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PATIENT IS A CANDIDATE FOR KELLER'S BUNIONECTOMY.THERE IS NO PAIN ON THE PLANTAR ASPECT OF THE 1ST METAHEAD.NO HISTORY OF ANY LESION OR ULCERATION UNDER THE METAHEAD. THE X-RAY SHOWS THE FIBULAR SESAMOID TO BE DISPLACED IN THE 1ST INTERSPACE.DO YOU TREAT THE PATIENT AND LEAVE THE FIBULAR SESAMOID INTACT OR DO YOU TREAT THE X-RAY AND REMOVE THE FIBULAR SESAMOID ? IF YOU REMOVE THE SESAMOID,WHAT ARE THE LIST OF POSSIBLE COMPLICATIONS ? DOES IT INCLUDE; SUBLUXATION OF THE 1ST METATARSAL ,NEW HALLUX VALGUS,AXIAL ROTATION OF THE DISTAL PHALANX WITH POSSIBLE FORMATION OF NEW BUMP ON THE DORSAL ASPECTOF THE HALLUX .WHAT ARE THE OTHER POSSIBILITIES ?
Given what you've described, I would leave the sesamoid. No reason to remove it. The Keller pretty much destroys normal active function of the 1st MTPJ (if there is any to begin with.)
As with any metatarsus primus adductus the sesamoids will be displaced in relation to the head anyway. If, intraoperatively you feel there is some lateral contraction which is hampering correct, you can do a soft tissue release of the sesamoid.
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Steve is (as he frequently is) smack on. The removal of the base of the proximal phalanx will release T.Flexor Hallucis Brevis which, over time, will retract proximally in relation to the 1st met. head and the seamoids will move with it. Sesamoid function is therefore lost, which is why transfer metatarsalgia is often seen when a Keller procedure is carried out on an active person - however elderly. Excision of the lateral sesamoid is therefore uneccessary and can lead to other complications. Personally, I only use the Keller procedure as a last resort when degenerative disease is advanced and even then only in cases of restricted mobility where the positives of the procedure outweigh the considerable negatives.
I agree with the above two posts. I really see no reason to remove the asymptomatic fibular sesamoid. Additionally, you raised an interesting point.....I rarely treat an "x-ray", but most often treat my patient.
Of course there are always exceptions if there is a significant finding on an x-ray such as a tumor or finding of concern. But as a general rule, I believe it is wise to treat the patient, and not treat the x-ray.
To Ian-Bloke,your'e bloody damm right! To drsarbes -I agree with you 100% To wjliggins-for the most part you are right.However,I firmly believe that this procedure should not be done on any active person,regardless of age To drdsw-you hit a home run on your answer All of you have a great holiday-emil1066