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Sunday, December 30, 2018

Cartiva vs. Arthrosurface vs Modified Keller for Hallux Rigidus: Email Advice


Dear Dr. Blake,


I hope you’re doing well. 
 I writing to ask your opinion on options for revisions to a failed Cartiva implant that I had done a year ago to address my long term hallux rigidus.  My problems started 25 years ago with a traumatic injury. While running on a road median, I managed to step into a hole that was obscured by long grass.  I went down like the coyote in the roadrunner cartoons, but had no noticeable injuries other than some minor grass burns.  I ran for another 2 miles and felt fine until I stopped running. I took ~5 steps walking then felt intense pain in my right big toe joint.  I iced it, took a couple weeks off, and thought I had recovered until a year later when I started feeling pain in the joint and an X-ray showed I had developed arthritis. After years of reading about this condition, my best guess is that I jammed the joint severely, and the trauma resulted in longer term deterioration of the cartilage.  I was able to run with orthotics for about 20 years, but eventually couldn’t get orthotics that helped.  I had to stop running about 4 years ago because I had worn out the medial meniscus in my right knee, probably from compensation for the hallux rigidus.  I started using a dancers pad instead of orthotics since the orthotics offloaded the big toe, but onloaded the outside of my foot which put more load on the medial side of my knee.  I shifted my cardio to rowing or an elliptical machine, which don’t aggravate the toe or my knee, but the hallux rigidus still caused my daily discomfort from just walking . ( I’ve read your blog for years and realize that I’ve been more fortunate than many people with this condition, but it eventually caught up with me.)
Dr. Blake's comment: This is normal that 20 years after an old injury, the deterioration begins to give us symptoms. I am happy that you got those 20 years of running on apparently great orthotic devices. Kudos to the provider who made them!!
I had avoided surgery because I was advised years ago that the surgical options aren’t great (a fact that I’ve confirmed in researching the condition other doctor’s recommendations).  About 18 months ago I came across reports of the Cartiva implant, which seemed attractive because of the published high success rate, seemed less invasive than a metal implant like Arthosurface, and because it had been used in Europe for 10 years so I presumed it was a well understood procedure.   I got a list of surgeons trained in Cartiva procedure, and saw one who had done it over 50 times, and eventually had the operation in Dec 2017.  I had lots of post op swelling and pain, tried physical therapy 7 months after the operation which took care of badly knotted muscles in my foot and ankle, but a follow up x-ray last Oct showed the inplant had subsided into the hallux bone so I had very little space in the joint.  I’ve attached a paper I found recently that describes the failure mechanism.  Anecdotally it seems that the success rate in America is less than the initial clinical trial paper, and I know the guidance on recovery times and the implant procedure have changed since I had my operation.
Dr. Blake's comment: It seems like 10-20% failure rate for implants is normal over a 5 year period. You chose well finding someone with experience at least. I am glad these are being converted to Arthrosurface hemicap so you can avoid fusion for now. I attached the Arthosurface blog and a video of the conversion. The Cartiva does take out very little original bone, so seems perfect (remember I am not a surgeon but I try to be logical) to convert to the Arthrosurface. I do not know why the Cartiva literature does not talk about cheilectomies first or Arthrosurface to try to avoid surgery. But I am happy to learn if someone knows.
The orthopedic surgeon who did my Cartiva implant said my only option for revision was a fusion, something I’ve been trying to avoid.  There’s a video on youtube that shows an Arthosurface hemicap revision after a failed Cartiva, so I got a list of doctors in my area for an Arthosurface consult. (Just because a procedure has been done once doesn’t mean it’s widely recommended).  I went to a podiatrist who does surgery, who turned out to have done both Cartiva and Arthosurface procedure (he didn’t show up when I got a list of doctors certified for Cartiva when I was looking for doctors in 2017).  We had a very informative conversation about various options for my toe.   First, he said my surgeon had done a good job on my Cartiva procedure (good joint alignment, good scar, etc)  He said his experience with Cartiva was not as good as the original clinical results, and the surgical guidance for Cartiva  had changed in the past year to leave the implant sticking further out to account for implant subsidence into the bone. He did not recommend an Arthosurface procedure, saying that I’d likely need another procedure in a few years.   After talking about fusion for a while, looking at X-rays, he thought I was too limited,  and suggested that a Keeler procedure would be a good alternative to fusion with similar long term results.  His opinion was that an orthopedic surgeon would favor a fusion as more robust, but that a podiatric surgeon would favor options that preserved natural motion.  I’ve found one reference that discussed the Keeler procedure for hallux rigidus and found comparable long term results to fusion, but would welcome your opinion. I’ve found shoe and supplement combinations that limit my discomfort, but I would like to get my toe taken care of sometime in the next few months.
Dr. Blake's comment: The Keller procedure removes most of the base of the big toe at the joint. The joint would not hurt and you could use it. The procedure permanently weakens the joint, but orthotics, taping, strengthening, could help. You can not run with your knee anyway. It is not high tech!!! Must be good then!! If you let me know where you live, I can send you a list of sports podiatrists that you can run this by. Interesting!! I sure hope I have helped you.

Here is an article supporting Modified Keller to Arthrodesis (joint fusion)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918259/

Best Regards




This article states that synthetic cartilage implants have a 10% chance of removal and joint fusion in 2 years, and another 8% more by 5 years.
https://www.ncbi.nlm.nih.gov/pubmed/30501401


Another article on synthetic cartilage noted excellent results with only 1 of 27 or 4% needing fusion, 2 of the original patients lost to follow up.
https://www.ncbi.nlm.nih.gov/pubmed/27909032




This article states that it is a viable surgery before fusion is recommended.


https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0891842217300952?returnurl=null&referrer=null


Our office uses the Hemi-Cap from ArthroSurface. This article shows no conversion to fusion after 3 years.
Another excellent article on Hemi-Cap. 13% were revised by 3 years in some way. "At 60 months, all patients reported excellent satisfaction with their current state and would repeat the procedure. Implant survivorship was 87% at 5 years. Of the 30 implants, 4 were revised at 3 years."
https://www.ncbi.nlm.nih.gov/pubmed/23407017


Here is the arthrosurface blog
https://www.arthrosurface.com/blog/




Here is the revision from Cartiva to ArthroSurface.


https://youtu.be/VHHlDAT_eLA




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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.