SLR - January 2023 - Kelly McKeon, DPM
Title: Arthroscopic Autologous Bone Grafting for Hallux Sesamoid Fracture Nonunion Results in a High Rate of Complete ResolutionReference: Nakajima K. Arthroscopic Autologous Bone Grafting for Hallux Sesamoid Fracture Nonunion Results in a High Rate of Complete Resolution. Arthrosc Sports Med Rehabil. 2022 Sep 1;4(5):e1789-e1797. doi: 10.1016/j.asmr.2022.07.007. PMID: 36312710; PMCID: PMC9596892.
Level of Evidence: Level IV
Scientific Literature Review ACFAS
Reviewed By: Kelly McKeon, DPM
Residency Program: MedStar Health Podiatric Surgery Residency Program, Washington D.C.
Podiatric Relevance: Fractures of the hallux sesamoids can be difficult to treat due to the overloading nature on the first metatarsophalangeal joint. Injuries treated through a conservative approach may take 4-6 weeks of protective weightbearing before a patient can gradually engage in returning to normal or sport activity. Most sesamoid fractures will heal, but there is a potential risk of nonunion. Fracture nonunion of the sesamoids can lead to delay in patients, particularly high-level athletes, returning to their preinjury sport level. After conversative treatments fail, a surgical option of open sesamoidectomy can be utilized; but has a high complication rate of 22.5%. The primary author investigated using an arthroscopic approach with incorporation of autologous bone graft would yield positive outcomes for patients and have less complications.
Methods: The procedure was performed on 11 patients for nonunion of a sesamoid fracture from July 2017 to April 2020 after failure of more than 6 months of conservative treatment. Inclusion criteria consisted of a patient undergoing the arthroscopic procedure with 2 years or more of follow up. Exclusion criteria was less than 2 years of follow up. All outcomes were measured using the Visual Analog Scale (VAS) for pain and the Japanese Society for Surgery of the Foot (JSSF) score. Data extrapolated from these scales was analyzed using Wilcoxon signed rank text.
Results: Eleven patients (3 women and 8 men) had symptomatic sesamoid fracture nonunion. The tibial sesamoid was affected in 10 patients and the fibular sesamoid in 1 patient. All patients were involved in high impact sport activities. The average age of the sample size was 18.6 years, BMI 21.9 kg/m2, and average follow up of 3.2 years. The mean to bone union was 2.9 months. The average VAS scores improved from 72.1 preoperatively to 12.0 postoperatively. The average JSSF score improved from 58.7 preoperatively to 95.0 postoperatively. Nine patients reported complete resolution of symptoms. Two patients, one with the fibular sesamoid and one with a hypoplastic tibial sesamoid, had poorer outcomes. One patient required a longer time to union and returning to sporting activity. One patient required an open sesamoidectomy. No complications were reported in this study.
Conclusions: The purpose of the study was to assess the outcomes of patients that underwent an arthroscopic autologous bone grafting using iliac bone crest for hallux sesamoid fracture nonunion. Nine of the 11 patients had significant improvements in the VAS and JSSF scores, achieved bone union on average of 2.9 months, and returned to a preinjury sport level activity on average of 5.3 months with no complications. Two patients experienced delays in their treatment, with one patient having to undergoing an open sesamoidectomy to resolve pain. No complication rates were reported during this series as compared to reported literature results of a 22% complication rate for an open sesamoidectomy. Although this study was limited with sample size, age diversity, and short follow up period, the results support an effective arthroscopic alternative surgical treatment for hallux sesamoid fracture nonunion compared to an open sesamoidectomy, decreasing risk of postoperative complications.