Hallux rigidus is the most common arthritic condition affecting the first metatarsophalangeal (MTP) joint, leading to stiffness, pain, and limited range of motion (ROM). This condition becomes particularly debilitating as it progresses, impacting daily activities and overall quality of life. Traditionally, the gold standard treatment for advanced hallux rigidus has been arthrodesis (joint fusion), but this method restricts joint motion. Recently, there has been a growing interest in synthetic cartilage implants, such as the Cartiva implant, which aim to preserve joint function while alleviating pain.
How Common It Is and Who Gets It? (Epidemiology)
Hallux rigidus typically affects middle-aged adults and is more prevalent in individuals who have a family history of foot deformities. It is most common in people with abnormal foot mechanics or who have had trauma to the big toe joint. The condition is more common in women than men, largely due to differences in footwear choices and foot structure.
Why It Happens – Causes (Etiology and Pathophysiology)
Hallux rigidus is caused by osteoarthritis or degenerative joint disease of the first MTP joint. The condition occurs when the cartilage in the joint deteriorates, leading to pain, stiffness, and limited mobility. Contributing factors include:
- Genetic predisposition to foot deformities.
- Previous injuries or trauma to the toe.
- Repetitive stress or pressure on the joint.
How the Body Part Normally Works? (Relevant Anatomy)
The first metatarsophalangeal joint connects the first metatarsal (foot bone) and the proximal phalanx of the big toe. This joint allows for movement necessary for walking, running, and pushing off the ground. In hallux rigidus, the cartilage wears down, causing pain and stiffness, which restricts the movement of the toe and limits the joint’s ability to function normally.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms of hallux rigidus include:
- Pain and stiffness at the base of the big toe.
- Difficulty in moving the toe or engaging in activities like walking or running.
- Swelling around the joint.
- Limited range of motion in the big toe.
- A feeling of grinding or catching in the joint during movement.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis involves:
- Physical examination to check for signs of pain and limited motion in the big toe.
- X-rays to assess the extent of joint degeneration and identify any bony spurs or irregularities.
- MRI or CT scans may be used to provide a more detailed view of the joint and cartilage.
Classification
Hallux rigidus can be classified into stages:
- Stage 1: Mild pain with minimal joint stiffness and no significant changes in the joint.
- Stage 2: Moderate pain, with joint stiffness and the development of osteophytes (bone spurs).
- Stage 3: Severe pain, significant joint stiffness, and a limited range of motion.
Other Problems That Can Feel Similar (Differential Diagnosis)
Other conditions that may mimic hallux rigidus include:
- Bunions (hallux valgus).
- Gout or pseudogout affecting the big toe joint.
- Tendonitis or tendinopathy in the foot.
- Arthritis affecting other joints in the foot.
Treatment Options
Non-Surgical Care
- Wearing wider shoes with a low heel to reduce pressure on the big toe.
- Orthotics to redistribute pressure and improve alignment.
- NSAIDs for pain relief and inflammation.
- Steroid injections to reduce swelling and pain in the joint.
- Physical therapy to maintain joint flexibility and strengthen surrounding muscles.
Surgical Care
- Cartiva Synthetic Cartilage Implant (SCI), which preserves joint function while alleviating pain.
- Arthrodesis (joint fusion), which provides permanent pain relief but eliminates joint motion.
- Osteotomy to realign the bones and improve joint mechanics.
Recovery and What to Expect After Treatment
Recovery after the Cartiva implant procedure generally involves:
- Non-weight bearing for 6 to 8 weeks post-surgery.
- Gradual increase in weight-bearing as healing progresses.
- Physical therapy to restore movement and strength to the foot.
- Full recovery can take 3 to 6 months, with continued monitoring of joint function.
Possible Risks or Side Effects (Complications)
Possible complications include:
- Infection at the surgical site.
- Implant failure or loosening over time.
- Reduced range of motion in the joint.
- Pain or discomfort that may persist despite the implant.
Long-Term Outlook (Prognosis)
The Cartiva implant has a survival rate of 82% at five years, with most patients reporting significant pain relief and improved function. However, some patients may experience a decline in joint motion or require revision surgery in the long term.
Out-of-Pocket Costs
Medicare
CPT Code 28291 – Cartiva Implant Surgery: $154.56
Medicare Part B typically covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans are designed to work alongside Medicare, ensuring comprehensive coverage and reducing your financial responsibility.
If you have Secondary Insurance through TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans generally cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your Cartiva implant surgery is required due to a work-related injury, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly pays for all approved treatments.
No-Fault Insurance
If your surgery is related to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgery and postoperative care. The only potential out-of-pocket expense may be a small deductible or co-payment based on your policy terms.
Example
Michael Anderson underwent Cartiva implant surgery (CPT 28291) for his painful arthritis in the big toe. His estimated Medicare out-of-pocket cost was $154.56. Since Michael had supplemental insurance through AARP Medigap, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is the Cartiva Implant?
A. The Cartiva Synthetic Cartilage Implant (SCI) is a polyvinyl alcohol-based device designed to mimic the properties of natural cartilage, used to treat hallux rigidus by providing pain relief while preserving joint motion.
Q. What is the benefit of the Cartiva Implant over traditional treatments like joint fusion?
A. Unlike joint fusion, which eliminates movement in the big toe, the Cartiva implant allows for continued joint motion while reducing pain, making it an attractive option for patients who want to maintain foot function.
Q. How is the Cartiva Implant procedure performed?
A. The procedure involves removing bone spurs and preparing the joint space for the Cartiva implant, which is then inserted into the joint to restore its natural movement and reduce pain.
Q. How long does the recovery take after the Cartiva Implant procedure?
A. Recovery typically involves 6 to 8 weeks of limited weight-bearing, with most patients able to resume normal activities after 3 to 6 months, depending on healing and rehabilitation progress.
Q. What are the risks associated with the Cartiva Implant?
A. Risks include infection, implant failure, limited motion, and the potential need for revision surgery. However, these risks are generally low and can be managed with proper care and follow-up.
Q. What are the expected outcomes of the Cartiva Implant procedure?
A. The procedure typically results in significant pain relief, improved joint function, and a preserved range of motion, enabling patients to return to daily activities without the need for a fusion.
Q. Is the Cartiva Implant suitable for everyone with hallux rigidus?
A. The Cartiva implant is most effective for patients with mild to moderate hallux rigidus. It is not suitable for patients with advanced arthritis or severe deformities where joint motion is no longer possible.
Q. How long does the Cartiva Implant last?
A. The Cartiva Implant has a survival rate of 82% at five years, and studies suggest that it provides long-term pain relief and functional improvement, though some patients may require revision surgery over time.
Q. How is the Cartiva Implant different from a total joint replacement?
A. Unlike total joint replacement, which replaces the entire joint with a prosthesis, the Cartiva Implant is designed to preserve the natural bone and joint structure, offering a less invasive option while maintaining joint motion.
Q. Can the Cartiva Implant be used for severe cases of hallux rigidus?
A. The Cartiva implant is primarily intended for mild to moderate cases of hallux rigidus. In severe cases, where the joint is extensively damaged, other treatments such as joint fusion or total joint replacement may be more appropriate.
Q. What is the long-term outlook for patients with the Cartiva Implant?
A. Most patients experience long-term pain relief and improved joint function with the Cartiva implant. However, some may experience a decline in joint motion over time, and in rare cases, a revision surgery may be needed.
Q. Will I need to use crutches or a boot after the Cartiva Implant procedure?
A. Yes, after the surgery, you will need to use crutches or a walking boot for several weeks to avoid putting weight on the foot and to allow for healing. Gradual weight-bearing is introduced as recovery progresses.
Q. Can I return to sports after the Cartiva Implant procedure?
A. Most patients can return to low-impact activities such as walking, cycling, and swimming within a few months. High-impact activities like running or jumping may take longer to resume and should be discussed with your surgeon.
Q. How soon can I drive after the Cartiva Implant surgery?
A. Most patients can return to driving within 2 to 4 weeks, as long as they are no longer using narcotic pain medications and have regained enough mobility and strength in the foot to operate a vehicle safely.
Q. How is the Cartiva Implant different from other non-surgical treatments for hallux rigidus?
A. While non-surgical treatments like orthotics, medications, and physical therapy can provide relief, the Cartiva implant addresses the underlying joint issue directly by replacing damaged cartilage, offering more lasting relief for moderate to severe cases.
Q. What should I expect during the first few days after the Cartiva Implant procedure?
A. After surgery, you will experience some swelling and discomfort, which can be managed with pain medications and ice. Elevating the foot and following the surgeon’s post-operative care instructions will help with the healing process.
Summary and Takeaway
The Cartiva Synthetic Cartilage Implant offers a promising solution for patients with hallux rigidus who want to avoid joint fusion and maintain mobility. With positive mid-term results, it represents a viable option for those looking for an effective, motion-sparing treatment. However, continued research and longer-term follow-up are necessary to fully understand its long-term durability and survival.
Clinical Insight & Recent Findings
A new study compared three surgical treatments for hallux rigidus—Cartiva synthetic cartilage implant, allograft interpositional arthroplasty, and arthrodesis. Researchers followed 99 patients and found that while all three procedures improved pain and function, outcomes were better with interpositional arthroplasty and arthrodesis compared to Cartiva implants.Â
Patients with Cartiva implants had slightly less pain relief and functional improvement, and 6% required revision to fusion, though overall satisfaction was similar across groups.Â
The findings suggest Cartiva offers a motion-preserving option, but fusion and biologic interpositional grafts may deliver more reliable functional gains. (“Study comparing Cartiva implant, interpositional arthroplasty, and arthrodesis for hallux rigidus – see PubMed”)
Who Performs This Treatment? (Specialists and Team Involved)
The Cartiva implant procedure is typically performed by orthopedic surgeons specializing in foot and ankle surgery. A multidisciplinary team may also include podiatrists, pain management specialists, and physical therapists for post-operative care.
When to See a Specialist?
If you experience pain, stiffness, or limited motion in the big toe, or if conservative treatments like orthotics and medication are no longer effective, it’s important to consult with an orthopedic surgeon to evaluate whether a Cartiva implant may be right for you.
When to Go to the Emergency Room?
Seek emergency care if:
- Severe pain or swelling occurs at the surgical site.
- Signs of infection such as fever, redness, or drainage from the incision.
- Inability to move the toe or bear weight despite treatment.
What Recovery Really Looks Like?
Post-surgery, you’ll need to wear a boot or walking cast and avoid weight-bearing for the first 6 to 8 weeks. Gradual mobilization with physical therapy will help you regain function. Full recovery typically takes 3 to 6 months, with some patients needing up to a year for complete healing.
What Happens If You Ignore It?
If left untreated, hallux rigidus can cause chronic pain, reduced mobility, and difficulty walking. The condition may progressively worsen, leading to permanent joint damage.
How to Prevent It?
Preventative measures include:
- Wearing proper footwear with adequate toe room.
- Avoiding repetitive trauma to the toe joint.
- Managing existing foot deformities with orthotics.
Nutrition and Bone or Joint Health
Maintaining healthy calcium, vitamin D, and protein intake supports joint health and healing post-surgery. Regular exercise can also help maintain joint flexibility and strength.
Activity and Lifestyle Modifications
Post-surgery, patients should avoid high-impact activities until the joint has fully healed. Gradually resuming physical activities with the help of physical therapy will restore strength and flexibility.
Dr. Mo Athar
