#885 Surgical options sesamoid fracture nonunion - DOC

#885 Surgical options sesamoid fracture nonunion

Today on the Doc On The Run podcast, we are talking about surgical options for sesamoid fracture nonunion.



If you have an injury to the sesamoid bones because it is fractured, the biggest concern is that it will turn into a thing called a nonunion and nonunion means it did not unite. It did not get back together and it did not heal.

I was talking to a runner who had this problem and she wanted to know whether or not surgery was a valid option or a good option in her case. We talked broadly speaking about three different possible kinds of surgeries and so, let us talk about those.

The sesamoids are down on the bottom of the big toe joint, and they are sitting underneath the first metatarsal bone, so down here. And so, when you look at them from above, like on an X-ray, when you are looking at the toes, it is interesting to me how many patients I have done X-rays on that have like a really badly broken bone or something and they do not really notice the fracture in their foot, but they notice the sesamoids. They would say, “Oh, what are those two things right there, is that normal?” Yes, it is normal. Those are the sesamoid bones.

To make this larger, let us say the this is one sesamoid, this is the other sesamoid and you have a fracture. It is broken. It is definitely broken. It is not one that is naturally into pieces. It is not a bipartite sesamoid. Okay, what are the options?

Well, one option is to remove it. Just take it out. Just take it right out of your foot, just cut it out of there. Well, why is that a problem? Well, number one, you have a tendon, the flexor hallucis longus tendon on the bottom of your foot, it is embedded in there. When you remove this one, the toe can drift in this direction. If your big toe winds up way over here, that is  a real problem, you do not want that problem. I am not going to go into more depth about that. That is a bad thing.  So, option number one remove it. We call it surgical excision because that sounds fancier than take it out. But that is really what it is. You take it out.

The second option is to try to fix it and get it to heal. How do we do that? Well, again, let us say this is a second option. We have doctors that have fancy names for everything to make themselves feel important. This one we call open reduction internal fixation.  You have no idea what we are talking about and what it really means is we put a screw in there. So, we go in from underneath, we put a little bitty wire in there. We put a tiny little screw across it like that. You put a tiny little screw in there and when you tighten the screw down, it comes back together so that it compresses it and hopefully that will make it heal, makes it more stable.

What is the good and bad in that. Well, let us say you have a real nonunion. You actually have a bunch of garbage in there. You have some scar tissue collagen that is sitting in that space. Sometimes when you have a fracture nonunion like a metatarsal fracture or something like that, or an ankle fracture, and it is not healing, we will go in and make an incision, open it up, spread the bones apart, and then clean out that stuff.

I invented a surgical instrument called the tarsal joint distractor, it is not important what it is, but it was designed for that to be able to open up a nonunion and clean out all this garbage that is blocking the healing between the two bones. Why does this matter? So, if you take a screw, it is metal and if we put that screw across here, and you have a bunch of scar tissue in there, when you walk because of the tendons pulling on it, you are stepping on it, you are bending it, you are basically bending the screw over and over and over and over and over.

Two things can happen. One of them is the screw can break. If it breaks, you then have a jagged piece of metal grinding away at the nonunion inside of the bone where it broke. That’s not good. The other thing is because it is a little piece of metal and two tiny little pieces of bone, you could crack the bone and it could kind of disintegrate and turn into gravel. That also would not be good. Now, if you did that, what was the solution? We take it out that would be the solution.

The third surgery is a thing that nobody does in practice and that is where we actually do what I was just mentioning where we look at it and we go, okay, you are getting the nonunion. You do have a bunch of scar tissue in there. We are going to open it up and we are going to go in there, clean out this garbage and then put some hardware in that. That’s logistically just too hard to do. It is very difficult. You cannot really open it up and clean it out, look at it the way that you would have broken ankle or something. So, this one nobody does in practice.

So, that really leaves you with two possible surgical options. One of them might help and it may not help, it just depends on where you are along your continuum of healing. But it is really important to carefully assess that. So, big risks with either of those two surgeries. If it is early in in the course, I would be more apt to do that to actually try to hold it still and get it to heal quickly while you can actually move it because it is still but the sesamoid bones when they get fractured often turn into a nonunion because there is too much motion at that site and it gets a bunch of garbage in between it that prevents the bone from actually healing together.

Hopefully this helps you understand a little bit more about sesamoid fracture nonunions and the surgical options but make sure that you understand all the specifics and make sure you tell your doctor and say, “I am a runner. I want to run. I want to know is this going to be better for me when I run.” It is not just about the fracture or the nonunion, it is about running. You have got to drive that home when you talk to your doctor.

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