Hallux Rigidus: Fusion or Implant?

By Duane J. Ehredt, Jr., DPM, AACFAS
Wednesday, April 12, 2017

Duane J. Ehredt, Jr., DPM, AACFAS

Hallux Rigidus is the term used to describe a severely painful 1st metacarpophalangeal joint (MPJ) secondary to range of motion limitation and osteoarthritis of the great toe joint. Historically the 1st MPJ arthrodesis procedure has been performed to fuse the great toe joint together, thereby eliminating pain and improving function. There are many long-term clinical studies that have demonstrated the safety and efficacy of this procedure. Despite these excellent results, some clinicians argue the need for joint replacements, citing the fact that the 1st MPJ is an “essential” joint for normal foot function and ambulation. Many patients also find the option of joint replacement initially more attractive and frequently present with the request for a joint replacement.

Unfortunately, the quest for a suitable prosthesis for the great toe joint has been difficult. Clinical studies show varying results, and revision rates tend to be quite high. In addition, most of the clinical studies are less than 5 years in length, making a prediction on long-term survivability nearly impossible. Interestingly, multiple studies comparing 1st MPJ arthrodesis vs. implant arthroplasty demonstrate similar results in patient reported outcomes in regards to pain and function within the first 5 years of the procedure. However, post-operative complications are much more frequent with MPJ replacement arthroplasty. In 2012, Kim et al. reported on the results of a large multicenter comparative study.1 Their results clearly demonstrated an increased complication rate following joint replacement, with revisional surgery frequent. This demonstrates a clear superiority of the 1st MPJ fusion procedure for longterm stability and predictability.

Although these findings are quite striking, I do occasionally perform 1st MPJ replacement in a select group of patients. Interestingly, the candidates for joint replacement are similar to those with end-stage ankle arthritis who qualify for an ankle replacement. These individuals are typically older (>60 years) with low ambulatory demands, and the inability to remain non-weightbearing for a fusion. Also considered are individuals who may require a certain amount of motion or function about the 1st MPJ for work related purposes. However, they are highly educated on the rate of failure and possible need for future revision (which tends to center around a more complicated bone-block arthrodesis procedure).

In summary, 1st MPJ fusion remains the gold standard for surgical treatment of hallux rigidus. However, a select group of patients may benefit from joint replacement. Any surgeon contemplating 1st MPJ fusion should be well versed in patient selection criteria, as well as revisional techniques if necessary.

Dr. Duane Ehredt is board qualified in Foot and Reconstructive Rearfoot/Ankle Surgery by the American Board of Foot and Ankle Surgery, and an Associate of the American College of Foot and Ankle Surgeons. He is an Assistant Professor in Foot and Ankle Surgery at Kent State University College of Podiatric Medicine in Independence OH.