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Abstract

Background:

Arthrodesis of the first metatarsophalangeal (MTP) joint is a well-established procedure with excellent outcomes for patients with forefoot disorders. Routine bone grafting is not typically required, but bone graft may be necessary in the setting of revision surgery. Because of potential harvesting morbidity and time associated with an extra incision, allograft bone is frequently used. In this study, we describe the outcomes of an approach to first MTP fusion with simultaneous medial sesamoidectomy for utilization as autograft.

Methods:

A retrospective review of all first MTP arthrodesis cases performed by one fellowship-trained foot and ankle surgeon were identified. Operative reports and radiographs were reviewed identifying patients who underwent simultaneous medial sesamoidectomy for autograft purposes. Indications for sesamoidectomy harvesting were noted. The primary outcome reviewed was fusion rate. Overall nonunion rates and patient outcomes were collected and compared between those undergoing sesamoidectomy for grafting and those undergoing standard procedure arthrodesis.

Results:

A total of 107 patients underwent first MTP arthrodesis. Of these, 24 underwent concurrent sesamoidectomy grafting with 9 requiring additional calcaneal grafting. Indications for the sesamoidectomy group included 5 primary cases of erosive hallux rigidus, 2 cases of hallux valgus, 6 nonunions, 3 failed Cartiva implants, 2 cases of avascular necrosis, 4 failed arthroplasties, and 2 conversion bunionectomy. All 24 patients in the sesamoidectomy group achieved successful union. For context, the broader cohort undergoing first MTP arthrodesis had a fusion rate of 92.1%. All patients in the sesamoidectomy group were satisfied with their surgical outcome.

Conclusion:

This study found highly successful fusion rates in a potentially higher risk population with the use of local autografting from the medial sesamoid. The medial sesamoid serves as a freely available, structurally supportive graft material for first MTP arthrodesis that can be readily harvested via the same incision, potentially reducing the need for additional graft sites. However, given the retrospective nature, single-surgeon cohort, and small sample size, further studies are warranted to confirm these findings and evaluate comparative outcomes.

Level of Evidence:

Level III, retrospective comparative study.

Keywords

sesamoid excision sesamoid-metatarsal joint first MTP arthrodesis

Introduction

Arthrodesis of the first metatarsophalangeal (MTP) joint is a well-established procedure with excellent outcomes for patients with forefoot disorders including hallux rigidus and hallux valgus.^4,12

Bone grafting is not typically required in a primary, standard MTP arthrodesis because fusion rates are historically quite high, more than 93%.³ However, grafting may be necessary for revision surgery, failed implants and/or arthroplasty, nonunion, or erosive bone loss in order to encourage biologic fusion and fill bone voids.¹⁵ Graft supplementation may also be necessary in older patients with osteoporosis and patients with autoimmune-associated arthritic degeneration.^10,19,21 In primary cases with bone loss or revision instances, additional bone void fillers/grafting may be required and certainly could carry implications for increased complication, cost, and/or nonunion.¹⁷

Autograft harvesting from the calcaneus, distal tibia, proximal tibia, or iliac crest are typical.^2,6,9,13,14 However, these techniques continue to face outcome, time, and cost challenges associated with secondary incisions for autografts.⁶ Because of potential harvesting morbidity and time associated with an extra incision, allografting is often the opted alternative.^8,16,17 However, well-known limitations of allografts have been detailed in the literature, including significant increased cost burden to the health care system. Because of these limitations with current MTP bone grafting techniques, there is a need for cost-effective solutions for surgical reconstruction of the first MTP joint that potentially have preexisting bone loss or in revision situations.

Previous literature has described successful surgical techniques for simultaneous MTP arthrodesis and sesamoidectomy.¹ This article focused on the safety and technique to prevent postoperative plantar foot pain, while not focusing on autografting or complex fusion cases. To our knowledge, there is no literature describing the results of sesamoidectomy for autografting in first-MTP joint arthrodesis. ^1,20 The aim of this article is both to describe our approach and algorithm to autografting for MTP arthrodesis in patients with preexisting bone loss and revision cases for failed previous surgical interventions.

Methods

A retrospective review of all cases of first MTP arthrodesis performed by one fellowship-trained foot and ankle surgeon were identified from 2021 to 2023. Operative reports and radiographs were reviewed and patients who underwent simultaneous medial sesamoidectomy for autograft purposes were identified, and whether additional grafting was performed. Routine bone graft was not typically used for primary first MTP joint fusion. In the setting of nonunion surgery, revisions, failed implants, or bone loss, autograft bone was harvested as needed to facilitate fusion. Two cohorts were devised based on the use of a sesamoidectomy autograft versus not. Any cases where bulk structural allograft for significant length restoration was excluded. Additionally, only patients with at least 6 months of follow up were included. The primary outcome reviewed in the study was the fusion rate of the first MTP joint, which was determined with clinical and radiographic evidence. Overall nonunion rates, revision rates, return to the operating room (OR), and postoperative complications were collected and compared between those undergoing sesamoidectomy for grafting and those undergoing standard procedure arthrodesis. Statistical analysis was completed using Fisher exact test for categorical variables and Mann-Whitney U test was used for continuous variables.

Surgical Technique

Patients were provided with a preoperative local anesthetic block and the procedures performed under general anesthesia or sedation based on patient preference. A field tourniquet was used around the ankle. A standard dorsal approach to the first MTP joint was used, unless previous incisions dictated a slightly different approach. The extensor hallucis longus (EHL) was mobilized and the joint exposed and released and prepped for fusion as needed. Previous hardware and implants etc were removed as needed. Bone voids were identified, assessed, and curetted as needed. If substantial bone loss was present on inspection or noted after deformity correction and provisional fixation, the decision to proceed with sesamoidectomy was made. Medial sesamoidectomy was performed via the same dorsal approach without use of an additional incision. A sharp retractor is helpful to pull dorsal traction on the metatarsal head, while a dull retractor plantarly assists the surgeon with visualization. The medial sesamoid is sharply removed in its entirety. Soft tissue is removed from the bone at the back table and the bone is morselized manually. The graft is then placed back into the fusion site/bony voids as needed. After this, if more bone graft is required, supplemental calcaneal autograft was harvested if the initial harvest was not adequate (ie, substantial bone voids). This is done via a small incision at the lateral wall of the calcaneus with manual introduction of a trephined drill guide into the calcaneal body removing small dowels of cancellous bone as needed. Instrumentation was then typically completed with a dorsal precontoured first-MTP plate.

Results

During the study period, a total of 107 patients underwent first-MTP arthrodesis that met inclusion criteria. Of these, 24 underwent concurrent sesamoidectomy grafting, with 9 of the 24 requiring additional supplemental calcaneal grafting. Demographics of these patients are listed in Table 1; there were no significant differences in age, sex, smoking, or diabetes status between the groups. Indications for the sesamoidectomy group included 5 primary cases of erosive hallux rigidus, 2 cases of severe hallux valgus, 6 nonunions, 3 failed polyvinyl alcohol implants, 2 cases of avascular necrosis, 4 failed arthroplasties, and 2 conversion bunionectomies (Table 2). All 24 patients went on to successful union as measured by radiographic assessment, whereas the nonsesamoidectomy group featured fusion rate was 92.1% (P = .57). All patients in the sesamoidectomy group were satisfied with their surgical outcome, and only 1 revision was required secondary to a rotational malunion, which then went on to successful osseous union. No postoperative complications specific and focal to the medial sesamoidectomy were noted (ie, lateral sesamoid overload). In the sesamoidectomy group, 3 patients had postoperative superficial wound infections managed with oral antibiotics, whereas 1 experienced deeper infection requiring return to the OR for irrigation and debridement, but still went on to fuse. There were no infections in the nonsesamoidectomy group. One patient in the sesamoidectomy group required return to the OR in delayed fashion for removal of hardware secondary to pain. In the nonsesamoidectomy group, there were 5 nonunions—2 of which were revised with sesamoidectomy or grafting, 2 were asymptomatic partial unions, and 1 declined revision. One patient in the nonsesamoid group ended up returning to the OR over 3 years postoperatively for a medial sesamoidectomy because of pain underneath the sesamoid after successful fusion. The patient did get relief from this procedure. Figures 1, 2, and 3 demonstrate representative cases before and after arthrodesis. Table 3 demonstrates postoperative reported complications.

Table 1.

Demographics.

Variable	Sesamoid (n = 24)	Nonsesamoid (n = 83)	P Value^a
Age, y, median (IQR)	67.50 (60.50-73.00)	68.00 (64.00-74.00)
Sex, n (%)			>.99
Male	6 (25.00)	19 (22.89)
Female	18 (75.00)	64 (77.1)
Diabetes, n (%)	0 (0.00)	4 (4.82)	.57
Tobacco, n (%)	1 (4.17)	9 (10.84)	.45
Nonunion, n (%)	0 (0.00)	5 (6.02)	.11

Abbreviation: IQR, interquartile range.

Mann-Whitney U test for continuous variables; Fisher Exact test for categorical variables.

Table 2.

Indications Requiring Sesamoidectomy Grafting.

Indication for Sesamoidectomy Graft	n
Primary hallux rigidus with bone loss	5
Primary hallux valgus with bone loss	2
Nonunion	6
Failed interposition implant	3
Avascular necrosis	2
Failed arthroplasty	4
Failed bunionectomy	2

Figure 1.

Pre- and postoperative radiographs with sesamoidectomy autografting failed hemiarthroplasty.

Figure 2.

Nonunion case: successful fusion obtained with sesamoid autograft after index procedure resulted in a nonunion.

Figure 3.

Failed Cartiva implant was successfully converted to fusion using sesamoid autograft.

Table 3.

Complications.

	Sesamoidectomy, n (%) (n = 24)	Nonsesamoidectomy, n (%) (n = 83)	P Value^a
Nonunion	0 (0.00%)	5 (6.02%)	.11
Delayed union	1 (4.17%)	0 (0.00%)	.37
Superficial infection	3 (12.50%)	0 (0.00%)	.05
Return to OR
Deep infection requiring I&D	1 (4.12%)	0 (0.00%)	.37
Revisions	1 (4.12%)	2 (2.40%)	.32
Removal of hardware	1 (4.12%)	2 (2.40%)	.32

Abbreviations: I&D, irrigation and debridement; OR, operating room.

Indicates statistically significant result.

Discussion

In this series of complex and/or revision first MTP fusions, the use of sesamoid supplemental autograft was successful in achieving a reliable bony fusion. The use of bone grafting in the setting of first MTP arthrodesis is not commonly required (as evidenced by high union rates); however, in the setting of more complex cases—revisions, restoration of large bone voids, nonunions—graft supplementation is a common technique that has been successfully explored.^{1,6,9,11,13,16,17} The novelty of this study lies in evaluating the medial sesamoid as a local autograft source in these challenging scenarios, which has not been previously reported. The results of proposed technique in this study demonstrate highly successful fusion rates with localized autograft harvesting of the medial sesamoid in first MTP arthrodesis. The technique was studied in a potentially higher-risk population (ie, bone loss and revision operations). Successful union was seen in all patients of the sesamoidectomy group. Successful fusion was also demonstrated across a wide array of indications for first-MTP arthrodesis. Although all patients in the sesamoidectomy group achieved union, the study design limits definitive comparative inferences.

The current body of literature supports relatively successful rates of fusion with the use of autografting for first MTP arthrodesis. Some studies suggest autografting provides greater rates of fusion as compared to allografting in other procedures about the foot and ankle.^5,11,15 Previous studies have examined autograft harvested from various locations including the calcaneus, distal/proximal tibia, and/or iliac crest. ^2,6,9,13,14 However, these techniques do face complications such as increased operative time, the need for a second operative field, and graft site morbidity.^6,18 Although Gross et al⁶ reported 2 nonunions in the setting of arthroplasty conversion with various autograft techniques, this strategy resulted in successful union in 4 failed arthroplasty patients without any issues with donor site pain.

Based on the current field of literature in foot and ankle surgery, cortical iliac crest harvesting has previously been considered the gold standard for autograft harvesting in lower extremity surgery because of it possessing the greatest cell counts from harvest alongside all 3 desired physiological properties of bone graft: osteoconduction, osteoinduction, and osteogenesis.⁷ A systematic review performed by Mankovecky et al¹³ demonstrated primary fusion rate to be generally successful with iliac crest autografting in salvage arthrodesis (95.2%). However, a study conducted by Myerson et al¹⁶ examined 24 patients who underwent first MTP arthrodesis, with 16 cases receiving supplemental autograft (iliac crest and distal medial tibia). All 5 nonunions (21%) in the study were observed in patients who received iliac crest autograft.

This technique demonstrated good union in this cohort, but sesamoid autograft certainly has its volumetric limitations. The bone quality of the graft does give some structural quality but would not be adequate for cases of severe shortening or bone loss. Even in this cohort, 9 of 24 required supplemental calcaneal autograft. This was obtained through a minimalistic approach, with the initial sesamoidectomy decreasing the need for extensive calcaneal harvesting and associated donor site pain or problems. If substantial shortening is present, this technique cannot accommodate enough structural length and supplemental iliac crest wedge, or precontoured cortical allograft may be required.

The largest concern with autografting is graft site morbidity, namely, superficial soft tissue or deep infection, pain, fracture risk, and/or surrounding neurovascular or tissue injury. The nature of complications may also vary depend upon the graft site. In this technique, there is no donor site morbidity as it is done in the same approach, and even can have the potential benefit of decreased plantar foot pain, as referenced in reports by Alshouli et al¹ and Brodsky et al.² The author did occasionally require additional calcaneal autograft harvesting, but the use of the sesamoid limited its need or extent and therefore may decrease the morbidity of the extra harvesting site. In this surgeon’s experience, there is certainly some variation in the quality and quantity of sesamoid autograft bone, but was always usable and worthwhile on removal and morselizing. Using the algorithm of starting with medial sesamoidectomy and then supplementing with slightly more vascular, cancellous calcaneal graft was a powerful combination, especially in the failed Cartiva situations. Patients did not particularly complain of calcaneal harvest pain in this cohort. This technique is quick and should be more comfortable for orthopaedic surgeons routinely working in the distal lower extremity as opposed to the process of harvesting more proximal sites (ie, iliac crest or proximal tibia), which takes more time and anesthetic requirements.^7,9

Another benefit of the use of a local autograft is the avoidance of the cost associated with allograft. Currently, there is a large industry push toward the use of biologic grafting. These commercially available allograft bone matrices from multiple orthopaedic vendors have not shown superiority to autograft in this situation and carry substantial cost. There is no major cost to the harvesting of the medial sesamoid and even carries potential reimbursement to the surgeon and facility (billing for autograft harvesting).

Another possible benefit from medial sesamoidectomy is to treat preoperative medial sesamoid pain and potentially prevent postoperative sesamoid pain. Alshouli et al¹ described this technique to prevent the occurrence of postoperative medial sesamoid pain. One patient in this study did end up proceeding with delayed medial sesamoidectomy, but certainly other patients may have had similar complaints that never went on to proceed to sesamoidectomy. This could have been prevented by primarily implementing a sesamoidectomy at the time of the index fusion. As such, the authors do encourage a low threshold to use medial sesamoid grafting. It is likely not required on all primary fusions, but with limited morbidity, cost, and high rates of fusion, it certainly should be employed with any higher-risk patients, revision situations, bone loss or deformity, or patients with preoperative sesamoid pain.

There were 4 infections in the sesamoidectomy group compared to zero in the control group. This could be possibly attributed to the soft tissue stripping required to retrieve the graft. However, these were typically higher complexity and revision cases that could confound the ability to make this inference. Because of the low sample size and zero infections in the control group, definitive conclusions on this clinical significance is difficult.

There are certainly limitations to this study. This is a retrospective review of a single surgeon’s experience. There is a limited patient sample size leading to decreased statistical power. Many of the patients also had concomitant supplemental calcaneal bone graft harvesting limiting the ability to fully elucidate the value of the sesamoid versus the calcaneal graft. Infections were only observed in the sesamoidectomy group, which may be attributable to the higher complexity of these cases but could also suggest procedural risks that require further investigation. No standardized measurement of graft volume or intraoperative graft quality was performed, and fusion was assessed using radiographs alone without advanced imaging confirmation. In addition, the true cost associated with this technique compared with control or allograft was not assessed. Further research with randomization and increased volume could increase the magnitude of the conclusions made in this work. Also, evaluating the true cost impact compared with allograft should be explored.

Conclusion

Harvesting and morselizing the medial sesamoid serves as a freely available successful graft material for first MTP arthrodesis that can be readily done via the same incision, reducing the potential need for other painful donor sites and the cost associated with allograft. However, the procedure’s benefits must be interpreted with caution given the small cohort size, absence of long-term functional outcome data, and co-use of other grafts in some cases.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251343071 – Supplemental material for Medial Sesamoidectomy as a Local Autograft Source in Revision or Complex First Metatarsophalangeal Joint Arthrodesis

Supplemental material, sj-pdf-1-fao-10.1177_24730114251343071 for Medial Sesamoidectomy as a Local Autograft Source in Revision or Complex First Metatarsophalangeal Joint Arthrodesis by Aaron Tran, Brennan Enright, Rachel Reichenbach, Jordan Henderson and David Jaffe in Foot & Ankle Orthopaedics

Footnotes

Ethical Approval

Ethical approval was not sought for this present study. This study represents a truly low-risk assessment of previously performed surgeries. All data were deidentified and retrospectively evaluated.

Declaration of Conflicting Interests

Dr. David Jaffe is a paid consultant for Fusion Orthopedics, who sponsored the APC for this article. Disclosure forms for all authors are available online.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author(s) received reimbursement for the publication fee from Fusion Orthopedics.

ORCID iDs

Jordan Henderson, BS,

David Jaffe, MD,

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Supplementary Material

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