Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Sesamoidectomy — surgical excision of the medial (tibial) or lateral (fibular) sesamoid bone of the first metatarsophalangeal joint — is the definitive treatment for avascular necrosis, osteomyelitis, irreparable fracture, and refractory sesamoiditis that has failed all conservative measures. The procedure carries a significant risk of iatrogenic hallux valgus (after tibial sesamoidectomy) or hallux varus (after fibular sesamoidectomy) from disruption of the flexor hallucis brevis tendon balance — and meticulous anatomical FHB repair and tendon rebalancing are the critical technical steps that determine whether the patient has a good functional result or an iatrogenic deformity worse than the original condition.

Indications and Preoperative Planning

Sesamoidectomy indications: avascular necrosis (MRI confirmed) refractory to prolonged offloading (>6 months); osteomyelitis from plantar ulceration that cannot be eradicated without bone removal; irreparable comminuted fracture nonunion; chronic sesamoiditis >12 months with failed conservative care (orthotics, dancer’s pad, cortisone injection). Choosing which sesamoid to excise: always excise only one sesamoid — bilateral sesamoidectomy produces severe instability of the first MTP joint, hallux valgus, and loss of push-off function; if only one sesamoid is pathological, excise only that one; if both are involved (rare — diabetic osteomyelitis), alternative procedures should be considered. Tibial (medial) sesamoid risk — hallux valgus: the tibial sesamoid crista (medial crease) and FHB medial head insertion are the primary stabilizers of the hallux against lateral drift; resection destabilizes the medial column and allows the hallux to drift laterally from the FHB lateral head’s unopposed pull. Fibular (lateral) sesamoid risk — hallux varus: conversely, fibular sesamoidectomy with FHB lateral head disruption allows medial drift (hallux varus).

Surgical Technique and FHB Repair

Tibial sesamoidectomy approach: medial plantar approach (not dorsal medial — the dorsal approach risks the hallux plantar-medial digital nerve); direct dissection onto the sesamoid avoiding the FHB medial tendon; sharp periosteal dissection of the sesamoid from the surrounding FHB tendon capsule; complete excision with osteotomes preserving as much FHB tendon as possible. FHB repair (critical step): the remaining FHB medial head tendon is advanced and repaired to the medial capsule and the plantar plate with non-absorbable sutures; the repair must be performed under sufficient tension to prevent medial capsule insufficiency; excessive plantar-medial capsular release increases hallux valgus risk. Fibular sesamoidectomy: lateral plantar approach; FHB lateral head tendon preserved and advanced; conjoined tendon of the FHB lateral head and adductor hallucis repaired to restore lateral stability. Postoperative: protected weight-bearing in a postoperative shoe × 4–6 weeks; hallux position monitored on weight-bearing X-rays at 6 weeks; early deformity addressed with K-wire or splinting. Dr. Biernacki at Balance Foot & Ankle performs sesamoidectomy with anatomic FHB repair to prevent hallux deformity at our Bloomfield Hills and Howell offices. Call (810) 206-1402.

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Frequently Asked Questions

Can bunions be corrected without surgery?

Bunion correctors and orthotics cannot reverse a bunion, but they can significantly reduce pain, slow progression, and improve function. Surgery is the only way to permanently correct the deformity — but conservative care often manages symptoms effectively for years.

How long does bunion surgery recovery take?

Recovery varies by procedure. Most patients are in a surgical boot for 4–6 weeks, return to regular shoes at 8–12 weeks, and are fully recovered with normal footwear at 3–6 months. Minimally invasive techniques often have faster recovery.

Do bunions come back after surgery?

Recurrence rates are low with modern surgical techniques (5–10%). Risk is reduced by wearing appropriate footwear after surgery and using custom orthotics to correct the underlying biomechanics that caused the bunion.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Township offices.

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Sesamoid Surgery in Michigan

Balance Foot & Ankle performs expert sesamoid excision for chronic fractures and avascular necrosis. Our podiatric surgeons use precise techniques to prevent hallux deformity and restore pain-free walking.

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Clinical References

1. Cohen BE. Hallux sesamoid disorders. Foot Ankle Clin. 2009;14(1):91-104.
2. Aper RL, et al. The effect of hallux sesamoid excision on the flexor hallucis longus moment arm. Clin Orthop Relat Res. 1996;(325):209-217.
3. Lee S, et al. Sesamoid disorders of the first metatarsophalangeal joint. Clin Podiatr Med Surg. 2019;36(3):409-422.