Avoiding Hallux Sesamoidectomy: A Narrative Review

TL;DR

This review explores non-surgical treatments like ESWT and PRP for hallux sesamoid pain as alternatives to sesamoidectomy.

Contribution

The paper introduces novel surgical alternatives and evaluates conservative treatments for avoiding sesamoidectomy.

Findings

ESWT and PRP show promise as conservative treatments for hallux sesamoid pathologies.

Surgical alternatives to sesamoidectomy have been identified and discussed.

Findings suggest these treatments may be applicable to various sesamoid conditions.

Abstract

Hallux sesamoid pain arises from various pathological conditions, such as fracture nonunion, painful plantar keratosis, sesamoiditis, and avascular necrosis. Traditionally, sesamoidectomy is the primary surgical approach for these conditions, but its outcomes are inconsistent. In recent years, extracorporeal shock wave therapy (ESWT) and platelet-rich plasma (PRP) have gained popularity as effective conservative treatments in orthopedic practice. This review explored treatment approaches that avoid sesamoidectomy. First, we examined studies on ESWT and PRP for hallux sesamoid pathologies. We also reviewed research on ESWT and PRP for other foot conditions with similar characteristics to evaluate whether these treatments could be applicable to different types of sesamoid pathologies. Finally, we discussed surgical alternatives to sesamoidectomy and introduced several novel techniques.

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Full text

1. Introduction

1.1. Sesamoidectomy

The hallux sesamoid complex bears up to 300% of body weight during the push-off phase of gait [1]. This sustained load may lead to a range of pathologies, including stress fractures, painful plantar keratosis, sesamoiditis, osteochondritis, and avascular necrosis (AVN) [1]. These diverse pathologies of sesamoid pain are commonly treated with sesamoidectomy as the primary surgical treatment, with several studies published since 1980 (Table 1) [2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34].

In Table 1, of the 33 studies on sesamoidectomy listed, 17 included more than 10 patients [4,10,11,13,15,16,17,20,22,25,26,27,28,29,31,32,34]. Although some studies have reported favorable outcomes [4,10,11,17,20,26,27,29,32,34] and early return to sports within 12 weeks [15,22,31], other studies have reported high complication rates (16% [15], 23% [25], 27% [13], 37.9% [34], and 85% [32]), residual pain on the visual analog scale (VAS) of 15–30 [16,17,28,32,34], postoperative hallux valgus (18% [13], 42.1% [4]), difficulty standing on tiptoes (30% [17]), inability to return to sports (20% [28]), transfer metatarsalgia (14% [17]), and reoperation (13% [34]). These findings suggest the need to explore alternatives beyond sesamoidectomy.

1.2. Extracorporeal Shockwave Therapy (ESWT) and Platelet-Rich Plasma (PRP)

In recent years, conservative treatments such as ESWT and PRP have gained attention in the field of orthopedics [35,36].

Originally developed for treating urinary stones, ESWT has since been used to treat various musculoskeletal disorders [35]. It can disrupt microfractures in old calluses, reduce subperiosteal hematomas, release bioactive substances, reactivate fracture healing, restore osteoblast–osteoclast balance, promote angiogenesis at the injury site, and stimulate osteoblast proliferation and differentiation within the bone marrow [37]. In the field of orthopedics, ESWT has been used to treat fractures (fresh, delayed union, and nonunion), osteonecrosis of the femoral head, Kienböck’s disease, bone marrow edema, osteoarthritis, tendinopathy, chronic skin ulcers, and spasticity [37,38,39,40,41,42,43,44,45,46,47].

PRP is a concentrated formulation of platelets and growth factors, which is obtained by removing red blood cells from whole blood [48]. The activation of platelets induces the release of bioactive factors, thereby promoting angiogenesis and cellular proliferation [48]. In orthopedics, PRP has been for managing cartilage damage, tendon and ligament injuries, fractures, and osteoarthritis [48,49,50,51,52,53]. Although the effectivity of PRP is questionable when used alone for fracture treatment, it can be effective when combined with other therapeutic modalities [54].

1.3. Scope of This Article

This review explored treatment approaches that avoid sesamoidectomy. First, we examined studies on ESWT and PRP for hallux sesamoid pathologies. We also reviewed research on ESWT and PRP for other foot conditions with similar characteristics, to evaluate whether these treatments could be applicable to different types of sesamoid pathologies. Finally, we discussed surgical alternatives to sesamoidectomy and introduced several novel techniques.

To prepare this narrative review, a literature search was conducted using PubMed between April and June 2025. Search terms combined anatomical descriptors (hallux, sesamoid, and foot) with treatment-related keywords (treatment, surgery, sesamoidectomy, extracorporeal shockwave therapy, and platelet-rich plasma). The inclusion criteria were as follows: (1) studies addressing surgical interventions for hallux sesamoid pathologies; (2) studies evaluating ESWT or PRP for hallux sesamoid conditions; (3) case reports, case series, narrative reviews incorporating case data, and systematic reviews; and (4) publications dated from 1980 onward. The exclusion criteria were as follows: (1) studies lacking clinical outcome data; (2) articles inaccessible for full text; (3) studies on conservative treatments other than ESWT or PRP; (4) studies on turf toe; (5) studies on sesamoidectomy for hallux rigidus; and (6) duplicate publications presenting identical data from the same author group. All retrieved articles were initially screened by title and abstract, followed by full-text assessment for eligibility. To mitigate citation bias, reference lists of several systematic reviews on hallux sesamoid disorders were also examined [55,56,57,58,59]. The above process led to exclusion of eight articles, resulting in a final selection of 65 studies. Extracted data included the number of patients, affected sesamoid side, treatment modality, clinical outcomes, and reported complications. Although this article is a narrative review, the search strategy adhered as closely as possible to the PRISMA guidelines for scoping reviews to ensure methodological transparency and reproducibility [60].

As Kadakia et al. noted, there is a lack of level 1 or 2 evidence sufficient to establish guidelines for hallux sesamoid disorders [55]. Moreover, Shimozono et al. emphasized that systematic reviews based on low-quality studies may overestimate treatment outcomes [57]. In the context of hallux sesamoid disorders, where high-quality evidence is scarce, a narrative review may provide more nuanced and clinically meaningful insights by incorporating noteworthy case reports and clinical experiences, even if derived from lower levels of evidence. Accordingly, we believe that this narrative review—focusing on alternatives to sesamoidectomy—offers a valuable perspective that not only complements but also, in some respects, surpasses the information presented in systematic reviews.

2. ESWT and PRP for Sesamoid Pathologies

2.1. ESWT, PRP, and Related Therapies for Sesamoid Pathologies

To date, only one case series has been reported on the application of ESWT, and one case series and one case report have been reported on the application of PRP for sesamoid pathologies (Table 2) [61,62,63,64,65].

Saxena et al. treated 10 patients with sesamoiditis, including those with AVN and symptomatic bipartite sesamoid, using radial ESWT [61]. Each session was delivered at 2.4 bar and 13 Hz, with 2500 pulses administered weekly for three sessions. At a mean follow-up of 22.6 months, the VAS score improved from 5.9 to 2.3, the Roles and Maudsley score improved from 3.1 to 1.5, and the average time to return to activity was 10.1 weeks.

Le et al. treated three adolescent athletes with PRP alone for hallux sesamoid stress fractures and sesamoiditis [62]. All three patients were able to return to high-impact activities (e.g., running and jumping) within 6–9 weeks after treatment. In addition, two studies used concentrated bone marrow aspirate harvested from the ilium or tibia as an alternative to PRP [64,65].

Although the studies cited in this section suggest that ESWT, PRP, and related therapies are effective for treating sesamoid pathologies, it is important to note that these conclusions are based on low-level evidence.

2.2. ESWT and PRP for Foot Problems Similar to Sesamoid Pathologies

We additionally reviewed studies investigating the use of ESWT and PRP for foot conditions unrelated to sesamoid disorders, as summarized in Table 3 [66,67,68]. While the sesamoid bone exhibits distinct characteristics compared with other bones of the foot, particularly in terms of morphology, vascularization, biomechanics, and load distribution, these prior findings may provide preliminary insights into the future consideration of ESWT and PRP for treating sesamoid pathologies. However, given the anatomical and functional uniqueness of the sesamoid, further dedicated research is warranted to determine the applicability and efficacy of these modalities in this specific setting.

Cao et al. treated patients with bone marrow edema in various foot regions (cuneiform, calcaneus, navicular, and metatarsal) using ESWT once weekly at 0.18 mJ/mm^2^ for five sessions; this treatment led to improvements in VAS scores (7.7 → 0.7) and AOFAS scores (62.1 → 93.1) [67]. Although their study did not specifically target sesamoiditis, their findings suggest that ESWT is a potential treatment option for cases of sesamoiditis accompanied by bone marrow edema.

In addition, combining PRP with ESWT or surgical intervention may offer enhanced therapeutic benefits compared with PRP alone. Omodani et al. reported the use of combined ESWT and PRP in a case of proximal phalangeal avulsion fracture [68]. Leukocyte-poor PRP was prepared by centrifuging 15 mL of venous blood at 1500 rpm for 5 min. After centrifugation, 4 mL of blood was obtained, of which 2 mL was injected into the fracture site. ESWT was administered at 2500 pulses with an energy level of 0.25 mJ/mm^2^ every 2 weeks for four sessions. Union was achieved within 4 weeks, and by 6 weeks post treatment, the patient had resumed training and unrestricted activity. Given the comparable size and anatomical depth of the proximal phalanx and sesamoid bone, this treatment protocol may be cautiously considered for application in cases of sesamoid fracture nonunion.

3. Surgeries for Sesamoid Pathologies

3.1. Surgeries for Sesamoid Fracture Nonunion

A systematic review by Robertson et al. evaluated the outcomes of conservative treatment, sesamoidectomy, and bone grafting/internal fixation for hallux sesamoid fracture nonunion [56]. Conservative management resulted in an 86% union rate, and patients returned to sports after an average of 13.9 weeks, with 64% regaining their preinjury performance level. After sesamoidectomy, the average time to return to sports was 10.5 weeks, with 86% returning to preinjury levels. Notably, after bone grafting/internal fixation, 100% were able to return to preinjury levels. Table 4 summarizes the literature on surgical techniques for sesamoid fracture nonunion other than sesamoidectomy.

Three studies described screw fixation techniques. Blundell et al. introduced a percutaneous method involving retrograde guidewire insertion through the plantar skin (with the hallux dorsiflexed), followed by cannulated screw fixation [70]. Pagenstert et al. employed open reduction and internal fixation with cannulated screws [71], while Park et al. used noncannulated screws for the same approach [72].

Two studies reported bone grafting techniques. Anderson et al. first described autologous bone grafting for sesamoid fracture nonunion [69]. More recently, the current author introduced an arthroscopic approach [73], which, despite its effectiveness, is technically demanding. To simplify the procedure, the author is now developing a fluoroscopic autologous bone grafting method (Figure 1 and Figure 2).

Moran et al. performed a novel technique [74] that involved temporary fixation of the first MTP joint to immobilize the sesamoid and promote healing. Afterward, fixation was achieved using K-wires or two-hole plates placed for 8 weeks, resulting in a 94% bone union rate.

Riley et al. reported on acute sesamoid fractures; their study is included in Table 4 to highlight the soft wire fixation technique [75]. Compared with screw fixation, this method is less invasive to flexor hallucis brevis tendon insertion; however, it offers relatively lower fixation strength.

3.2. Surgeries for Plantar Keratosis

Plantar keratosis may develop when the sesamoid bone excessively protrudes toward the plantar side (Figure 3). In such cases, partial shaving of the sesamoid can be more effective than complete sesamoidectomy (Table 5) [13,76,77,78]. The rationale for favoring partial shaving of the sesamoid over total sesamoidectomy is to reduce the risk of postoperative hallux valgus [76,77,78]. Nayfa and Sorto reported postoperative changes in hallux valgus and intermetatarsal angles of 6.2° and 2.2°, respectively [4], whereas Aquino et al. observed changes of only 0.7° and 0.6°, respectively [76]. Although outcomes are generally good, insufficient bone resection has been reported in approximately 10% of cases.

Van Enoo and Cane described a minimally invasive surgical technique for treating plantar keratosis using a Shannon #44 bur [77]. In our approach, we use a 3.0 mm arthroscopic abrasion burr (Formula Compatible, Stryker, Kalamazoo, MI, USA) to shave the lower half of the tibial sesamoid under fluoroscopic guidance (Figure 4). After resection, we endoscopically confirm that the flexor hallucis longus tendon remains intact.

3.3. Surgeries for Sesamoiditis

Sesamoiditis is an inflammatory condition resulting from mechanical overload or degenerative changes [26,27,79]. On magnetic resonance imaging (MRI), it typically presents as bone marrow edema, characterized by low and high signal intensity on T1- and T2-weighted images, respectively [80].

Although surgical interventions for sesamoiditis other than sesamoidectomy have not been documented in the literature to date, we have cautiously employed metatarsal sliding osteotomy in selected cases presenting with sesamoid-related pain accompanied by plantar prominence beneath the metatarsal head. This approach has yielded favorable clinical outcomes in our experience (Figure 5).

3.4. Surgeries for AVN of the Sesamoid

AVN of the sesamoid bone is an ischemic condition with distinct imaging and pathological features. Early stage AVN typically presents with high and low signal intensity on T1- and T2-weighted MRI, respectively, whereas late-stage AVN shows low intensity on both T1- and T2-weighted MRI. Meanwhile, lytic and sclerotic changes alongside fragmentation are commonly observed on X-ray [79,80,81]. The pathologic findings of the AVN of the sesamoid bone include bone cell loss, eosinophilic osteonecrosis, and granulation tissue proliferation [81].

To date, no studies have explored surgical treatment options for sesamoid AVN beyond sesamoidectomy [7,21,23,26,27,28,29,34]. In this context, we cautiously propose a novel surgical strategy for early stage AVN. In the initial phase of AVN, radionuclide tracer uptake within the affected sesamoid suggests that some degree of vascular perfusion is preserved [80]. Given that the vascular supply is derived from the surrounding periosteum, it may be feasible to excise the central necrotic region and subsequently perform autologous bone grafting (Figure 1 and Figure 2), potentially augmented by adjunctive therapies such as ESWT and PRP. This approach is intended to preserve the anatomical integrity of the sesamoid. However, if this intervention proves to be unsuccessful, sesamoidectomy is the viable salvage option. As the proposed technique is currently theoretical, further empirical investigation is warranted to assess its clinical feasibility and therapeutic efficacy.

Sesamoidectomy may be unavoidable in certain cases, such as end-stage AVN with extensive fragmentation (Figure 6) and osteomyelitis with uncontrolled infection [11,19,82]. Nevertheless, we believe that sesamoidectomy can be avoided in certain cases when guided by the therapeutic strategies reviewed above.

4. Summary

This review discussed the potential alternatives to sesamoid resection in the management of sesamoid pathologies. However, evidence supporting these approaches remains limited as all cited studies were small case series or individual case reports.

Only one study reported on ESWT for the treatment of sesamoiditis, AVN of the sesamoid, and symptomatic bipartite sesamoid. A case series and a case report used PRP for treating sesamoid stress fracture, sesamoiditis, and AVN. ESWT and ESWT combined with PRP are promising therapeutic strategies for bone marrow edema and fracture, respectively.

Surgical options for sesamoid fracture nonunion include open or arthroscopic autologous bone grafting, open reduction with screw fixation, and percutaneous screw fixation. Temporary fixation of the first metatarsophalangeal (MTP) joint has also been reported to immobilize the affected sesamoid. Plantar keratosis may be addressed through partial shaving of the sesamoid. In cases of sesamoiditis associated with plantar prominence beneath the first metatarsal head, metatarsal osteotomy may be considered. For early stage AVN, excising the central necrotic region and subsequently performing autologous bone grafting could be a potential surgical option, although its clinical feasibility remains to be established.

Sesamoidectomy may be avoided through the judicious integration of surgical techniques, ESWT, and PRP. Nevertheless, sesamoidectomy may still be necessary as a salvage procedure when these alternatives prove ineffective or in specific conditions such as advanced AVN with extensive fragmentation or refractory osteomyelitis.