Surgical approach to the tibial sesamoid can be either medial or plantar. A low medial longitudinal incision is centred over the 1st metatarsophalangeal joint between the dorsal and plantar cutaneous nerves to the hallux. This incision is deepened to the level of the joint capsule and the capsule is incised in the same plane. The tibial (medial) sesamoid is visualized within the joint capsule beneath the metatarsal head. The capsule is grasped with a clamp and the sesamoid is shelled out with a Beaver No. 64 mini-blade or No. 15 scalpel blade. The fibular (lateral) sesamoid is more difficult to reach through a medial incision, and may be more accessible from a dorsal longitudinal approach, over the first webspace. This is a reasonable approach if the sesamoid is located in the intermetatarsal space.

A plantar approach is indicated for excision of the ulcer, and allows for direct visualization of both sesamoid bones.

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