Tag Archives: absent sesamoid

Complete Agenesis of Both Metatarsophalangeal Sesamoids with Contralateral Agenesis of Fibular Sesamoid Associated with Hallux Valgus

by Lyndon W. Mason, MB BCh MRCS (Eng)1, Gemma Digby, MB BCh2, Hiro Tanaka, MB BCh MSc (Orth Eng) FRCS (Ed) FRCS (Orth)3

The Foot and Ankle Online Journal 5 (4): 2

We report a rare case of complete hallucal sesamoid agenesis in combination with severe symptomatic hallux valgus. This was successfully treated with a Scarf osteotomy. We present 2 case illustrations of hallux valgus deformity with sesamoid agenesis to contribute to the literature.

Keywords: Complete Sesamoid Agenesis, Metatarsalgia, Fibular Sesamoid Agenesis.

Accepted: March, 2012
Published: April, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0504.0002

The metatarsophalangeal joint of the great toe differs from that of the lesser toes because it has a sesamoid mechanism and a set of intrinsic muscles that stabilize the joint and provide motor strength to the first ray.[1] The hallucal sesamoids are a consistent entity in humans, originating in the tendons of flexor hallucis brevis. They appear within the seventh or eighth week of embryonic development as islands of undifferentiated connective tissue.

By the twelfth week, chondrification begins, but it is not until 8 to 10 years of life through multiple ossification centers that they ossify.[2] Often these centers of ossification do not coalesce and remain partite in a significant portion of the population. The function of the hallucal sesamoids is to absorb weight-bearing forces and enhance the load-bearing capacity of the first ray. They power plantar flexion of the first ray by increasing the moment of the flexor hallucis brevis and function to elevate the first metatarsal head, which dissipates the forces on the metatarsal head.[3]

On a review of the literature, Le Minor found that in 3305 feet there were no reports of sesamoid absence.[4] There are eleven case reports of single sesamoid agenesis in the literature, seven cases of which are tibial sesamoid agenesis [5-10] and three cases of fibular sesamoid agenesis.[11-13]

There is one reported case of unilateral complete agenesis of the sesamoids[14] and one bilateral complete agenesis of the sesamoids reported in the literature.[15] More recently, there was a report of adolescence hallux valgus with bilateral absence of hallux sesamoids.[16] We report a case of unilateral complete absence of sesamoids with contralateral agenesis of the fibular sesamoid with symptomatic hallux valgus.

Case Report

A 49 year-old, Caucasian male, who worked as a line manager in a hospital laundry department, attended our clinic due to a painful left hallux valgus. He experienced pain over the medial eminence of his left great toe due to rubbing shoe wear, and on the plantar surface of his 1st metatarsophalangeal joint after exertion. Pain and stiffness of the left first metatarsophalangeal joint was also experienced in the morning. He enjoyed evening walks and found this was being curtailed due to pain. He was a type 2 diabetic patient being treated with an oral hyperglycemic medication.

On examination it was noted that he had bilateral severe hallux valgus with callosities under both first metatarsophalangeal joints. The left first metatarsophalangeal joints had a pain free range of motion of 30° dorsiflexion to 50° plantarflexion.

Radiographs illustrated a left forefoot adductus with severe hallux valgus (Inter-Metatarsal Angle 16° and Hallux Valgus Angle of 25°), and it was noted a complete absence of sesamoids. (Figures 1A, 1B and 2) The patient had normal sensation and a normal vascular exam.


Figure 1A and 1B Left foot weight bearing anteroposterior (A) and lateral (B) radiographs illustrating hallux valgus and complete lack of hallucal sesamoids.

Figure 2 Intraoperative sesamoid view of the left foot showing lack of hallucal sesamoids, and no discernible sesamoid grooves or crista.

The left symptomatic hallux valgus was treated with surgical intervention. We performed a lateral release through a small dorsal incision and a medial eminence resection with Scarf osteotomy through a mid medial incision as described by Barouk.[17] Intraoperatively, there was no evidence of tibia of fibular sesamoids. Intraoperative radiographs of the contralateral foot revealed absence of the fibular sesamoid but presence of the tibial sesamoid. This foot had no discernible hallux valgus deformity. (Figures 3A and 3B) Post operatively, the patient was mobilized in a heel weight bearing shoe for 6 weeks and radiographs obtained at this stage showed satisfactory reduction in the intermetatarsal angle. (Figures 4A and 4B) The patient’s symptoms were successfully treated with this procedure, and remains recurrence free at 3 years postoperative.


Figure 3A and 3B Right foot anteroposterior radiograph (A) and sesamoid view (B) showing tibial sesamoid presence and absence of fibular sesamoid, with no deformity at the first metatarsophalangeal joint.


Figure 4A and 4B Anteroposterior (A) and lateral (B) weight bearing radiographs post Scarf osteotomy showing correction of intermetatarsal angle and hallux valgus.


Not much is known of the repercussions of sesamoid agenesis. Most of the single sesamoid agenesis in the literature were reported to be asymptomatic, apart from one case of associated metatarsalgia.[7] Metatarsalgia was also the complaint of the only reported case of unilateral complete sesamoid agenesis.[15] The bilateral complete sesamoid agenesis reported hallux varus deformity, however there has been no associated hallux valgus deformity reported with sesamoid agenesis.[14] In comparison, the acquired loss of hallucal sesamoids through surgery or injury can result in significant deformity. Removal of the fibular sesamoid as described in the McBride procedure for hallux valgus, can result in hallux varus.[18] The loss of both sesamoids during hallux valgus surgery or through injury has been reported to cause hallux malleolus, hallux varus or hallux valgus.[18-21]

However, total sesamoidectomy for painful hallux rigidus has been reported to not cause such complications.[22] It is unlikely that the sesamoid itself but rather the surrounding ligamentous structures that are insufficient in causing the deformities present in surgical excision of the sesamoid, and possibly why it has not been reported in any cases of sesamoid agenesis, either partial or complete, until now.

It is generally accepted that the medial supporting structures of the first metatarsophalangeal joint, i.e. the metatarsosesamoid ligament, phalangealsesamoid and medial collateral ligaments, fail early in hallux valgus deformity.[23] The proximal phalanx that is anchored at its base to the sesamoids by the plantar plate is pulled into valgus and pronation. It is important to note that the oblique head of the adductor hallucis muscle inserts onto the lateral sesamoid and the lateral capsule of the metatarsophalangeal joint and the transverse head inserts onto the lateral sesamoid, lateral capsule of the metatarsophalangeal joint and the lateral plantar side of the proximal phalanx.[23,24] As the medial sesamoid ligament is one of the key structures in the valgus stability of the first metatarsophalangeal joint, it is likely in this case to have been weaker as a consequence of sesamoid agenesis.

We treated this patient with a Scarf osteotomy which resulted in a successful outcome. This does not address the anatomical insufficiencies, but by shifting the metatarsal head laterally, the soft tissues are once again balanced with the flexor and extensor hallucis longus no longer providing deforming forces. This is only anecdotal, but considering the rarity of this case we would recommend a first metatarsal osteotomy for the treatment of such a case in the future. The patient’s symptoms were a consequence of the hallux valgus deformity and not the absence of sesamoids. However, it is likely that the sesamoid absence would have predisposed the foot to the development of hallux valgus.


1.  Stein HC. Hallux Valgus. Surg Gynec Obstet 1938 66: 889-898.
2. Sammarco GJ, Idusuyi OB. Complications after surgery of the hallux. Clin Orthop Relat Res 2001 391: 59-71. [PubMed]
3.  Aper RL, Saltzman CL, Brown T. The effect of hallux sesamoid excision on the flexor hallucis longus moment arm. Clin Orthop Relat Res 1996 325: 209-217. [PubMed]
4.  Le Minor JM. Congenital absence of the lateral metatarsophalangeal sesamoid bone of the human hallux: a case report. Surg Radiol Anat 1999 21(3): 225-227. [PubMed]
5. Kanatli U, Ozturk AM, Ercan NG, Ozalay M, Daglar B, Yetkin H. Absence of the medial sesamoid bone associated with metatarsophalangeal pain. Clin Anat 2006 19: 634-639. [PubMed]
6. Day F, Jones PC, Gilbert CL. Congenital absence of the tibial sesamoid. JAPMA 2002 92:153-154.[PubMed]
7.  Jeng CL, Maurer A, Mizel MS. Congenital absence of the hallux fibular sesamoid: a case report and review of the literature. Foot Ankle Int 1998 19: 329-331. [PubMed]
8.  Goez J, DeLauro T. Congenital absence of the tibial sesamoid. JAPMA 1995 85: 509-510. [PubMed]
9.  Zinsmeister BJ, Edelman R. Congenital absence of the tibial sesamoid: a report of two cases. J Foot Surg. 1985 24: 266-268.
10.  Inge GA. Congenital absence of the medial sesamoid of the great toe. JBJS 1936 18A: 188-190.[PubMed]
11.  Williams TH, Pasapula C, Robinson AH. Complete sesamoid agenesis: a rare cause of first ray metatarsalgia. Foot Ankle Int 2009 30: 465-467.[PubMed]
12.  Yildirim Y, Saygi B. Congenital absence of the lateral sesamoid. JAPMA 2006 96:78-81. [PubMed]
13.  Lapidus PW. Congenital unilateral absence of the medial sesamoid of the great toe: Report of a case. JBJS 1939 21A: 208-209. [WebSite]
14.  Wilson D. Treatment of hallux valgus and bunions.  Br J Hosp Med 1980 24: 548-559.  [PubMed]
15.  Wright SM. Congenital hallux varus deformity with bilateral absence of the hallucal sesamoids. JAPMA 1998 88: 47-48. [PubMed]
16.  Alshryda S, Lou T, Faulconer ER, Adedapo AO., Adolescent hallux valgus deformity with bilateral absence of the hallucal sesamoids: a case report.  J Foot Ankle Surg 2012 51: 80-82. [Pub Med]
17.  Barouk LS. Scarf osteotomy of the first metatarsal in the treatment of hallux valgus. Foot Diseases 1995 2: 35-48.
18.  Cohen BE. Hallux sesamoid disorders. Foot Ankle Clin Mar 2009 14: 91-104. [PubMed]
19.  Grace DL. Sesamoid problems. Foot Ankle Clin 2000 5: 609-627. [PubMed]
20. CampbellAC, McBride DJ, Anderso EG. Surgical treatment in disorders of the sesamoids of flexor hallucis brevis. The Foot 1993 3: 43-45. [Website]
21. RichardsonEG. Injuries to the hallucal sesamoids in the athlete. Foot Ankle 1987 7: 229-244. [PubMed]
22.  Tagoe M, Brown HA, Rees SM. Total sesamoidectomy for painful hallux rigidus: a medium-term outcome study. Foot Ankle Int 2009 30: 640-646. [PubMed]
23.  Arakawa T, Tokita K, Miki A, Terashima T. Anatomical study of human adductor hallucis muscle with respect to its origin and insertion. Ann Anat 2003185: 585-592.[PubMed]
24.  Perera AM, Mason L, Stephens MM. Current concepts review: The pathogenesis of hallux valgus. JBJS 2011 93A:1650-1661. [PubMed]

Address correspondence to: Mr. Lyndon Mason, Foot and Ankle Unit, Trauma and Orthopaedic Department, Royal Gwent Hospital, Newport, NP20 2UB

1, 2, 3 Foot and Ankle Unit, Trauma and Orthopaedic Department, Royal Gwent Hospital, Newport, NP20 2UB

© The Foot and Ankle Online Journal, 2012

Congenital Fibular Sesamoid Aplasia: A case report

by Tugrul Alici, MD1, Semih Dedeoglu, MD2, Yunus Imren, MD3, Hakan Gundes, MD4

The Foot & Ankle Journal 2 (2): 1

Congenital absence of the lateral sesamoid bone is a relatively rare condition. Literature review reveals very few case presentations relevant to this condition. We present a case of lateral sesamoid aplasia that was incidentally detected upon roentgenograms of a patient presenting with a fracture to the base of the proximal phalanx.

Key words: Lateral sesamoid, fibular sesamoid, phalangeal fracture, aplasia, absent sesamoid

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: January, 2009
Published: February, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0202.0001

Case Report

A 31 year-old male hit his right foot during a rafting event. The patient presents with pain and swelling to the right foot. Previous treatment included cold compression and irregular use of analgesics for pain and swelling. The physical examination demonstrated edema around the first metatarsophalangeal joint, palpation-induced tenderness at the medial aspect of the joint, with complete and painful range of motion. Further examination with plane foot anteroposterior radiographs showed a medial, non-displaced fracture at the base of proximal phalanx. (Fig.1)

Figure 1  Radiograph showing medial, non-displaced, proximal phalangeal fracture.  Aplasia or an absent fibular sesamoid is also seen.

In addition, the lateral or fibular sesamoid appeared aplasic or absent in routinely-ordered foot axial sesamoid radiograph. (Fig.2)

Figure 2  Axial sesasmoid radiograph reveals absent fibular sesamoid with a slightly visable ossified region central to the aplastic sesasmoid.

The patient was questioned about any previous problems relating to his right foot. The patients other sport activity included basketball once or twice a week. He denies any injury to his right foot from this activity and has had no previous foot surgery. Physical examination of the right foot was considered as normal except of the signs associated with the proximal phalangeal fracture. It was decided that this variation had no bearing on functional loss or activity for the patient. He was placed in a short leg circular cast, non-weight bearing for 2 weeks. The cast was then removed and partial weight bearing was provided through soft shoes. Complete weight bearing was allowed at 4 weeks and sport activities was permitted at the end of 2 months. A 6-month follow-up of patient demonstrated that the lateral or fibular sesamoid aplasia, considering his younger age, did not adversely influence his attendance to sport activities before or after injury.


Sesamoid bones of the foot originate from a cartilage bud at the 12th gestational week. [1] Ossification usually occurs between 8 and 10 years of age. [5] Inferior contact surfaces of metatarsal heads become flattened with compression and form the intersesamoid ridge called crista. [2]

The reasons for development of sesamoid aplasia are not fully understood but it is thought to be congenital. Congenital absence or aplasia of one or two of the sesamoid bones of toe is reported to be rare. It is reported that lateral or fibular sesamoid aplasia is rarer than medial or tibial sesamoid aplasia. [6,7] It is known that sesamoid bone excision in hallux valgus surgery (i.e. McBride bunionectomy) may result in varus, valgus, and hallux extensus or cock-up hallux deformities by altering the biomechanics of the toe. [2,4]

Similar to the reviewed literature, findings of physical examination of this aplasia was assessed to be within normal limits without rendering loss of function. The hallucal sesamoids, although small and seemingly insignificant, play an important role in the function of the great toe by absorbing weight-bearing stress, reducing friction, and protecting tendons. [8,9] They are also known to exert biomechanical features similar to that of the patella by increasing the efficiency of flexor hallucis brevis muscle by elevating its lever arm. [4,5] Secondary causes of aplasia may include infection. A case of sesamoid bone resorption secondary to infection was reported by Conway, et al. [3] The reason for normal biomechanics of toe in congenital sesamoid aplasia may be the presence of a cartilaginous sesamoid, which is non-calcified, and hence not seen in direct roentgenogram. [7]


1. Brenner E, Gruber H, Fritsch H. Fetal Development of the first metatarsophalangeal joint complex with special reference to the intersesamoidal ridge. Ann Anat 184:481-487, 2002.
2. Brenner E. The intersesamoidal ridge of the first metatarsal bone: anatomical basics and clinical considerations. Surg Radiol Anat. May;25(2):127-131, 2003.
3. Conway WF, Hayes CW, Murphy WA. Total resorption of the lateral sesamoid secondary to Pseudomonas aeruginosa osteomyelitis. Skeletal Radiol 18:483-484,1989.
4. Coughlin MJ. Sesamoids and accessory bones of the foot. In Mann RA, Coughlin MJ (eds) Surgery of the Foot and Ankle, 7th Edition. Mosby, St Louis, vol. 1, pp.437-499, 1999.
5. Downey MS, Merritt SC, Sharrock-Maher CJ, Bernbach MR. Digital and Sesamoid Fractures. McGlamry’s Forefoot Surgery ,LWW, Philadelphia 559-573, 2004.
6. Goez J, De Lauro T. Congenital absence of the tibial sesamoid. J Am Podiatr Med Assoc 85:509-510,1995.
7. J.M. Le Minor. Congenital absence of the lateral metatarso-phalengeal sesamoid bone of the human hallux. Surg Radiol Anat. 21(3):225-227,1999.
8. Richardson EG: Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg 7(4):270-278,1999.
9. Cardona,T., Kline, A. Surgical excision of painful fibular sesamoid. The Foot and Ankle Journal 1(8):2, 2008.

Address correspondence to:
Tugral Alici, MD
Department of Orthopedics and Traumatology
University of Maltepe, Istanbul, Turkey
Feyzullah Cad. No:39 34843

Email: tugrulalici71@hotmail.com

1Asistant Prof. , Department of Orthopaedics & Traumatology, Maltepe University, Istanbul.
2Department of Orthopaedics & Traumatology, Vakif Gureba Training and Research Hospital, Istanbul.
3Department of Orthopaedics & Traumatology, Vakif Gureba Training and Research Hospital, Istanbul.
4Prof., Department of Orthopaedics & Traumatology, Maltepe University, Istanbul.

© The Foot & Ankle Journal, 2009