Dr. Michael Campbell discusses how to match the right patient with CARTIVA® for hallux rigidus, along with setting expectations for this surgical option.
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just thanks a lot. That's a great introduction from my talk on Guy. Couldn't agree more with the comments you are making about the proximal phalanx Osti autumn ease for the, uh, Alex rigidness patients where you're trying to do some type of motion sparing procedure. I can't remember the last time now that I've done to collect New York art Eva without one. So I think that's pretty critical and really good. Take home point from this, um so talking a little bit about cart Eva, You know, before cart Eva came along in, You know, 2015 or so you know, was first mtp arthritis a solved problem because we had fusion and we all do fusions, and we're all usually very happy with the results of our fusions because they provide great durability and they provide great pain relief. But there's a problem with fusion. It doesn't allow for someone to come in wearing a pair of high heels, and it doesn't allow for people to do things like run on the beach or or yoga or Pilates. And there is certainly an advantage anytime you're doing the foot and ankle surgery. If you can maintain motion versus losing motion. And you know, this is something that kind of hit home. I trained up in Pennsylvania and I moved and I started my practice in Virginia Beach, Norfolk, And, um, it's a little bit of a different population. I have a lot of really athletic people. I have a lot of people who live at the beach. They spend a lot of time barefoot and walking in the sand and stuff, and selling someone on a fusion is tough sell. Selling someone on the motion sparing procedure is really easy. Um, you know, And like you spoke about earlier, You know, collecting me is a great surgery. And for the earlier stage, how it's Richard is probably all you need to dio. Certainly something, you know, if I open someone up and they've got a bump, but they've got good cartilage, they're not going to get a cart. Eva. There's no reason, Thio, um you know, when it comes to trying to do motion sparing people have tried this in the past on drily, The problem was, the results were unreliable. Hemi Arthur plast ease Total joint replacements, silicone joint replacements, Really none of them had great results in any large studies. And more importantly, like you alluded to earlier, these procedures burn bridges. You know, if you do it a total joint replacement in the first metatarsal. Flynn, Jill, joint. You're gonna lose a lot of bone. Any of us have ever taken out an old silicone Arthur plastic, where there's bad silicone ST Vitus and trying to convert it to a fusion. It's sort of like a bomb went off in there from all the the breakdown. So Kartika came along and I was pretty excited about this because this is really a solution I was looking for, you know, for, uh, that I didn't have a good alternative for And you know, the purpose, the importance for how it's originates patients. You're looking for long term mobility and reduce pain. The Kartika implant. It's indicated for this problem, and it's something that came along with absolutely incredible, uh, research backing it, you know, the bound our study that has been so many times quoted his Level one study Great a Evidence 236 patients. It was the largest randomized multi center trial for first mtp osteoarthritis, so it's always nice when you're talking to your patients and you can say this is the success rate. You know, this is how I can tell you that. And there's and there's riel actual data because there's so many things in foot and ankle in orthopedics in general, where the data is sparse or or low quality. Um, what's nice about that study to is they followed those patients out now, and they have published long term 5.8 year results on what they've shown in nearly six years is there's significant pain reduction, 97% significant functional improvement and good patient satisfaction. Three Other thing that's always nice, just from an efficiency standpoint, is cart Eva surgeries air quick. I could definitely do a cart even faster than I could do a first MTP fusion. On average, it's 23 minutes quicker. So when this came out, I started looking at my patients and collecting data because I wanted to see if it really was working. Um, you know, there was some conflicting evidence in the community, you know, whether it worked or not, and whether the results really were as good as published. So I went back and I followed my patients with FAM scores and pain scores and also range of motion and, you know, going back and looking Between 2016 in 2018 at 87 patients that I did cart Eva on, I had an average follow up 38.7 weeks. Three average patient age was 56.6 with a pretty wide range from 21 all the way to 80. And the results were pretty good. I had, uh, fam 80 else scores of 81.2. Um, and I had pain scores that on average work 0.6 So certainly pretty close. And And this is, you know, this wasn't a perfectly clean study population. This was a real world data. People have had previous procedures people with diabetes, you know, different co morbidity, ease and certainly different activity demands. Of those patients, two of them were converted to fusion and about 7% had some type of complication. Several of them had pain that I treated with a corticosteroid injection. I had one patient who had some pretty significant sesamoid itis. I was probably a bad call. I probably did the wrong procedure because of the sesamoid issue. One patient who had some persistent arthritis afterwards, and I had one patient who had a stress fracture. She was a marathon runner who really pushed the limits with it. Um, clinical data. You know what the recent studies show Things study that was published there is going to be published in July. 2020 ft ankle, um, showed follow up 13.9 months with promised scores and the patients who had had the cart. Eva did really nicely. They had improvement in physical function, pain, interference, pain, intensity on global health domains. Um, what was interesting was what was a negative prognostic factor was patients who had had previous surgery on the M T P J. They tended to have more pain, and what it also showed was something that Hodges was talking about earlier that a failing sauced IATA medium Oberg or a Mohican type of Osti Autumn e tended to be beneficial and helpful. One of the things that's critical of any foot and ankle surgeon is picking the right patient and then setting realistic expectations. So what is the ideal cart Eva patient look like? You want a patient who wants to maintain motion. It's not realistic to expect them to dramatically increase motion just like any total joint replacement. The best predictor of post op motion is pre op motion. They need to have good bone stock to implant the cart. Eva implant into they can't have any significant or severe angular deformities. It doesn't correct a Bunyan on board. It doesn't correct for, says Moya, arthritis. If that's a significant source of their pain, the patient at the I should say, uh, so cart Eva indicated how it's rigidness. Typically for a grade 23 and four. Um, they need to have some motion. If they have no emotion whatsoever, it's probably not gonna be so beneficial. They need to have a reasonable alignment. Contra indications for cart Eva and these air pretty self explanatory. But someone with an active infection, someone who's allergic to that type of implant polyvinyl alcohol, someone who isn't adequate bone stock, Um, or if someone has a you know, you know, Gowdy, Toaff, I things like that, Uh, more than anything, sort of common sense, um, other considerations, things you really need to look closely at, and and more importantly, I think in in my hands into my clinical exam, you know, Are they having pain with, says voids? And then if they've had previous surgery of the great toe, you need to be cautious, and you probably need thio temper their expectations a little bit. Um, in the initial study, 17% of the patients who have persistent pain had some type of fracture or they had a inadequate bone rim Thio contain the cart. Eva, 22% of them who had persistent pain, had diabetes or says mode arthritis, and 17% had had prior surgery. So, for example, I just saw a patient this week who in 2015 I did a collect me on, and she did well initially. But she's developed arthritis. Um, and she's pretty much lost all the emotion, and she has pain. And when she came in and we started talking, I did not bring up Cartier. That's an option, for I just recommend she goes straight to fusion. Realistic expectations are critical. One of the things and and I have another slide that we talk about this, but the pain reduction is graduate cart Eva. It's not as fast as with fusion and really, it takes probably a good 12 months to get to the point where the patient's gonna be as good as they're going to be. Patients receive A. We'll have to gradually return to activities, even though I let them immediately wait there. That doesn't mean they should go back to running or high impact sports. Probably not the perfect thing for someone who's really interested in, you know, extended or long runs or super aggressive athletics. You have to tell them sometimes they don't work. The good part is it doesn't burn any bridges. I think this graph is really critical, and this is actually something that I carry a picture of around on my phone. When I'm talking to a cart Eva Patient, I show them this so they can see your pain will get better, but it's not going to get better At six weeks or three months. You have to be patient. You have to give it some time. It typically around three months, is where you start to see the pain really start to drop off and then somewhere between three months and a year is really where the cart Eva implant is optimal. What's need is if you look at the same graph, but you carry it out from two years to 5.8 years. It maintains, in fact, improves on the pain relief. So this is what I tell my patients when I'm counseling and we're talking about a cart. Eva, my goal is paying improvement and maintaining your current motion. The one of the most important things I try to drive home is immediate weight bearing does not equal immediate recovery, swelling and stiffness or normal initially. And if you lay this down ahead of time and you know what patients you know, expect this, then they're not surprised and they're not worried. And the most important thing is we're not gonna burn a bridge. Thank you, Jeremy. I think it's a little bit about arthritis fusion. Correct. All right. Hey, Way had a couple of questions. Michael. The first is, um, there's, ah, surgeon out in California who has been fairly, um, it says that 50% of the cart Eva's have failed in his practice. Um, what what do you think is the reason he's had a different result than you have? Well, I don't know for sure, obviously, Um, I think there's a couple things you have to take into consideration when you're doing a cart. Eva, I think you have to be careful about who you're putting it in. Um, that's one of the things. It's it's if you have someone who is expecting to go out and run on it or someone who is going to be doing heavy manual labor on it, they're gonna have some degree of pain. It's not really perfect for that. It's better for lower demand folks. Um, I think part of the problem and I think part of it is a confusion. Andi, I think I'll show you in a case towards the end here later. But I think sometimes people you know their patients come back, they x ray it. They look at the X ray and they say, Well, it doesn't look like a normal joint, so therefore it must not have worked. I've seen people who have come to me in second opinion, who they're referring Surgeon is recommending revision and they have little to no pain and they're only four months out from the surgery. You know, in those cases, I think it's just simply just just, you know, not being patient and not understanding. Um, I think 11 issue with the cartoons and something that I'm always very careful with subsidence in patients, especially osteoporotic patients. If you put the implant to deep, sometimes it can fall sort of into a cavity. I always probe after I drill my cart Eva implant to make sure that there's a decent bone block, and I often take some of the remains from the, uh, the rumor that is used to make the whole and I impact shin bone graft the area. And if there's any concern or doubt, I'll even put a little backstop in a little screw or block. Just to make sure that the implant doesn't fall into a cavity in the metatarsal head, you made a mention about the proximal phalanx ost IATA me? What percentage do you think you're adding that at this point I'm adding it 100% of the time? I really don't see a disadvantage to it. If they have any angular deformity, I correct it. If they don't, then I just do ah straight. You know, dorsal Moe Berg, type of Osti Autumn E. It's such a simple, quick procedure. And it Doctor Giuliano, my mentor. He used to say, I've never been sorry for doing an aching, but there's been times where I'm sorry that I haven't. So that's something that I carry around with me. Yeah, I really do think there was a recent paper out of H s s that talked about the patients that had approximate family exhaust. IATA me, um, did better. I think there's something to that and and the more that I talked to folks who continue to love this maybe, and one of them I have made that evolution Thio adding, Approximate families Osiander me, um, contraindications Got a question, um, psoriatic arthritis, even though there no large erosions can use it for for auto immune issues. Well, so I think this is something that's changing. You know, I think I think 20 years ago inflammatory arthritis really required fusion is the only way to treat it. Um, and I think now, with, you know, the better disease modifying rheumatoid agents. Um, if I have a patient who comes in who's really well controlled and it seems like they're doing well, um then I'll consider, you know, conventional bunion surgery as opposed to only go into a fusion. Where. Cart Eva If the patients having pain from inflammatory arthritis, Well, then cart Eva is not going to fix that. It doesn't address the pathology. Really the you know, the cart. Eva is going to be successful when there's loss of cartilage of the metatarsal Flynn deodorant, and that's the source of the pain. So I think that's really the key. Is trying Thio Figure that out? So, you know, if it was a board exam question, I would say definitely it's, you know, it's not the indication for it, but I think in the real world, I think if you have a patient who has an arthritic joint and and it's probably not the inflammatory arthritis and you sort of feel like they're well controlled, then it's reasonable to try it. Um, one other question. Um, there there is a trend, and I've heard this from a couple of folks going, you know, the original cart Eva came out and they said, Make it is Bigas. You can as long as you have two millimeters on either side and and now more and more people are doing a little more aggressive. Collect a me and and going with an eight or even a six rather than a 10. Have you continued with the 10? Or have you changed the sizing at all? I would say the vast majority of mine that I do. At this point, I use an eight, I think for the Daleks MPPJ The six is pretty small, but I try to stay away from the 10 if I can. Just part of it is I think, uh, leaving more bone stock if you have to do something else. Um, I think one of the most important things and I think one of the mechanisms of failure And I had a few of these early on Andi, I've learned from my mistakes in my experience is a lot of times you get the patient who has the osteo fight on the dorsal aspect of approximate failings, and my initial reaction, as soon as I used to open the joint, was to nip that off. But in a lot of cases, I leave that and and by doing so, I could get away with using a smaller cart, even implant, um, if the if the patient has pretty decent motion and you lied. And you take those osteo fights off. And sometimes what I was finding was the cart, Eva the failings with sub blocks under the cart, Eva and sometimes wedge. And then the solution was either you had to bury your cart even deeper. You or you're potentially have something that's gonna be unstable and edge loading. So, um, I one thing that I've learned is I leave that osteo fight in the central portion and actually that allows for a larger range of motion without subluxation and allows me to get away with a smaller cart. Eva implant. I think that's a really good technical trick. Alright, to other questions. You you mentioned the screw, and, uh and have you ever thought about taking down in the M. P J Fusion and converting it cart? Eva, Um, I had one patient who came in with a M p j nonunion times two. And it had the last time it was revised, you know, kind of got the works Bone graft, bone stimulator, vitamin D supplementation, um, augment. You know, everything. You could throw it this thing and it just wouldn't heal Onda in that case. I took it down and revised that to a cart. Eva and he had minimal motion. Um, but he a good pain relief. But, you know, I think the problem is, if you take a standard fusion down, you're not gonna see tremendous motion, so I don't think there would be an advantage, so I certainly wouldn't. Wouldn't look at it. Like the way we maybe you look at a total ankle, you know, ankle fusion takedown. All right, a couple of more quick. Um, I think we're gonna have an X ray with cart, Eva and I can maybe. But when those you you emulate him, quickly fix him with the screw and get him going. Yeah, I typically, uh, typically fix my aching with the staple. And because I'm doing it open with the cart. Eva, Um, and it's just quick and easy, and I let mine walk immediately. Would have been a post op shoot. Um, the new cart, Eva instruments. Now, um, provide you with, um, it leave. Leave the implant proud. 2 to 3 millimeters around three. Have you found you needed to do the little free or trick anymore or the new instruments are are pretty sound. Got the I think the new instruments are definitely better. Um, one is I like how it's sort of it seats the cart, Eva. In the whole, it's less likely to miss and go shooting across the room. Um, but number two I usedto under drill all of mine for that exact reason. And leave him prouder than that. So you don't really, you know, now it Now it's setting for you, and you're not guessing. Yeah, The new instruments do do that. Um, alright. And final is, um um a supposed to previous, especially human implants. Why not interpose soft tissue into the first M p. J is supposed to putting putting another form of implants? Our experience with soft tissue is they get super super stiff regardless of what you put in there. We've tried everything from graft jacket to the patient's own tissue. Um, and carted has been been more consistent. Same thing with you, Michael. Yeah, I've tried several those techniques, and I've never really had anything that was overwhelmingly successful. Eso I'm much happier with the Cartago results personally. So case one Miss Dr Campbell's case. So this is a 52 year old female schoolteacher several years their first MTP joint pain conservative treatment with the Mortons extension and inflammatories. Cortical steroid injection had failed, and they were unable to make it through their school day without an incident and pain ready. They're paying nine out of 10. At the end of the day, the patient reported that the limp up the stairs to go to bed. Um, non significant past medical history, um on exam have about 20 degrees of Doris Reflection. About 10 degrees of plan reflection. They do have an actual grind tests and painted end range. Doris Reflection. No pain under the says voids as a key point. Eso hajj. This This isn't your case. This is Dr Campbell's case. You're looking at these X rays with that history, so no pain under the says voids. But they do have some pain with Grind Limited about a 30 degree arc of motion. What are your thoughts with this 50 something year old patient? What's your conversation going to be like? Yeah, you know, my experience with Collect Amis is that if they don't have a bump to collect me, doesn't do much. And so this is a patient. If this is patient, I would inject. And if the injection helps him even in for a short period of time, I would definitely consider cart Eva in this patient. Um, and And I probably would do, um Oberg also because they're a little stiff. So this is a Coughlin grade 0 to 1, and and I I think it's probably a one. And that's where I would go with this, that if they don't have a bump, I think Kirk, um, kinda like me doesn't work particularly well. And if they had pain under their says voids with a joint that looked like this, would that change your decision making? If I'm clinical exam, they had planner pain for sure, for sure it would because I just think the sad boy is a nonstarter for the motion deriving operations and and I've even to the point said, all right, I need to make that. Sure that says more pain is right, especially in a joint that looks like this. And I'll often doing memory just to make sure that the says boards are involved. And sometimes you know the dorsal pain is the least of it. It really is arthritis and says more joints and in my hands, fusion works better for that. And so here is the patient. Um, Dr Campbell elected to do a cart. Eva for this patient on here, their x rays, 24 months post up any comments, Mike on, um, some of the discussion we had or Hodges about about choosing what case to do. Well, so So I definitely agree with Hodges what he was saying about getting the m r. When you have a patient that has a joint, that doesn't look bad. Um, and you know, for this patient that, you know, this would be something that I would definitely get a memory because I've seen sesamoid pain sort of be very difficult to distinguish from intra articular mtp pathology. And you don't want to get that wrong with cart, Eva, Um, you know the other thing too. This is one of the early ones. I didn't You could say I did it without the Moe Berg, and definitely 100%. Now, this would get a Milberg. This was one of the ones from 2016 that I had longer term follow up, but part of the reason I wanted to pick this was you know, when I look at this post op x ray 24 months, I don't think that joint looks great. Um, you know, it looks to me like there's not a tremendous amount of space and, you know, I think I think if you show this to people that say, Oh, maybe that cart Eva subsided or something. But the reason I picked this was because she had a tremendous outcome with this joint right here. She's having no pain. She's got great motion, not great motion, but, you know, functional motion and improvement over what she had pre operatively and little to no pain. So but definitely again, you know, Adam Oberg to this and the outcomes even better in the motions. Better, and Hodges or Mike for those patients in the audience who have experience with interposition Arthur plastic, whether it be, you know, we alluded to it earlier, whether it be the patient's own tissue or whether it be some of the dermal Allah graphs that are on the market graft, jack or likes, Um, what would you say toe to a provider who might say, Well, I could get justice good. A result with an interposition Arthur plastic rather than a cart. Eva, what would be some points you would make Thio proponent cart Eva by comparison, my experience with those is that they get stiff really stiff and then then you have to do something to the proximal phalanx. And so either you could do a fairly aggressive Moe Berg or you can you could do ah Keller type thing, which is they've all been described. My experience is that they never get their strength back, and so so that they just don't love it. And you think the stiffness is any different than you know? I mean, Mike was saying that this patient didn't have a great arc emotion, but their pain was better. Do you think the stiffness is different enough, or is it mawr? If you have to come back, you know, it's a little easier to address this type of joint. I'm talking. They're just rock stiff and, uh and often with without pain relief. And so then you're coming back to a joint. You've done a bunch of work to and try to do a fusion later. You know those the resurfacing ones that I've done. When you see him a year, two years down the road, there's still kind of swollen and boggy and just just it seems like they get to the point that cart Eva's out at four months and they never get past there. So in my hands, this works better. Okay, um, how we doing on time, folks? Um, yeah, I think we can probably dio Let's do one more Jeremy. And then we'll go from there. Okay, s Oh, this is just a little more data that was presented with Mike's case fans. Score was was very good for this patient, and she did very well. Azaz was pointed out.
