Posted by Dr. David S. Wander on 5/15/07 08:40
The actual procedure(s) performed must always be based on the physical examination, x-ray findings and actual intra-operative findings which reveal the true findings of the joint during surgery.
I will give you my opinion based on my 21 years of experience. I am not an orthopedic surgeon, but I'm a podiatric surgeon that has significant experience treating this condition.
Depending on the condition of the first MTPJ, and most importantly the findings at the actual time of surgery, the choices of procedures really are:
1) Cheilectomy: This is a procedure which is basically a simple 'cleaning up of the joint' and removes any bony proliferation of the joint surfaces that is hindering joint motion. It will not increase the joint space and will sometimes alleviate a significant amount of pain for a given amount of time. It often 'buys' the patient some time. It is by far the 'simplest' procedure and can often result in very satisfying temporary relief.
2) Cheilectomy with osteotomy: This is the same as above, but with a cutting and realignment of the bone. This can only be performed IF there is enough healthy cartilage remaining on the joint surfaces to allow this procedure to be performed. This procedure is based on the theory that it is realigning the joint to a more functionally 'correct' position, to allow the joint to align more correctly and articulate more correctly, eliminating the situation that caused the original problem. This usually is done by lowering the metatarsal bone and/or shortening the metatarsal bone, because many times hallux limitus is caused by an elevated first metatarsal or excessively long first metatarsal. Therefore, by lowering or shortening the first metatarsal, it 'decompresses' the joint and allows for increased motion, decreased pain and a more anatomically correct alignment.
However, recently there has been some controversy regarding the long term benefits of these osteotomies and whether the altered biomechanics caused by this procedure are beneficial in the long run.
3) Joint implants: There are basically three types of implants. Silicone implants that fell out of favor years ago because the silicone was breaking down. Then the manufacturers came up with a solution by making small metal 'grommets' that fit over the ends of the implants to prevent erosion. The second type of implant is a 'hemi', which only replaces one portion of the joint, usually the base of the large toe and is metallic. The third type of implant mimics total knee implants and is a two piece non constrained implant with one piece going into the base of the large toe and one piece going into the metatarsal head.
I am NOT a big fan of first MTPJ implants, ESPECIALLY the two piece implants. I have not seen impressive results with these and have seen some disastrous results with joint jamming, implant loosening and I have personally removed A LOT of these put in by other surgeons. I would stay away from the two piece implant.
4) Fusion/Arthrodesis: This is an end stage and non reversible procedure that fuses the joint in a set position and eliminates motion and eliminates pain. It is usually a VERY successful procedure which eliminates pain and usually has very few complications. If your joint is non-salvageable, I would probably opt for a fusion over an implant, since a fusion is basically forever, and most implants will have to be replaced in about 10-15 years if you are active.
5) Keller type procedure: this is a joint destructive procedure that does not involve a fusion or an implant, but does remove the diseased portion of bone and simply has soft tissue interposed in the area. This procedure is usually reserved for more elderly, less active patients due to biomechanical changes following the procedure.
6) There are more esoteric/exotic procedures that I will not discuss at this time, such as joint distraction procedures, etc., which are beginning to gain popularity but are not yet the 'norm', and other less popular procedures that don't warrant discussion.
Take this information and discuss it with your doctor, who knows your case better than anyone.
Follow Ups To This Message:
Post A Response to this Message:
| |
