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Greetings all!
I have a current patient (22yo female) who presented with 12 months of plantar 1st MTP pain. She was originally diagnosed with gout- no prizes for spotting the actual problem...
I have had a similar case before in a sprinter which we managed conservatively with good results, however the sesmoid in that case was in 2 pieces cleanly whereas this is obviously quite fragmented.
Pain was originally significant, but settled although it is still quite irritable.
While waiting to get her xrays, I taped her foot which immediately improved her discomfort.
Now- I am confident I can make her quite comfortable with appropritae orthoses, however I am wondering whether I am simply prolonging the inevitable and she will definite require surgery (prolonging is ok as she is moving to Boston in 6 months time and would wait until then for the surgery)
Has anyone had long term success with this type of problem without surgery?
(I thought about posting this in the surgery thread, but I know what the answer would be there...)
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
The Following User Says Thank You to CraigT For This Useful Post:
A comminuted # of this nature should have a fair chance of healing with 6-12 weeks in a cast or removable cast walker. I would always attempt this before moving into orthoses - so that plantar pressures under the sesamoid are maximally reduced.
The danger (and main indication for surgery) is intractable pain secondary to avascular necrosis.
Fibular sesamoids can be excised, but there is a reasonable chance of long term pain in the tibial sesamoid. Some can be lucky and have a good long term prognosis and a full return to sporting activity with an appropriate orthosis.
Either way you have 6 months to manage this with 'aggressive conservatism" until her return to Boston.
LL
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***************************************** Remember, it's just a foot.
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Re: Non operative prognosis for sesamoid fracture?
I agree that avascular necrosis is a concern here. An MRI with vascular contrast can answer that question but with or without confirmation, I would strongly suggest a series of posterior tibial nerve blocks a la Marvin Steinberg, DPM to collateralize the area.
I have seen this problem in sprinters, ballet enpointe and safeties in American Football who back pedal intensely.
I do this therapy as I provide biomechanical compensation, foot type-specific using Foot Centrings with excellent results in about four months.
I had one sprinter cadet from West Point who wanted to return to track rapidly and opted for the surgery, which went well (something to consider).
Dennis
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CraigT (25th February 2009),
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Re: Non operative prognosis for sesamoid fracture?
Thank you both for your thoughts...
Quote:
A comminuted # of this nature should have a fair chance of healing with 6-12 weeks in a cast or removable cast walker. I would always attempt this before moving into orthoses - so that plantar pressures under the sesamoid are maximally reduced.
The danger (and main indication for surgery) is intractable pain secondary to avascular necrosis.
One of the concerns that I have is the fact it is 12 months old already- I expect that there is a reasonable chance of avascular necrosis. I am trying to get hold of the old xrays to get an idea of the progression of this problem.
Does the presence of AVN change the management, or just the prognosis?
Quote:
I would strongly suggest a series of posterior tibial nerve blocks a la Marvin Steinberg, DPM to collateralize the area.
Thanks Dennis- can you expand on this? She is not in great pain, but it is affecting her daily activities.
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
Re: Non operative prognosis for sesamoid fracture?
Quote:
Originally Posted by CraigT
Greetings all!
I have a current patient (22yo female) who presented with 12 months of plantar 1st MTP pain. She was originally diagnosed with gout- no prizes for spotting the actual problem...
I have had a similar case before in a sprinter which we managed conservatively with good results, however the sesmoid in that case was in 2 pieces cleanly whereas this is obviously quite fragmented.
Pain was originally significant, but settled although it is still quite irritable.
While waiting to get her xrays, I taped her foot which immediately improved her discomfort.
Now- I am confident I can make her quite comfortable with appropritae orthoses, however I am wondering whether I am simply prolonging the inevitable and she will definite require surgery (prolonging is ok as she is moving to Boston in 6 months time and would wait until then for the surgery)
Has anyone had long term success with this type of problem without surgery?
(I thought about posting this in the surgery thread, but I know what the answer would be there...)
Craig:
The sesamoid does look fractured, looks like it is trying to heal, but I have been fooled before by the appearance of plain film radiographs in these cases. It would be very helpful if further diagnostic studies could be performed, preferably MRI, but also a CT scan would be helpful.
If the bone is still fractured, as seen on MRI or CT scan, then most sports podiatrists would tell you that there is little hope at this point of getting it to completely heal since it would be considered a non-union at this point, over a year from the fracture. Certainly trying foot orthoses with a thick Reverse Morton's extension, medial heel skive, more inverted balancing position and higher medial arch han normal would help reduce pain and may allow her to walk comfortably but probably wouldn't allow her to run, jump or squat comfortably. If the patient wants to try everything before surgery, then one to three cortisone injections into the area surrounding the sesamoid is worth a try and may help calm down the area a bit.
Honestly, if it were my sesamoid that looked like this a year after the injury, was still preventing me from running, jumping or playing sports, or even walking comfortably, I would want it surgically excised. I have done this surgery a number of times and, if the surgery is carefully performed by an experienced foot surgeon, good to excellent results would be expected.
Hope this helps.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Re: Non operative prognosis for sesamoid fracture?
I taught injection therapy as Associate Professor in Medicine at NYCPM from 1981-88. Much of Steinberg's amazing work is unpublished and therefore anecdotal and folkloric but tell that to someone with an AVN that heals.
AVN in this case is a loss of circulation due to interruption of the single vessel that feeds the sessamoid.
PT Blocks perfuse distally with additional circulation assuming patency. Clinically, it opens up the faucet in the circulatory plumbing.
If helpful, three days later and then once a week until strong healing signs.
It is like a bypass in that it increases capillary pressure and causes collateralization.
Instill 3 cc's of a mixture of
1% xylocaine with epinephrine 1:100,000 and 0.5% Marcaine into the area of the PT pulse at about a 60 degree angle, aspirate and then introduce.
A positive "take" would have the foot numb and hot in about 15 minutes and last for 6-8 hours.
I have cured AVN of the 1st met head complication post Austin with PT Blocks.
Craig:
What would you be hoping to accomplish by introducing an antiphysiologic like cortisone in this case.
Dennis
Re: Non operative prognosis for sesamoid fracture?
Quote:
If the bone is still fractured, as seen on MRI or CT scan, then most sports podiatrists would tell you that there is little hope at this point of getting it to completely heal since it would be considered a non-union at this point, over a year from the fracture. Certainly trying foot orthoses with a thick Reverse Morton's extension, medial heel skive, more inverted balancing position and higher medial arch han normal would help reduce pain and may allow her to walk comfortably but probably wouldn't allow her to run, jump or squat comfortably. If the patient wants to try everything before surgery, then one to three cortisone injections into the area surrounding the sesamoid is worth a try and may help calm down the area a bit.
Honestly, if it were my sesamoid that looked like this a year after the injury, was still preventing me from running, jumping or playing sports, or even walking comfortably, I would want it surgically excised. I have done this surgery a number of times and, if the surgery is carefully performed by an experienced foot surgeon, good to excellent results would be expected.
Thanks for your thoughts Kevin- this is pretty much what I am doing at this stage.
With respect to the imaging, I will hold off at the moment as it will not change the current treatment. This decision will be revisited closer to the time she will be heading to Boston.
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
Last edited by CraigT : 1st March 2009 at 05:50 AM.
Reason: typo
Re: Non operative prognosis for sesamoid fracture?
Quote:
Originally Posted by drsha
I taught injection therapy as Associate Professor in Medicine at NYCPM from 1981-88. Much of Steinberg's amazing work is unpublished and therefore anecdotal and folkloric but tell that to someone with an AVN that heals.
AVN in this case is a loss of circulation due to interruption of the single vessel that feeds the sessamoid.
PT Blocks perfuse distally with additional circulation assuming patency. Clinically, it opens up the faucet in the circulatory plumbing.
If helpful, three days later and then once a week until strong healing signs.
It is like a bypass in that it increases capillary pressure and causes collateralization.
Instill 3 cc's of a mixture of
1% xylocaine with epinephrine 1:100,000 and 0.5% Marcaine into the area of the PT pulse at about a 60 degree angle, aspirate and then introduce.
A positive "take" would have the foot numb and hot in about 15 minutes and last for 6-8 hours.
I have cured AVN of the 1st met head complication post Austin with PT Blocks.
Interesting Dennis- thank you
Just one question- is the epinephrine significant? The rationale for the treatment is increased perfusion, however epinephrine is a vasoconstritor....?
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
Re: Non operative prognosis for sesamoid fracture?
Craig Wrote:
Interesting Dennis- thank you
Just one question- is the epinephrine significant? The rationale for the treatment is increased perfusion, however epinephrine is a vasoconstritor?
The answer here is histopathologic as Dr. Steinberg would say anecdotally.
The major tree of the posterior tibial nerve "sympathectomized" by the block (85%of the sympathetics into the foot) are PT. What we would like the block to do is not be diluted into the return circulation so that it could be more profound and longer lasting.
The epinephrine works microscopically at the level of the small blood vessels that provide the nerve at the injection site with circulation. These are known as vaso nervorum (there are , nervo nervorum, nervo vasorum and vaso vasorum as well).
So you are constricting locally to maintain the cocktail longer and vasodilating distally therapeutically.
Dennis
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Re: Non operative prognosis for sesamoid fracture?
Thank you for the discussion. That PT block is something I've never heard. I wonder if I didn't have Dr. Steiberg's son as a classmate-- John Steinberg, DPM?
Anyhow, I wonder how this patient will do-
Very interesting.
__________________
Dr. John G. Fasick
LSUHSC New Orleans
Clinical Insructor, LSU School of Medicine jfasic@lsuhsc.edu
Re: Non operative prognosis for sesamoid fracture?
Craig,
I have successfully treated this via manipulation. The first thing I look for in chronic 1st MTP joint pain of varied apparent diagnosis, is peroneal strength. If the peroneus longus is inhibited, there is just no ability to stabilize the 1st MTP joint, and pain persists. I have literally "exploded" appearing, chronically fractured sesamoids, have immediate relief once peroneal facilitation is restored via ankle manipulation. The also usually require some type of orthoses with a 1st ray c/o..and look very careful for LLD as this is often a contributing factor.
This was technique published in JAPMA (Dananberg, HJ, Shearstone, J, Guiliano, M “Manipulation Method for the Treatment of Ankle Equinus, “ Journal of the American Podiatric Medical Association, 90:8 September, 2000 pp 385-389) or you can go to the www.vasylmedical.com website for articles on this procedure.
Non operative prognosis for sesamoid fracture?
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