Excision of fibular sesamoid in modified Keller procedure. With base of proximal phalanx removed and medial eminence excision, exposure of fibular sesamoid is not as difficult from medial incision. A, Operative photograph showing elevation of first metatarsal with strong two-tooth retractor and use of small osteotome to mobilize fibular sesamoid and lateral capsuloligamentous (frequently contracted) structures. Osteotome is between metatarsal head and lateral sesamoid. When mobilization of fibular sesamoid is complete, entire sesamoid is visible for excision. Note chondromalacia of tibial sesamoid articular surface medial to osteotome. B, Fibular sesamoid has been excised, and lateral capsular structures and conjoined tendon (in forceps) have been released. Neurovascular bundle to lateral side of hallux is adjacent to these structures. C, Diagrammatic representation of modified Keller procedure. By excising fibular sesamoid, valgus moment of conjoined tendon of flexor hallucis brevis and adductor hallucis no longer pulls flexor hallucis longus tendon laterally (carrying hallux with it) through capsulosesamoid plantar plate and pulley system. D, Metatarsal head must be lifted dorsally to excise fibular sesamoid under direct vision. E, Note exposure of fibular sesamoid after mobilization of metatarsal head. F, Two 0.062-inch Kirschner wires are drilled distally. G, First metatarsal head is manually displaced laterally, and hallux is placed end-on the first metatarsal. Kirschner wires are drilled proximally across joint. H, Capsule is mobilized dorsally and plantarward. I, 2-0 or 3-0 absorbable sutures placed in purse-string fashion are used for capsular closure. J, Capsule must be closed over joint. Note pins cut off at skin level; they also can be bent at skin level. SEE TECHNIQUE 82.2.