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Background: This study aimed to evaluate the effectiveness of conservative treatment in selected patients with atraumatic medial sesamoid pain (MSP) that developed during sports activities. The secondary aim was to determine the detailed underlying pathology in patients who did not respond to conservative treatment using magnetic resonance imaging (MRI). Methods: From March 2015 to August 2022, we prospectively followed 27 patients who presented to our outpatient clinic with atraumatic sports-related MSP. The conservative treatment protocol for MSP included the use of oral analgesics, activity restriction, insole modification, local corticosteroid injections, and boot walker application with crutches. MRI was performed for all patients who experienced persistent pain despite the completion of conservative treatment. Results: After the completion of the conservative treatment protocol, 48.1% of the patients reported a reduction in pain. Patients with younger age at pain onset (p = 0.001), higher body mass index (p = 0.001), and a bipartite medial sesamoid (p = 0.010) were more likely to experience persistent pain after conservative treatment. The type of sports activity was also a factor since running- and dancing-related MSP tended to respond better to conservative treatment compared to MSP originating from golf, futsal, and weightlifting with squatting. On MRI, 42.8% of patients showed no specific abnormal findings, with signal changes in soft tissues such as the subcutaneous fat and bursa being the most common, followed by intraosseous signal changes of the medial sesamoid bone and chondral or subchondral lesions of the medial sesamoid metatarsal joint (28.6% each). Conclusions: Conservative treatment was successful in less than half of the patients who experienced MSP due to sports activity. Practitioners should be aware of the numerous possible causes of conservative treatment failure, such as bursitis, medial sesamoiditis, stress fracture, or chondral lesions between the medial sesamoid and metatarsal. MRI evaluation may be helpful in MSP patients who do not respond to conservative treatment.

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BACKGROUND: Sesamoid pathology can lead to significant pain and disability both with activities of daily living and high-impact athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain, but complications were reported. A proposed alternative medial approach using a burr may provide many advantages compared with traditional approaches. This study presents patient outcomes and complications for this technique. METHODS: This was a retrospective chart review of patients undergoing sesamoidectomy (tibial, peroneal, or both) using a burr through a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. RESULTS: Twenty-seven patients (29 feet) were included. The mean age was 38.4 years followed up for a mean of 30.9 months. VR-12 physical component improved from 35.98 ± 7.86 to 51.34 ± 8.01 (P < .001), FAAM ADL and sport improved from 58.33 ± 16.61 to 83.27 ± 18.28 (P < .001) and 26.37 ± 20.31 to 63.75 ± 29.74 (P < .001), respectively. Patient satisfaction with the treatment was 80.59% ± 27.06%. The overall complication rate was 11 (37.9%) whereas the overall reoperation rate was 4 (13.7%) of 29 feet. Complications included 1 arthrofibrosis, 1 flexor hallucis longus subacute rupture, and 1 asymptomatic hallux valgus. There were no sesamoid excision revisions. CONCLUSION: Sesamoidectomy using a medial approach with a burr provided significantly improved short-term functional outcomes, 80% patient satisfaction rate, with a relatively acceptable complications rate including 20% persistent pain. The medial approach is familiar to orthopaedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar scar while avoiding disruption of the plantar plate, flexor hallucis brevis tendon, and ligamentous structures attached to the sesamoids. Larger studies with long-term follow-up from other centers are needed.

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Introduction: Sesamoid bones absorb and disperse weight from the metatarsal bones. Sesamoid injuries occur primarily in dancers and runners, with nonoperative management as the first line of treatment. Due to the lack of secondary blood supply, the sesamoids are at risk for osteonecrosis and nonunion fractures. The literature supporting orthobiologics for the treatment of sesamoid injuries is limited. Methods: In this case, a 28-year-old female dancer with sesamoid osteonecrosis underwent a leukocyte-rich platelet-rich plasma (LR-PRP) injection to the fibular sesamoid. Results: The patient reported significant improvement in pain at the 2-month follow-up and returned to regular auditions at the 3-month follow-up. At 2-year follow-up, the patient's symptoms returned to baseline. Conclusion: This is the first known case of sesamoid osteonecrosis treated with LR-PRP. LR-PRP should be considered in the treatment of sesamoid osteonecrosis in those who show limited improvement with standard conservative measures.

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BACKGROUND: Changes in the proximal sesamoid bones (sesamoids) and the insertional region of the adjacent suspensory ligament branch (branch) are of particular importance in young Thoroughbreds sold at public auction. Little is known about the prevalence of concurrent ultrasonographical branch change, relative to the various grades of radiological sesamoid appearance. OBJECTIVE: To examine the existence of concurrent radiological and ultrasonographical findings in individual sesamoid-branch units in sales horses; to determine whether there are any radiological findings that are consistently accompanied by a particular degree of insertional branch change, and to provide practical recommendations as to when suspensory branch ultrasonography may be warranted in a sales environment. STUDY DESIGN: Prospective cohort study using an enrolled sample. METHODS: Horses were enrolled with consignor permission from a large Thoroughbred yearling sale and five 2-year-old Thoroughbred sales the following year. Data from the radiological evaluation of forelimb sesamoids and the ultrasonographical examination of the adjacent forelimb suspensory branches were described. RESULTS: A total of 2204 yearling forelimb sesamoid-branch units and 1336 2-year-old forelimb sesamoid-branch units were included, from 551 sales yearlings and 334 sales 2-year-olds. The proportion of yearling sesamoids with grade ≤1 vascular channels that had adjacent grade ≥2 fibrillar branch change was 1.2%. The same proportion for 2-year-olds was 3.8%, with medial forelimb sesamoids with grade 1 vascular channels overrepresented in 2-year-olds in this category. In yearlings, 31% of sesamoids with grade 2 vascular channels had adjacent grade ≥2 fibrillar branch change and 59% of sesamoids with grade 3 vascular channels had adjacent grade ≥2 fibrillar branch change. In 2-year-olds, 47% of sesamoids with grade 2 vascular channels had adjacent grade ≥2 fibrillar branch change and 67% of sesamoids with grade 3 vascular channels had the same. Only one yearling sesamoid and one 2-year-old sesamoid with radiological abaxial concavity had grade ≥2 fibrillar branch change. MAIN LIMITATIONS: Hindlimbs were not included. Clinical examinations were not performed and the status of any past or present inflammatory process at the sesamoid-branch enthesis could not be inferred from radiographs and ultrasonographic images alone. CONCLUSIONS: The existence and prevalence of concurrent radiological and ultrasonographical findings in the proximal sesamoid bones and adjacent suspensory ligament branches in yearling and 2-year-old Thoroughbred sales horses has been established. General recommendations have been made for selective branch ultrasonography on the basis of radiological sesamoid appearance. The results support a separate aetiology for radiological sesamoid abaxial concavity that does not primarily involve the suspensory branch insertion.

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INTRODUCTION: Sesamoiditis is a common, and often painful, musculoskeletal pathology frequently encountered by podiatrists. However, there are currently no recommendations to guide podiatrists in the assessment and management of people with sesamoiditis. The aim of this study was to develop consensus-driven clinical recommendations on the assessment and management of people with sesamoiditis. METHODS: A four-round online Delphi survey was conducted with a panel of New Zealand and Australian podiatrists. In the first round, panellists answered open-ended questions that were used to create statements. In round two, the panellists scored the statements from 1 to 9 (1 = not at all important, 9 = absolutely essential). Consensus was defined using the RAND/University of California Los Angles Disagreement Index. Panellists were asked to reconsider statements that did not achieve consensus in round three. In the final round, content validity and acceptability of the statements for inclusion in clinical recommendations were determined using content validity ratios and the Content Validity Index (CVI). RESULTS: Eighteen panellists completed round one with 16 (89%) completing all four rounds. A total of 118 statements were generated following round one. Following rounds two and three, 78 statements were accepted by panellists as being important, with 62 statements achieving sufficient content validity for inclusion in clinical recommendations. The CVI for these 62 statements was 0.58. These recommendations provide guidance on subjective assessment (pain characteristics/symptomology, activity/sports/training history and medical history) objective assessment (establishing a diagnosis, identifying contributing biomechanical factors, footwear/orthoses, ruling out differential diagnoses) and management (temporary padding/strapping, education, footwear, foot orthoses and when to consider referral). CONCLUSION: This consensus exercise has provided a set of consensus-based recommendations for the assessment and management of people with sesamoiditis. In the current absence of research-based evidence in this area, these recommendations are intended to support clinicians. The recommendations may also serve as a basis for future clinical trials evaluating the efficacy of conservative interventions for people with sesamoiditis.

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BACKGROUND: Radiological findings in the proximal sesamoid bones (sesamoids) are a persistent source of controversy at Thoroughbred sales, due to inconsistent classification and conflicting assignment of potential clinical importance. OBJECTIVES: To define the prevalence of sesamoid findings on sales repository radiographs in yearling and 2-year-old Thoroughbreds and to analyse associations with racing performance. To track the changes in sesamoid findings between 1 and 2 years of age in horses that present for sale at both ages. STUDY DESIGN: Prospective cohort study using an enrolled sample. METHODS: Horses were enrolled from a 2016 yearling sale and five 2017 2-year-old sales with consignor permission. Radiological findings relating to sesamoid vascular channel appearance, abaxial contour changes and sesamoid fragments were examined. Associations between sesamoid findings and racing performance from 2 to 4 years of age were examined using multivariate regression analyses. Clinical follow-up was sought to ascertain why horses that did not race never started. RESULTS: A total of 2508 yearlings and 436 2-year-olds were included for evaluation. Interobserver agreement using the new grading system was substantial. Yearling findings associated with a significantly reduced probability of starting a race were: Grade 3 vascular channels in forelimb sesamoids (0.52, P < 0.001, 95% confidence interval (CI): 0.37-0.67), abaxial new bone in forelimb sesamoids (0.62, P = 0.01, 95% CI: 0.49-0.73), apical or abaxial fragments in forelimb sesamoids (0.55, P = 0.005, 95% CI: 0.37-0.72). For affected horses that did race, Grade 3 vascular channels in forelimb sesamoids were associated with fewer race starts (9.9 starts, P = 0.03, 95% CI: 8.0-12.2) and Grade 3 vascular channels in hindlimb sesamoids were associated with a delayed start to racing careers (54 days, P = 0.01, 95% CI: 20-89). Abaxial new bone in forelimb sesamoids was associated with a 54% reduction in total earnings (P = 0.003, 95% CI: 24-72) and a 46% reduction in earnings per start (P = 0.002, 95% CI: 21-64). Abaxial concavity occurred predominantly in yearling medial forelimb sesamoids, had no impact on racing performance and mostly resolved by 2-year-old sale. MAIN LIMITATIONS: These findings are applicable to horses presented for sale at public auction and may underestimate the prevalence of severe lesions in non-sales horses. CONCLUSIONS: Grade 3 vascular channels, forelimb sesamoid abaxial new bone and forelimb sesamoid fragments are important findings in sales repository radiology. The new grading scale assigns a numerical grade for vascular channel appearance that matches the number of enlarged vascular channels evident in a given sesamoid. Abaxial contour changes, when present in sesamoids that are Grade 0 for enlarged vascular channels, are noted separately as either abaxial new bone or abaxial concavity. Fragments are also noted and interpreted separately.

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OBJECTIVE: The objective of this study was to develop a robust machine-learning approach for efficient detection and grading of sesamoiditis in horses using radiographs, specifically in data-limited conditions. SAMPLE: A dataset of 255 dorsolateral-palmaromedial oblique (DLPMO) and dorsomedial-palmarolateral oblique (DMPLO) equine radiographs were retrospectively acquired from Hagyard Equine Medical Institute. These images were anonymized and classified into 3 categories of sesamoiditis severity (normal, mild, and moderate). METHODS: This study was conducted from February 1, 2023, to August 31, 2023. Two RetinaNet models were used in a cascaded manner, with a self-attention module incorporated into the second RetinaNet's classification subnetwork. The first RetinaNet localized the sesamoid bone in the radiographs, while the second RetinaNet graded the severity of sesamoiditis based on the localized region. Model performance was evaluated using the confusion matrix and average precision (AP). RESULTS: The proposed model demonstrated a promising classification performance with 92.7% accuracy, surpassing the base RetinaNet model. It achieved a mean average precision (mAP) of 81.8%, indicating superior object detection ability. Notably, performance metrics for each severity category showed significant improvement. CLINICAL RELEVANCE: The proposed deep learning-based method can accurately localize the position of sesamoid bones and grade the severity of sesamoiditis on equine radiographs, providing corresponding confidence scores. This approach has the potential to be deployed in a clinical environment, improving the diagnostic interpretation of metacarpophalangeal (fetlock) joint radiographs in horses. Furthermore, by expanding the training dataset, the model may learn to assist in the diagnosis of pathologies in other skeletal regions of the horse.

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Introducción: Los sesamoideos del hallux son huesos constantes de pequeño tamaño y lentiformes. Se localizan en la región plantar de la cabeza del primer metatarsiano dentro de la cápsula de la primera articulación metatarsofalángica. El diagnóstico diferencial de metatarsalgia sobre el primer radio del pie, sin antecedente traumático, incluye patologías referidas a los sesamoideos y otras. Entre las primeras se encuentran principalmente la sesamoiditis, las fracturas de estrés y la necrosis avascular de los sesamoideos. Objetivo: Presentar un caso de sesamoiditis y su evolución después del tratamiento quirúrgico. Presentación del caso: Mujer de 25 años con un cuadro de fractura por estrés del sesamoideo peroneal. Tras infiltración seriada con corticoesteroides, desencadenó una necrosis séptica del sesamoideo. Se determinó realizar una sesamoidectomía por abordaje plantar. Conclusiones: La sesamoidectomía resulta una opción quirúrgica en procesos degenerativos de los sesamoideos, cuando los tratamientos conservadores son insuficientes. El abordaje plantar se considera adecuado para la extirpación del sesamoideo peroneal. Esta técnica requiere un adecuado seguimiento posoperatorio para optimizar la cicatrización plantar.

Introduction: The hallux sesamoid are constant bones of small size and lentiform. They are located in the plantar region of the first metatarsal head within the capsule of the first metatarsophalangeal joint. The differential diagnosis of metatarsalgia over the first radius of the foot, without traumatic history, includes pathologies related to the sesamoids and others. Among the former are mainly sesamoiditis, stress fractures and avascular necrosis of the sesamoids. Objective: To report a case of sesamoiditis and its evolution after surgical treatment. Case report: This the case of a 25-year-old woman with a stress fracture of the fibular sesamoid. After serial infiltration with corticosteroids, it triggered a septic sesamoid necrosis, it was decided to perform a sesamoidectomy by plantar approach. Conclusions: Sesamoidectomy is a surgical option in degenerative processes of the sesamoids, when conservative treatments are insufficient. The plantar approach is considered adequate for removal of the fibular sesamoid. This technique requires adequate postoperative follow-up to optimize plantar healing.

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BACKGROUND: Sesamoiditis is a common inflammatory condition affecting the sesamoid bones at the plantar aspect of the first metatarsophalangeal joint (1MTPJ). However, there are currently no recommendations or clinical guidelines to support podiatrists in their assessment or management of sesamoiditis. The aim of this study was to explore the views of podiatrists in Aotearoa New Zealand on their approaches to the assessment and management of patients with sesamoiditis. METHODS: This qualitative study included focus group discussions with registered podiatrists. Focus groups took place online via Zoom and were guided by a detailed focus group question schedule. The questions were designed to encourage discussion around assessment approaches used in the diagnosis of sesamoiditis and the treatment tools used to manage patients with sesamoiditis. Focus groups were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to analyse the data. RESULTS: A total of 12 registered podiatrists participated in one of three focus groups. Four themes were constructed relating to the assessment of sesamoiditis: (1) obtaining a patient history; (2) recreating patient symptoms; (3) determining contributing biomechanical factors; and (4) ruling out differential diagnoses. Seven themes were constructed relating to the management of sesamoiditis: (1) consideration of patient factors; (2) patient education; (3) cushioning of the sesamoids to allow more comfortable weightbearing of the 1MTPJ; (4) pressure redistribution and offloading of the sesamoids; (5) immobilisation of the 1MTPJ and sesamoids; (6) facilitating efficient sagittal plane motion during gait; (7) referring to other health professionals to find different ways to treat or manage patient symptoms. CONCLUSION: Podiatrists in Aotearoa New Zealand demonstrate an analytical approach in the assessment and management of patients with sesamoiditis based on their clinical experience and knowledge of lower limb anatomy. A range of assessment and management techniques are selected based on the practitioners personal preferences, as well as the patient's social factors, symptomology, and lower limb biomechanics.

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Dancers are highly vulnerable to injuries due to high dynamic overload, extreme positions and motions, and excessive use. Increased load at the forefoot with jumping and high-impact lands can cause sesamoiditis and stress fractures of the metatarsals. Significant plantarflexion can lead to posterior joint impingement and flexor hallucis longus tendonitis, whereas forced dorsiflexion can cause anterior joint impingement. Most pathologies can be diagnosed on physical examination and various imaging modalities. Treatment should be tailored to the dancers' needs and should begin with a course of conservative therapy with immobilization, physical therapy, and activity cessation.

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Forefoot pain is common in clinical practice. Careful history taking and routine physical examination are initially performed for diagnosis, but imaging can confirm the clinical suspicion and play a key role in management. Ultrasound (US) can provide a visualization of the fine anatomy of the forefoot and is a useful method for evaluating various lesions causing forefoot pain. In this review, we provide the detailed anatomical structures of the forefoot and their normal appearances on US. We also focus on the most common pathologies affecting the forefoot, including plantar plate tear, sesamoiditis, bone fracture, synovitis, tenosynovitis, bursitis, Morton's neuromas, and foreign bodies.

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Concentrated bone marrow aspirate (CBMA) offers an alternative to sesamoid resection in end stage sesamoid pathology. CBMA potentiates the anti-inflammatory effect, stimulates local tissue regeneration and osteogenesis, when injected into bone. The purpose of this study is to evaluate the functional outcomes in a cohort of athletes following CBMA injection for the treatment of hallux sesamoid disorders. A retrospective case series of consecutive patients treated with CBMA injection for hallux sesamoid disorders were identified. Radiographs, Foot and Ankle Outcome Scores (FAOS), and Visual Analogue Scale (VAS) score were collected pre- and postinjections. Descriptive statistics were presented as the mean and standard deviation for continuous variables and frequency as percentages for categorical variables. Fifteen consecutive patients with were included with a mean follow-up time of 20.1 (range 12-34) months. Significant improvement in all scoring subscales of the FAOS and VAS score was noted preinjection compared to final follow-up postinjection (p < .001). Eight of 11 patients that were involved in sports prior to the CBMA injection returned to play, with 7 successfully returning to preinjury level status. Three patients required further treatment (20%). The case series suggests that CBMA injection is a safe and effective treatment option for hallux sesamoid disorders with a high rate of return to play.

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INTRODUCTION: The sesamoid disease is a cause of lameness in dogs, and there is limited literature relating to diagnosis, treatment and outcome of treatment in dogs with the sesamoid disease. Our aim was to compare the efficacy of intra-articular metacarpophalangeal/metatarsophalangeal joint injection with methylprednisolone and bupivacaine (IMPB) or conservative management with nonsteroidal anti-inflammatories and rest (CMNR) for treatment of this disease. MATERIALS AND METHODS: We conducted a retrospective survey of dogs treated for the sesamoid disease with IMPB or CMNR. The medical records of all dogs that received IMPB or were recommended CMNR for treatment of sesamoid pain were reviewed, and a client questionnaire was delivered to owners. Response to treatment, rapidity of response, length of resolution and recurrence of clinical signs associated with the sesamoid disease were assessed. RESULTS: A total of 78 dogs were included in the study. One week after IMPB, 52/58 (89.7%) dogs demonstrated resolution of lameness compared with 1 week of CMNR, 0/18 (P < 0.001). There was limited statistical evidence in client satisfaction between treatment groups, IMPB 36/53 (67.9%) and CMNR 16/17 (94%) (P = 0.052). Dogs presenting with the sesamoid disease had comorbidities in 51/78 (65.4%) of cases. Elbow disease was the most common comorbidity 29/78 (37.2%). CONCLUSION: Our results support the use of IMPB for short-term (1 week) resolution of lameness associated with sesamoid disease in dogs. Dogs treated with CMNR had slower improvement; however, there was no difference in lameness or client satisfaction between treatment groups at long-term follow-up (12 months).

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Recreational sports are more popular, with many athletes involved year-round in multiple sports and on multiple teams. Most athletes do not take proper rest, making them more susceptible to stress-related injuries. There are numerous sports-related injuries in the foot and ankle. These issues can be non-traumatic, due to chronic repetitive stresses, or traumatic. Most of these injuries are managed conservatively, and athletes do well and return to play, while some do better with operative management. This article discusses a few of the sports injuries that are common in the leg, foot, and ankle and the recovery process.

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BACKGROUND: Sesamoid injuries can have a significant effect on the ability of athletes to return to play. The literature shows mixed results with sesamoid excisions and the ability to return to sports. HYPOTHESIS/PURPOSE: The purpose was to describe patient-reported outcomes and return to sports in athletes after sesamoidectomy with a proper surgical technique and a well-structured rehabilitation protocol. It was hypothesized that sesamoid excision would demonstrate reproducible and encouraging long-term patient outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients from a single surgeon's practice who underwent sesamoidectomy between January 2006 and September 2015 were identified. Medial sesamoids were excised through a medial approach, and lateral sesamoids were excised through a plantar approach. The plantar structures were adequately repaired after excision. The Foot Function Index-Revised (FFI-R), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey and Single Assessment Numeric Evaluation (SANE) questionnaire were also collected. Athletes were defined as those who participated in sports at a high school level or higher. RESULTS: Of the 108 feet that met the inclusion criteria, 26 werelost to follow-up, leaving 82 feet for analysis at a mean 31.3 ± 26.0 months. There were 72 female patients and 10 male patients included in the final analysis, with a mean age of 44.9 ± 20.2 years. There were 54 medial, 18 lateral, and 10 medial and lateral sesamoid excisions. There were 26 competitive athletes with follow-up appointments (dancer, n = 12; pivot sport athlete, n = 8; runner, n = 6). Both the entire study population and the athletes demonstrated a significant improvement in SF-12, SANE, VAS, and FFI-R cumulative at the latest available follow-up (P < .05). Among the athletes, 80% were able to return to competitive sports at a mean 4.62 ± 1.01 months after surgery. The median satisfaction score among all patients was 97.5%. There was no difference in the success rate between the different etiologies at any of the follow-up intervals. CONCLUSION: Chronic sesamoid pain is difficult to treat, but this study confirms that with a meticulous surgical technique and a dedicated postoperative rehabilitation program, encouraging patient-reported outcomes can be expected with a minimal risk of complications. Moreover, in the current study, 80% of competitive athletes were able to return to sports at a mean of 4.62 months after surgery.

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A wide variety of pathologies can affect the hallux sesamoid complex of the foot, including traumatic, micro traumatic, degenerative, inflammatory, vascular, infectious, and neoplastic conditions. Symptoms are quite nonspecific, mainly related to pain in the plantar surface of the first metatarsal head. In this context, imaging is important for the etiologic diagnosis of hallux sesamoid complex pathology with implications in patient management. The hallux sesamoid complex has a complex anatomy, and pathologic processes of this region are poorly known of radiologists. Besides, some entities such as "sesamoiditis" remain poorly defined in the literature. Schematically, conditions affecting sesamoids will be divided into two major groups: intrinsic anomalies (sesamoid bone being the center of the pathologic process) and extrinsic anomalies (diseases secondarily involving sesamoid bones). Thus, in this article, after a review of anatomical key points and pathologies affecting the hallux sesamoid complex, a practical multimodality approach for the diagnosis of hallux sesamoid pathologies will be proposed.

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BACKGROUND: Abnormalities in vascular channel appearance within the proximal sesamoid bone (PSB) are the most common findings in Thoroughbred yearling presale radiographs and are often evaluated on radiographs of adult racehorses. Despite this, their pathogenesis and clinical significance are poorly understood, and associations with racing performance are inconsistent. OBJECTIVES: To determine microstructural characteristics of the PSBs associated with the radiographic appearance of vascular channels using microcomputed tomography (µCT) and to determine associations with past racing performance in mature horses. STUDY DESIGN: Cross-sectional. METHODS: One pair of PSBs were isolated from a forelimb of 59 Thoroughbred racehorses undergoing post-mortem examination. Each PSB (n = 118) was radiographed, assigned a vascular channel grade using previously published and novel grading systems, then imaged using µCT. Associations between radiographic, µCT and performance variables were investigated with uni- and multivariable generalised linear models. RESULTS: All PSBs had at least one vascular channel (mean 3.6 ± 0.89) observed on µCT originating from the abaxial border, yet in only 63.6% (75/118) were channels observed radiographically. Proximal sesamoid bones with a higher bone volume fraction (odds ratio [OR] 1.08; 95% confidence interval [CI] 1.01-1.15; P = .03) and wider channel diameter (mm) on µCT (OR 20.67; 95% CI 3.29-130.00; P = .001) were more likely to have vascular channels identified on radiographs. Greater radiographic channel number (OR 0.96; 95% CI 0.92-1.00; P = .04) and channel diameter (mm; OR 0.96; 95% CI 0.92-1.00; P = .04) were associated with fewer career placings. MAIN LIMITATIONS: Radiographs of isolated bones avoided the normal superimposition of tissue encountered in the live horse. CONCLUSIONS: The ability to identify vascular channels radiographically indicates widening of channels and densification of the PSB. More radiographic channels and greater channel diameter were associated with similar or poorer measures of past performance, suggesting that these changes are not desirable.

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Foot and ankle pathology is common in the pediatric population. Common issues may be traumatic in nature, congenital, or age dependent. This article reviews common problems and pathology found in the pediatric foot and ankle.

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BACKGROUND: The purpose of this study was to evaluate patients for intermediate-term pain relief, functional outcome, and changes in hallux alignment following isolated, complete fibular sesamoidectomy via a plantar approach for sesamoid-related pain recalcitrant to conservative treatment. METHODS: A retrospective query of a tertiary referral center administrative database was performed using the Current Procedural Terminology code 28135 for sesamoidectomy between 2005 and 2016. Patients who underwent an isolated fibular sesamoidectomy were identified and contacted to return for an office visit. The primary outcome measure was change in visual analog pain score at final follow-up. Secondary measures included satisfaction, hallux flexion strength, hallux alignment, pedobarographic assessment, and postoperative functional outcome scores. Patients who met the 2-year clinical or radiographic follow-up minimum were included. Ninety fibular sesamoidectomies were identified. Thirty-six sesamoidectomies met inclusion criteria (median 60-month follow-up). The average patient was 36 years old and underwent sesamoidectomy 1.1 years after initial diagnosis. RESULTS: Median visual analog scale scores improved 5 (6 to 1) points at final follow-up (P < .001). Final postoperative mean hallux valgus angle did not differ from preoperative values (10.5 degrees/8.5 degrees, P = .12); similarly, the intermetatarsal angle did not differ (8.0 degrees/7.9 degrees, P = .53). Eighty-eight percent of patients would have surgery again and 70% were "very satisfied" with their result. Hallux flexion strength (mean 14.7 pounds) did not differ relative to the contralateral foot (mean 16.1 pounds) (P = .23). Among the full 92 case cohort, 3 patients underwent 4 known reoperations. CONCLUSION: Fibular sesamoidectomy effectively provided pain relief (median 5-year follow-up) for patients with sesamoid pathology without affecting hallux alignment. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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We report a case of a competitive athlete who complained of chronic pain over the first metatarsal head in the absence of preceding trauma that was exacerbated with forced plantar flexion of the big toe. Initial radiographic findings suggested a tripartite appearance of the medial hallux sesamoid, and the patient was treated as for sesamoiditis. However, persistent symptoms over a period of 12 months necessitated further imaging with magnetic resonance, which confirmed a fracture of the bipartite medial hallux sesamoid. Considering that it is clinically important to differentiate between a tripartite/multipartite hallux sesamoid variant and a fracture of a bipartite hallux sesamoid, an expedient diagnosis is vital to avoiding complications of stress fractures. This can be a diagnostic challenge for the radiologist, emergency physician, and orthopedic surgeon, requiring a high index of suspicion. Accurate and timely diagnosis can be achieved with a clear history, detailed physical examination, and appropriate radiological evaluation.

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