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Three Part Question

IN [adults with arthritis of the big toe]
IS [arthroplasty better than arthodesis]
FOR [improvement in pain and function]

Clinical Scenario

A 59 year old women has painful osteoarthritis of the 1st MTPJ (great toe). She has been told that a MTPJ fusion is the best surgical solution but has read on t'internet that there are now joint replacements for the big toe MTPJ. She asks for your advice but before imparting wisdom, you wonder if there has been any study comparing the two techniques.

Search Strategy

Medline via OVID; EMBASE via OVID; the Cochrane collaboration from 1950 to June 2020
Medline, EMBASE: [{(exp.Metatarsophalangeal joint OR first MTPJ.mp OR Hallux.mp OR great toe.mp) AND (OA.mp OR exp.osteoarthritis OR degenerative changes.mp OR Hallux rigidus.mp) AND (exp arthroplasty OR joint replacement.mp OR hemiarthroplasty.mp OR hemicap.mp OR North Star.mp) AND (randomised controlled trial)}] LIMIT to human AND English language.
Cochrane database: arthroplasty OR joint replacement ti; ab; .mp

Search Outcome

277 papers were retrieved. Three systematic reviews were identified which were relevant to the 3 part question. There were 2 RCTs found which were cited in some but not all these reviews. A 5 year follow up study of the 2015 RCT by Baumhauser et al was not included as there was a lack of outcome data for the group having arthrodesis.
Each systematic review contained different numbers of papers which were either prospective or retrospective case series of arthrodesis or arthroplasty. None of these were able to directly compare arthroplasty with arthrodesis for first MTPJ arthritis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gibson 2005 UK	38 toes undergoing arthrodesis (mean age 54.2 ± 10.6yrs) compared to 39 toes undergoing a Biomet unconstrained total arthroplasty (55.5 ± 8.7yrs) for osteoarthritis (Hallux Rigidus) of the 1st MTPJ.	Level I, prospective randomized study.	VAS for pain (arthrodesis v arthroplasty)	@ 1 yr FU 14±21 v 34±28, 2 yrs FU 34±28 . Effect size 0.80 (95% CI, 0.31 – 1.28)	Surgeons and subjects not blinded to group allocation. Small deviations from protocol. Some patients had bilateral procedures which may have affected pain perception,
			Maximal 1st MTPJ Plantar pressure (within groups analysis compared to baseline)	@ 2 yrs FU arthroplasty group reduced by 2.3 N/cm2 (NSS). Arthrodesis group increased by 2.9N/cm2 (NSS)
Park 2019 Korea	7 studies; 740 subjects. Mix of retrospective & prospective studies comparing arthrodesis and arthroplasty of the first MTP joint for the treatment of advanced hallux rigidus.	Systematic review and meta-analysis	1. VAS for pain	1. Decrease in VAS from arthrodesis. Overall Mean Diff arthrodesis versus arthroplasty = 9.81; (95% CI: 6.54 , 13.09) p < .00001	Varied type of implants used for arthroplasty.
			2. AOFAS-HMI	2. NSS
			3. re-operation rate	3. NSS
			4. complication rate	4. NSS
Stevens 2017 Netherlands	741 feet in 678 patients mean ages range 50 - 68.5 yrs Mix of retropective & prospective studies of arthrodesis and arthroplasty of the first MTP joint for the treatment of symptomatic end stage hallux rigidus. 1 RCT s, 7 retrospective cohort studies, 3 retrospective & 2 prospective case series	Systematic review without meta-analysis	1. AOFAS_HMI score	1. Arthrodesis group had significantly lower (better) AOFAS-HMI scores than arthroplasty group (p < 0.0001)	No meta analysis Effects of arthrodesis and arthroplasty analysed separately between studies but not within studies.
			2. VAS pain	2. Arthrodesis group had significantly lower VAS pain score than arthroplasty group (p < 0.0001)
Brewster 2010 UK	10 articles, 5 on arthroplasty. 5 on arthrodesis 5 retrospective case series 5 prospective case series 242 patients surgery to first MTPJ. Pathology not specified	Systematic review without meta-analysis	1. AOFAS-HMI	1. median postoperative score for arthroplasty = 83/100 (range 74–95) For arthrodesis = 82/100 (range 78–89)	Compared the AOFAS-HMI between different studies (either arthroplasty or arthrodesis rather than within studies. No RCT included in appraisal. High chance of publication bias Some types of implants not Included
Baumhauer 2016 UK & Canada	152 arthroplasty (mean age 57.4 ± 8.8yrs) and 50 arthrodesis (mean age 54.9 ± 10.5yrs) patients with advanced-stage hallux rigidus	Level I, prospective randomized study.	1. VAS for pain @ 1 yr & 2 yrs (arthroplasty v arthrodesis)	1. @ 1 yr FU 17.8 (±23) v 5.7(±8.5) p=0.0011 @2 yrs FU 14.5 (±22.1) v 5.9 (±12.1) p=0.002	23% loss of the arthrodesis patients who initially consented to randomization.
			2. FAAM ADL score @1 yr & 2 yrs (arthroplasty v arthrodesis)	2. @ 1 yr FU 88.6 (±14.4) v 94.1 (±6.8) NSS. @2 yrs FU 90.4 (±15.0) v 94.6 (±7.4) NSS.
			3. FAAM Sportscore @1 yr & 2 yrs (arthroplasty v arthrodesis)	3. @ 1 yr FU 75.8 (±24.8) v 84.1 (±16.9) p = 0.043 @ 2 yrs FU 79.5 (±24.6) v 82.7 (±20.5) p = 0.461

Comment(s)

The 3 systematic reviews incorporate a mixture of RCT, and cohort and case studies comparing first MTPJ arthrodesis with arthroplasty. There are only 2 randomised trials comparing arthroplasty surgery versus arthrodesis (Gibson & Thomson 2005; Baumhauer et al 2016).

Clinical Bottom Line

There is some evidence based mainly on retrospective non-randomised case series systematic reviews and 2 RCTs that arthrodesis is superior to arthroplasty at improving pain in symptomatic end stage hallux rigidus.

References

1. Gibson JNA, Thomson CE. Arthrodesis or Total joint replacement for Hallux rigidus. A randomised controlled trial Foot and Ankle International 2005; 26(9): 680-690
2. Park YH, Jung JH, Kang, SH, Choi GW, Kim HJ. Implant arthroplasty versus arthrodesis in the treatment of advanced hallux rigidus: a meta-analysis of comparative studies Journal of Foot & Ankle Surgery 2019 vol 58: 137-143
3. Stevens J, de Bot RTAL, Hermus JPS, van Rhijn LW, Witlox AM. Clinical Outcome following total joint replacement versus arthrodesis for JB&JS Reviews 2015; 5(11): e2
4. Brewster, M. Does total joint replacement or arthrodesis of the first metatarsaophalangeal joint yield better functional results? A systematic review of the literature. The Journal of Foot & Ankle Surgery 49: 546-552
5. Baumhauer J, Singh D, Glazebrook M, Blundell C, et al Prospective, Randomized, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus Foot & Ankle International 2016 37(5)