Cartiva implant reduces toe pain, improves motion

Surgery to put Cartiva Synthetic Cartilage Implants in the large joints of my big toes has reduced pain and restored motion and function.

By last October, I was down to exactly three pairs of shoes I could wear – a pair of cork bed sandals, my combat boots, and my hiking shoes. I had cut way back on physical activity — I dropped karate classes, stopped running, and tried my best to keep going to spin class and walking lots — but my feet were still sore and swollen. The bone bumps kept getting larger. Over a few years, I had developed arthritis in my big toes.

About big toe arthritis

In a healthy joint, cartilage provides a smooth surface for bones to move across as you articulate the joint. When cartilage is destroyed by osteoarthritis, bone rubs on bone, causing inflammation. But cartilage is a tissue that does not regenerate, so the body tries to compensate by growing more bone. That excess bone growth causes pain when it presses on shoes and limits the range of motion of the joint.

X-rays confirmed that I had lost a lot of cartilage in the large big toe joints in both feet. My right foot had grown more excess bone, so I suspect that the degeneration started with an injury in karate class a few years earlier, but I may also have a genetic predisposition for developing osteoarthritis.

Hallux rigidus, the technical name for “big toe arthritis,” is the most common foot arthritis condition that affects 1 in 40 people over the age of 50.

Fun fact: the first metatarsophalangeal (MTP) joint, the large big toe joint, carries about 119% of your body weight with each step.

Cartiva Synthetic Cartilage Implant

The Cartiva Synthetic Cartilage Implant (SCI) is a medical device, the size of a jelly bean, made from hydrogel material that is compatible with the human body. It was designed to have similar properties to human cartilage: it’s compressible and has a low-friction and durable bearing surface. It comes in two sizes, the 8 mm and the 10 mm. I am the proud owner of two 10mm implants. Here is an animated video showing the procedure:

Cartiva MTP Surgical Technique from Cartiva Inc on Vimeo.

What was my other option?

The current standard of care treatment for hallux rigidus is total joint fusion with screws and plates. Fusion is effective for eliminating pain, but it permanently prevents movement of the joint. For me, maintaining mobility was a top priority for physical fitness and long-term health.

What were the clinical study results?

At my consultation appointment, my surgeon advised that they have data showing the device lasts up to 8 years. He expected it would last much longer, but as a new product, they didn’t have data further out. He had performed about 70 procedures at that point and said there were only two cases that he was watching closely that might require revision surgery.

The MOTION clinical study was a 236-patient, multi-centre, prospective, randomized trial that compared Cartiva SCI to total fusion, the standard of care treatment. My surgeon, Timothy Daniels MD, FRCSC was the primary investigator at St. Michael’s Hospital in Toronto, one of 12 sites across Canada and the United Kingdom, and co-author on the published paper.

In the study, patients received either the Cartiva SCI implant or total fusion. The key findings were:

  • Patients in the Cartiva group achieved clinical success of 80% for the composite primary endpoint score for pain, function and safety at 24 months, compared to 79% success for the fusion group. (For my health journalism friends, this was a non-inferiority trial).
  • Patients in the Cartiva group:
    • Achieved a 93% reduction in pain
    • Saw a 168% improvement in ability to perform sporting activities and a 65% improvement in activities of daily living
    • Experienced a 26% improvement in range of motion compared to baseline

If the Cartiva implants didn’t work, I could still have total joint fusion in the future. In the clinical study, less than 10% of the Cartiva implant group needed revision fusion surgery at the two-year mark. Those odds sounded good!

Waiting times!

I asked so many questions at the consultation appointment that my surgeon asked me what I did for a living. After I told him, he suggested that I write about excessive wait times. Here is my timeline:

  • April 2014: Consultation with my family doctor and initial X-rays
  • February 2015: Consultation with orthopedic surgeon
  • October 2o16: Surgery

So all in, from start to finish, it took two and a half years to go from the initial consultation with my family doctor to the surgery date. But wait, there’s more! It would have been even longer if I had not been on the cancellation list. I spoke to my surgeon’s assistant in February 2016 to make sure, and at that point, she was doing call-backs from 2011. I said I would be able to commit to a date on short notice. By October, I got my chance.

Given that I had already waited so long, I agreed right away when the surgeon said I could have both feet repaired in the same operation. It was brave, and a bit tricky getting around the first few days after, but I’m glad I did both feet in one procedure.

Recovery

It’s been about three months now and my feet are healing nicely. I have regained a lot of motion and the pain and swelling have subsided a lot. My right foot is taking longer than the left, but much more excess bone was removed from that foot. I expect my feet will continue to improve over the next three months. I’m able to return to more activities as the weeks go by — I’m back to my spin class, wearing my spin shoes, and I can tolerate standing while biking for part of the class. I’m looking forward to running again in a few months and doing some stair training with a friend when the summer rolls around.

Here is a video, featuring another patient and Dr. Daniels talking about the procedure.

Availability

The Cartiva Synthetic Cartilage Implant is available in Canada. In spite of the long wait time, I’m glad my family physician referred me to Dr. Daniels. In addition to serving as a lead investigator in the MOTION trial, he is head of the Division of Orthopedic Surgery at St. Michael’s Hospital in Toronto.

In the United States, the FDA issued premarket approval for the device in July 2016 and the first patient received implants that month.

Disclaimer: Several people have asked me about my recent foot surgery, so I wrote this blog post to share information. If you have pain due to osteoarthritis in your big toes, this procedure might be an option to discuss with your physician. This information is NOT medical advice. Your mileage may vary. 

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24 Responses to Cartiva implant reduces toe pain, improves motion

  1. Susan Trudeau May 22, 2017 at 2:47 pm #

    Jane,

    Thank you for the encouragement in medical technology of the future! I am in need of surgery on both feet and am seeking out a surgeon in Quebec. Do you know of any in the Montreal area? I have been on a waiting list for a year and a half – my condition is worsening to say the least.

    I actually live in Gatineau – close to Ottawa, but believe the surgeons in Montreal/Qc City area may be using Cartiva.

    Susan

    • Jane May 22, 2017 at 4:53 pm #

      Hi Susan,
      Glad you found my post helpful! I haven’t heard about a surgeon located in Quebec who is doing the procedure. I suggest you check out the Cartiva website and submit a query through their contact form about locating a surgeon in your area https://cartiva.net/. Good luck!

  2. William Viveen May 21, 2017 at 8:10 am #

    Had cartiva surgery April 29 right foot in Grand Rapids Mi. Now after a little over three weeks the toe is still painful. Stitches came out after 15 days. Have hallux rigidus in both toes probably due to a lot of backpacking and genetics. Dr. would not due both feet at once. At this point slightly discouraged and hope i did the right thing. I was getting by with rocker shoes. Foot will not fit into regular shoe yet. Time will tell. Only thing Dr told me was to grap toe and wiggle it up and down periodically.

    • Jane May 22, 2017 at 4:51 pm #

      Hi William,
      Hang in there, recovery to a normal-sized foot does take a while. You are at about a month post-surgery. I found I could get back into regular shoes at about the three-month mark, but your mileage may vary. I also found it helpful to lace my running shoes by intentionally missing the top eyelets and starting lower down, especially on my right foot which is still a bit swollen at the 6-month mark. (Leftie is doing much better, but less excess bone was removed from it). Another trick is to remove insoles to gain a bit of space.

  3. Sandy May 13, 2017 at 8:24 am #

    I found your article during my search for information about Cartiva. I became aware of Cartiva from a tv news report and found only one doctor within a 150 mile distance who performs the procedure (Columbus OH). He has performed only one however. I am wondering why it’s not more widely used here. Your information has been helpful – any words of wisdom in finding a doc qualified for the procedure?

    • Jane May 18, 2017 at 4:33 pm #

      Hi Sandy,
      Cartiva is still pretty new, approved by the FDA last summer. I would recommend contacting the manufacturer to find an orthopedic surgeon in your area. If you scroll to the bottom of this webpage, they have a “find a physician” contact form: https://cartiva.net/. Good luck!

  4. karen skolnik April 24, 2017 at 10:48 pm #

    I had chilectomy and modified arthroplasty in 2015. It is now April 2017 and I am bone on bone, have developed beginnings of spurs again. My doctor said I was a candidate for cartiva and if it failed, fushion would be next best option. Were you bone on bone, stage 3-4 hallux rigidous? I am considering surgery as I am in pain in every shoe. Would like to know more about healing time after this surgery. Thanks, ks

    • Jane April 29, 2017 at 7:55 am #

      Hi Karen,

      I had lost more than half the cartilage and recall that I was stage 3-4 hallux rigidus. So many commenters have asked me about healing time, which is understandable, but it will vary by person. I was walking, gingerly, in the hard-bottom surgical sandals four days later. At two months, I could return to spin classes but stay seated and my right shoe was still pretty tight with a swollen foot, but I’m stubborn. Yes, fusion is possible if the Cartiva option fails. I chose to try Cartiva first for the added mobility and based on the study results that showed faster improvements in pain reduction and return to sports. Note that the study was a non-inferiority trial – so those measures were the same for Cartiva and total fusion at 2 years.

  5. Bruce perone April 9, 2017 at 10:23 am #

    Hi Jane,
    I’m in the USA and they recently allowed this procedure.
    So I went for it in Late December, so at a little over 3 months I don’t feel as if my motion to bend when I walk is there it seems like it just stops and the pain is awfull under the big toe with every step , I went to PT for about 2 months, my question is will this toe bend more in the future and will the pain subside?
    I’m very active and want to run again
    Thanks,
    Bruce

    • Jane April 10, 2017 at 6:27 pm #

      Hi Bruce,
      Everyone heals differently. According to the clinical study, there were large reductions in pain and increases in the range of motion at 3, 6 and 12 months. What does your doctor say? Did you have a lot of excess bone trimmed away as part of the procedure?
      Jane

    • ramona howard April 30, 2017 at 7:23 am #

      Hi Bruce,
      I’m having the same pain and limited mobility as you’ve described. I had my surgery in late January. I go to PT 2-3 times a week and have made some progress but far from what Jane describes. Question, did your physician put your foot in a surgical boot immediately after surgery or a orthotic shoe immediately after surgery. My doctor believes that may have caused some of the problems. She says they are considering eliminating using the boot.

  6. Rosalyn Yellin April 1, 2017 at 12:19 pm #

    Hi! I had cartiva surgery March 1,2017 and I am still swollen and I have mild pain with each step. I’m wondering if the pain is general surgery inflammation that I am feeling. I have some range of motion in my toe as I do the toe exercise the doctor has me doing. I am back in my sneakers. Did you have any pain while walking at first? I don’t have the pain in Birkenstocks (probably because o the rigid bottom)only in my sneakers. When did the swelling go away in your left foot? My main concern is the swelling as I think it hinders healing. Is your right foot still swollen? Thanks!

    • Jane April 3, 2017 at 8:13 pm #

      Yes, I certainly did have pain while walking at first. It’s hard to remember exactly when the swelling went away in my left foot, but I recall a marked improvement at the 3-month mark. My right foot can still swell if I overdo exercise, but is almost caught up to the left foot at the almost 6-month mark. You’re only 1-month post surgery, so it sounds like things are going fairly well. What does your doctor say? Ice and elevation worked well to help reduce the swelling.

      • Rosalyn Yellin April 12, 2017 at 5:29 pm #

        I go back to the doc at 7 weeks post op. I have mild swelling around the joint and almost none in rest of the foot until I am up and about for a few hours then the entire front of the foot swells. It does go away quickly with ice and elevation. Are you able to raise onto your toes? Like stand tippy toe? My toe bends very well and I am very happy with my range of motion but I can’t put weight on my joint if I am elevated. Is that something you can do now? I am a dance fitness instructor and I would like to be able to do that. Thank you for your blog. I appreciate your response.

        • Jane April 16, 2017 at 4:24 pm #

          Hi Rosalyn, I couldn’t rise up onto my toes at 7 weeks, more like around the three-month mark. But your mileage may vary, depending on how much else they did during your procedure. I had a lot more excess bone removed from my right foot, which can still swell if I over do it (spin class and weights class, or like yesterday when I walked more than 10,000 steps).
          Jane

  7. Mary-Lea March 31, 2017 at 7:47 pm #

    Hi Jane,

    I really enjoyed your article as it gave me a good feel as to how the procedure works. I am also going to the Centric Health a Centre to see if I am eligible for the surgery. The rep for Cartivia Canada connected me with the Doctor there. It seems the private route is working towards getting more people treated. I tried to get an appointment with Dr Daniels and I can’t get in until next year which is frustrating. Hope that you continue to enjoy the benefits from the surgery!

    • Jane April 3, 2017 at 8:15 pm #

      Good luck with your surgery, Mary-Lea! I imagine Dr. Daniels is quite popular now since the implant was funded by Health Canada. One of my follow up appointments was with a Fellow instead of Dr. Daniels as he was in the UK giving a talk about the device.

    • Edina April 20, 2017 at 10:28 pm #

      If you don’t mind me asking, what is the price range for this procedure at the health centre?

  8. Michelle March 17, 2017 at 11:00 am #

    Hello! I hope recovery is still going well! I’m in my early 30s and am considering this surgery in hopes of being able to run marathons again! Have you been able to try running yet?

    • Jane March 17, 2017 at 11:39 am #

      Hi Michelle,
      My recovery is coming along, even if it has been slower than I was hoping. My left foot is great, but the right foot had much more excess bone removed and has been taking longer for the swelling to subside. At 4.5 months, my doctor said it could take up to a year for all of the inflammation to calm down, since it’s still an arthritic foot, regardless of the implant.

      So…To answer your question – I tried running on a treadmill in December (at two months) for 15 minutes and it felt great, but my right foot swelled up by evening and was pretty sore. Yesterday, I tried a slow trot for 4 km and was able to keep going just fine. I switched to walking when it felt like my feet had had enough, and this morning they are still fine. I have never run a marathon and have no plans to, but you are much younger. I’ll be happy to be able to run a 5K again a few times a week and have switched to spin classes for cardio. If you want to run marathons again, you should speak to your doctor about whether the Cartiva will help you meet that goal, depending on what’s going on inside your foot.

  9. Vera February 18, 2017 at 2:10 pm #

    I did not realize Cartiva was available in the public system. I am thinking of just using Centric Health, as Cartiva, but not fusion, seemed to be available privately in Ontario with, get this, a one month wait time from start to finish (self-refer too). I feel lucky that feet are not considered “medically necessarily” body parts for some reason in Ontario, so we can skip the queues. The cost privately is about the same as my single dental implant, so certainly doable.

    As a medical writer maybe you would have some knowledge as to why some surgeries, like Cartiva, I can pay for privately but others, like a knee or hip joint, I could not. Is it just feet that are setup this way? I also could get private bunion surgery.

    • Jane February 22, 2017 at 9:34 am #

      Hi Vera,
      I did not know Cartiva was available through private clinics for a fee. However, I’m a skeptic and was glad to have the primary investigator for the MOTION trial do my surgery for this new technology, especially after he said he had performed more than 70 operations.

      We have a mixed-bag of public-private health care options in Canada, further confused by the fact that each province makes its own decisions about which procedures and technologies to fund. From what I could find, it’s low-risk surgeries that can be accessed privately. Knee and hip replacements are more involved surgeries than toe implants. http://healthydebate.ca/2011/07/topic/cost-of-care/publicprivate

      • Lynn March 16, 2017 at 10:05 pm #

        Hello. I’m planing on getting the surgery in the near future. Can you tell me how long it took to go back to work. I’m able to limit my activity at my job. Can you give me details about your surgical experience. Thanks so much. I’ve been putting surgery off but pain to my right great toe is constant now. Lynn

        • Jane March 17, 2017 at 11:28 am #

          Hi Lynn,
          As a freelance writer, I work in a home office and have a short commute. After having both feet done at the same time, I was pretty wiped out on pain meds for the first few days, but up and about on day five and able to work sitting at my desk or the dining room table, with feet elevated on other chairs and resting when I needed to. I was able to go to my son’s graduation on day nine post-surgery and at that point I was still wearing the surgical sandals over the bandages and gauze wrappings. I had stitches out the day after, on day ten, and then wore other shoes as I could find to fit, such as my cork bed Birkenstocks with the buckles loosened or my husband’s hiking shoes if I went outside (not for pain, but for size due to swollen feet). If you are considering surgery for one foot, you could use crutches for the first few days if your foot was not quite ready for weight-bearing.

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