Osteochondral Defect - 3.5 years later

Members do not see these Ads. Sign Up.

Here are three photos. The first two show an osteochondral defect that I debrided and drilled in October of 2004.
The last picture is the same joint on 5/15/08. The defect was filled and relatively smooth.
Hope you enjoy these, it was tough convincing this patient to have surgery just so I could take this follow up picture!!!!!!

Steve

 

Steve, That is an interesting set of pics I've often wondered how these things look down the road.

What was the history of this patient prior to 1st surgery, and did you do anything else at the time. How are the patients symptoms now.

And exactly how did you sell the 2nd surgery?

regards

s

 

Hi Simon:
Pre-op symptoms originally were classic hallux limitus symptoms. Pain on ROM with slight crepitation. There were osteophytes dorsally as well but as you can see, the cartilage (except for the obvious) looked pretty healthy! There was no indication for a joint replacement so I did the debridement. These debridements, in my experience, NEVER give long term relief. I view them as serial procedures.

When she came in this year, I told her I really need a follow up picture for her records, so.............

Only kidding.

She actually did well until this year when she (as normally happens) had a progression of the joint pathology. She could not push off the first ray nor even get an enclosed shoe on without pain. As you can see from the last photo, there were quite a large number of osteophytes on the met. - what you can't see is that her joint was so restricted that I had to take the base of the Prox Phalanx off in order to get the photo.

Steve

 

Hi Steve,

Thanks for the background. Out of curiosity what would be your typical treatment algorithm for management of hallux limitus.

regards

simon

 

"Thanks for the background. Out of curiosity what would be your typical treatment algorithm for management of hallux limitus. "

Hi Simon:
Well, first I need to explain that I specialize in Foot and Ankle Surgery, so most patients that I see have had some previous conservative treatments prior to my examination. I try not to reinvent the wheel and many patients are at the point with their problem that the conservative treatment has not helped and they want it surgically fixed, if possible.

On rare occasions I will get a patient with more pain than I would expect from their exam and radiograph, and I will give them an intraarticular cortisone injection. If this helps for 10 or 12 months I don't mind seeing them once a year for a repeat injection if that's what it takes.

That being said, when I see a patient with arthritis of the 1st MTPJ with radiographic asymmetrical and severe joint narrowing with secondary osteophytic proliferation and posibly a fractured spur, I normally think surgery. If they have a relatively good joint space and perhaps localized specific pain over an osteophyte that may or may not be fractured, I sometimes perform a simple debridement. I may make an intraoperative decision to replace the joint if I feel it's indicated (the cartilage looks worse than I expected.)

For the most part, debridements are serial, meaning I'll see them back at some point in time as the joint becomes more and more arthritic.

The implants I perform are good for at least 13-15 years. I've been doing these long enough to have a pretty good feel for them and having done at least 3 per month times 28 years, that a lot of joint replacements!!!!!! The re-replacement is a simple matter.

Thanks for listening.
Steve

 

Thanks for that Steve,

Have you any preference regarding the implant you use. I have only used double stemmed sillicone impants a handful of times and not over a long enough period to judge their long term outcome.

Do you have a place for decompression type osteotomies, ie Green-Waterman, Youngswick, Kessell- Bonney and the like?

Btw your intra operative pics are beautifully clear, what camera are you using?

cheers

Simon

 

"Have you any preference regarding the implant you use."

I use the Lawrence design Total implant (Futura)
It use to be the La Porta, but lawrence tweeked it a bit and put his name on it.

Steve

 

Osteochondral Lesion of the Talus: Is There a Critical Defect Size for Poor Outcome?
Choi WJ, Park KK, Kim BS, Lee JW.
Am J Sports Med. 2009 Aug 4. [Epub ahead of print]

 

Osteochondral lesions of the talus: predictors of clinical outcome.
Cuttica DJ, Smith WB, Hyer CF, Philbin TM, Berlet GC.
Foot Ankle Int. 2011 Nov;32(11):1045-51.

 

Osteochondral Lesions of the Talus: Effect of Defect Size and Plantarflexion Angle on Ankle Joint Stresses
Kenneth J. Hunt, Arthur T. Lee, Derek P. Lindsey, William Slikker III, Loretta B. Chou
Am J Sports Med February 23, 2012 0363546511434404