Abstract
Background
Hallux amputations are commonly performed for conditions such as osteomyelitis, gangrene, and chronic ulceration. While wound complications and reoperation are well-recognized, the role of sesamoid excision in these complications remains unclear. This study evaluates complication rates associated with hallux amputations performed with and without sesamoid excision.
Methods
This retrospective study included patients aged 18 years or older who underwent hallux amputation at the metatarsophalangeal joint level between 2012 and 2024. Complications were defined as the need for reoperation, postoperative incisional dehiscence, or wound complications leading to proximal amputation. Statistical analyses were performed using Fisher’s exact test and logistic regression.
Results
A total of 62 patients were included, with 27 undergoing sesamoid excision and 35 not undergoing sesamoid excision. The overall complication rate was significantly higher in the sesamoid excision group (40.74%) compared to the non-sesamoid excision group (17.14%) ( p = 0.044). Patients who underwent sesamoid excision were 3.32 times more likely to experience complications (95% CI: 1.0344–10.6749). Peripheral arterial disease was a statistically significant risk factor for complications ( p = 0.007), while hemoglobin A1c levels showed no significant correlation ( p = 0.604). However, the study’s statistical power of 42.79% presents a limitation, warranting cautious interpretation of the results.
Conclusion
Sesamoid excision during hallux amputation was associated with a higher complication rate. The higher complication rate is potentially due to more extensive soft tissue dissection rather than the presence of an infectious nidus. As the first study to explore this relationship, these findings provide valuable insights and highlight the need for further prospective research to guide clinical decision-making.
Introduction
Hallux amputation is a frequently performed surgical intervention for a variety of pathologies, including infection, osteomyelitis, and gangrene. Prior research highlights that hallux amputations, particularly at the metatarsophalangeal joint (MTPJ) level, inherently increase the risk of biomechanical instability and subsequent re-ulceration. While numerous studies have compared complication rates between hallux amputations and partial ray amputations, none have specifically addressed the role of the sesamoid apparatus in these outcomes. ,,
The sesamoid apparatus is a vital anatomical structure that contributes significantly to the biomechanics of the first ray. Despite its importance, there is a conspicuous absence of studies investigating the impact of sesamoid excision during hallux amputations. Surgical protocols often advocate for the removal of poorly vascularized structures, such as tendon stumps and the plantar plates of the MTPJ, as they have the potential to harbor infection. Given that the sesamoid apparatus is intricately attached to the plantar plate, it may similarly function as a potential nidus for infection. Additionally, sesamoid excision is frequently performed to enhance soft tissue mobility and facilitate tension-free closure. Our study aims to evaluate the complication rates associated with hallux amputations performed with and without sesamoid excision at our institution.
Methods and patients
Institutional review board approval was obtained through the University of Pittsburgh. We conducted a retrospective analysis of operative reports for patients treated between 2012 and 2024. Inclusion criteria comprised patients aged 18 years or older who underwent hallux amputation at the MTPJ level with or without sesamoid excision and had a minimum follow-up of one month. Exclusion criteria included patients who did not meet the age or follow-up requirements, were lost to follow-up, underwent partial hallux amputations, multiple digital amputations, or had hallux amputation as part of a staged procedure. During the primary surgeon’s first five years in practice, it was standard to perform hallux amputations with concomitant sesamoid excision. After that period, hallux amputations were routinely performed without sesamoid excision. The surgeon felt as though they were not providing any benefit being left in and can be prominent. Furthermore, the surgeon believed they could facilitate skin closure by debulking more tissue. After that period, hallux amputations were routinely performed without sesamoid excision. This switch was based on surgeon observation that a small percentage of patients were having problems with skin healing and was therefore finding ways to limit dissection. The surgeon particularly noted that skin healing issues were medial and he had been making a slightly longer incision medially when removing the sesamoids therefore he began performing the hallux amputations without sesamoid excision.
Complications were defined as the need for reoperation or the occurrence of postoperative incisional dehiscence or wound complications resulting in proximal amputation. Complications were verified by chart review. Data were de-identified and compiled into an Excel spreadsheet. For each patient, operative reports, perioperative radiographs, and postoperative notes were reviewed. Demographic data, including age, sex, diabetes status, peripheral arterial disease (PAD), chronic kidney disease (CKD), and neuropathy, were recorded. Statistical analyses were performed using Python, employing Fisher’s exact test and logistic regression to evaluate complication rates between the two groups ( Figs. 1 and 2 ).
