes and nonathletes. This study included 82 feet that received either medial, lateral, or medial and lateral complete sesamoid excisions. All patients completed a meticulous rehabilitation protocol. Outcome measures taken pre- and post-operatively included the Foot Function Index-Revised (FFI-R), Short Form 12 (SF-12), visual analog scale (VAS), a patient satisfaction survey, and the Single Assessment Numeric Evaluation (SANE). 

Results: All patients reported statistically significant improvements in SANE, VAS, SF-12, and FFI-R Cumulative. No significant differences in outcomes were noted between groups of medial versus lateral, or single versus double sesamoid excisions. In the athlete cohort, 67 percent of patients returned to their previous level of activity or more, 13 percent returned to some level of activity, while 20 percent did not return to previous athletic activities. Athletes demonstrated significantly higher SANE, FFI-R Cumulative and Difficulty, and SF-12 scores post-operatively. Three patients experienced complications consisting of RSD, instability, or hallux valgus, and all required revisional surgery. 

Conclusions: This study demonstrates that complete sesamoid excision can produce excellent results in both competitive athletes and nonathletic patients, however not without risk. Although an impressive 80% of athletes returned to sports, this study impacts my practice by demonstrating how imperative it is to exhaust conservative treatment prior to risking a 20 percent chance that your patient will not return to sports. This study re-affirms the importance of technique and post-operative protocols, as this study attributes their success to these two factors. Firstly, the authors emphasized to spare as much plantar plate as possible, and to transfer any soft tissue structures that are compromised during the procedure. Second, the authors highly recommend a deliberate and meticulous post-operative rehabilitation protocol that they designed.

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