The Journal of Foot & Ankle Surgery (www.acfas.org), January/February 2019, Volume 58, Number 1:
I previously reported on an article on the treatment of hallux rigidus from The Journal of Foot & Ankle Surgery (www.acfas.org), September/October 3013, Volume 52, Number 5. There, the authors’ conclusion was that “arthrodesis” or fusion of the big toe joint (metatarsal-phalangeal joint) was found to be a reliable procedure in addition to joint replacement. A recent article from the same journal, however, written by a different set of authors, presents an analysis of various studies comparing joint fusion with joint replacement. See The Journal of Foot & Ankle Surgery (www.acfas.org), January/February 2019, Volume 58, Number 1, page 137.
These authors remind us that traditionally the treatment for advanced hallux rigidus was a fusion of the joint. Remember, hallux is the great toe. Rigidus means the toe does not move at its joint with the metatarsal due to arthritis, meaning loss of cartilage and, usually, bone-on-bone contact. (Cartilage cannot be replaced although currently a product known as Cartiva is being used in place of lost cartilage.)
Arthroplasty is surgery performed to alter a joint; implant arthroplasty is surgery in which an artificial joint is used in place of the natural joint. The latter procedure involves cutting away the bone surfaces from the head of the metatarsal and the base of the proximal phalanx and replacing them with the implant. However, it is well recognized that the lifespan of an implant is limited, and most surgeons inform their patients that the implant will likely need to be replaced at some point.
The advantage of simply fusing the joint is that nothing will need to be replaced and the pain from the hallux rigidus will be eliminated. The disadvantage is lack of mobility at that joint, the limited ability to toe-off and therefore run, and the limited ability to wear certain types of shoes and heels.
The advantage of an implant is the preservation of mobility at the big toe joint. This is an improvement over fusion since it allows for a greater ability to toe-off, an ability important to many patients who are physically active. The disadvantage of an implant is that it can fail or deteriorate to the point at which it needs to be replaced or removed with the joint needing to be fused.
Both fusions and joint implant surgeries may fail or result in complications which are “iatrogenic,” meaning due to the actions of the surgeon. This means that many failed surgeries are the fault of the surgeons who perform them. Similarly, patient compliance with post-operative instructions is always important. When such post-surgical instructions are not properly followed, complications or failed surgery may result.
The authors studied a number of studies by others, especially since newer implants have been developed which reduce the failure rate and produce better outcomes. The authors conclude that both joint fusion and implant arthroplasty provide satisfactory results although some studies show that fusion is a bit better at eliminating pain.
What should you take away from this? If your surgeon — podiatrist or orthopedist — recommends a fusion, you should know that a joint implant may be a viable option and if she does not recommend an implant it may be because she has not had experience with such procedures or has used them with only limited success On the other hand, if your surgeon recommends implant surgery, you should consider the possibility that, in your particular case, a fusion may be a better choice.If your surgeon is not discussing both procedures with you, you should get another opinion to make sure you know all of your options. You should also know that, in some cases of hallux rigidus, other less invasive surgical procedures may be a better option. These less invasive approaches called “joint salvage” procedures and generally involve removing bone which is contributing to the lack of motion of the great toe and sometimes shortening a bone to help get a little more joint space.