Hallux Rigidus: Is Arthrodesis Ultimately The Best Option?

Point

Here the authors share evidence from the literature and their own experience that supports arthrodesis as a superior surgical option not only for end-stage hallux rigidus, but for more mid-stage cases of hallux limitus and hallux rigidus as well.

By Troy Boffeli, DPM, FACFAS and Chloe Sakow, DPM, MPH, 

There is no question that the first metatarsophalangeal joint (MPJ) arthrodesis is the gold standard procedure for end-stage hallux rigidus, but more attention is warranted as far as its effectiveness in mid-to-late stage 3 disease. Patients with late stage 2 or early stage 3 hallux limitus/rigidus (HL/HR) can fare well with cheilectomy, especially when cartilage loss is isolated to the dorsal third of the first metatarsal head. Stage 4 will almost always require fusion, although Keller arthroplasty is a consideration for elderly patients, in our experience. The key dilemma that exists with procedure selection is for active patients who present with mid-to-late stage 3 HL/HR. The surgeon and patient must decide whether arthrodesis is the best answer to provide a predictable long term solution despite loss of motion, or if implant arthroplasty is the best answer to restore motion despite the potential need for a more complex fusion procedure later in life.

Does Arthrodesis Inherently Mean That Patients Will Have A Poor Functional Outcome? 

There is a classic assumption by patients and some surgeons as well, that by fusing the joint, the patient will have significant limitations in their postoperative activity. In one study of return to sport after a first MPJ arthrodesis in young patients, subjects rated 27.4 percent of activities as less difficult, 51.2 percent as the same, and 21.4 percent as more difficult postoperatively, reaching their maximal level of sport participation in 88.6 percent of physical activities.¹Overall, patients that able to run prior to surgery will most likely be able to run postoperatively.¹ A prospective gait analysis of patients who underwent first MPJ arthrodesis demonstrated statistically significant improvements in propulsive power, weight-bearing function of the foot and stability during gait after fusion.² Many surgeons have a misconception of poor function after a fusion, which ultimately may bias them towards suggesting first MPJ implant arthroplasty, if they have adequate training and experience in performing that procedure.

In our experience, a well-positioned (neither too dorsiflexed nor plantarflexed) fusion will reliably allow for good postoperative function in active patients. We find that malalignment of the first MPJ following implant arthroplasty can lead to significant pain and disability which may then necessitate a much more complicated revision fusion procedure. Our experience has also shown us that proper positioning in the transverse and sagittal planes at the time of fusion is the key to patient satisfaction and good functional outcomes. We then contend that fusion is therefore more reliable than implant arthroplasty as long as the surgeon achieves solid fusion in the desired position.

What Does The Literature Say About Implant Safety And Patient Satisfaction? 

There are numerous implant arthroplasty options available, but in our observation, most surgeons are only comfortable with one or two (if any). There is an absence of large multicenter trials affirming the intermediate and long-term efficacy and safety profile of specific implants.³ The few quality studies that evaluated implants for first MPJ arthroplasty demonstrate good results for pain relief and patient satisfaction, however there is concern over the longevity and viability of implants secondary to implant failure.³ Radiographically, there may be clear signs of implant loosening, fractures through and surrounding the implant, possibly with abnormal sclerotic, cystic or avascular changes to the bone. Silicone, a common material used in implants, is linked to synovitis and lymphadenopathy.⁴ Titanium and metallic implants have been associated with similar radiographic signs of implant failure, including metallic debris and aseptic implant loosening.⁴ This creates a dilemma for both surgeons and patients, in that one can’t predict who will have a reaction to the implant material or suffer periprosthetic bone complications.

One study by Gibson and colleagues evaluated outcomes for arthrodesis versus total replacement implant arthroplasty for HL/HR in a randomized control trial setting.⁵ At 24 months, although pain improved in both groups, the arthrodesis group had significantly greater improvements (p=0.01). The study noted a greater risk of implant component loosening and necessity of revision arthrodesis in those undergoing implant arthroplasty.⁵ In arthroplasty patients, the range of motion gained was poor and certain patients tended to bear weight on the outer border of their foot.⁵ These results may be due to errors in technique, implant choice and/or surgeon experience, but these issues are less common with fusion.⁵ Overall, the literature points to inconsistent implant arthroplasty outcomes, specifically long-term, when implants are prone to eventual failure.⁵

A Closer Look At More Benefits Of First MPJ Arthrodesis 

In general, implant arthroplasty carries a higher cost of care associated with implant materials and a higher likelihood of a future revision surgery.⁵ Arthrodesis is a permanent procedure, with a longer immediate recovery, but less likely to require a second surgery or additional time off work beyond the initial postoperative period of healing, as we have found in our experience. One should consider the potential cost of a future revision surgery when deciding which procedure is best for a given patient, including the cost of the bone graft, locking plate, OR time, surgeon fees and time off work if the implant fails or wears out.

Many patients with hallux limitus or hallux rigidus also suffer with complicating factors including neuromuscular disorders such as cerebral palsy, peripheral neuropathy and prior stroke, where the most predictable choice in our experience is joint arthrodesis. Additional indications for fusion include infective arthritis, gout and salvage of replacement or resection arthroplasty. First MPJ arthritis with associated hallux valgus also best responds to arthrodesis, with literature supporting low complication rates and high patient satisfaction.⁶

The typical postoperative care plan for first MPJ fusion in our observation involves six weeks of limited weight bearing in a below-the-knee fracture walker. This is a longer and more restrictive recovery process than implant arthroplasty, but the key here is patients will likely only have one recovery period. Studies show that fusion is safe, with few complications that rarely require a secondary surgical procedure. Surgeons can then reasonably reassure patients that they will likely only have to endure one surgery that will last them a lifetime. The biggest problem with implant arthroplasty is the greater likelihood of revision surgery, which typically entails transition to a fusion. The literature suggests that 15 to 58 percent of first MPJ implants do require removal and subsequent revision.⁷ Many patients and surgeons choose implant arthroplasty due to the quicker recovery, but should do so knowing the reasonable risk of needing a more complex fusion procedure in the future.

In Conclusion 

We contend that first MPJ arthrodesis is a reliable, cost-effective option for mid-range HL/HR patients who are interested in a one-stage surgery while maintaining prior athletic function and pain-free activity. The choice between implant arthroplasty and arthrodesis is often biased by surgeon experience and preference, but research demonstrates time and time again that arthrodesis is the option with the best long term outcomes, fewer complications and lower risk of future surgery. 

Dr. Boffeli is the Foot and Ankle Surgical Residency Program Director and Department Chair at Regions Hospital/HealthPartners Medical Group in St. Paul, Minn. He is a Fellow of the American College of Foot and Ankle Surgeons. 

Dr. Sakow is a first-year Foot and Ankle Surgical Resident at Regions Hospital/ HealthPartners Medical Group in St. Paul, Minn. 

Counterpoint

In their side of the debate, the authors contend that implant hemiarthroplasty may be a preferable option, sharing their own experience as well as support from the literature, including maintenance of motion, pain relief, decreased recovery time and favorable complication rates.

By Kyle Abben, DPM, FACFAS and Garrett D. Nelson, DPM

“Umm, doctor, I don’t want my big toe joint fused.” We’ve all heard it, probably daily. In our observation, most of our patients don’t want their big toe joint fused. Even patients that acknowledge that fusion is necessary, we find they would still rather have some motion of the joint if they could also get good pain relief.

Hallux rigidus is a well-known condition that describes arthritis of the first metatarsophalangeal joint (MPJ) with accompanying range of motion limitations. Treatment options for hallux rigidus vary, depending on the severity of the first MPJ arthritis. Coughlin and Shurnas developed a classification system for determining the grade of hallux limitus/rigidus that is widely used as a reference today.¹ This condition often requires surgical treatment after failure of conservative treatments, such as steroid injections, orthotics, shoe and activity modifications and over-the-counter pain medications. Surgical treatment options include arthrodesis, implant arthroplasty, soft-tissue arthroplasty, decompression osteotomies, and cheilectomy. Surgeons typically reserve joint destructive procedures for later stage hallux limitus/rigidus.^1-4

Traditionally, arthrodesis of the first MPJ is the gold standard for advanced first MPJ arthritis, yielding good patient satisfaction due to pain elimination and improved functionality, backed by many long-term studies.^2-4 As medicine continues to evolve and becomes more patient satisfaction-driven, patients have a larger say in their surgical care. As both technology and surgeon skill advances, challenges arise to the traditional “gold standard” procedures. An alternative surgical option to fusion for mid-to-late-stage hallux rigidus that we will focus on is in this article implant hemiarthroplasty of the first MPJ. There are numerous implants available on the market, but for the sake of this article, we will focus on the implant we have the most experience with, which is a resurfacing implant hemiarthroplasty of the first metatarsal head (HemiCAP DF^®, Arthrosurface).

Studies show that total joint replacement of the first MPJ yields higher postoperative complications.³ Conversely, hemiarthroplasty implants of the first MPJ exhibit favorable results with studies showing an increase in positive patient outcomes and success rates of up to 95 percent.^5,6 This implant offers restoration of anatomical range of motion to the first MPJ and a shorter recovery time compared to fusion, as there is no need to restrict return to shoes and activities based on osseous fusion. In our experience, for many patients, even despite later-stage hallux rigidus, this is a viable option to improve pain and function. Don’t just take our word for it though, as the literature shows favorable results for this implant.^7-11 We are not here to disqualify first MPJ fusion as a great procedure for advanced arthritis. We are here to challenge the idea that MPJ fusion is a superior option in patients that could otherwise be a candidate for a MPJ implant hemiarthroplasty. In our opinion, the lack of confidence in first MPJ implants today often comes from a lack of exposure and familiarity with various implant systems, either during surgical training or clinical practice. For surgeons less inclined towards implant hemiarthroplasty, we encourage them to closely examine their hallux rigidus patient population. They’ll likely find a large subset of patients that have joint disease beyond the limitations of a cheilectomy, but that don’t want a joint fusion.

When Might Implant Hemiarthroplasty Be A Superior Option? 

So, here’s the scenario we’re challenging. A pleasant middle-aged patient has struggled for the last several years with progressing arthritis of the first MPJ. They’ve tried orthotics, over-the-counter pain medications and various shoe modifications. Their foot pain forced them to step down from their competitive tennis league. They used to practice yoga every Saturday morning with friends but had to stop because many of the poses were too painful. Even going for walks around the park or lake are a real struggle. They’re gaining weight due to lack of physical activity. Clinically, they have limited range of motion of the first MPJ, but it’s not ankylosed. Attempted joint range of motion is quite painful. They don’t have any sesamoid pain. The joint appears too arthritic radiographically for a cheilectomy or joint-sparing osteotomy.

Are you going to tell your patient that their only surgical option is fusion? If so, we contend that at minimum, a discussion about implant arthroplasty is in order. We always give our patients an option for implant or fusion in our practice, as long as they are candidates for both procedures. We find that patients are empowered when included in the decision-making process regarding their care. For us, the typical implant patient candidacy qualifications are no sesamoid pain, minimal deformity at the joint, and some degree of range of motion left. We believe that largely ankylosed joints are likely to remain stiff after surgery and thus are better served with fusion. Basically, any hallux limitus/rigidus patient with more than simple “bump pain” (treatable with a cheilectomy) could be a candidate for implant hemiarthroplasty, given these few exceptions and others including lack of metatarsal head cartilage. Patients with hallux interphalangeus can utilize an Akin for deforming force correction in addition to the implant. Inflammatory arthritis, untreated peripheral vascular disease, and prior joint infection are contraindications for implant hemiarthroplasty.^12,13

Postoperative recovery time is also important to patients. Our implant patients are allowed to fully bear weight in a postop shoe immediately after surgery and remain in that for two weeks, until suture removal. At the two-week suture removal visit, they then transition back to tennis shoes and may walk, bike, swim and exercise on the elliptical to tolerance. At six weeks postop, they have no activity restrictions. That is a significantly faster recovery than that for a MPJ fusion, as we are not waiting for bony union to occur. Some surgeons keep their MPJ fusion patients non-weight bearing for six or more weeks after surgery.

Evaluating The Risks Of First MPJ Fusion 

Although most consider arthrodesis the gold standard treatment for late-stage hallux rigidus, it does not come without drawbacks. Several include malunion or nonunion (found to be as high as 5.4 percent),14 painful or prominent hardware, permanent activity modifications, shoe gear wear and limitations, transfer metatarsalgia, and longer recovery time.^2,4,15One of the toughest drawbacks to fusion is managing patient expectations postoperatively. It is also important to consider the patient’s occupation, as well as activity level and types of activities they enjoy. Patients with high-demand hobbies or jobs that require running, kneeling, squatting or wearing heeled shoes can prove to be extremely difficult, if not impossible, after MPJ fusion. Abnormal biomechanical alterations are also associated with first MPJ arthrodesis, such as loss of ankle plantarflexion, decreased step length, and altered gait.¹⁵

Promising results have emerged/ in several investigative studies for the HemiCap hemiarthroplasty system. Hassleman and Shields reported an increase in the American Orthopaedic Foot and Ankle Society (AOFAS) score of 82 after 1.7 years of follow up in 25 patients.⁷ They further reported outcomes at 30 months including high patient satisfaction rates with great functional outcomes and only two percent revision rate with no reports of implant loosening or osteolysis. Of note, these outcomes were amongst patients with varying active occupations including carpenters, manual laborers, homemakers and physicians. With a follow-up period of 27.3 months, Carpenter and colleagues reported successful AOFAS scale scores without any revisions or removals during their mid-term follow-up period.⁸ Aslan and team studied 27 patients with an average follow-up time of 37 months and reported no evidence of loosening, despite a decrease in the visual analog scale (VAS) score from 8.3 to 2.05.¹¹ Kline and Hasselman studied 30 patients with two different follow-up points of 27 and 60 months, noting only four needing revision at the three-year mark.⁹ Hilario and coworkers provided a 10-year follow up for 45 implants on 42 patients with a resulting AOFAS score of 90.60, and only one implant needing removal.¹⁰

So, when offered either MPJ fusion or implant hemiarthroplasty, which do you think patients would prefer? In the senior author’s six years of busy surgical practice, patients choose implant arthroplasty over fusion every single time. In fact, he finds patients are disappointed when they are told they are not a candidate for an implant and need a fusion. We do give all implant patients the disclaimer that fusion may still be necessary at some point in the future, but they feel the prospect of retaining some degree of joint motion while also getting good pain relief are worth that risk.

Closing Thoughts 

First MPJ metatarsal head resurfacing implant hemiarthroplasty is an alternative that challenges the “gold standard” of MPJ fusion for mid-to-late-stage hallux rigidus patients, assuming they meet the proper candidacy criteria. It is a reliable and reproducible alternative that maintains an improved anatomic range of motion and yields good pain-reducing results.

Like any procedure that we do, careful patient selection and proper surgical technique is vital for postoperative success. Implant hemiarthroplasty has a quicker recovery than arthrodesis and has 10-year follow-up data positively demonstrating its longevity, though more studies are obviously needed. Arthrodesis is still a valuable procedure that we perform often, but we challenge the dogma that MPJ fusion is the best procedure for all patients with mid-to-late-stage hallux limitus/rigidus. We encourage you to read the literature, find a local representative for whatever system you like, learn proper technique and offer your patients more than just a fusion. 

Dr. Abben is a Diplomate of the American Board of Foot and Ankle Surgery, a Fellow of the American College of Foot and Ankle Surgeons and in practice with TRIA Orthopedics in Maple Grove, Minn. 

Dr. Nelson is a first-year resident with the Foot and Ankle Surgical Residency Program at Regions Hospital/HealthPartners Medical Group in St. Paul, Minn.

Point

1. Da Cunha RJ, MacMahon A, Jones MT, et al. Return to sports and physical activities after first metatarsophalangeal joint arthrodesis in young patients. Foot Ankle Int. 2019;40(7):745-752.

2. Brodsky JW, Baum BS, Pollo FE, Mehta H. Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot Ankle Int. 2007;28(2):162- 165.

3. Deheer PA. The case against first metatarsal phalangeal joint implant arthroplasty. Clin Podiatr Med Surg. 2006;23(4):709-723.

4. Ghalambor N, Cho DR, Goldring SR, Nihal A, Trepman E. Microscopic metallic wear and tissue response in failed titanium hallux metatarsophalangeal implants: two cases. Foot Ankle Int. 2002;23(2):158-162.

5. Gibson JN, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial. Foot Ankle Int. 2005;26(9):680-690.

6. Banks AS. Use of 1st metatarsophalangeal joint fusion for repair of geriatric hallux valgus deformity. Revista Española De Podología. 2016;27(2) ;e13-e19.

7. Gross CE, Hsu AR, Lin J, Holmes GB, Lee S. Revision MTP arthrodesis for failed MTP arthroplasty. Foot Ankle Spec. 2013;6(6):471- 478.

8. Boffeli TJ, Collier RC. Lateral stress dorsiflexion view: a case series demonstrating clinical utility in midterm hallux limitus. J Foot Ankle Surg. 2015;54(4):739-746.

Counterpoint

1. Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2003;24(10):731-743.

2. Ho B, Baumhauer J. Hallux rigidus. EFORT Open Rev. 2017;2(1):13-20.

3. Kim PJ, Hatch D, Didomenico LA, et al. A multicenter retrospective review of outcomes for arthrodesis, hemi-metallic joint implant, and resectional arthroplasty in the surgical treatment of end-stage hallux rigidus. J Foot Ankle Surg. 2012;51(1):50-56.

4. Lam A, Chan JJ, Surace MF, Vulcano E. Hallux rigidus: How do I approach it? World J Orthop. 2017;8(5):364-371.

5. Perler A, Nwosu V, Christie D, et al. End-stage osteoarthritis of the great toe/hallux rigidus. Clin Podiatr Med Surg.2013; 30(3):351-395.

6. Endler F. Development of a prosthetic arthroplasty of the head of the first metatarsal bone, with a review of present indications. J Orthop Grenzeb.1951;80(3):480-487.

7. Hasselman CT, Shields N. Resurfacing of the first metatarsal head in the treatment of hallux rigidus. Techn Foot Ankle Surg. 2008;7:31–40.

8. Carpenter B, Smith J, Motley T, Garrett A. Surgical treatment of hallux rigidus using a metatarsal head resurfacing implant: mid-term follow-up. J Foot Ankle Surg. 2010;49(4):321–325.

9. Kline AJ, Hasselman CT. Metatarsal head resurfacing for advanced hallux rigidus. Foot Ankle Int. 2013;34(5):716–725.

10. Hilario H, Garrett A, Motley T, Suzuki S, Carpenter B. Ten-year follow-up of metatarsal head resurfacing implants for treatment of hallux rigidus. J Foot Ankle Surg. 2017;56(5):1052- 1057.

11. Aslan H, Citak M, Bas EG, Duman E, Aydin E, Ates Y. Early results of HemiCAP resurfacing implant. Acta Orthop Traumatol Turc. 2012;46:17–21.

12. Delman C, Kreulen C, Sullivan M, Giza E. Proximal Phalanx Hemiarthroplasty for the Treatment of Advanced Hallux Rigidus. Foot Ankle Clin. 2015;20(3):503-512.

13. Mermerkaya MU, Alkan E, Ayvaz M. Evaluation of Metatarsal Head Resurfacing Hemiarthroplasty in the Surgical Treatment of Hallux Rigidus: A Retrospective Study and Mid-to Long-Term Follow-up. Foot Ankle Spec. 2018;11(1):22-31.

14. Roukis TS. Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. J Foot Ankle Surg. 2011;50(6):710-713.

15. DeFrino PF, Brodsky JW, Pollo FE, Crenshaw SJ, Beischer AD. First metatarsophalangeal arthrodesis: a clinical, pedobarographic, and gait analysis study. Foot Ankle Int. 2002;23:496–502.