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Cartiva implant failure and sesamoiditis after cheilectomy
(Washington, DC USA)
MTP Cartiva 1 mos & 3 mos Post-Op
52 yo female with R hallux limitus. 3 mos out from a cheilectomy R MTPJ with a Cartiva implant. Surgeon also did a soft tissue release of the sesamoids. I have had continued pain in the sesamoid area since surgery. Post-op images at 1 mos while still walking in a rigid bottom post-op shoe showed the implant appeared to be in good position with decent joint space. 2 mos later I have continued pain with limited ability to bear wt thru the sesamoids, and limited ability to dorsiflex the toe with weight bearing. This pain in the 1st MTP joint is causing alterations in my gait mechanics and I am finding myself walking on the outside of my foot. Incidentally, I had an extensive medial meniscus tear with associated medial compartment articular cartilage tear requiring a significant debridement of both 3 weeks prior to the foot surgery. The inability to bear weight thru the MTP joint of the foot is impacting my ability to rehab and strengthen the knee/leg. Plus the altered gait mechanics from the foot pain is putting increased stress on the medial (injured) compartment of the knee. So getting the foot better is even more important because of the impact it is having on the knee. I am attending PT.
XR at 3 mos post-op now shows resorption of the implant and the joint space has significantly decreased. There is talk of maybe needing to re-do the implant (OMG!). DPM suggested a custom orthotic to possibly help with the sesamoid pain plus allow me to be more aggressive with my knee rehab. I will use the orthotic for at least a mos then we will re-eval pain and ROM. They scanned my foot and suggested I get an OTC dancers pad to use until the orthotic came in.
The orthotic has arrived. The orthotic has plate specifications for Device Width as Bisect 1st. Posting: Forefoot Intrinsic to casts; Posting: Rearfoot low profile, extrinsic to vertical. Padding: 1/16" padding from distal end to toes.
The left and right orthotics are made to the same specs, but the left foot is not having any issues. There is no dancers pad in the orthotic. I have been having sesamoid pain since the surgery,but not prior to it.
Shouldn't an orthotic for sesamoid pain have a dancer's pad? I have used the orthotic for a cpl days and don't feel like there is any less stress on the sesamoids. Still painful. OTC dancer's pad helped some but tended to move around on my foot requiring repositioning every few hours. Since this was caused by surgery (not a high impact trauma where we'd worry about a fx), would getting a steroid injection soon be reasonable?
Also, how common is it to need to re-do the cartiva implant? It's relatively new in the US, only approved in the middle of 2016, but I haven't come across many studies reporting problems with it. Could the hole drilled to set the implant in have been made too deep? Is it because the implant is a little crooked? If I am now almost bone on bone, could that be why I am having pain with dorsifexion? There is no longer a bone spur in the way, but could it be the actual head of the metatarsal and the prox phalanx are colliding?
Thx in advance for your feedback.
Let me start off by saying that I have no personal experience with the Cartiva implant, but the exciting "feature" of this type of implant is that it will create a synthetic or artificial cartilage over the head of the first metatarsal bone which is something silastic and metal implants cannot do. Silastic implants tend to resorb and break down over time, and metal implants tend to wear down bone simply because metal is harder then bone.
I can see by your two x-rays that the joint space has diminished over the period of a few months. I would not be surprised if that is a common finding with this type of implant.
The purpose of implants for hallux rigidus is more to reduce pain and less for creating greater range of motion. I have no hard statistics but am willing to bet that most people who have great toe implants really do not end up with a greater range of motion, but in most cases end up with significant reduction in pain, and at the end of the day, that is what most people want.
Work was done on your sesamoids in an effort to give you further motion in the great toe joint and more then likely as a result, that is why you are having sesamoid pain. Even though you did not have blunt trauma to the sesamoids, you did have surgical trauma and there is always the possibility that there might be a fracture, although more commonly the pain is do to trauma to the ligaments that attach to the sesamoids.
An orthotic would be the advisable option here but based on your narrative I have two issues with your orthotics. 1. They were made narrow by bissecting the first metatarsal which may give you more flexibility in your shoe selection, BUT, will probably aggravate your tibial (medial) sesamoid, since making the orthotic slightly narrow will probably end up pressing into the tibial sesamoid. 2. A dancer's pad should have been built into the orthotic as the sole purpose of the orthotic with the use of the dancer's pad is to take weight off the sesamoids.
Before you consider a cortisone injection, you want to make sure that one of the sesamoids is not fractured. For that you would need a bone scan or MRI as a simple x-ray might not show a small sesamoid fracture. Assuming no fracture, a cortisone injection might not be a bad idea.
I do not know if I would personally recommend another Cartiva implant. From a surgical standpoint, it is not that big a deal, but if it did not work the first time, what will be different the second time?
The views you provided me in the x-ray do not give me enough information to offer any other suggestions. I would be interested in seeing a lateral view as there are certain issues that may be part of your problem.
In summary, my suggestion would be try and get the sesamoid issue in order with a proper orthotic, perhaps a cortisone injection if there is no sesamoid fracture. I would continue with physical therapy in an effort to reduce the pain in the joint.
If your surgeon suggests further surgery, definately get yourself a second opinion. You do not want to fall into the trap of having repeated surgeries on the same joint. Each subsequent surgery creates more scar tissue which can actually make matters worse in this type of situation.
Marc Mitnick DPM
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