Q&A: Treating Osteoarthritis with Toe Implant Surgery

Patients suffering from painful osteoarthritis in the big toe joint, the most common arthritic condition of the foot, are now finding relief from a new surgical implant that has been restoring motion and reducing pain. The Cartiva SCI implant is a small, soft device that replaces damaged cartilage. The Orthopaedic Associates of Central Maryland care center’s foot and ankle specialist Dr. Patrick Maloney was one of the first orthopedic surgeons in the state of Maryland to perform the procedure. We sat down with Dr. Maloney to get a better understanding of the type of patients who could benefit from the surgery and what the procedure entails.

Can you explain what osteoarthritis is, and what patients deal with day-to-day, particularly those who suffer from osteoarthritis in the big toe joint?

In the simplest terms, arthritis occurs when the normal smooth cartilage of a joint wears away and the underlying joint is exposed. As an arthritic patient moves or walks, the big toe joint essentially grinds against itself. Patients with arthritis in the big toe joint often develop bone spurs on the top of the joint, which can rub against their shoes, causing pain and discomfort. 

What are the traditional treatments for osteoarthritis in the big toe joint? 

Non-operatively, we typically recommend a rigid or stiffer soled shoe with an insert to decrease motion through the joint, which stops the joint from grinding and decreases pain. Some physicians also perform steroid injections. I typically do not recommend this treatment because the big toe joint is so small, and the amount of steroid we can inject is so minimal that there is only a week or two of pain relief. Since this is a short-term remedy, I often don’t feel it is worth the procedure.

Surgically, there are several options. A cheilectomy is an early stage surgery in which a foot and ankle surgeon removes painful excess bone. This surgery is typically very successful in patients who have large bone spurs, and most of the cartilage surrounding the joint is still preserved. We can also perform a fusion, which we turn to as a way to correct deformities when there is minimal cartilage and the bones are rubbing directly on each other.

Previously, patients could undergo a silicone implant surgery, but that wasn’t always a successful surgical option. There are also various metal resurfacing options, but the treatment lasts five to 10 years and isn’t a long-term solution because the metal breaks down the bone and leaves a gap. In the case of revision surgery, the physician would have to use a cadaver bone graft to regain bony architecture.

Unlike a bone fusion, the main benefit of the Cartiva implant is that it allows for motion through the big toe joint and patients can eventually return to pursuing most athletic endeavors. It’s an incredibly small device – only 10 millimeters – so we are able to preserve the majority of the patient’s bone. This not only gives patients the full use of their toe joint, but simplifies any future revision surgery.

Can you explain the Cartiva SCI implant surgery?

The surgery requires a roughly three inch incision on the top of the big toe, which allows the surgeon to open the capsule of the joint, remove or clean up any prominent bone spurs and drill a wire into the metatarsal head. Using a drill, the surgeon then creates a small hole in which the device is implanted. After implanting the device, I range the toe to ensure the joint has a smooth range of motion, and then I close the incision. Overall the procedure takes less than an hour.

What does the recovery process look like for patients? 

My recovery protocol includes partial weight bearing in a boot for two weeks following surgery. At the two-week follow up appointment, I examine the incision and remove the stitches if it is healing well. Once the stitches are removed and the incision has healed, patients can start with passive stretching exercises and can wear regular shoes if they feel comfortable. Most patients continue wearing the boot for about a month because of sensitivity surrounding the incision. I see patients again after six weeks for their second post-op appointment, and the majority of patients are in a regular shoe and are able to increase physical activity at that point in recovery. 

What types of patients do you recommend for the surgery? 

Patients who have early arthritis and are experiencing pain from bone spurs but still have good range of motion likely wouldn’t need this procedure. On the other hand, patients at the other end of the spectrum who have extensive arthritis and serious deformities in the joint won’t respond well to the implant, and would instead benefit from fusion surgery. Most patients who fall between the two extremes would likely be a fit for the implant surgery. However, we evaluate patients on a case-by-case basis, looking at X-rays and clinical exams, evaluating range of motion, bone spurs and pain levels. 

You first performed the surgery back in October. Do you feel that the initial surgery was a success? 

One of the first patients I worked with had the procedure done in October and was back to work on her feet before the holidays. At the three month post-op visit, the patient had minimal swelling but admitted she had been very active. She was incredibly happy and was already interested in scheduling the procedure for her other big toe.

I have a few other patients who are at the three month post-op milestone and are quite pleased with the recovery process. One of my patients is a professional photographer and does a lot of hiking and walking outdoors, and was back outside within six weeks.

How many times have you performed the surgery to date?

I’ve performed close to ten surgeries at this point. I was one of the first in the state and region to perform the Cartiva implant, and I look forward to offering this surgical option to more osteoarthritis patients in the future. 

How did you become one of the first surgeons to offer this treatment?

I attended a foot and ankle conference last summer, right around the time when the Cartiva implant was approved by the FDA. Cartiva had a booth at the conference, and when speaking with the device representatives, I expressed interest in being trained to perform the procedure. I went through a training module in September and practiced in labs, and was ready to operate by October. 

Do you think the surgery will continue to gain popularity?

Yes, its adoption will likely mirror the success of the procedure in Canada and Europe, where it has been widely utilized since 2002. The FDA recently published five year follow up data on pilot patients who participated in the study, and the results are remarkable. Pilot patients reported satisfaction rates over 90 percent after five years, so we are optimistic that the procedure will continue to do well both in the short term and long term. My patients have read up on the procedure and many have come into my office with the patient booklet printed off the website. The surgery has taken off very quickly and many patients want to have it done.

Dr. Patrick Maloney is a foot and ankle surgeon with expertise in orthopaedic trauma, fracture fixation, deformity correction, complex reconstruction and treatment of arthritic conditions of the ankle and foot. He earned his medical degree from Jefferson Medical College in Philadelphia. He completed his residency at Geisinger Medical Center and was fellowship trained at the Florida Orthopaedic Institute.