Reconstruction of the temporomandibular joint by the transfer of the free vascularised second metatarsal
Introduction
Entin et al. described the use of the second metatarsal as a free bone graft in 1968.1 In 1971 its potential as a non-vascularised free bone graft for bilateral reconstruction of the temporomandibular joint was reported by Dingman.2 It was first used as a free vascularised composite graft for reconstruction of the floor of mouth and mandible but not the temporomandibular joint (TMJ) by Bell and Barron in 1980.3 Ting et al. described the use of a free vascularised second metatarsal for reconstruction of the TMJ in four cases of ankylosis in 1985.4 We have used the technique mainly as a salvage operation to reconstruct the mutilated TMJ in patients who have had several previous attempts at reconstruction.
We describe the surgical anatomy for harvest of the second metatarsal together with the results of the small series of patients who have had this type of reconstruction in our unit during the last 18 years.
Section snippets
Surgical anatomy and graft harvest
The second metatarsal receives its arterial supply from the dorsal metatarsal artery, which is the terminal continuation of the dorsalis pedis artery in the forefoot (Fig. 1). This is the normal anatomy as reported in 91% of cases but it may also arise laterally from the lateral tarsal artery as reported in 9% of cases shown in cadaveric dissections by Lee and Dauber.5 The dorsal metatarsal artery supplies the first and second metatarsal as the artery passes through the interosseous muscle
Results
All our patients were female with an age range 14–45 years. The mean follow-up period was 9.35 years with the longest follow-up being 18 years. One graft failed (case 4) due to technical failure of the anastomosis. The remaining six joints were still functioning well at the time of writing, with good interincisal opening (Table 2). All the functioning joints provided good occlusion and all patients were pain free at rest and reported minimal dietary interference.
Complications included the need
Discussion
There are several ways of reconstructing the TMJ, both autogenous and alloplastic and controversy still exists over the most suitable method of reconstruction.6
Recently, much has been reported about the use of alloplastic reconstructive joint systems.7., 8., 9. The advantages of such reconstructions are said to include reproduction of near normal anatomy, no donor-site morbidity, a reduced risk of recurrent ankylosis and a shorter operative time. Custom-made prostheses are now available which
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