10/14/2019    Michael Loshigian, DPM

Osteoarthritis Both Sesamoids (Don Peacock, DPM)

I agree that additional views are necessary to
fully evaluate the condition of this joint. Three
standard and axial sesamoid views are necessary.

However, and with all due respect to Dr. Peacock,
I don’t understand how anyone can make a
determination from the image provided as to where
the arrow is pointing along the dorsal to plantar
dimension of the foot. This is not a radiographic
marker but most likely an indicator added to the
image electronically after the image was taken.
What we can observe from the image provided is
that the metatarsal head was not fully reduced
over the sesamoids and that the tibial sesamoid is
bearing the majority of the force of the first
metatarsal at least with the joint in this
position which emulates the majority of stance
phase of gait.

What is often seen on an axial sesamoid view is a
reduction of the sesamoid position relative to the
crista which more closely represents the alignment
during propulsive phase of gait. The difference
between these two sesamoid/ metatarsal
relationships gives us an indication of the
transverse and to some degree the frontal plane
excursion of the first metatarsal as the patient
transitions from stance to propulsive phase. This
is often relevant information in understanding the
pathomechanics of the joint.

Also, the periarticular erosion seen in the
provided image may be an indicator of an
underlying crystalline or autoimmune related
arthropathy and it may be a good idea to have some
lab work done to establish if this is a factor in
this patient's case before subjecting them to
additional invasive treatments.

Most podiatrists worth the paper their degree is
printed on can distinguish sesamoid pain from a
dorsomedial nerve injury/ entrapment. As I
understand the original post, the patient had a
primary issue with the sesamoids before the two
surgical procedures were performed, making it less
likely that a dorsomedial nerve injury could
manifest as sesamoid pain, even if the patient had
some abnormal nerve anatomy where a dorsal sensory
nerve somehow provided sensation at the plantar
aspect of the foot. I am not aware of significant
published research supporting the concept that the
dorsomedial surgical approach causes nerve injury
in 50% of cases. That being said, I typically
only read three or four peer reviewed articles a
week and may not be aware of the referenced
statistic. The article provided by Dr. Peacock
discusses a very small patient population, does
not mention sesamoid pain, and is primarily
anecdotal. A 50% nerve injury rate is also not
consistent with my own limited experience
performing first MTPJ surgery nearly every week
for twenty four years (anecdotally speaking).

Sesamoid pain can be challenging to differentiate
and treat. When the cause is not obvious I
usually use an intraarticular anesthetic injection
to determine if the source of pain is intra or
exra articular. I give this injection by a
dorsolateral approach. I do not use ultrasound or
fluroscopic guidance.

In this case, if the pain is relieved by an
intraarticular injection of anesthetic and the
sesamoids are arthritic on imaging and the patient
has already failed two surgical procedures,
steroid injections, orthotics, shoe modifications,
accupuncture, gait plates, and physical therapy it
is unlikely that injecting some biologic or
viscosupplementation is going to yeild any better
results.

As with many other arthritic joints in the foot
they can be managed by splinting them or "fixing"
them. In this case I recommend a carbon foot
plate insert to my patients that usually provides
some degree of relief. I have found this to be
more effective in most cases than an orthotic
alone.
https://www.myfootshop.com/spring-plate-
carbongraphite-fiber-insert
I have no financial interest in this company.

"Fixing" them often is best achieved by a joint
fusion. Contrary to Dr. Peacock's statement
"removal of the sesamoids, fusion, etc. will
further the pain. The joint is not pathological
enough to justify fusion or injections." I have
found this to be a reliable and predictable
procedure that allows patients to return to normal
or near normal activity. I typically do not remove
the sesamoids during these procedures. The high
success rate, patient satisfaction, and functional
outcomes of first MTPJ fusions are well documented
in the medical literature. Anecdotally, I have had
more than a few patients go on to run the NYC
Marathon with their first MTP joint fused.

If the patient can live with their discomfort they
should do so. If they are unhappy enough with
their pain and limitations, a fusion might be
considered. Not wanting a fusion does not mean
that it is still not a good and reliable way to
manage their problem. The patient ultimately needs
to make that decision for them self.

In the immortal words of The Rolling Stones "you
can't always get what you want".

Michael Loshigian, DPM, NY, NY

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