What is the difference between a sesamoidectomy and a first metatarsal osteotomy for pain under the big toe joint? Well, if you are wondering, that is what we’re talking about today on the Doc On The Run Podcast.
Sometimes I get patients who have been doing a whole lot of digging trying to figure out the difference between a couple of problems or procedures when they have a specific problem. One of the problems that you can get is if we look at the ball of the foot and if this is your foot very simply put and you have the first metatarsal bone here, then you have the second, the third, the fourth, and the fifth metatarsal bones, and you have these two little bones called sesamoids, then you get pain under your big toe joint, it can often be because you are getting a stress reaction or a stress fracture in one of these two bones and it is pressure to that bone that is causing all the trouble.
So how do you treat that? Well, there are a couple of different options, always options. If we look at this from above and this is your big toe and that is your second, your third, and your fourth, and your fifth toe and this is the metatarsal bone, that is this one, and then underneath there you have the two sesamoid bones and then you have the bones in the toe and that is basically your foot. We won’t draw all the other stuff, but you get the idea.
If that is the spot where you have pain is right where your tibial or medial sesamoid is and you want to try to get it away from the ground, how can you do that? Well, you have a couple of options. Again, if we look at it from the side and this is the first metatarsal bone, side view, and that is the sesamoid bone here, and you have all this pain under the sesamoid because you have all this pressure, what can you do? Well, you can do anything to move it up. Two options.
One option is to take out the sesamoid, just remove it, right? So, if then, if we make an incision, we go into your foot and underneath we just take this one out, so it is no longer there, well what does that mean? It is gone. And then if you look at it from this view, after you’ve had a sesamoidectomy, if this one was a problem and now it is gone, well now there’s zero pressure there, right, because we took it out. Same thing here if you look at it from the side and we remove that sesamoid bone and it is gone, there’s no more pressure there, at least on that one. Of course, you have two of them under there so if you take that one out you are going to probably start getting more pressure here but that is not the point of this video, not the point of this episode at all.
If you want to do that and not take one of the sesamoids out, there’s another way to do it. You can make a bone cut and simplest way, we don’t do it like this, but the simplest way would be cut straight through it and let that bone slide up and reposition it here so that it is in higher up and then the sesamoid will drift up with it and so then the sesamoid is going to be sitting up here. It is higher up, there’s less pressure.
The way that most doctors are going to do it is a thing called a distal metatarsal osteotomy. They’ll make a bone cut kind of like this that allows them to slide it back and forth but at the same time if they make an additional bone cut here and remove this piece of bone, when the bone slides up it does two things. It shortens because you close that gap but then it also because the bone is pointing downward, if you make the bone cut like this and make the second bone cut so that it has to slide back a little further before it makes contact, that also shortens it because the metatarsal bone is coming up from the ground. The head of the bone is coming up from the ground.
This is a thing that is done a lot in patients who have diabetes and get ulcerations or open sores where they basically worn a hole right through the skin and it won’t stay closed. Obviously, that is bad. It is bad because it gets infected and that is how diabetics wind up getting an infection that leads to them being in the hospital and maybe even getting a leg amputated. Really and truly, that is how that happens. But basically, that is all you need to know is that when we talk about a sesamoidectomy, the term “ectomy”, that part of the word sesamoidectomy, “ectomy” is cut it out, take it out.
So, when you remove that bone, that is sesamoid “ectomy”. Just like if you have an appendectomy, it is where we remove your appendix. If you have an osteotomy, an osteotomy, osteo for bone, osteotomy is where we do a bone cut. When you have a procedure called an osteotomy, we are just cutting the bone and reconfiguring it in some way to reposition it and change the way that it is hitting the ground to alter your biomechanics.
If you had pain on your sesamoids, I wouldn’t be looking into either of these two procedures because every surgery comes with lots of possible complications and although I think surgery is a lot of fun for the surgeon, not always so for the patient. And if you get a complication, that is a real problem. So, if you think that you might need to have your sesamoids looked at, figure it out. Try to figure out everything you can do to reduce the pressure to that bone without cutting your foot open, taking out a bone or cutting an important bone and trying to reconfigure it to reduce pressure because there’s nothing free.
As soon as you remove pressure, you put it somewhere else. It doesn’t go away. You can’t change physics. You can just alter the pressure distribution by doing something like that, but it doesn’t alter the pressure altogether unless your weight changes or the planet you are on changes and the gravity changes.
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