Why First MPJ Fusion Is Superior To Implant Arthroplasty

A few weeks ago, fellow Podiatry Today blogger Ron Raducanu, DPM, FACFAS, advocated that he prefers to use implant arthroplasty over arthrodesis when treating hallux rigidus.1 His blog illustrates some concerns I have regarding accurate reporting of the medical literature and the need to utilize evidence-based medicine in the selection of surgical procedures.2,3

Dr. Raducanu cited a recently published article to support his position, which is critical of arthrodesis of the first metatarsophalangeal joint (MPJ).4 Dr. Raducanu cites the study from McNeil and colleagues, which supposedly agrees with his own position condemning cheilectomy and arthrodesis as acceptable surgical procedures for the treatment of hallux rigidus. Further scrutiny reveals that the McNeil study actually supports arthrodesis over implant arthroplasty.

McNeil and colleagues performed a comprehensive evidence-based literature review of 135 articles that were relevant in assessing the efficacy of common operative interventions for hallux rigidus.4 They then assigned the 135 studies a level of evidence (I-V) to denote quality. Next, they reviewed the studies to provide a grade of recommendation (A-C, I) in support of or against surgical intervention in general in treatment of hallux rigidus.

Based on the results of this evidence-based review, the researchers granted arthrodesis the highest grade (B) while giving implant arthroplasty a lower grade (C). The authors point out the need for further high quality studies in order to provide stronger recommendations.4 However, they also conclude “the grade B recommendation assigned to arthrodesis may make it the logical leading candidate for future high-quality randomized controlled trials.”

This is an example of how writers can cite research to support a position but only report a limited part of the study. Furthermore, there are several quality studies that are head-to-head comparisons of outcomes from surgical arthrodesis versus implant arthroplasty for hallux rigidus, which Dr. Raducanu’s blog did not cite.

Gibson and Thomas conducted a Level 1 randomized controlled trial comparing arthrodesis to total first MPJ implant arthroplasty in the treatment of hallux rigidus.5 The authors found that both procedures reduced pain although arthrodesis provided significantly better pain relief in comparison to arthroplasty. There was significantly higher patient satisfaction at the 24-month follow-up in the group that had arthrodesis procedures. More importantly, five patients in the arthroplasty group had a subsequent revision procedure versus none in the arthrodesis group underwent surgical revision.

Brewster published an excellent systematic review of 10 published studies comparing functional outcomes of arthrodesis versus total joint replacement for hallux rigidus.6 Brewster limited his review to papers that utilized the American Orthopaedic Foot and Ankle Society-Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scale to evaluate postoperative results. He concluded that arthrodesis was superior to implant arthroplasty with respect to functional outcome and reduced rate of revisional surgery.

In Conclusion

Evidence-based medicine currently strongly favors arthrodesis over implant arthroplasty in the surgical treatment of hallux rigidus. In spite of this, colleagues continue to promote implants, often because of financial bias or lack of knowledge of the medical literature.

I would agree that there is no perfect surgical solution for hallux rigidus but arthrodesis is clearly the lesser of all evils. Published studies have shown that fears of serious gait disturbance from arthrodesis are unfounded.7-9 Patients with moderate to severe hallux rigidus already have significant compensation in gait, which improves with pain relief from surgery.10

The clear superiority of arthrodesis over implant arthroplasty is not only based upon functional outcome but reduced risk of revisional surgery and significant difference in cost between the two procedures as well.5

References
1. Raducanu R. Why I prefer first MPJ implants to being a ‘fusion guy’. Podiatr Today. Available at https://www.podiatrytoday.com/blogged/why-i-prefer-first-mpj-implants-be… . Published Aug 10, 2013. Accessed Aug 20, 2013.
2. Richie Jr. D. Who is fact checking the podiatric profession? Podiatr Today. Available at https://www.podiatrytoday.com/blogged/who-fact-checking-podiatric-profes… . Published Sept 27, 2012. Accessed Aug 20, 2013.
3. Richie Jr. D. Assessing recent systematic reviews on surgical treatment of hallux rigidus. Podiatr Today. https://www.podiatrytoday.com/blogged/assessing-recent-systematic-review… . Published Mar 1, 2011. Accessed Aug 20, 2013.
4. McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013; 34(1):15-32
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. Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature. J Foot Ankle Surg. 2010; 49(6):546-552.
7. De Frino PF, Brodsky JW, Pollo FE et al. First metatarsophalangeal joint arthrodesis: A clinical, pedobarographic and gait analysis study. Foot Ankle Int. 2002; 23(3):496-502.
8. Brodsky JW, Baum BS, Pollo FE, Mehta H. Prospective gait analysis in patients with first metatarophalangeal joint arthrodesis for hallux rigidus. Foot Ankle Int. 2007; 28(2):162–165.
9. Mulier T, Steenwerckx A, Thienpont E, et al. Results after cheilectomy in athletes with hallux rigidus. Foot Ankle. 1999; 20(4):232–237.
10. Nawoczenski DA. Nonoperative and operative intervention for hallux rigidus. J Orthop Sports Phys Ther. 1999; 29(12):727–735.