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sesamoidectomy for cystic degenerative arthritis and aseptic necrosis

Discussion in 'Ask your questions here' started by Unregistered, Dec 29, 2011.

  1. Unregistered

    Unregistered Guest

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    Today I was diagnosed with cystic degenerative arthritis and aseptic necrosis of the sesamoid. I've had pain off and on from this for over a year, with increasing, unremitting pain in the last half year. The only treatment that provides some temporary relief is foot taping.

    My doctor recommended a sesamoidectomy as first choice (versus excision of bone cyst and filled with autologous bone, which he thought might not be successful).

    He told me to research sesamoidectomy, but I am finding almost no useful information in my web search (just chat rooms and blogs).

    Is sesamoidectomy my only real option for this? What are the potential complications? What if I don't have the surgery--will the problem get worse?

    Thanks very much.
  2. Unregistered

    Unregistered Guest

    What sesamoid bone is it? If its in the foot go to MyFootShop sesamoid fracture on google
    Last edited: Dec 30, 2011
  3. Unregistered

    Unregistered Guest

    If its the one the big toe sesamoids you can google, "myfootshop sesamoid fracture". It seems if you have a dying painful sesamoid, that won't get better with more conservative measures, a sesamoid excision is a good option for relieving your pain. But I am no Doctor so take that with a grain of salt.
  4. Unregistered

    Unregistered Guest

    I don't usually post on these boards, but your case has similarities to mine and you're right; it's very hard to get clear, credible information. I am not a physician, so you can take whatever I say with a grain of salt, but here is what I have learned:

    The sesamoid complex is an extremely delicate and critical part of your foot. Excision can be the right decision, but once the sesamoid is removed, there is, obviously, no turning back. I had a comparable diagnosis 6 years ago and had my medial sesamoid excised (removed) 4 1/2 years ago. In my case, excision was the right choice, with a few caveats. Even now, I live with daily pain and have had to abandon most sports I loved. Before surgery, my daily pain averaged about an "8-9", and I couldn't walk well enough just to go to the grocery store. Now, with activity modification, it's "4-5." I couldn't run if I were being chased by a lion, even though I used to be an athlete.

    If you proceed with surgery, get the absolute best doc you can find, and make sure you ask how many sesamoidectomies he/she does annually. If the doc tells you he/she has done "lots," ask about success rates and complications. You really need to press for answers and be your own advocate.

    Questions to ask yourself and/or your doctor:

    1. What are your physical demands? Are you an athlete, a weekend warrior, or more sendentary? Are you young, middle aged, or "other"?

    2. Do you have arthritis in other joints? If not, your pain may have started with a sesamoid stress fracture. This information can be useful to your decision-making, since a stress fracture can (though not necessarily) point to general bone weakness or mechanical issues with the way you walk. If you had a previous diagnosis of sesamoiditis, be aware that "sesamoiditis" has become a rather generic term, much like "metatarsalgia." Basically, both words mean something is irritated and painful (the sesamoids or metatarsal heads, respectively), but neither word really constitutes a true diagnosis except for medical coding purposes.

    3. What imaging have you had done? Has your doc considered partial excision (removing loose particles and shaving rough edges -- doesn't always work, but might be worth considering)?

    3a. Do you have a bunion? Do you have hallux valgus? They are not the same thing, though the terms are sometimes misused interchangeably. A bunion is an obvious, bony bump on the medial side of the first metatarsal head. In contrast, hallux valgus describes the relationship between the first metatarsal and the bone constituting the base of your big toe. Ideally, as you look down at your foot, your big toe should form a more or less straight line with the first metatarsal. Using the R foot as an example, if the first metatarsal points to, say, "10 o'clock", and your big toe points to "2 o'clock", that's hallux valgus. If there is ALSO a protruding bump at the joint, you have hallux valgus with a bunion. Whether or not you have either of these conditions can dramatically affect the results of a sesamoidectomy.

    3b. Are your sesamoids currently sitting in a good position beneath your metatarsal head (may the dead one RIP), like front wheels under a car, or are they off-center (subluxed)? It's hard to accurately assess sesamoid position from the usual AP image (the xray image of your foot as it looks to you when you look down). An axial view (sometimes called a sky or sesamoid view) will show where your sesamoids actually "live" when they are engaged. If you are thinking about having one sesamoid removed, consider how the other sesamoid will manage without its partner sesamoid. Each sesamoid is encased inside a (flexor) tendon that attaches to the base of the big toe, and to an attachment point much further back toward your heel. (Imagine your big toe as a horse's head; each tendon is like the rider's reigns.) But these two tendons are not attached to the bottom of your first metatarsal head. Instead, these two sesamoid-containing tendons slide along two little "grooves" on the underside of the first metatarsal head. (There is also a little prominence of bone [crista] that helps them to track smoothly.)

    Sesamoids are also attached to the SECOND metatarsal head, in a little chain: medial sesamoid attaches to lateral sesamoid, lateral sesamoid attaches under the second metatarsal head, which is why sesamoids can become "subluxed." More accurately, in hallux valgus, the first metatarsal skates medially away from (off) the sesamoids, which are relatively stationary. Sometimes the connection between the sesamoid and the second metatarsal is surgically cut, but doing so can sometimes lead to excess flexibility in your forefoot (another topic).

    3c.Do you have high, neutral, or low arches? This is something I didn't realize was relevant until after the fact. (My arches are high.) Among other things, sesamoids help hold up your metatarsal head and protect it, and neighboring soft tissue, from ground forces. The elevation created by the sesamoids also helps keep the first metatarsal complex aligned with the neighboring metatarsals so that weight is distributed evenly across the ball of your foot. When you take away one sesamoid, your first metatarsal head can become like a car with a flat front tire. If you have high arches, your remaining sesamoid will be stressed that much more. Depending on your foot shape, this may or may not be an issue.
    Most importantly, the surgeon needs to preserve the tendon "slip" and adjust the tendon tension, after the sesamoid has been removed, so that the "pull" on the "reigns" at the base of the big toe remains balanced.

    Note: I was told I had mild hallux valgus (I'd never even noticed it), and that if the sesamoid was removed, I would also need a bunionectomy, on the theory that the resulting tendon imbalance would cause my big toe to gravitate in the "2 o'clock" direction. I regret the bunionectomy. If it ain't broke, don't fix it.

    4. How does your bad foot compare to your good foot? Have you had your good foot imaged?

    5. Have you gotten multiple opinions? This is very important. Even the best docs will have differing opinions about how this cat should be skinned. In the end, the choice is up to you. And a final thought, which is admittedly subjective, but also worth considering: IMO, Even if the doctor has won a Nobel Prize for sesamoidectomies, if you don't feel comfortable with him/her, go elsewhere. Sesamoidectomies CAN be tricky, and frustrating, and create additional problems, so pick a doctor you can work with on an interpersonal level. Hopefully, you'll never need to see each other again, but if there are complications, having a doctor you like is invaluable.

    I hope I haven't scared you with too much info. As I stated at the top, excision was the best choice for me, though there really weren't any terrific options. If your foot is well aligned and you do not have other health problems (and you keep surgical intervention to "minimum necessary"), removal of a sesamoid is much less complicated. I do question some of the things I've read about competitive athletes returning to full function after sesamoidectomy, but I suppose it's possible. Best of luck to you.
  5. Unregistered

    Unregistered Guest

    Thank you so much for your extremely helpful post. I truly appreciate it.

    I got three opinions prior to having the tibial sesamoidectomy a month ago. Surgery was the only option at this point. My doctor planned to do a partial sesamoidectomy if less than half the bone was dead; however, 50% of the bone was necrosed and the cartilage was destroyed, so he removed the whole sesamoid.

    I have had pain with this sesamoid off and on for years (I believe I fracture it a decade ago, but am not sure). We used conservative measures off and on for the last 1 1/2 years, but the pain progressed to the point of feeling like I was walking on a broken bone all the time and no longer wanted to even walk in the grocery store.

    I hope I made the right decision. The recovery is brutal. I just started physical therapy, and it is excruciating. If I wind up with the same amount of pain (or worse) than prior to the surgery, I will be very depressed.
  6. Unregistered

    Unregistered Guest

    I forgot to answer your other questions (I don't know the answers to all of them).

    I have a flat foot. I am 45 years old. I used to walk three days a week for 1/2 hour and swim three days a week. I also skiied for 40 years. When I was in my 20s, I did a lot of high-impact aerobic dancing and salsa dancing. My surgeon did not think that I am at risk for a bunion. I have a history of corticosteroid bursts for asthma.

    A decade ago I broke my foot, but I don't know which bone (although I suspect it was this bone). I walked around on the broken foot for a month, thinking it was a sprain. When I finally had it x-rayed, the doctor (not my current one) said it was broken but too late to do anything about it.

    I had pain off and on over the next decade from it, and it was diagnosed as sesamoiditis. I had a few cortisone shots over the years. For the last 5 months (prior to getting the MRI that showed the cysts in my sesamoid), my podiatrist was taping my foot, which helped control the pain a little bit. After several months of taping, however, and also not walking for exercise, I had a huge flareup in pain, which prompted the doctor to order the fated MRI. After the flareup, I felt like I was walking on a broken bone, even with the taping.

    Again, thank you so much for taking the time to write such a detailed post!
  7. Unregistered

    Unregistered Guest

    Hi, I'm keen to know how you are post surgery now?

    I am a recreational jogger (hoping to due marathon later in the year) and I have been struggling with a sesamoid problem for over 6 months: cysts in bilateral sesamoid. (probably due to a trauma, exacerbated by high arches, carrying children, and probably jogging!).

    Had CT scan and saw Surgeon in December. He told me to continue jogging and advised my podiatrist to alter my othodics. I ice after ever run and have found anti inflamms have helped (but worried probably also just masking pain, and I may be aggravating problem).

    Am due a followup scan and visit with the surgeon in a few weeks.

    Would appreciate any advice...
  8. Pain

    Pain Guest

    I had one sesamoid removed a year ago. I had another surgery to repair the damage to one metatarsal that collapsed due to both sesamoids "jumping their track". Six months later, the third toe metatarsal collapsed, pushing the bone outwards on the botton of my foot. This has been the most excruiating, painful experience of my life (I'm 48). I am again having pain around the remaining sesamoid. I'm scared to death of another surgery (I've had 5 total in a year), but I cannot live with this pain. The pain is no where near as bad as the arthitically attacked sesamoid damage, however, it seems to be intensifying. I hate that I feel some sort of "comfort" knowing this has happened to others and I am not just a freak !
  9. tiffany

    tiffany Guest

    I am in the same boat as most of you here... And many days, I feel alone and confused. My surgeons (yes, I've now had two!) don't even seem to fully comprehend my situation or what to tell me regarding my future. I fractured my sesamoid some time in 2011, but didn't notice anything until I suffered a mid-foot sprain in August of that year. After many months of PT, boots, cortisone shots, doc opinions (one said nothing was wrong with me a tall), pain, loss of sleep, etc., I finally found an ortho surgeon who recognized the tibial sesamoid fracture, plantar plate tear, and lovely hammertoes. He also suggested that, along with the sesamoid removal and fusion of my second toe, I should probably have the bunion "done". I had surgery on April 24, 2013.
    I now regret ALL of the procedures, aside from the second toe fusion. In the fall of 2013, I thought I was improving a bit, or at least on a decent rehab path, and I made certain to get into PT (my surgeon basically said I wouldn't even need it--ha!!). Then I had a major setback, and, long story short, after removal of hardware in March, my new surgeon did an MRI and discovered "mild bone marrow edema" in various spots, including my fibular sesamoid, first metatarsal head, and flexor hallucis. Oh, and "thickening" of the abductor hallucis tendon. I went directly back into a CAM boot for approx. 9-10 weeks, coming out here and there to "test" out the foot. Though it only shows mild marrow edema, the location of it (ball of foot) makes it that much more difficult to manage. Since then, I've been in PT (just started with a new PT a couple of weeks ago) to work on balance, gait re-training, and strength. My ortho considers this to be a "bone contusion", but couldn't give me any real direction as to what I should be doing/not doing. He said I could wear the boot if I wanted to or just go with orthotics if those felt comfortable. Nothing really ever feels comfy, so I went with the boot. Over the past couple of years of "foot drama", I have lost SO much strength and mass in my foot that it looks quite tiny and pathetic compared to my other foot. I also have more "clawing" of the toes, as they are working overtime to "protect" the ball of the foot. It appears that this type of surgery was not meant for a foot like mine, but no one shared that with me going into it. Between the many docs and PTs I have now seen, I would say maybe two of them have even SEEN someone with a sesamoidectomy in the past, and usually no one with this combination of procedures... Some days I DO feel like I am turning a corner, only to stop short the next day with some "new" type of pain. I am a very active person still--I have learned to modify exercises such as rowing, biking on a stationary bike, Pilates/yoga (this has been helping lately, I think), and anything upper body-related. That said, I would LOVE to be able to take a long, "normal" walk without living in fear that my foot won't make it. Some days I can do it relatively "easily", and other days not so much... I switch my shoes throughout the day. I have a set of orthotics that just isn't quite right, so I'm moving on to a new orthotics lab, hoping for the best... I just feel so hopeless some days, like at 39, this will just be my life forever. Some days I get the pain down to a 2. Other days, like today, I have weird new types of pain--rather like my big toe joint has been wrenched and battered--and it rockets up to an 8. I don't seem to be able to control it with any type of pain med, either. I know that I have a ton of internal scar tissue, which is complicating thing and pressing on nerves, though my scars look perfectly fine and my foot is not misshapen... But it feels completely mangled some days, and I feel so misled and confused. I also live in fear of "re-injuring" it somehow, or making the bone contusion worse!
    Anyway, it's so comforting to come here and realize that I am not alone. How is everyone else faring these days?

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