Tag Archives: implant arthroplasty

A 12-month review of patients with advanced metatarsophalangeal joint osteoarthritis undergoing synthetic cartilage hemi implant arthroplasty

by James Lee Harmer FCPodS, MSc, BSc (Hons)1*; Anthony John Maher FCPodS, MSc, BSc (Hons)2 

The Foot and Ankle Online Journal 13 (1): 3

The aim of this study was to present patient reported outcomes (PROMS) and complications at 6 and 12 months following metatarsophalangeal joint (MTPJ) hemiarthroplasty with a synthetic cartilage hemi implant in patients with advanced MTPJ arthritic degeneration treated by a surgery team in the English National Health Service. Over a 12-month period between January 2016 and February 2017 a total of 20 patients underwent MTPJ hemiarthroplasty with a synthetic cartilage hemi implant. Patients were reviewed at both 6 and 12 months. All outcome data were collected using the PASCOM-10 audit database, an online resource which is able to report clinical and patient reported outcomes for selected cohorts. At 6 months, 65% of patients felt that their original complaint was now better or much better, while 4 patients (20%) felt their foot condition had deteriorated. At 12 months, 60% of patients felt better or much better and only 1 patient (5%) reported a deterioration in their foot condition. At 6 months 80% of patients felt that their original expectations from before surgery had been met or partly met and 95% reported they would be prepared to have surgery performed under the same conditions again; this reduced to 75% and 80% respectively by 12 months. The most common complication was joint pain and stiffness (60%) at 6 months, and 25% of the cohort had the implant revised to a joint destructive procedure by 12 months. Initial results for the synthetic cartilage hemi implant arthroplasty for the surgical treatment of advanced MTPJ arthritic degeneration were disappointing and did not compare well with previous studies. Although validated PROMS demonstrate a subtle improvement in health related quality of life and patient satisfaction at 6 months and 12 months, the results were not convincing and both complication and revision rates were high. 

Keywords: metatarsophalangeal, osteoarthritis, implant arthroplasty

ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0003

1 – Specialist Registrar in Podiatric Surgery, Nottinghamshire Healthcare NHS Foundation Trust, Department of Podiatric Surgery, Park House Health Centre.
2 – Consultant Podiatric Surgeon, Nottinghamshire Healthcare NHS Foundation Trust, Department of Podiatric Surgery, Park House Health Centre. 
* – Corresponding author: james.harmer@nottshc.nhs.uk

Historically arthrodesis for advanced arthritis of the 1st metatarsal phalangeal joint (MTPJ) was considered as the gold standard, with good reduction in pain and high patient satisfaction levels reported [1]. However, sacrificing the range of motion of the MTPJ following arthrodesis is not ideal, it can restrict footwear, interfere with activities that require joint motion, can lead to transfer metatarsalgia, and arthritic degeneration in adjacent joints [2]. A desire to preserve joint motion has prompted the development of several joint implants, unfortunately many have not lived up to expectations and have demonstrated high rates of failure as a result of loosening, malalignment, dislocation, subsidence, implant fragmentation, and bone loss [3-4]. The advancement of technology has led to the introduction of novel new implants one of which is the Cartiva® synthetic cartilage hemi implant arthroplasty (SCHIA) (Cartiva® Wright Medical Group N.V.). This is a polyvinyl alcohol (PVA) hydrogel MTPJ hemi implant. PVA has been used with great success in several different medical devices but it is particularly useful as a joint implant material as its viscoelasticity and tensile strength are very similar to healthy human articular cartilage [5-8]. 

Initial outcomes for the SCHIA appear promising, Buamhauer and colleagues in an industry funded prospective, randomised, multi-centred, clinical trial named ‘the Motion study’ followed 202 patients at two years and found the implant to be equivalent to 1st MTPJ arthrodesis for advanced hallux rigidus with the added advantage of maintaining dorsiflexion, reducing pain and having few safety concerns [9]. The study used 2:1 randomised allocation in favor of the implant group, 23% of the arthrodesis control group withdrew after initially consenting to randomisation, 152 implant patients and only 50 arthrodesis patients started the trail with a further 4% lost to follow-up by the end of the study. Although unfortunate, this disproportionate ratio of patients between the two groups may bias the results in favor of the implant group. A total of 11% of patients in the implant group underwent revision surgery with 9.2% of the implants failing and having to be converted to a 1st MTPJ arthrodesis. The root cause of the implant failure was not determined or discussed. Although implant patients’ VAS pain scores improved by >30% at 1 and 2 years follow-up these scores were higher than the MTPJ arthrodesis group at all time points, though not statistically significant. 

In a subset of 27 first MTPJ SCHIA patients followed up at five years, Daniel et al., showed an impressive 96% implant survivorship with only one implant having to be removed and converted to arthrodesis [10]. They also demonstrated continued improvements in function and pain scores over the five-year period compared to baseline scores for those patients with retained implants. Postoperative radiographs evaluation showed no bone loss, loosening or wear of the implant, and patient tolerance and satisfaction were high. They conclude that the SCHIA was a viable alternative to first MTPJ arthrodesis in the treatment of patients with advanced hallux rigidus, however generalizability of these results is limited, as only the first 43% of patients from the original RCT were evaluated, and no control group was included to compare results against. More recently the group have published their complete multi-centred midterm results for the SCHIA. They found that clinical and safety outcomes observed at two years were maintained at 5.8 years [11]. It is difficult to determine the relevance of these results as over 15% of patients were removed from the trial following revision to arthrodesis and it is unclear how a further 12% of patients progressed as they were lost to follow-up, hence results for almost a third of the original cohort were absent from the 5-year study.

Although not quite as common and certainly not as well covered in the literature as hallux rigidus lesser MTPJ degenerative joint disease can be equally debilitating and just as challenging for surgeons to treat [12]. Etiology can follow a similar course as a consequence of trauma, either acute or repetitive, and can lead to an interruption in the blood supply commonly affecting the 2nd metatarsal head, but any metatarsal can be affected resulting in avascular necrosis better known as Freiberg’s Infraction [12,13]. Freiberg’s is characterised radiographically by fissuring and fracture of the articular cartilage, leading to collapse and flattening of the metatarsal head, and finally resulting in severe arthritic degeneration of the joint, as described by Smillie in 1914 [13]. Surgical management is driven by the stage of the deformity and presence of arthritic degeneration. In advanced lesser MTPJ arthritic degeneration surgeons tend to shy away from arthrodesis and prefer to opt to maintain joint function with either excisional arthroplasty or implant arthroplasty [12]. The SCHIA is available in several sizes and although it has not received clearance in the USA for use in joints other than the 1st MTPJ, there is potential for it to be used as an alternative surgical option for advanced lesser MTPJ degeneration [14].    

The initial results from the MOTION study look promising, however further studies are still required to help substantiate their findings. The purpose of this study was to present patient reported outcomes and complications at 6 and 12 months following MTPJ SCHIA in patients with advanced MTPJ arthritic degeneration treated by a foot surgery team in the English National Health Service.  


A retrospective case series review of patients and their records was carried out at 6 and 12 months following MTPJ SCHIA. All patients over the age of 18 and who underwent surgery with the synthetic cartilage implant to address painful moderate to severe arthritic degeneration of an MTPJ, were included in the study. Patients with early MTPJ arthritic degeneration with minimal cartilage loss or those who had not previously received conservative care, or had marked transverse plane deformity were not offered surgery with the SCHIA. Over a 12-month period (Between January 2016 and February 2017) a total of 20 patients underwent MTPJ SCHIA. Surgical technique for SCHIA in the 1st MTPJ has previously been described in the literature [4,15].  Our surgical technique for implanting lesser MTPJ synthetic cartilage implants was no different except for the mobilisation of the sesamoid apparatus required in 1st MTPJ’s, all surgeries were combined with a dorsal joint cheilectomy. Surgeries were carried out under local anaesthesia with an ankle tourniquet by one of the department’s three surgeons. All patients were fit and healthy at the time of surgery and classed as either American Society of Anesthesiologists (ASA) 1 or ASA 2 [16] (Table 1). Mean Body Mass Index (BMI) was 27.9 ranging from (18.7 – 39.1) a third of the cohort had a BMI above 30. 

All patients underwent preoperative x-ray evaluation, patients diagnosed with hallux rigidus had their joint degeneration graded using the Coughlin and Shurnas classification system for hallux rigidus [17]. Patients diagnosed with lesser MTPJ degenerative disease were graded according to the Smillie classification system for Freiberg’s infraction [13] (Table 1). Subsequently seventeen 1st MTPJ, two 2nd MTPJ and one 3rd MTPJ hemi-arthroplasties were performed using a size appropriate synthetic cartilage implant. As long as wounds were healed patients returned to supportive footwear at two weeks and started a post-operative physiotherapy programme of 1st MTPJ strengthening and range of motion exercises.   Patients returned to the clinic on request and were reviewed by the authors at 6 months and 12 months following their surgical procedures. Governance approval for the study design was sought from Nottinghamshire Healthcare NHS Foundation Trust Research and Development Department.

All outcome data were collected using the PASCOM-10 audit database, an online resource which is able to report clinical and patient reported outcomes for selected cohorts [18]. PASCOM-10 benefits from the inclusion of a patient satisfaction questionnaire, the PSQ-10 [16]. For the measurement of patient-reported outcomes, PASCOM-10 uses the Manchester Oxford Foot/Ankle Questionnaire (MOXFQ), which is a validated measure of health-related quality of life (HRQOL) [19]. The MOXFQ assesses patient outcomes across 3 domains; pain, walking/standing, and social interaction with a maximum score of 100 in each domain. High scores signify poor HRQOL [20]. The PASCOM-10 system includes a reporting package, which was used to extract summary descriptive data for the cohort, this was then transferred into Microsoft Excel for further analysis. Descriptive statistics are presented throughout for demographic and outcome data. 

Minimal clinically important change (MCIC) scores were interrogated for all MOXFQ domains at each postoperative measurement point (6 months and 12 months). MCIC is an anchor based estimate of score change where a patient notices an actual, rather than statistical improvement in their foot health status. In the context of foot surgery, Dawson et al. [21] determined the MCIC estimate to be a 13-point score change across each of the 3 domains. 


All 20 patients completed preoperative MOXFQ questionnaires, 19 patients returned at six months and 18 patients returned at 12 months to complete postoperative MOXFQ, and patient satisfaction PSQ-10 questionnaires. Two patients (10%) were lost to follow-up at 12 months but the remaining 18 patients did return for a final review at a mean 18.95 months (range 11- 24 months). Only one case was a revision procedure following moderate 1st MTPJ degeneration after a hallux valgus correction with scarf and Akin osteotomies. MOXFQ scores improved at 6 months and a further improvement was recorded at 12 months across all three domains compared to baseline scores (See Figure 1). The MOXFQ score change at both 6 and 12 months exceeded the threshold for MCIC demonstrating an actual improvement in patients HRQOL (See Table 2). 

Demographics Measure Number Percentage %
ASA 1 8 40
ASA2 12 60
Female 17 85
Male 3 15
Mean Age 51 years
Age Range 35-72
Joint involvement Hallux Rigidus stage 2* 8 47
Hallux Rigidus stage 3* 8 47
Hallux Rigidus stage 4* 1 6
Lesser Metatarsal II** 2 67
IV** 1 33

Table 1 Patients diagnosed with lesser MTPJ degenerative disease were graded according to the Smillie classification system for Freiberg’s infraction. *Hallux Rigidus Classification (0-IV) Coughlin & Shurnas (2003). **Lesser Metatarsal – Smillie Classification (I-V).

Domain Pre-op 6/12 


Score change 12/12 


Score Change Minimal clinical important difference
Walking 67 47 20 33 34 16
Pain 80 45 35 32 48 12
Social  60 33 27 20 40 24
Mean PSQ-10 76 78

Table 2 Six- and 12-month follow-up: Summary of Mean MOXFQ and PSQ10 Scores.

Sequelae Number Percentage %
6 Months
Joint Pain & Stiffness 12 60
Swelling 2 10
Transfer Metatarsalgia 1 5
Implant failure revised to joint destructive procedure  3

1st MTPJ Arthrodesis

1st MTPJ Primus Implant

2nd MTPJ Interplex Rod

12 Months 
Joint restriction 4 20
Joint Pain & Stiffness 5 25
Implant failure revised to joint destructive procedure  2

1st MTPJ Arthrodesis 


Table 3 Six- and 12-month complications.

Figure 1 MOXFQ scores improved at 6 months and a further improvement was recorded at 12 months across all three domains compared to baseline scores.

Table 2, illustrates patient satisfaction scores recorded using the PSQ10 questionnaire at both 6 and 12 months, scores did meet the benchmark suggested for UK podiatric surgery of 75 and above [22]. Further descriptive data from the PSQ10 questionnaires demonstrated that at 6 months post operation, 65% of patients felt that their original complaint was now better or much better, while 4 patients (20%) felt their foot condition had deteriorated. At 12 months, 60% of patients felt better or much better and only 1 patient (5%) reported a deterioration in their foot condition. At 6 months 80% of patients felt that their original expectations from before surgery had been met or partly met and 95% reported they would be prepared to have surgery performed under the same conditions again, this reduced to 75% and 80% respectively by 12 months.

Within the first six months following surgery 12 patients, 60% of the cohort, had returned complaining of joint pain and stiffness and subsequently underwent MUA with intra-articular corticosteroid injection. Marked swelling was noted in two patients (10%), and one patient (5%) developed transfer metatarsalgia, there were no episodes of suspected or proven post-operative infection (See Table 3). Three implants failed and had to be revised to a joint destructive procedure in the first 6 months, this equated to 15% of the cohort and by 12 months the revision rate had risen to 25% a significantly higher figure than reported by the MOTION study. A further 25% of patients continued to experience pain and stiffness within the joint, and only 20% noticed an improvement in joint ROM at 12 months. Table 3 details the full list of complications recorded at 6 and 12 months following surgery.


In our study population, initial results for SCHIA in the surgical treatment of advanced MTPJ arthritic degeneration were suboptimal and not as good as previous studies stating positive outcomes in over 90% of patients [9-12]. Although validated PROMS demonstrate a subtle improvement in HRQOL and patient satisfaction at 6 months and 12 months, our results were not convincing and both complication and revision rates were high compared to the MOTION study group [9-11]. To our knowledge this is the first study to indicate suboptimal results for the SCHIA. 

Level I evidence from Baumhauer et al., demonstrated extremely promising results for the SCHIA. They found that clinical outcomes of pain, function and safety were equivalent to the gold standard 1st MTP joint arthrodesis, for treating advanced hallux rigidus at two-year follow-up, with the added advantage of improving joint dorsiflexion [9]. Two subsequent studies carried out by the MOTION study group showed these positive outcome scores were consistently maintained at 5.8 years when compared with those observed at two years [9-11]. The improvements from baseline exceeded the MCID for each outcome measure for the vast majority of patients at 5.8 years (90.5%-97.2%) [11]. 

It is difficult to directly compare our results to the previous studies as the study design, methodology and outcomes are dissimilar, however, it is still apparent that our early outcomes for SCHIA did not fare as well as the original study [9]. Within the first six months following surgery 12 patients (60% of the cohort) returned complaining of joint pain and stiffness and subsequently underwent MUA with an intra-articular corticosteroid injection. In a recent retrospective study of 60 patients undergoing 64 SCHIA’s for the management of stage 2-4 hallux rigidus yielded an overall neutral patient satisfaction, mild pain and dysfunction at an average follow up of 15.2 months [23]. Over half of their cohort had at least one injection of corticosteroid for joint pain postoperatively at 2 or more months after surgery, for a total of 79 injections and 82% of injections were given within the first year. As a consequence of our initial results we now routinely counsel patients about the risk of persistent pain and swelling and the potential need for a manipulation under anaesthetic with intra-articular corticosteroid injection within the first 6 months of surgery. 

The MOTION study noted few safety concerns at 2 or 5 years, with overall survivorship of the SCHIA reported to be 84.9% at 5.8 years [11]. Our study noted a lower implant survivorship of 75% at 12 months. Surgical revision rate was therefore high in-comparison with 25% of the cohort having the implant removed and converted to a joint destructive procedure as a result of persistent or recurrent joint pain and stiffness.

A 9.2% surgical revision rate and conversion to a 1st MTPJ arthrodesis at 24 months was reported by the MOTION study. Daniel et al., showed an impressive 96% implant survivorship with only one implant having to be removed and converted to arthrodesis [10]. It should be noted that this was a small subgroup of patients taken from the MOTION study followed up at 5 years, and therefore may not be a true representation of the original cohort. Glazebrook et al., did publish the complete midterm results for the MOTION study and, although there was a loss to follow-up of 17%, they reported a more realistic implant survivorship of 84.9% by 5.8 years [11]. Cassinelli et al., also found excellent implant survivorship of 92%, however they had a reoperation rate of 20% in their short-term follow-up study [23]. A third of patients underwent magnetic resonance imaging (MRI) postoperatively due to persistent pain. Revision surgery included implant removal and conversion to arthrodesis (5 patients), lysis of adhesions (4 patients), Moberg osteotomy (1 patient), and implant exchange with bone grafting for impinging soft tissue or implant subsidence (3 patients). It was not made clear if postoperative MRI imaging was helpful in determining if reoperation was necessary and whether it played a part in deciding whether to retain or remove the implant, but it is clear that this would have added a further expense to an already expensive procedure. A longer-term follow-up of these patients would be useful to evaluate the reoperation success rate and to determine how implant removal and arthrodesis compared with the less aggressive procedures, including implant exchange. All of our revision surgeries involved a joint destructive procedure of either MTPJ arthrodesis or total implant arthroplasty, intraoperatively in all cases the implant was found to have subsided below the cortical bone of the metatarsal head with resultant bony contact between the proximal phalanx and metatarsal head. Due to the advanced arthritic degeneration and the fact that the SCHIA had already failed, we felt that a joint destructive procedure would yield the most reliable surgical outcome for these patients.

Rothermel et al., carried out a systematic review of the available literature and compared the cost of SCHIA and 1st MTPJ arthrodesis. The total direct cost of MTPJ arthrodesis was $3632, using a conservative failure rate of 9.2% with subsequent conversion to MTPJ arthrodesis, the total cost of SCHIA was $4565. They concluded that significantly higher inclusive costs were associated with the SCHIA, and sensitivity analysis revealed that MTPJ fusion was more cost-effective even if the failure rate increased to 15% and SCHIA failure rate was 0% [24].

Other than secondary surgeries carried out for implant failure, the original prospective randomised study does not provide any other information on postoperative complications, nor does it give an explanation for implant failure [9]. Cassinelli et al., thought that implant failure was largely a result of the implant subsiding, they recommended only using SCHIA in patients with adequate bone stock and that leaving the implant prominent may reduce the risk of subsidence [23]. Given our study demographics that included 85% women with a mean age of 51, hence a high portion of our cohort were at high-risk of osteoporosis. This may offer some explanation for the high rate of implant subsidence and our high implant failure rate compared to other studies with a lower female to male ratio and age comparison [9-11]. 

In our study, all patients underwent six-month postoperative x-ray evaluation, typical findings showed marked narrowing of the joint space, proximal impaction of the synthetic cartilage implant into the head of the metatarsal and there was significant arthritic involvement of the sesamoid apparatus. Daniels et al., reviewed 23 of the 27 patients radiographs at five-year follow-up. They reported no signs of implant loosening or subsidence and no evidence of implant wear. Radiographs did show signs of further arthritic joint degeneration compared to baseline films, however none required further surgery [10].    

One of the main reasons patients choose a joint implant procedure over an arthrodesis is to maintain or improve function and joint ROM [2,3,4,8,9,10,11,25]. The MOTION study demonstrated a mean improvement of 27.3% in 1st MTPJ dorsiflexion at 24 months, these improvements in dorsiflexion were maintained at 5.8 years following surgery compared to baseline results [9-11]. In our study 60% of patients noticed an improvement in symptoms at 12 months, however only 20% of patients noticed an improvement in joint ROM, 80% had no improvement or a deterioration in joint ROM with the SCHIA. Cassinelli et al., reported that 14% of patients noticed a restriction in 1st MTPJ ROM postoperatively and were provided with a dynamic splinting device to aid postoperative rehabilitation and improve joint ROM. A further 19% were found to have restricted 1st MTPJ ROM intraoperatively and in these patients in addition to releasing the sesamoids they also added a Moberg dorsiflexion osteotomy of the proximal phalanx in an attempt to restore normal MTPJ ROM and kinematics, none of these patients complained of restricted joint ROM at short-term follow-up [23]. 

Another explanation for our suboptimal results may at least in some part be due to technical error. We feel that whilst being described as a joint resurfacing implant, in actual fact the synthetic cartilage implant has more of a buffer effect and if the Implant is inserted too deep within the metatarsal head there is a greater risk of subsidence due to the softer trabecular bone found in the metatarsal diaphysis. Leaving the Implant significantly prouder will not only reduce the risk of subsidence, as stated by Cassinelli et al., but also distend the joint and increase the implants buffer effect. We found that SCHIA limited the size of the dorsal metatarsal head exostectomy that could be taken, subsequently dorsal joint impingement was more likely, leading to reduced joint dorsiflexion and increased pain at end range of motion. Reducing the size of the implant or placing the implant more plantarly within the metatarsal head may address this issue, further studies on implant position and subsidence are needed. Finally, in advanced hallux rigidus, the sesamoids are often involved, showing significant hypertrophy on x-rays and clinically being ankylosed to the base of the metatarsal head, causing joint pain and stiffness. In our experience despite releasing the sesamoids intraoperatively, SCHIA does not address the sesamoid apparatus and continued plantar joint pain and stiffness was a recurrent issue in our cohort at 6 and 12 month follow-up. 

Limitations of this study lie with its single center retrospective design, small sample size, and short- term follow up, which undermines the reliability of these results. Due to the small cohort of patients we were unable to perform any statistical analysis and instead used descriptive analysis. The low patient numbers were because we quickly stopped using SCHIA to treat advanced arthritic degeneration of the MTPJ’s, as a consequence of cost and suboptimal results noted at early follow-up. We are unable to comment regarding mid to long-term results and perhaps patient satisfaction rates, complications and revision rates may all improve with time in our study population and measures have already been put in place to follow these patients up at 3 and 5 years. 

We acknowledge that combining the outcomes of the 1st MTPJ and lesser MTPJs may be a methodological error, as they are different pathologies and there is no equivalent of the 1st MTPJ sesamoid apparatus in the lesser MTPJs and, moreover, it is not typically salvageable by arthrodesis. However, reviewing the conditions separately would have reduced the numbers in the study further and we do not believe that combining the results in this case has detracted from the purpose of this study, which was to present our initial experience including patient reported outcomes and complications relating to MTPJ SCHIA. 

In conclusion, our initial results for the SCHIA were suboptimal, complication and revision rates were high and did not compare well with previous results published by the MOTION study group. From our experience, we would recommend judicious use of the SCHIA in the surgical treatment of patients with advanced MTPJ arthritic degeneration. We feel that further work around patient selection, implant positioning and subsidence is necessary. 


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Implant arthroplasty versus arthrodesis for end stage hallux rigidus

by Anita Patel DPM1, Steven F Boc DPM FACFAS FACFAO2pdflrg

The Foot and Ankle Online Journal 7 (3): 1

End stage arthritis of the first metatarsophalangeal joint (MTPJ) is a debilitating condition that affects thousands of patients yearly. The treatments for it has been well known and studied for many years, however, controversy still remains with the different surgical options available. Arthrodesis has always been considered the mainstream treatment for advanced hallux rigidus, but with newer technologies and development of more functional implants, implant arthroplasty has become more popular and may someday surpass arthrodesis. The purpose of this paper is to review the two procedures and provide a literature-based comparison of the overall outcomes. Three retrospective studies with variable methods were reviewed and used to compare the two procedures and their results. Utilizing this data, it was concluded that arthrodesis produces overall superior results with better patient satisfaction and fewer complications, but has lower functionality as it does not restore the first MTPJ motion.

Key words: Hallux rigidus, arthrodesis, implant arthroplasty.

ISSN 1941-6806
doi: 10.3827/faoj.2014.0703.0001

Address correspondence to: Anita Patel, DPM PGY-3
e-mail: anitap1084@gmail.com

1 Hahnemann University Hospital. Podiatric Medicine and Surgery/Reconstructive Rearfoot and Ankle Surgery
2 Director, Podiatric Medicine and Surgery/ Reconstructive Rearfoot and Ankle Surgery
Assistant Professor, Department of Surgery, Drexel University College of Medicine

End stage arthritis of the first metatarsophalangeal joint is a painful condition that results in significant limitation of motion of the joint. The condition has been well documented and studied over the years, however, surgical treatment still remains controversial. There are numerous surgical options which can be categorized into joint destructive and joint sparing procedures. Our main focus is to compare arthrodesis and implant arthroplasty for the treatment of end stage hallux rigidus.


There are two main causes of hallux rigidus; congenital or adult-acquired. The congenital form has an onset during the teenage years caused by an underlying structural deformity such as an abnormally long hallux proximal phalanx or a long first metatarsal. The adult acquired form typically affects patients in their 40’s or 50’s due to high impact activities such as running or dancing. Abnormal biomechanics of the foot contribute to hallux rigidus which includes excessive pronation, hypermobile first ray, or metatarsal primus elevatus. Hallux rigidus is most commonly seen bilaterally, however, it can be seen unilaterally in cases when trauma is the cause of the pathology.  Other causes include neuromuscular imbalance, metabolic disorders, or post-surgical complications.

Clinical Presentation

Initially, the patient will present with a painful and stiff big toe joint specifically with weight-bearing forces or increased during activity. Activities that require excessive extension of the first MTPJ will exacerbate the symptoms [3]. They will complain of pain at the first MTPJ when wearing high heeled shoes. Patients may complain of pain with certain shoes due to soft tissue irritation from rubbing of the shoe gear. In earlier stages of the arthritis, pain will mainly be present with palpation to the dorsal aspect of the first metatarsal head with a possible palpable dorsal exostosis on physical exam. As the condition progresses, pain will be present during passive end range of motion of the metatarsophalangeal joint. With severe arthritis, there will be crepitus and pain during midrange motion of the joint. Gait alteration or compensatory changes may also cause lateral metatarsalgia [3]. Other common clinical findings include plantar hyperkeratotic lesions specifically at the plantar aspect of the hallux IPJ.


Today, the most widely used classification for hallux rigidus remains the Regnauld Classification as described below [1]:

  • Grade I: Mild limitation of dorsiflexion, mild dorsal spurring, pain, no sesamoid involvement, subchondral sclerosis, mild sesamoid enlargement.
  • Grade II: Broadening and flattening of the metatarsal head and base of the proximal phalanx, focal joint space narrowing, structural first ray elevatus, osteochondral defect, sesamoid hypertrophy.
  • Grade III: Worsening loss of joint space, near ankylosis, extensive osteophyte formation, osteochondral defects, extensive sesamoid hypertrophy, with or without joint mice.

Treatment for hallux rigidus can be divided into 2 groups: joint sparing versus joint destructive procedures. Joint sparing procedures include cheilectomy, first metatarsal osteotomy, and phalangeal osteotomy.


Figure 1 Radiographic evaluation of hallux rigidus as described by Regnauld. Images A/B corresponds with Grade I/II Regnauld. Images C/D corresponds with Grade III. Images E/F corresponds with Grade IV.

Surgical Treatment

Joint destructive procedures include excisional arthroplasty, implant arthroplasty, and arthrodesis. The procedure chosen is determined by the underlying deformity or the stage of hallux rigidus. In the earlier stages, cheilectomy or a decompression osteotomy of the first metatarsal is sufficient to relieve patient symptoms. However, the patient should be made aware that hallux rigidus is a progressive disorder and further surgical intervention in the future may be necessary. For the later stages of hallux rigidus, implant arthroplasty and arthrodesis are the most viable available options. Prior to any procedure, every surgeon must take into consideration each patient’s biomechanical factors, lifestyle, age, activity level, as well as their overall short-term or long-term expectations to the surgery [2]. Surgeons must also consider their own past outcomes as well as experience and comfort level with the types of procedures proposed [2].

Implant arthroplasty

Implant arthroplasty for the first MTPJ was first introduced in the 1950’s, however, it became more mainstream in the early 1970’s when Dow Cornings’ Swanson-Silastic hemi- implant gained widespread use and acceptance [4]. Within a few years of its use, however, various complications resulted from the implant such as reactive synovitis, fractures of the material, fibrous hyperplasia, and lymphadenitis which discredited these implant [4]. In the late 1970’s to early 1980’s, a variety of new designs created by Swanson, LaPorta, Lawrence, Sgarlato, and Hetal aimed to eliminate these complications by creating new hinged, non-articulating silicone implants with the addition of grommets [4]. These implants were later referred to as second generation first MTPJ implants. The 1990’s brought about different materials such as metallic hemi-implants (unipolar) or total joint implants (bipolar) which reduced the complications from the traditional silicone implants and are still used today.

These newer implants are referred to as third generation first MTPJ implants [5]. The development of these third-generation implants was a result of advancements in technologies and an improvement in the properties of silicone elastomers. [4]. Lawrence et al published a study in March 2013 which discusses the success of these new third-generation implants in 54 patients with 70 implants having an average follow up period of 66.4 months. Patients had an average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score of 88.2 and an average VAS score of 8.5 with 10 being the highest [4].  Very little data is published in the long term success for some of the latest designs, but technology continues to evolve with new advancements in foot and ankle orthopedic biologics being made every day.  Although implants have been around since the 1950’s, they are still evolving and changing, and therefore considered investigational in the minds of some surgeons.


Arthrodesis remains the gold standard surgical treatment for end stage 1st MTPJ arthritis with predicable outcomes and patient satisfaction. The procedure was first described in 1984 for the treatment of hallux valgus. Although  joint functionality is decreased since the motion is completely eliminated, the procedure provides stability through the medial column for a plantigrade foot during ambulation and a stable lever arm for propulsion [3]. Therefore, this procedure is often indicated for patients with an active lifestyle allowing them to return to their daily recreational activities without painful motion at the joint [1].

The main focus for a successful procedure and better overall outcome is not so much the technique used but rather the position of the fusion. The sagittal plane position is determined by the normal declination of the first metatarsal relative to the floor and transverse plane position is based relative to the lesser toes [3]. The hallux should be positioned in 10⁰ of dorsiflexion relative to the weightbearing surface and 15 to 20⁰ of abduction ensuring that the hallux does not impinge against the second toe [6]. In addition, the frontal plane and rotational correction should be maintained in a neutral position making sure the toenail faces straight upward [6]. Fixation is based on surgeon preference but most commonly used with the greatest success are dorsal plates or crossed cannulated screws. Non-union rates for arthrodesis range from 0-23% with union rates ranging from 91-100% [1].


Multiple studies on arthrodesis and implant arthroplasty have been performed with sufficient long term follow-up comparing the two procedures. We reviewed three recent articles describing results from both procedures in attempts to compare outcomes of 1st MTPJ arthrodesis and implant arthroplasty. One study published in 2012 by Kim et al looked at 158 patients (105 female and 53 male). The patients had undergone one of three procedures: arthrodesis, hemi-implant or resectional arthroplasty. The patients were followed for an average of 159 weeks. Function, alignment and subjective assessment of pain were evaluated and their outcomes determined were successful procedure versus need for further intervention. Out of the 158 patients, 51 underwent arthrodesis, 52 hemi-implants and 55 resectional arthroplasty. There were three revisional surgeries performed, two with bone graft and one without.

In the arthrodesis group, complications included non-union, malunion, metatarsalgia and continued first MTPJ pain. Complications in the hemi-implant category included radiolucency around the implant, bony overgrowth into the joint, migration into the joint, dorsal drift of the hallux, cystic changes to the implant, metatarsalgia, elevation of the first ray, subsidence of the implant and continued first MTPJ pain. Two revisional surgeries were performed for this category with removal of implant and resectional arthroplasty. Complications of the arthroplasty group included floating hallux, metatarsalgia, sesamoiditis and remodeling of the first metatarsal head. There were no revisional surgeries required for this group. No statistical significant difference was found when comparing the procedures for function, alignment and subjective pain with an average follow up of 3 years.
A second study published by Raikin et al, in 2008 performed 21 hemi-arthroplasties and 27 arthrodesis in 46 patients. The patients were followed for an average of 79 months. The patient satisfaction rates were quantified in four categories: excellent, good, fair and poor. The outcomes for the hemiarthroplasty were excellent or good for 12 cases, fair in two cases and poor or failed in seven.  The mean pains score level was 2.4 out of 10. There were five hemiarthroplasties that failed, four were revised into arthrodesis and one into revisional hemiarthroplasty. The fusion rate was 100% for the 27 arthrodesis and no revisional surgery was required. The patients were followed for a mean of 30 months and the outcomes for the arthrodesis group was twenty-two excellent or good, four fair, and one poor. The mean pain score level was 0.7 out of 10.

The most recent study conducted by Erdil et al, published in 2013 reviewed 38 patients who had a total joint replacement, hemiarthroplasty or arthrodesis and were followed for at least two years. Out of the 38 cases, 12 were total joint replacement (group A), 14 were hemiarthroplasties (Group B) and 12 were arthrodesis (Group C). Complications of the procedures included one superficial soft tissue infection (Group A), One non-displaced first metatarsal fracture due to non-compliance (Group A), metatarsalgia (Two in group A, Two in group B and Three in group C) and delayed union. There were no major complications that required revisional surgical intervention and were resolved with conservative treatment. Functional outcomes were evaluated using American Orthopaedic Foot and Ankle Society-Hallux metatarsophalangeal interphalangeal  (AOFAS-HMI) scale and Visual analog scale (VAS). With regards to AOFAS-HMI score there was no significant difference between groups A and B. Group C had a significantly lower AOFAS-HMI score which was expected due to the lack of range of motion.  With regards to the VAS score there was also no significance between groups A and B. The VAS score was also decreased in group C.


First metatarsophalangeal joint implant arthroplasty versus arthrodesis in hallux rigidus is a controversial topic and most often depends on each individual case presentation. The studies mentioned above cover multiple methods to quantify each procedure. The first study focused on function, alignment and subjective pain. The second looked at patient satisfaction, and the third study looked at orthopaedic functionality and scoring post surgically. This variety allows us to best analyze the outcomes of each procedure.

The first study by Kim et al. indicated similar long term overall patient satisfaction with both arthrodesis and hemi-implant. The arthrodesis had the least amount of complications and revisional surgical intervention needed but this did not affect the final results as there was no statistical significance in the patient subjective scores. In the study by Raikin et al. where patient satisfaction and pain level were evaluated, arthrodesis supersedes hemiarthroplasty. There were fewer complications with arthrodesis as seen in the other two studies. The study by Erdil et al. also revealed that fewer complications were seen in the arthrodesis group, although the biomechanical functionality is decreased. The total joint and hemiarthroplasties were also successful procedures in this study so they suggested that arthrodesis be considered a salvage procedure if functionality needs to be preserved.

In conclusion, arthrodesis in cases of advanced hallux rigidus is the most successful and reliable procedure when every criteria is taken into consideration. Besides low functionality and maintaining the integrity of the joint, it provides fewer overall complications, lower revisional rates, and higher patient satisfaction. Nonetheless, hemi-arthroplasty and total joint replacement are also viable options that need to be considered in every case, specifically for patients that are less active and wish to maintain their first MTPJ motion.


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