Cartiva

[CutsWithFury]

This recent journal article caught my attention and further backs up the argument that Cartiva is not as great as it was originally promoted to be

SAGE Journals: Your gateway to world-class research journals

Subscription and open access journals from SAGE Publishing, the world's leading independent academic publisher.

journals.sagepub.com

I know a lot docs who actually hate it...a lot. There have been several companies who have designed and are actively promoting revision systems for it.

Do you have any first hand experience with Cartiva or dealing with complications? Would love to read what other podiatrists think about it.

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[heybrother]

Curious to hear what people have to say. Can't remember exactly when, but a classmate of mine told me at a conference his residency was putting tons of them in and that they were awesome. Was likely 2-3 years ago.

Addressing First MPJ Arthritis: A Roundtable Discussion

Sharing insights from their experience in treating first MPJ arthritis, these panelists discuss non-surgical modalities, biologics, the cheilectomy, implants and fusion. Is it time to rethink the role of cheilectomy for first metatarsophalangeal joint (MPJ) arthritis? Can biologics have an...

www.podiatrytoday.com

Exploring Revision Options For Failed Cartiva Implant Procedures

Hallux rigidus or osteoarthritis of the first MPJ is a very common problem we see as foot and ankle surgeons. The issue is caused by repetitive microtrauma or an acute traumatic event, which contributes to an arthritic process in the great toe joint. Commonly, I see patients who have moderate to...

www.podiatrytoday.com

https://www.podiatrytoday.com/sites/default/files/2019-08/46-47_PT0919_Cartiva_1.pdf

Another Perspective On The June Cover Story And The Cartiva Implant

The June 2019 cover story, “Addressing First MPJ Arthritis: A Roundtable Discussion,” published in Podiatry Today, provides the reader with an overview of current non-surgical and surgical options for the management of first MPJ osteoarthritis.1 When considering treatment options, it is...

www.podiatrytoday.com

When the Cartiva Big Toe Joint Implant Fails

The Cartiva implant was considered to be a revolution in great toe arthritis therapy. It came out with a splash and the original studies to get the

www.footankleinstitute.com

Cartiva may not be a game changer after all

Professor Hylton B Menz - bio, papers, blog

www.hyltonbmenz.com

 

[Utvolsdpm]

I used them for a while. Not a big fan. Seemed like a crap shoot who would get pain relief. Xrays almost always ended up bone on bone several months out and range of motion was never great. I either use the total arthrosurface or fuse now.

 

[GreenHousePub]

Do you have any first hand experience with Cartiva or dealing with complications? Would love to read what other podiatrists think about it.

Absolute garbage. I always told the patient before that they may need a fusion regardless. Of the ones I put in, no-one got improved range of motion. Half of the people I put em in had acceptable pain reduction so they kept them, others I took out, filled with bone graft and fused.

Would never use them again. I have heard they work better for freibergs.

 

[Redsting]

It never made sense to me cause whats keeping it from recessing with the retrograde pressure on the joint?
I like in2bones Reference Toe.

 

[air bud]

Have multiple well trained very busy friends. Most have used, all hate it.

 

[NatCh]

I put in I think ten of them. I haven’t done any in the last couple of years though. One patient had postop sesamoid pain but the others were happy with their results at their final checkup. I don’t know how they are a few years out.

I think one of the biggest issues that I saw was that surgeons were not following the indications as given by the manufacturer. For example, you can’t use Cartiva for hallux valgus (yet I’ve seen X-rays of an implant in a patient who had a bunion and was unhappy with the results). You can’t use Cartiva if the cartilage erosion is larger than 1cm diameter (yet I’ve seen X-rays of implants in grade 4 ankylosed joints).

Subsidence is a big issue. You can put a small cortical screw (or bent 0.045 k-wire) across the metatarsal behind the Cartiva to try to hold it in place.

I stopped using them because the indications are so narrow and the ideal patient is rare.

One of my happiest patients with the easiest recovery and quickest return to activity was an interpositional arthroplasty using Graft Jacket. I did that one like a decade ago and saw her more recently for something unrelated. Still has excellent, smooth, pain free ROM. I don’t do those any more because it’s expensive, off label, and the literature is thin, but man did I like it.

Mostly I do fusion or an occasional cheilectomy now.

 

[Halux]

We did a lot in residency. Had a lot of subsidence. Natch is right you need to put a screw behind it. Did a lot of revisions for them. The arthrosurface stem fits nicely. I also agree with natch on the graft jacket being much better and you don't burn any bridges with it. Usually lasts 3-5 years in my experience.

 

[G0dFather]

Xrays almost always ended up bone on bone several months out and range of motion was never great

Same here ... the pathology is still there as the patient goes about their life it will just get grinded down

 

[NatCh]

What could work is an implant made of Cartiva material but instead of a plug it would be a cap that goes over the entire met head. You could roll it on like a condom. You could name it Toejan.

 

[G0dFather]

What could work is an implant made of Cartiva material but instead of a plug it would be a cap that goes over the entire met head. You could roll it on like a condom. You could name it Toejan.

Great idea!, but i think the capsule would always interfere and getting it on plantarly would be challenging if you dont want to be too aggressive in the manipulation/dissection

 

[NatCh]

Great idea!, but i think the capsule would always interfere and getting it on plantarly would be challenging if you dont want to be too aggressive in the manipulation/dissection

If the clearance is tight you could use the Toejan Ultra Thins.

 

[air bud]

I still think people underestimate how active people can be with a fusion.

 

[NatCh]

I still think people underestimate how active people can be with a fusion.

Yep. They have a hard time wrapping their head around the idea of no motion.

 

[Scrantonicity]

Good grief, I can't believe the Cartiva is even a thing. Someone fell asleep at the wheel at the FDA when this was approved. I fell for it, and I implanted probably 20-30 of them. They are fun and easy to put in. I'm pretty sure I took at least 10 of them back to surgery to put the Arthrosurface in. The other 20 are probably cursing my name. Arthrosurface even have a stem specifically designed for replacing the Cartiva--that's pretty bad haha.

I would have had better luck with those gummy candies that have the same shape.

 

[NatCh]

I'm not a huge fan of the Arthrosurface either, TBH. I put in dozens then saw many of them return years later with bony overgrowth and/or implant migration. I always was miffed at how ROM was great on the table then gone seemingly the minute the patient came out of anesthesia.

Edit: maybe “dozens” is an overestimation. Couple dozen? I don’t recall exactly.

 

[josebiwasabi]

I've put in a couple of cartiva in training, none as an attending. Was a very easy procedure to do but post op results weren't great. I agree with needing the post screw if you are going to do it.

In fellowship I probably had to revise at least 6 arthrosurfaces to mpj fusions and they had all been implanted less than 2 years prior. They were all done by the same surgeon though, so not sure if that's more of a indictment on the surgeon or the implant.

 

[GreenHousePub]

Honestly I'm a fan of a good ole Youngswick. Not sure why more people don't do them.

 

[dtrack22]

For example, you can’t use Cartiva for hallux valgus (yet I’ve seen X-rays of an implant in a patient who had a bunion and was unhappy with the results)

I don't even offer Cartiva anymore but the above comment is very important in 1st MPJ arthroplasty in general. It's one of the most common reasons I've seen hemi-resurfacing implants fail. You cannot put an implant in a joint that isn't well aligned and expect it to last. Hemicaps can fail relatively quickly if you don't address/correct valgus or elevatus, for example.

One of my happiest patients with the easiest recovery and quickest return to activity was an interpositional arthroplasty using Graft Jacket. I did that one like a decade ago and saw her more recently for something unrelated. Still has excellent, smooth, pain free ROM. I don’t do those any more because it’s expensive, off label, and the literature is thin, but man did I like it.

I was part of an industry performed bench study (sorry, not published) on dermal graft use in larger joints. After tens of thousands of cycles, the dermal matrix was still intact. I think it makes a lot of sense in the 1st MPJ and there is no reason to expect it to fail any sooner than other joint sparing procedures IMO.

 

[DYK343]

I was part of an industry performed bench study (sorry, not published) on dermal graft use in larger joints. After tens of thousands of cycles, the dermal matrix was still intact. I think it makes a lot of sense in the 1st MPJ and there is no reason to expect it to fail any sooner than other joint sparing procedures IMO.

Why did the article fail to be published. Industry didnt get the results they wanted?

I've read an article about graft jacket in the ankle joint for osteoarthritis. If I remember correctly the low population of patients in the under powered study all had 100% pain reduction. No personal experience with it (or cartiva).

 

[NatCh]

Why did the article fail to be published. Industry didnt get the results they wanted?

I've read an article about graft jacket in the ankle joint for osteoarthritis. If I remember correctly the low population of patients in the under powered study all had 100% pain reduction. No personal experience with it (or cartiva).

The articles that I read were authored by a Dr. Berlet (Ortho) and 100% of his patients in the study had pain relief, but he had low numbers, like N=13 or something small.

 

[CutsWithFury]

I can't get on board with dermal substitutes in the ankle for arthritis. Especially if there intrinsic deformity. That's a hard no for me. I do think dermal substitutes in the 1st MTPJ secured with anchors is a reasonable procedure to do. I used to think it was stupid but I have a couple close colleagues who do a lot of them who have seen good results. I honestly would do this rather than do Cartiva or a hemi implant.

 

[dtrack22]

Why did the article fail to be published. Industry didnt get the results they wanted?

It was never really designed to be published. It was essentially R&D with a company, using similar but less sophisticated wear testers that they use to cycle joint implants. The big boys run internal tests that we never hear about all the time. Even good results aren’t necessarily “published” so this wasn’t out of the ordinary.

 

[air bud]

I don't even offer Cartiva anymore but the above comment is very important in 1st MPJ arthroplasty in general. It's one of the most common reasons I've seen hemi-resurfacing implants fail. You cannot put an implant in a joint that isn't well aligned and expect it to last. Hemicaps can fail relatively quickly if you don't address/correct valgus or elevatus, for example.


I was part of an industry performed bench study (sorry, not published) on dermal graft use in larger joints. After tens of thousands of cycles, the dermal matrix was still intact. I think it makes a lot of sense in the 1st MPJ and there is no reason to expect it to fail any sooner than other joint sparing procedures IMO.

That this has to be stated blows mind.

 

[air bud]

I still think people underestimate how active people can be with a fusion.

As in one of the guys who I scrubbed a lot with was a triathlete. Had zero problem putting in runners. Triathletes maybe not...but above average Joe that runs 3-4 miles a week sure.

 

[NatCh]

As in one of the guys who I scrubbed a lot with was a triathlete. Had zero problem putting in runners. Triathletes maybe not...but above average Joe that runs 3-4 miles a week sure.

I don't see any reason to avoid a fusion in a triathlete (assuming no contraindications of course).

 

[Scrantonicity]

I'm not a huge fan of the Arthrosurface either, TBH. I put in dozens then saw many of them return years later with bony overgrowth and/or implant migration. I always was miffed at how ROM was great on the table then gone seemingly the minute the patient came out of anesthesia.

Edit: maybe “dozens” is an overestimation. Couple dozen? I don’t recall exactly.

Hm I've only really seen the bony overgrowth happen once, and it was because the patient did zero range of motion exercises. Bad patient selection, for sure. I let my patients take off the boot and dorsiflex their toe against the floor from day one--I stress that we're trying to avoid adhesions. I usually see a much bloodier dressing change the first week (as compared to a bunion or fusion), and the occasional popped suture, but I haven't seen too much stiffening.

Another mistake I made was doing a Lapidus AND an arthrosurface. The 1st MPJ locked up sure enough, because the patient was unable to do near as much as far as early weight bearing and ROM.

Anyways, I know it's totally surgeon's preference/experience/training, but I have yet to find a reason to stop using the Arthrosurface--wish I knew how many I've put in, but I'm sure it's gotta be over 100 so far in my career--the flaws of the Cartiva, on the other hand, showed up almost immediately for me.

I like fusions too, but say what you want--the active (especially athletic) patient will prefer to be able to bend that 1st MPJ. I give them all the options, and they pick the implant every time. I tell them there is a chance it could go to a fusion down the line, but that could be years and even decades from now.

 

[dtrack22]

You should have some sort of arthroplasty procedure in your tool bag. Personally I use arthrosurface products, I’m open to do interpositional procedures, and I do MIS cheilectomies. You could fuse everyone but there will be certain individuals who don’t do well with it and will likely seek treatment elsewhere. Or will hate you shortly after surgery. Nothing wrong with just not operating on those folks if you don’t believe in anything other than arthrodesis.

 

[CutsWithFury]

You should have some sort of arthroplasty procedure in your tool bag. Personally I use arthrosurface products, I’m open to do interpositional procedures, and I do MIS cheilectomies. You could fuse everyone but there will be certain individuals who don’t do well with it and will likely seek treatment elsewhere. Or will hate you shortly after surgery. Nothing wrong with just not operating on those folks if you don’t believe in anything other than arthrodesis.

I’m a youngswick or fusion or go somewhere else kind of guy

 

[GreenHousePub]

Is there a technical article for using a dermal substitute in the 1st MPJ? I haven't heard of it until now.

 

[NatCh]

Hm I've only really seen the bony overgrowth happen once, and it was because the patient did zero range of motion exercises. Bad patient selection, for sure. I let my patients take off the boot and dorsiflex their toe against the floor from day one--I stress that we're trying to avoid adhesions. I usually see a much bloodier dressing change the first week (as compared to a bunion or fusion), and the occasional popped suture, but I haven't seen too much stiffening.

Another mistake I made was doing a Lapidus AND an arthrosurface. The 1st MPJ locked up sure enough, because the patient was unable to do near as much as far as early weight bearing and ROM.

Anyways, I know it's totally surgeon's preference/experience/training, but I have yet to find a reason to stop using the Arthrosurface--wish I knew how many I've put in, but I'm sure it's gotta be over 100 so far in my career--the flaws of the Cartiva, on the other hand, showed up almost immediately for me.

I like fusions too, but say what you want--the active (especially athletic) patient will prefer to be able to bend that 1st MPJ. I give them all the options, and they pick the implant every time. I tell them there is a chance it could go to a fusion down the line, but that could be years and even decades from now.

Sounds like the implants are working for you, so high five!

 

[NatCh]

Nothing wrong with just not operating on those folks if you don’t believe in anything other than arthrodesis.

I'm at that point with virtually ALL treatment. "This is what I recommend. If you don't like that option I'm sure you can find someone else who will do what you want based upon your Facebook support group recommendations, with inferior results and years of regret. And no, I won't give you a pedi while we're here."

Kidding -- I'm more tactful than that (I think).

 

[NatCh]

Is there a technical article for using a dermal substitute in the 1st MPJ? I haven't heard of it until now.

Look for articles with the name Greg Berlet:

Interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus - PubMed

These excellent early results and lack of complications may be due to the minimal bone resection associated with the procedure. This technique does not require autograft harvesting, is bone-sparing by preserving the plantar plate, and maintains the natural intrinsics of the joint by preserving...

pubmed.ncbi.nlm.nih.gov

Interpositional arthroplasty of the first metatarsophalangeal joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus: 5-year case series follow-up - PubMed

Interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix has led to reliable pain relief and preserved function at an average follow-up of 5.4 years in 6 patients. The authors recommend this technique to active patients with advanced hallux rigidus who want to delay...

pubmed.ncbi.nlm.nih.gov

I can try to describe the procedure to you if you'd like but I think his article(s) have illustrations. Basically you fold the Graft Jacket over the met head like a parachute then suture it in place via two dorsal-plantar tunnels.


More discussion: Podiatry Management Online

 

[Scrantonicity]

Speaking of arthrosurface, they make a "dermal substitute" arthroereisis implant now (if you're a fan of that procedure). Acellular dermis, called the SpiralUp. Anyways, may have some promise. I like that there is no "hard stop" like the titanium implants have when the patient tries to pronate.

Edit: to be clear, I don't work for Arthrosurface--guess I'm just a fanboy lol

 

[Scrantonicity]

Sounds like the implants are working for you, so high five!

*gives awkward high five

 

[NatCh]

Speaking of arthrosurface, they make a "dermal substitute" arthroereisis implant now (if you're a fan of that procedure). Acellular dermis, called the SpiralUp. Anyways, may have some promise. I like that there is no "hard stop" like the titanium implants have when the patient tries to pronate.

Edit: to be clear, I don't work for Arthrosurface--guess I'm just a fanboy lol

Their website shows the SpiralUP as International only and has a link for Medical Tourism. Do you know of approval for use in the USA?

 

[dtrack22]

Is there a technical article for using a dermal substitute in the 1st MPJ?

what natch said. But “interpositional arthroplasty 1st MPJis what you should be searching for. I thought Hyer had a case study/small series/technique type paper on it but I could be wrong

Their website shows the SpiralUP as International only and has a link for Medical Tourism. Do you know of approval for use in the USA?

I’ll ask them if/when it should be available but it might be like their talar resurfacing implant, it’s still not available in the US. I’ll report directly to you at Bachelor. Will need to be in January at least so I’ve got enough days in that my legs are ready to keep up with you.

 

[Scrantonicity]

Their website shows the SpiralUP as International only and has a link for Medical Tourism. Do you know of approval for use in the USA?

I should have mentioned that I've already put in a couple of them, so they must just need to update that on their website. So far so good, but I don't have any long term results yet of course. The only thing I didn't like about the instrumentation was the flimsy guide wire. You have to be super careful not to put a bend in it while you're trialing the sizers. Anyways, pretty cool alternative to the metallic implant--and post op pain seems to be less (could be placebo/bias cause I haven't done a lot of them yet).

 

[NatCh]

I’ll ask them if/when it should be available but I believe much like their talar resurfacing implant, it’s still not available in the US. I’ll report directly to you at Bachelor. Will need to be in January at least so I’ve got enough days in that my legs are ready to keep up with you.

I bet we could figure out a way to get some CME credits out of it...

 

[dtrack22]

I should have mentioned that I've already put in a couple of them

You still have to use questionable billing to get it covered? Or did facility eat the cost? Or did patient pay?

I bet we could figure out a way to get some CME credits out of it...

If I remember correctly we already had some bang up lecture topics brainstormed

 

[ExperiencedDPM]

If the arthroereisis was billed as ANYTHING other than the S code for the device or billed as an unlisted code, then it is considered 100% fraud.

I was hired as an expert by two large insurers who are investigating all providers who have billed more than X number of subtalar arthrodesis procedures or X number of ORIF of a talo tarsal dislocation.

These are for cases that were already paid. They are doing a retro review and are asking for op reports. I have been reading those op reports and let them know of any that were actually an arthroereisis.

They will be asking for refunds. And I can tell you there is one doc who is going to likely have to shut down. He’s been popping these things in like candy for years and every single one was billed fraudulently.

He presently owes back several hundred grand.

 

[CutsWithFury]

If the arthroereisis was billed as ANYTHING other than the S code for the device or billed as an unlisted code, then it is considered 100% fraud.

I was hired as an expert by two large insurers who are investigating all providers who have billed more than X number of subtalar arthrodesis procedures or X number of ORIF of a talo tarsal dislocation.

These are for cases that were already paid. They are doing a retro review and are asking for op reports. I have been reading those op reports and let them know of any that were actually an arthroereisis.

They will be asking for refunds. And I can tell you there is one doc who is going to likely have to shut down. He’s been popping these things in like candy for years and every single one was billed fraudulently.

He presently owes back several hundred grand.

That describes many of the Hyprocure disciples on Instagram or LinkedIn. When you ask them what code they billed for you get defensive responses or no response at all.

Fundamentally, arthroereisis implants are completely useless.

 

[dtrack22]

If the arthroereisis was billed as ANYTHING other than the S code for the device or billed as an unlisted code, then it is considered 100% fraud.

I was hired as an expert by two large insurers who are investigating all providers who have billed more than X number of subtalar arthrodesis procedures or X number of ORIF of a talo tarsal dislocation.

These are for cases that were already paid. They are doing a retro review and are asking for op reports. I have been reading those op reports and let them know of any that were actually an arthroereisis.

They will be asking for refunds. And I can tell you there is one doc who is going to likely have to shut down. He’s been popping these things in like candy for years and every single one was billed fraudulently.

He presently owes back several hundred grand.

If I alert them to someone in Louisiana that does this can I get a finders fee?

 

[DYK343]

Why is there no artheroresis code? Its a thing. There should be a code.

 

[CutsWithFury]

Why is there no artheroresis code? Its a thing. There should be a code.

Huh?

 

[NatCh]

If I remember correctly we already had some bang up lecture topics brainstormed

Haha, woohoo! We can call ourselves the Podiometry Institute and have an entire series of seminars. Do any of you regulars on this forum want to be faculty and give lectures? Let us know!

 

[msuDPM]

Have never put in a cartiva. Considered it once for a grade 1/2 HR with a more significant central lesion, but just opted for the cheilectomy. My most close colleagues have done them with mixed results.

Have done a handful of interpositional arthroplasty +/- plantarflexory (base) osteotomy in younger (30s) people with elevatus. Good results with no pain at discharge. All are probably 18 to 36 months out currently.

As an aside, reading through this and the RFC thread, I would probably be a poor PP pod. In general, I think 1st ray pathology is probably over operated on. If I dont think you need a 1st mpj fusion or lapidus, I'm probably not operating on you. In 4 years (still time to change my mind) I've probably done 5 or 6? Distal bunions and less cheilectomies, while doing 5-10 cases/week.

 

[msuDPM]

Why is there no artheroresis code? Its a thing. There should be a code.

I've never put in in outside of training, but I agree with this. I think they do have a (small) place. Make a code, make it pay equivalent to a neuroma or something. Boom. No more fraud.

 

[Sartorius P.O.D.]

I still think people underestimate how active people can be with a fusion.

The problem with cartiva was when it first came out (prior to wright acquisition) they were marketing it hard as choice for people who wanted to be super active. Those are the WORST patients for the procedure. My residency director was an early consultant and we went from doing a ton my first year to fusing everyone my last year. I feel like most patients are best served by fusion especially if there will be a high mechanical demand on the joint. I often quote this study and have even provided a copy for a patient.

Return to Sports and Physical Activities After First Metatarsophalangeal Joint Arthrodesis in Young Patients - PubMed

Level IV, retrospective case series.

pubmed.ncbi.nlm.nih.gov

 

[dtrack22]

Haha, woohoo! We can call ourselves the Podiometry Institute and have an entire series of seminars. Do any of you regulars on this forum want to be faculty and give lectures? Let us know!

you will be paid in pow.

and I’m pleased to announce that given all of the white stuff on the ground, in the air, and on your face if it’s deep enough...bradlet bakotic will be sponsoring the meeting