Healing of a Chronic Diabetic Plantar Hallux Ulcer following Surgical Resection of Hallux Interphalangeal Sesamoid

The hallucal interphalangeal sesamoid is often situated within the plantar joint capsule above the long flexor tendon and can cause the formation of a painful hyperkeratotic lesions inferior to the interphalangeal joint (IPJ) of the hallux due to biomechanical abnormalities, especially in the diabetic patient population. It has been well documented that hyperextension of the IPJ of the hallux with plantar hyperkeratotic lesion formation is diagnostic of an interphalangeal sesamoid. This is an important clinical observation since radiographs rarely show the radiolucent, cartilaginous nodule.

A 27-year-old female with diabetic neuropathy presented with a chronic full thickness ulceration under the left hallux at the level of the interphalangeal joint with hallux malleus deformity. Patient had been following up at the local wound care center with little improvement with collagen dressing and offloading. Radiographs obtained were negative for any osseous abnormalities. An MRI was obtained for further evaluation and demonstrated the hallucal interphalangeal sesamoid within the plantar joint capsule and long flexor tendon. The patient underwent surgical resection of the sesamoid and the chronic plantar ulceration showed complete healing in 3.5 weeks status post-surgery.

The location of the seemingly innocuous hallucal interphalangeal sesamoid is associated with the development of several biomechanical and clinical pathologies including plantar ulceration.  The importance of appropriate clinical examination and imaging studies cannot be overstated for diagnosis and treatment of this etiology. This case demonstrates that surgical resection of the offending sesamoid led to full resolution of the chronic ulcer without recurrence.

Trademarked Items (if applicable):

References (if applicable): 1. Martin DE, Blitch EL. Hallux Interphalangeal Joint Ulceration: A Surgical Correction. Podiatry Institute: Update 1997, Chapter 49. 1997

2. Roukis TS, Hurless JS. The Hallucal Interphalangeal Sesamoid. J Foot Ankle Surg. 1996 Jul-Aug;35(4):303-8