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Chapter 83 Tibial Sesamoidectomy

Simon Lee, Johnny Lin, and George B. Holmes

DEFINITION the tibial sesamoid, thus accounting for the increased incidence
of tibial sesamoid injuries.
■ Sesamoiditis is a general term that indicates an injury to the ■ Biomechanically the sesamoids function as a fulcrum to pro-
sesamoid bone. There are multiple possible causes, such as
vide a mechanical advantage to the FHB tendon during
trauma (fracture, contusion, repetitive stress), infection,
metatarsal phalangeal joint plantarflexion.7
arthrosis, osteonecrosis, and osteochondritis dessicans.3,5,13–15 ■ Ossification of the sesamoids typically occurs from multiple
■ There are two sesamoid bones located plantar to the
centers and occurs during the seventh to tenth years of life.
metatarsal head of the hallux: the lateral or fibular and the me-
The multiple ossification centers may account for the incidence
dial or tibial sesamoid. The tibial sesamoid typically bears more
of bipartite and tripartite sesamoids.5
stress than the fibular sesamoid and is more likely to be injured.4 ■ The tibial sesamoid is bipartite in about 19% of the popula-

tion and bilateral in 25% of patients (FIG 3 ).6


ANATOMY
■ The two sesamoid bones are located plantar to the PATHOGENESIS
metatarsal head within the tendon of the flexor hallucis brevis ■ Symptoms can arise from a single acute traumatic event, or
(FHB). They are held together by the intersesamoid ligament more commonly there is a history of minor or repetitive
and plantar plate. The two sesamoids’ dorsal surface articu- trauma as the cause of sesamoid pain.
lates with the head of the first metatarsal facets, and they are ■ Acute injuries typically occur with a similar mechanism to a

separated by a crista. The sesamoids function to absorb the turf toe injury, acute hyperextension to the hallux metatar-
weight-bearing stress across the medial ray as well as protect- sophalangeal (MTP) joint, or a direct contusion to the
ing the flexor hallucis longus (FHL) tendon that passes be- sesamoid region of the forefoot. This can also result in a frac-
tween them. The tibial sesamoid is typically larger and located ture or an injury to a bipartite sesamoid.
slightly more distal than the fibular sesamoid (FIG 1). ■ In nonacute injuries the patient often cannot remember a spe-

■ During the stance phase of gait the sesamoids are slightly cific incident or injury and can only initially recall activity-re-
proximal to the metatarsal head, but with dorsiflexion of the lated discomfort to the forefoot. This history is typically noted in
hallux the sesamoids are pulled distally, protecting the ex- cases of repetitive stress, osteochondritis dissecans, and arthrosis.
posed surface of the metatarsal head (FIG 2 ). During the act A bipartite sesamoid can similarly be injured in this case.
of toe raising, the sesamoids bear a significant amount of ■ Neuritic pain has also been described with compression to the

stress. This stress is typically concentrated more medially over plantar medial cutaneous nerve underlying the tibial sesamoid.

Dorsal digital n.

Sagittal hood

Flexor hallucis longus t.

Medial metatarsophalangeal lig. Abductor hallucis t.

Medial metatarsosesamoid lig. Medial sesamoid

A Plantar digital n. Flexor hallucis brevis t.

FIG 1 • A. Medial view of relevant anatomy with special note of the adductor hallucis brevis and the
relationship to the plantar cutaneous nerve. (continued)

1
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2 Part 2 FOOT AND ANKLE • Section X TITLE

Proximal phalanx
Medial metatarso-
phalangeal lig.
Medial metatarso-
Sesamoids sesamoid lig.
Tendinous slips
to sesamoid from
Intersesamoid lig. abductor hallucis m.
Plantar plate
Flexor hallucis
brevis m.,
lateral and
Adductor medial heads
hallucis m.,
transverse and Adductor
oblique heads hallucis m.

Flexor hallucis FIG 3 • AP view of the foot showing a bipartite sesamoid.


longus t (cut)
(From Lee S. Technique of isolated tibial sesamoidectomy. Techn
Foot Ankle Surg 2004;3:85–90, with permission.)

localized to the great toe region. It is localized more plantar-


B
ward and is worse with weight-bearing activity. Patients will
often prefer cushioned shoewear versus barefooted activity.
FIG 1 • (continued) B. Plantar view of the sesamoid complex ■ Performing activities that require a dorsiflexed MTP joint

and the investing structures. such as running, jumping, toe raising, or stair climbing can be-
come very irritating to this region.
■ Gait can be antalgic, specifically in the toe-off phase, and
NATURAL HISTORY
can also reveal evidence of medial off-loading and lateral foot
■ Most sesamoid injuries resolve with appropriate nonopera- overload as the patient walks with the foot externally rotated.
tive treatment. ■ Clinical inspection will reveal swelling over the plantar as-
■ Sesamoiditis that does not resolve with conservative treat-
pect of the hallux MTP joint as well as tenderness to palpation
ment is unlikely to improve significantly after 3 to 12 months. under the tibial sesamoid. This pain can be exacerbated with
■ As a result, patients often have pain that prevents them
forced dorsiflexion of the hallux MTP joint. There may be
from participating in athletic activities. evidence of loss of dorsiflexion and less commonly plantarflex-
■ Performing everyday activities that involve a dorsiflexed
ion of the MTP joint. Plantarflexion strength against resistance
MTP joint such as stair climbing, toe raising, and in women or with a single-limb toe raise may also be affected due to pain.
wearing heels also can become bothersome. ■ In acute injuries or in patients with a bipartite sesamoid a

drawer test of the hallux MTP joint may also reveal laxity, in-
PATIENT HISTORY AND PHYSICAL dicating a fracture of the sesamoid or disruption of the syn-
FINDINGS chondrosis of a bipartite sesamoid.
■ Most patients cannot remember a specific incident or injury, ■ Direct palpation over the tibial sesamoid may also reveal a

unless it was acute, and can only recall a gradual onset of dis- positive Tinel sign or paresthesia distally, indicating a com-
comfort to their forefoot. This pain is often generalized and pression over the plantar medial cutaneous nerve.
■ Assessment of hallux alignment is critical.

■ Evidence of pre-existing hallux valgus or a cavus foot

requires careful planning to identify patients who may re-


quire concomitant procedures to prevent further migration
after tibial sesamoidectomy.
■ Augmenting a tibial sesamoidectomy with a lateral capsu-

lar release, medial capsular reefing, or metatarsal or pha-


langeal osteotomy may be considered to prevent progressive
deformity.5
■ Methods for examining the tibial sesamoid include: AQ1
■ Direct palpation under the tibial sesamoid with the foot in

neutral and with dorsiflexion of the MTP joint


■ Range of motion (ROM): One hand should be placed on

FIG 2 • A sagittal MRI view of the sesamoid–metatarsophalangeal the proximal phalanx with the other stabilizing the metatarsal.
complex showing the increased stress across the tibial sesamoid in Dorsiflexion and plantarflexion ROM should be assessed.
metatarsophalangeal dorsiflexion. Symmetry between the right and left side should be noted.
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Chapter 83 TIBIAL SESAMOIDECTOMY 3

FIG 4 • A sesamoid view of the foot. Note the significant frag-


mentation of the tibial sesamoid. (From Lee S. Technique of
isolated tibial sesamoidectomy. Techn Foot Ankle Surg 2004;3:
85–90, with permission.)

■ Drawer test: The examiner grasps the proximal phalanx


in one hand and the metatarsal head in the other and per-
forms a dorsal to plantar stress of the MTP joint. B
■ Toe raise: The patient is asked to do double-limb and
FIG 6 • A. Coronal MRI view highlighting the signal change of
single-limb toe raises. the tibial sesamoid, and reactive plantar bursitis, compared to
the fibular sesamoid, indicating tibial sesamoid avascular necro-
IMAGING AND OTHER DIAGNOSTIC sis. B. Sagittal MRI view of a tibial sesamoid fracture and subse-
STUDIES quent reactive plantar bursitis. (From Lee S. Technique of iso-
■ Routine radiographs should consist of standing anteropos- lated tibial sesamoidectomy. Techn Foot Ankle Surg 2004;3:
terior (AP), lateral, oblique, and axial sesamoid views. 85–90, with permission.)
■ Plain radiographs will often be diagnostic in cases of

arthrosis and osteochondritis dissecans if fragmentation is


present (FIG 4 ). ■ MRI is more expensive but allows the examiner to iden-
■ A bipartite tibial sesamoid (Fig 3) occurs in up to 19% of tify most causes of hallux MTP pathology in addition to
the population, and differentiating it from a fracture or in- sesamoiditis (FIG 6 ).
jury to the bipartite sesamoid can be difficult.6
■ A fractured sesamoid may have a sharp radiolucent line DIFFERENTIAL DIAGNOSIS
that may assist in differentiation. ■ Infection, sesamoid–metatarsal or MTP arthrosis or chon-
■ AP radiographs in neutral and dorsiflexion may assist
dromalacia, bursitis, flexor tendinosis, fracture, osteochondritis
in evaluating separation of the sesamoid segments. dissecans, intractable plantar keratosis, nerve compression, bi-
■ A triple-phase bone scan or MRI is often required to con-
or tripartite sesamoid, turf toe injury
firm the diagnosis.
■ A triple-phase bone scan, with collimated views of the
NONOPERATIVE MANAGEMENT
MTP joint, is very sensitive and may demonstrate increased ■ Most patients will respond to conservative therapy. This
uptake before radiographic changes become present (FIG 5 ). consists of rest or immobilization for 2 to 4 weeks, followed
by protected weight bearing with an orthotic, walker boot, or
cast for an additional 4 to 6 weeks.

FIG 5 • A. Triple-phase bone scan showing increased


uptake of the tibial sesamoid region in an AP view
of bilateral feet. B. Collimated view showing the in-
creased uptake of the tibial sesamoid. (From Lee S.
Technique of isolated tibial sesamoidectomy. Techn
A B Foot Ankle Surg 2004;3:85–90, with permission.)
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4 Part 2 FOOT AND ANKLE • Section X TITLE

A FIG 8 • Intraoperative picture showing the planned incision and


the natural externally rotated view of the foot.

in an isolated tibial sesamoidectomy, the surgeon needs to


keep in mind that any failure of reconstruction of the tibial
FHB complex or failure to address pre-existing hallux
malalignment will compromise patient outcome.
■ In general, any patient whose hallux alignment would be

considered for surgical realignment without tibial sesamoiditis


should have the malalignment corrected during the tibial
sesamoidectomy.
Positioning
B ■ Anesthesia should be similar to a bunion procedure.
FIG 7 • A. Dancer’s pad with sesamoid cut-out. B. Example of a ■ An ankle block with some mild sedation is typically well tol-
Morton extension in an orthotic. erated.
■ A well-padded supramalleolar Esmarch tourniquet is also

used and is well tolerated.


■ Typically a hard-soled shoe will decrease the dorsiflexion ■ The patient should be placed on the operating table in a
stresses across the MTP joint, and a negative-heel shoe will de-
supine position.
crease forefoot loading. ■ The natural external rotation of the lower extremity allows
■ An orthosis such as a turf-toe plate or dancer’s pad with a
excellent exposure to the medial aspect of the forefoot (FIG 8).
medial longitudinal arch support will decrease the stresses
across the sesamoids (FIG 7 ). Approach
■ In athletes, taping the MTP joint to prevent dorsiflexion
■ Dorsomedial, straight medial, and plantar medial incisions
may allow continued participation. to approach the tibial sesamoid have all been described. The
■ The use of nonsteroidal anti-inflammatory medication may
most commonly used incision is a longitudinal medial skin in-
augment treatment. cision that is slightly plantar to the standard incision for a
■ The judicious use of steroid injections for chronic sesamoidi-
bunion excision (FIG 9 ). With the dorsomedial incision, it is
tis is also indicated. very difficult to obtain adequate exposure of the plantar aspect
of the foot, while the plantar medial incision is typically di-
SURGICAL MANAGEMENT rectly over the plantar cutaneous nerve and near the weight-
■ Pain under the tibial sesamoid that is not responsive to con- bearing surface of the foot, increasing wound complications.
servative treatment is the main indication for operative inter-
vention. The presence of hallux MTP malalignment, a cavus
foot, or stiffness requires careful evaluation and may require
additional surgical procedures to improve clinical results.
■ Previous excision of the fibular sesamoid or absence of the

fibular sesamoid is the main contraindication to a tibial


sesamoidectomy.1,2 A history of peripheral vascular disease, soft
tissue or wound healing problems, diabetes mellitus, and smok-
ing are also relative contraindications that require proper evalua-
tion and discussion with the patient before operative intervention.
Preoperative Planning
■ The initial evaluation of hallux alignment is of utmost im-
portance.
■ Although there is little literature in regard to the appropri-

ate criteria for the addition of a hallux realignment procedure FIG 9 • Note the slightly plantar incision line.
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Chapter 83 TIBIAL SESAMOIDECTOMY 5

TECHNIQUES
TIBIAL SESAMOIDECTOMY
■ The most commonly used incision is a longitudinal me- ■ This can be facilitated by the use of a Beaver mini-
dial skin incision that is slightly plantar to the standard blade, using a pushing technique rather than a cut-
incision for a bunion excision. ting motion, as well as grasping the sesamoid with a
■ The plantar cutaneous nerve must be identified and small towel clamp or Kocher clamp for stability.
mobilized for protection during the procedure (TECH ■ Take utmost care to protect the nerve medially as
FIG 1). well as the FHL laterally to prevent injury.
■ The nerve can usually be found along the inferior ■ Once the sesamoid is removed, carefully assess the conti-
border of the abductor hallucis brevis tendon along- nuity of the FHB complex. Typically there are some re-
side the MTP joint. maining fibers of the FHB complex.
■ Typically the nerve is mobilized inferior to the surgi-
cal dissection, although dorsal retraction has been de-
scribed as well.
■ A vessel loop can also be placed around the nerve to
protect it.
■ Perform initial evaluation of the tibial sesamoid and
metatarsal head articulation through an intra-articular
exposure.
■ Make a longitudinal incision in the capsule in line with
the skin incision.
■ This incision is usually dorsal to the fibers of the inser-
tion of the abductor hallucis tendon.
■ Assess the sesamoid articular surface for significant dis-
placement or step-off in acute fractures or bipartite
sesamoids. In chronic cases, assess the resultant articular TECH FIG 2 • Intracapsular view showing the articulation of
cartilage injury to the sesamoid or metatarsal head artic- the tibial sesamoid and the metatarsal head. (From Lee S.
ulation of the hallux from osteonecrosis, osteochondritis Technique of isolated tibial sesamoidectomy. Techn Foot
dissecans, or arthrosis (TECH FIG 2 ). Ankle Surg 2004;3:85–90, with permission.)
■ At this stage, when the decision is made to remove the
sesamoid, the use of a Beaver mini-blade to outline the
tibial sesamoid from the intra-articular approach will
assist in its later removal.
■ In an acute fracture or a bipartite sesamoid without ar-
ticular damage, consider using bone grafting of the de-
fect as opposed to performing a sesamoidectomy.
■ Repair the capsulotomy with a 2-0 nonabsorbable suture
before proceeding with the sesamoidectomy exposure
(TECH FIG 3 ).
■ Expose the sesamoid through an extra-articular plantar
medial incision in line with the FHB fibers.
■ The sesamoid is embedded within a dense fibrous
sheath, and careful dissection out of the FHB and its
soft tissue attachments is required (TECH FIG 4 ). TECH FIG 3 • The tip of the Freer elevator is underneath the
tibial sesamoid before dissection of the flexor hallucis brevis
complex. Also note the longitudinal capsulotomy and repair.

TECH FIG 1 • Intraoperative picture; the Freer elevator is TECH FIG 4 • After the initial incision to separate the flexor
underneath the plantar cutaneous nerve. hallucis brevis in line with its fibers.
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6 Part 2 FOOT AND ANKLE • Section X TITLE

■ In all patients, repair the defect with a 2-0 nonabsorbable


TECHNIQUES

suture in a triangular, figure 8 or pursestring fashion,


with careful reapproximation of the FHB complex (TECH
FIG 5 ). The use of a UCL taper needle is recommended
due to its non-cutting aspect as well as a needle with a
smaller radius of curvature, allowing easier manipulation.
■ The FHL tendon can often be seen during this stage. Also
assess the tendon at this time.
■ Once the FHB complex is reapproximated, take the hal-
lux through ROM to confirm that the FHB is intact and
that the FHL tendon has not been inadvertently sutured.
■ Complete the closure in standard fashion for a bunion
procedure. TECH FIG 5 • Note the flexor hallucis longus tendon deep to
■ Reapproximate the skin edges with a 3-0 nylon suture the operative incision as well as the subsequent pursestring
and dress the wound with a bunion dressing, with the repair of the flexor hallucis brevis complex.
hallux protected in plantarflexion and in mild varus.
■ The patient is provided with a firm-soled postoperative
shoe and allowed immediate heel weight bearing.

PEARLS AND PITFALLS


Hallux malalignment ■ The presence of a cavus foot, hallux valgus, claw toe, cock-up deformity, or stiffness requires
careful evaluation and may require additional surgical procedures to improve clinical results.
Plantar cutaneous nerve ■ The nerve is most commonly located plantar to the inferior border of the abductor hallucis
brevis tendon. This nerve should be visualized and protected throughout the case.
Flexor hallucis brevis repair ■ A UCL taper needle, with its smaller radius of curvature, is easier to use in the limited surgical
field. Careful and meticulous repair of the FHB complex is required to prevent the develop-
ment of malalignment.

POSTOPERATIVE CARE ■ Kaiman and Piccora9 also reviewed tibial sesamoidec-


■ Patients are limited to heel weight bearing for 2 weeks. tomies and concluded that assessment of the osseous rela-
■ At the 2-week follow-up visit stitches are removed, a toe
tionship was crucial to prevent hallux valgus deformity.
spacer is placed, and patients are allowed to bear weight as Their average follow-up was only 13.2 months and they
tolerated in a postoperative shoe or a short walker boot. found no evidence of valgus drift, but they recommended
■ Standing radiographs should be performed to confirm main-
tendon balancing or capsulorrhaphy in conjunction with the
tenance of hallux alignment (FIG 10 ). tibial sesamoidectomy.
■ The toe spacer should remain in place for 6 to 8 weeks post- ■ Van Hal et al15 found no evidence of deformity or dimin-

operatively to prevent hallux valgus deformity. ished range of motion.


■ If a hallux realignment procedure was also performed, I use a ■ Lee et al10 reported on 20 patients without preoperative

taping technique for 4 to 6 weeks similar to a bunion procedure. malalignment and noted no significant difference in postop-
■ Patients are encouraged to begin active and passive ROM
erative ROM or the development of subsequent hallux
exercises for the hallux MTP joint after stitches are removed. malalignment.
■ In active patients, formal physical therapy is warranted to ■ Saxena and Krisdakumtorn14 reported on active individuals

monitor patient progress and to assist in ROM and soft tissue who had isolated tibial sesamoidectomies.
modalities. ■ One patient developed loss of hallux flexion after surgery.

■ Patients return at 6 weeks postoperatively and are then al- ■ Two patients with hallux valgus deformity were identified

lowed to progress to accommodative shoewear and activity as before surgery. One patient had a concomitant distal
tolerated. metatarsal osteotomy with no further drift, while the other
■ Patients may occasionally require continued short-term use
patient did not have a concomitant procedure at the same
of a sesamoid relief orthotic while returning to activity. time and went on to a bunion correction at a later date.
■ Inge and Ferguson8 and Mann et al11 found that 41% to

OUTCOMES 50% of their patients continued to have mild to severe pain


■ Hallux malalignment with resultant claw toe and cock-up after a tibial sesamoidectomy. More recently, however, Van
and hallux valgus deformity after tibial sesamoid excision have Hal et al,15 Saxena and Krisdakumtorn,14 and Lee et al10 have
been described.8,9,11,12 reported excellent pain relief in the majority of their patients
■ Historical studies have found that a 10% to 42% inci- with tibial sesamoidectomies in their athletic population.
dence of hallux valgus and a 33% to 60% incidence of loss ■ Aper et al1 showed in two cadaveric studies that the FHB

of motion on follow-up.8,11,12 effective tendon moment arms are significantly decreased with
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Chapter 83 TIBIAL SESAMOIDECTOMY 7

FIG 10 • Preoperative (A) and postoperative (B) stand-


ing radiographs of the foot showing no change in the
clinical alignment of the metatarsophalangeal joint
after tibial sesamoidectomy. (From Lee S. Technique of
isolated tibial sesamoidectomy. Techn Foot Ankle Surg
A B 2004;3:85–90, with permission.)

the excision of both hallux sesamoids. However, FHL effec- ■ The loss of single-limb toe raise has also been reported and
tive tendon moment arms are noted to be diminished with iso- may be related to the decreased moment arm and inadequate
lated sesamoid excisions as well.2 These studies may help to repair of the FHB complex.10
explain the functional weakness reported by Mann et al.11
However, Van Hal et al15 and Saxena and Krisdakumtorn14 REFERENCES
have not found any functional weakness of plantarflexion in 1. Aper RL, Saltzman CL, Brown TD. The effect of hallux sesamoid re-
any of their patients. Their patients were also able to return section on the effective moment of the flexor hallucis brevis. Foot
to their previous level of athletic participation with no func- Ankle Int 1994;15:462–470.
tional deficit. Lee et al10 also reported that 30% of their pa- 2. Aper RL, Saltzman CL, Brown TD. The effect of hallux sesamoid ex-
tients could not do a single-limb toe raise, indicating some cision on the flexor hallucis longus moment arm. Clin Orthop Relat
Res 1996;325:209–217.
plantarflexion weakness, but this did not affect any subse-
3. Beaman DN, Nigo LJ. Hallucal sesamoid injury. Oper Tech Sports
quent athletic activity. Med 1999;7:7–13.
4. Bizzaro AH. On the traumatology of the sesamoid structures. Ann
COMPLICATIONS Surg 1921;74:783.
5. Coughlin MJ. Sesamoid pain: causes and surgical treatment. AAOS
■ Complications related to tibial sesamoid excisions can be Instructional Course Lectures 1990;39:23–35.
separated into intraoperative complications, insufficient pain 6. Dobas DC, Silvers MD. The frequency of partite sesamoids of the
relief, functional weakness, and hallux malalignment. first metatarsal phalangeal joint. J Am Podiatry Assoc 1977;67:
■ The most common intraoperative complication reported is 880–882.
injury to the plantar digital nerve. 7. Helal B. The great toe sesamoid bones: the lus or lost souls of the
■ Patients typically complain of nerve irritation postopera- Ushaia. Clin Orthop Relat Res 1981;157:82–87.
8. Inge GAL, Ferguson AB. Surgery of the sesamoid bones of the great
tively. This generally responds well to observation or local- toe: an anatomic and clinical study, with a report of forty-one cases.
ized steroid injections. It occurs more commonly with fibular Arch Surg 1933;27:466–489.
sesamoid excisions. 9. Kaiman ME, Piccora R. Tibial sesamoidectomy: a review of the liter-
■ Complete laceration of the nerve has never been reported, ature and retrospective study. J Foot Surg 1983;22:286–289.
and this nerve irritation appears to be the result of aggres- 10. Lee S, William JC, Cohen BE, et al. Evaluation of hallux alignment
and functional outcome after isolated tibial sesamoidectomy. Foot
sive retraction during surgery. This can be avoided by using
Ankle Int 2005;26:803–809.
meticulous technique with identification and protection of 11. Mann RA, Coughlin MJ, Baxter D, et al. Sesamoidectomy of the
the plantar digital nerve during surgery. great toe. Presented at the 15th Annual Meeting of the American
■ Isolated complete sesamoidectomies are thought to alter the
Orthopaedic Foot and Ankle Society, Las Vegas, Jan. 24, 1985.
mechanical balance of the hallux MTP joint. Clinical studies 12. Nayfa TM, Sorto LA. The incidence of hallux abductus following
have described stiffness, functional loss, cock-up deformity, tibial sesamoidectomy. J Am Podiatr Assoc 1982;72:617–620.
claw toe deformity, and the development of a hallux valgus 13. Richardson EG. Hallucal sesamoid pain: causes and surgical treat-
ment. J Am Assoc Orthop Surg 1999;7:270–278.
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14. Saxena A, Krisdakumtorn T. Return to activity after sesamoidectomy
■ As noted earlier, identifying and addressing any signifi-
in athletically active individuals. Foot Ankle Int 2003;24:415–419.
cant malalignment of the hallux MTP can decrease the rate 15. Van Hal ME, Keene JS, Lange TA, et al. Stress fractures of the great
of future deformities. toe sesamoid. Am J Sports Med 1982;10:122–128.
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AUTHOR’S QUERY
AQ1: Author, The exam tables have been moved to the front of the section. The copy below was
extracted from the table for use in the chapter. Please review with care. Thank you.

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