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Surgeons put foot in mouth to aid patients with jaw disorder
Portland, Ore. - Surgeons here have tried to cure a patient's excruciating painful temporomandibular joint (TMJ) disorder using her toes to create new joints.
This is the first time the operation has been done to repair damage caused by a Teflon proplast jaw implant-a device prescribed for some TMJ disorder patients until 1991 when it was taken off the market.
The patient was "desperate" and had to give up her work as an intensive-care nurse at the Emanuel Hospital in January 1995 because of uncontrollable pain, according to Dr. Eric Dierks, a maxillofacial surgeon at the hospital.
"The majority of her difficulties were caused by her treatment," he said. Since the first diagnosis of TMJ disorder in 1982, she had 33 operations.
She was among thousands of patients who had Teflon proplast implants. "At the time the Teflon proplast implant was a wonderful thing and initially she did well. In retrospect it was a disaster," said Dr. Dierks in an interview.
Made of smooth Teflon and a porous plastic-like material called proplast, the implant was designed to restore jaw movement and alleviate pain. Instead, it caused irritation, the material shredded, causing the jaw to collapse, leading to further bone erosions, said Dr. Bryce Potter, also a maxillofacial surgeon on the toe transplant team.
"Teflon has a definite and limited lifespan: 10-12 years at best, maybe 15 years," he said. An estimated 26,000 Teflon proplast implants were manufactured but it is not known how many were used.
For the toe transplant operation, two Emanuel Hospital reconstructive microsurgeons, Dr. Mark Buehler and Dr. Kenneth Wilson, removed the second toes from both feet with the blood vessels intact.
Then Dr. Dierks and Dr. Potter fashioned the toes into jaw joints and fixed them to the jaw and the base of the skull. Dr. Buehler and Dr. Wilson used microscopic sutures to connect the artery and veins so the toe graft had a good blood supply.
Dr. Dierks said: "The big toe is pretty important but the second one - the little piggy that stayed home - is pretty expendable and people get along without it very well. She's walking around a bit duck-footed at the moment, but she'll adjust."
The operation took eight and a half hours in total, and the trickiest part was fitting the toe joint into the defective part removed from the TMJ. "It was a close match but not perfect. The second toe is a bit big.
"The digital nerve to the toe was anastomosed to the sensory nerve in the neck to help avoid the formation of a charcot joint-the painless deterioration of a joint only detectable on X-ray," Dr. Dierks said.
People who have suffered TMJ destruction have two options generally: a metal joint held in place with screws or having a piece of their rib or fibula transplanted. "The fibula transplant is vascularized, but it's still a false joint," Dr. Potter said.
Dr. Dierks thinks the toe joint will work because it is a living natural joint contained in a sac with a lubricated slippery lining and its own blood supply. "But it's too early to say whether this procedure has been successful," he said. "I'll declare limited success when she returns to work in a couple of months, but she'll need to be followed up for several years."
A bone scan of the patient three days after surgery showed capilliarization indicating that the grafts were taking.
A tumor patient whose jaw joint on one side was replaced with a single toe in April by the same surgical team is doing well, Dr. Dierks said.
He thinks the Emanuel doctors are probably the first in the world to implant two toes in a patient's jaw at the same time, but noted that toes have been substituted for the TMJ by teams from Shanghai in China and Pittsburg, although "not for specific types of TMJ disorders."
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