New in Bunion Treatment
On this page are some of the notable, and in my opinion useful, new developments in treatment of bunion deformity.
Cartiva, synthetic cartilage implant
When a patient's great toe joint becomes damaged and painful for any number of reasons, the foot Dr. has two main avenues of surgical treatment. The joint can either be fused in a functional position, or the joint can be replaced with a joint replacement prosthesis. Now, there is a third intermediate option, a partial cartilage surface replacement, the Cartiva procedure. previously, the most reliable and final solution to a painful damaged joint, has been a fusion. This leaves the joint painless but stiff, but it almost never needs additional intervention. Some patients are however put off by the idea of having a permanently stiff joint, and have tended to opt for a joint replacement procedure that preserves flexibility. The problem is that these small prostheses have a limited life span and sometimes don't last for a lifetime. When these prostheses fail, just putting in a new one, or converting to a joint fusion, is not so easy. Lots of bone is usually resected to create a space for a traditional joint replacement prosthesis, and the foot bones are not so big to begin with. Enter the Cartiva procedure, where a very limited amount of bone is resected. The Cartiva procedure is attractive from the standpoint of being less invasive. And, because it leaves the bones largely intact, it doesn't burn any bridges. The Cartiva procedure has been around since 2013, so its real long-term durability is somewhat of an unknown. Our experience with the Cartiva implant has been good, but no man-made material can be expected to last forever, especially in the high stress environment of the human foot. So, our view point is, if the Cartiva implant ever fails, a sufficient amount of bone stock remains to effectively fuse the joint, or convert to yet another joint implant.
Learn more here: https://www.cartiva.net/
A Lapiplasty bunionectomy is a significant refinement of an old bunion correction technique, the Lapidus bunionectomy. For the surgeon, unique single purpose jigs and plates,yeald consistant excellent results, and virtualy eliminates the possibility of bunion recurrence. For the patient, much earlier resumption of weight bearing. Dr Schechter and Dr Singh have taken special trining in this technique.
Learn more here:https://vimeo.com/199272477
Polly L Lactic Acid (PLLA) or similar compound has been available for several years. It is a man-made material related to starch, and similar to the material that absorbable suture has been made of for years. This material has come of age and is now being used to make absorbable fixation pins, screws, implants, and even plates. There are many advantages to using absorbable fixation devices, but also some significant limitations.
No hardware left behind or that has to be removed later (this is the big one). The pins or screws will dissolve slowly and space will gradually fill in with bone.
No metallic hardware is left behind to hinder with future MRI or CT scans.
No pins are left protruding through the skin, which can act as a track for postoperative infection.
Absorbable fixation devices are not as strong as their metallic counterparts and therefor there are limitations to their use.
On very rare occasion, a reaction to the absorbable material has occurred.
Advances in engineering, manufacturing techniques, and materials have made these new devices feasible for use in feet. Large external fixation devices, that look like erector sets that have been grafted on, have been used for leg and arm immobilization for years. Small external fixation devices have also been used on hands and wrists. But these old, small, versions did not have to withstand weight bearing. Now, a new generation of small, incredibly strong and versatile external fixators has emerged. These devices can be used to fixate difficult deformities; distract tight arthritic joints; withstand significant weight bearing, and when the job is done, everything comes out.
What to do about Bunions with Arthritis
I) Joint Surface Revitalization
Any joint in the body can become arthritic, and the great toe joint frequently does. Bunion formation is often the underlying cause for premature arthritis of the joint, but sometimes it’s due to trauma from sports or work injuries. If only a portion of the joint (cartilage) is damaged, then an attempt can be made to revitalize the joint. Traditionally this is done by scraping away the remaining rough, left over, cartilage and exposing the raw bone underneath it. Next, this exposed bone is drilled with multiple very tiny holes that allow bleeding, and a blood clot to form over the surface defect. Over time, this clot is formed and polished by the opposing joint surface, and blood vessels come through the holes to provide nutrition. If all goes well, this clot is converted to a patch of cartilage-like tissue. In the real world this doesn’t always work, or only works temporarily.
Recent evidence suggests that performing the above procedure, followed by gentle distraction of the joint space for several weeks, gives the best results. External fixators (as described above) that are also fitted with a hinge are ideal for this purpose, and permit both distraction and range of motion exercises.
A new technique called O.A.T.S. (an abbreviation for Osteochondral Autograph Transfer System) attempts to transplant joint cartilage, along with its underlying bone, from one "over endowed" joint area to the damaged area. Disposable instrument kits to facilitate this tricky procedure have been created. When it comes to repair of and arthritic bunion with this technique the downfall is in the lack of suitable donor joints. Very few donor cartilage sites in our body have the appropriate Sphericity(shape) to match what’s needed in the great toe joint. This procedure works much better for ankle and knee arthritis.
II) Great-toe Joint Replacement
If the great toe joint is so damaged (arthritic) that it cannot be improved by realignment or surface revitalization, then replacement of the joint with a prosthetic joint is an option. Prosthetic great toe joint replacement has been available since the mid 70’s. It tends to go in and out of favor with each immergence of new joint technology. I think that we still have a long way to go before; uniform, predictable, good results can be expected from this product. However, today’s new products are better then ever, and can be useful in a select group of patients.
Usually, if a joint can no longer be refurbished, I recommend that the joint be fused (an arthrodesis). The results from this procedure are much better than people think, and the outcome is both durable and can accommodate most levels of activity. The exception to this recommendation is a woman that wants to wear heels to work and flats on weekends (or vice versa). An arthrodesis will not meet her needs, and she will be frustrated. This type of patient is pretty much the only one in my practice who gets an implant (prosthetic joint). Even so, there is one major caveat with implants; they have a limited lifespan. Unlike our own living body parts, that are capable of self-repair, manmade parts can’t do this. I tell my patients to expect approximately 10 years from a man-made joint.
III) Fusion (arthrodesis) of arthritic bunions
One of the most reliable methods of treating arthritic bunions is to fuse the joint. That’s right, it will not move anymore. Yes, it will be stiff. No, it is not drastic, as long as the doctor exercises good patient selection. Executed correctly, this procedure gives predictable and lasting results, and interferes minimally with daily activities. As I stated before, unless the patient wants to wear high heels one day, and flip-flops the next, this procedure will work well.
This procedure is not new. However, the incredible abundance of new, miniature, internal fixation technology is making this procedure easier to execute. Holding together big bones with big hardware has always been possible. But holding together small bones requires some versatile, refined devices and space age metals, which are now available.