First metatarsophalangeal joint arthrodesis versus arthroplasty for hallux rigidus

INTRODUCTION

Hallux rigidus is the osteoarthritic degeneration of the first metatarsophalangeal joint, characterized by progressive cartilage loss, dorsal osteophyte formation, pain, and a reduction of dorsiflexion that alters the push-off phase of gait.(1) It is the most common arthritic condition of the foot, affecting approximately 2.5% of adults older than 50 years, with a prevalence that rises further in later decades and a clear predominance in women.(2,3) The etiology is multifactorial and includes trauma, an elongated or elevated first metatarsal, and a positive family history, although most cases are idiopathic, and the Coughlin and Shurnas classification grades the disease from mild dorsal osteophytes to end-stage loss of joint space.(1) The condition restricts footwear tolerance, limits activities that require hallux dorsiflexion, and measurably reduces health-related quality of life, which explains why surgical referral is common once nonoperative measures such as stiff-soled shoes, orthoses, and injections no longer control symptoms.(4)

Two surgical families dominate the treatment of moderate and advanced hallux rigidus. First metatarsophalangeal joint arthrodesis eliminates the painful articulation and has been considered the gold standard for decades because it reliably relieves pain and restores a stable, plantigrade first ray.(4,5) Its principal drawback is the permanent sacrifice of motion, which some patients perceive as a functional loss that affects footwear choice and sport. Arthroplasty, by contrast, aims to preserve motion and includes several distinct devices: interpositional arthroplasty with autograft or allograft tissue, silastic hinge implants, metallic hemiarthroplasty and total replacement, and the polyvinyl alcohol hydrogel implant marketed as Cartiva.(5,6) Each option carries a different profile of failure, bone loss, and revision burden. Resection and interposition arthroplasty avoid a permanent implant but can shorten or destabilize the joint; silastic hinges can fragment and provoke a particulate synovitis; metallic components can loosen at the bone interface; and the hydrogel device can subside into the metatarsal head and erode the opposing surface.(7,8) Arthrodesis, for its part, can fail by nonunion or malunion, and its result depends on precise positioning of the hallux in slight dorsiflexion and valgus.(5)

The existing literature does not settle the choice between these two families. Systematic reviews published in the last few years have reached partly conflicting conclusions: some report that arthrodesis and arthroplasty yield equivalent pain relief and function, whereas others document higher complication and revision rates after implant arthroplasty, particularly for the synthetic cartilage implant.(9-12) A comparative review of metallic hemiarthroplasty and arthrodesis found similar patient-reported outcomes but was limited by mostly retrospective, non-comparative evidence.(11) A broader synthesis concluded that arthrodesis retains the most consistent results while arthroplasty remains acceptable only in carefully selected patients.(13) These reviews are themselves constrained by the same weaknesses of the underlying studies: heterogeneous implant generations, variable outcome instruments, and short follow-up. The interposition arthroplasty literature, reviewed separately, suffers the additional problem of surgical technique heterogeneity, because the spacer can be autograft, allograft, or synthetic and the joint preparation differs between authors.(14,15) The synthetic cartilage implant, in turn, has generated divergent results in reviews, with early trials reporting equivalence to arthrodesis and later series reporting higher revision.(12)

Randomized evidence exists but is limited in scope and age. The MOTION trial demonstrated that a polyvinyl alcohol hydrogel hemiarthroplasty was noninferior to arthrodesis for a composite outcome at 24 months,(16) and an earlier randomized controlled trial found that total replacement arthroplasty and arthrodesis produced comparable outcomes at two years.(17) However, both trials predate the recent registry and device-surveillance reports that describe early implant subsidence, bone erosion, and conversion to arthrodesis.(8,18) In practice, the treating surgeon therefore needs an updated comparison that separates pain relief, function, complications, and revision, and that distinguishes comparative from single-cohort evidence. The practical question for the surgeon is not whether arthroplasty is technically possible, but whether it delivers durable pain relief and function without an unacceptable revision burden relative to arthrodesis, and motion preservation is the reason this question persists: the joint transmits loads of approximately 119% of body weight during gait, and its dorsiflexion is required for a normal push-off, so the loss of motion after arthrodesis is not a purely cosmetic concern.(2) Motion-preserving devices have evolved through several generations, from silastic hinges to metallic components and, most recently, to a polyvinyl alcohol hydrogel hemiarthroplasty designed to reproduce the viscoelastic properties of cartilage, yet the registry and device-surveillance data published since 2018 suggest that each generation has only partially solved the osteolysis, subsidence, and soft-tissue reaction that undermined its predecessors.(5,6,8)

Two gaps justify an updated synthesis. First, the most influential randomized evidence predates the current implant generation, and the single-surgeon series and registry reports published between 2023 and 2026 have changed the picture of arthroplasty durability without yet being integrated into a comparative review.(19,20) Second, most prior reviews treated arthroplasty as a single category, which obscures the differences between silastic, interpositional, metallic, and hydrogel devices that are apparent in the primary literature.(12,14) To address these gaps, the aim of this systematic review was to compare pain relief, functional outcomes, complications, and revision rates between first metatarsophalangeal joint arthrodesis and arthroplasty in adults with hallux rigidus, and to characterize the risk of bias of the available evidence.

METHODS

RESULTS

Study selection

The searches identified 495 records, of which 272 duplicates were removed and 223 records were screened by title and abstract (Figure 1). Scopus contributed 307 records, PubMed contributed 88, and OpenAlex contributed 100. After screening, 191 records were excluded and 32 reports were sought for retrieval. The most common reasons for exclusion at this stage were a study design that did not compare or report the two procedures, a population with rheumatoid forefoot deformity or hallux valgus rather than hallux rigidus, and narrative reviews or surgical technique papers. Full text could not be retrieved for 18 reports because they were behind a paywall, and 14 reports were assessed for eligibility. One record was excluded at full text because it described a single clinical case, leaving 13 studies included in the review.

DISCUSSION

For practitioners, the principal implication is that arthrodesis remains the most durable option when the priority is a single definitive procedure, and this should be stated plainly when consenting patients. The comparative evidence showed that arthrodesis and arthroplasty reduce pain to a comparable degree in most studies, but the revision and radiographic failure signal was consistently higher for implant arthroplasty, particularly the polyvinyl alcohol hydrogel device.(20,26) This implies that a surgeon who recommends arthroplasty is accepting a meaningful probability of later conversion to arthrodesis, which is itself a more demanding operation in the presence of bone loss.(18,34)

The four head-to-head comparisons, taken at face value, also suggest that the choice between the procedures cannot be resolved on pain and function alone. The two studies that found no difference used modest samples and short or intermediate follow-up, so a true but small advantage of arthrodesis could easily have been missed.(23,25) The largest comparison, with 122 patients, detected an advantage for arthrodesis on both the visual analog scale and the Manchester-Oxford Foot Questionnaire, and the matched study detected an advantage only on exertion pain, which indicates that the difference, when present, is concentrated in load-related symptoms rather than in resting pain.(24,26) A clinician should therefore not promise that arthroplasty equals arthrodesis for pain; the most defensible statement is that arthroplasty approaches arthrodesis for most patients but leaves a subset with residual exertion pain.

These findings align with the most recent systematic reviews. A review of arthrodesis versus arthroplasty for moderate and severe hallux rigidus concluded that the two procedures achieve similar clinical scores but that implant-related complications and reoperations are more frequent after arthroplasty.(9) A meta-analysis of comparative studies reached the same conclusion for implant arthroplasty,(10) and a review focused on the Cartiva device found that fusion remains the standard while the synthetic cartilage implant retains an uncertain role.(12) The present review adds registry and single-surgeon series that postdate several of those syntheses and reinforce the revision concern.(19,20)

Adjacent reviews converge on the same reading. A systematic review of interposition arthroplasty found that the procedure relieves pain and preserves motion but rests on heterogeneous techniques and modest follow-up,(14) a conclusion repeated by a later synthesis of the same procedure.(15) A review written from a biomechanical perspective noted that arthrodesis and total arthroplasty are both acceptable for end-stage disease without severe angular deformity, and that arthroplasty may restore a more physiological gait pattern.(35) Reviews of complications emphasize that arthrodesis carries nonunion and malunion as its characteristic failures, whereas arthroplasty fails through instability, loosening, and bone loss that complicates salvage.(7) The return-to-sport literature adds a practical dimension: arthrodesis reliably returns patients to activity, while motion-preserving implants are advocated for the active patient despite weaker long-term data.(36)

The randomized evidence must be read in context. The MOTION trial reported noninferiority of polyvinyl alcohol hemiarthroplasty at 24 months,(16) and the earlier randomized controlled trial found equivalence between total replacement and arthrodesis at two years.(17) Those results describe short-term and midterm outcomes in selected patients, whereas the single-cohort and matched studies summarized here describe subsidence, erosion, and conversion to arthrodesis over longer observation.(8,20,26) The discrepancy is more likely explained by follow-up length and implant generation than by any single methodological error.

A second set of comparative studies published within the search window but not retrievable in full text reinforces the central trade-off. A Brazilian comparison of appropriately selected patients reported higher American Orthopaedic Foot and Ankle Society scores after arthroplasty than after arthrodesis, the main discrepant signal in the literature, which probably reflects deliberate patient selection.(37) A silicone arthroplasty series was compared against arthrodesis in osteoarthritis of the first metatarsophalangeal joint,(38) and a short-term Turkish study compared two total joint replacements with arthrodesis.(39) Database work contributes the revision denominator that single-center series lack: a national administrative cohort characterized trends in arthrodesis and arthroplasty for hallux rigidus and identified patient factors associated with revision of arthroplasty to arthrodesis.(40) Long-term studies of cheilectomy, Keller arthroplasty, and arthrodesis indicate that arthrodesis maintains durable patient-reported and radiographic results beyond a decade,(41) and capsular interposition arthroplasty was compared with arthrodesis at fifteen years in one cohort.(42) Kinematic and gait comparisons, although small, suggest that arthroplasty preserves a more physiological loading pattern, which is the principal functional argument in its favor.(43,44)

Heterogeneity in this evidence base has identifiable sources. The arthroplasty arm in the included studies encompassed resection, interpositional, silastic, and hydrogel devices, which are biomechanically dissimilar and should not be treated as one intervention. Silastic implants showed the lowest revision rate among arthroplasty options,(29) while the hydrogel implant showed the highest,(20) and metallic hemiarthroplasty was associated with less favorable results than arthrodesis in earlier comparisons.(45,46) Outcome instruments also differed, with the American Orthopaedic Foot and Ankle Society score, the Foot and Ankle Ability Measure, the Manchester-Oxford Foot Questionnaire, and the Self-reported Foot and Ankle Score all represented, which prevented pooling.

The measurement of success also differs across studies in ways that affect interpretation. The American Orthopaedic Foot and Ankle Society hallux score was used most often, but it mixes examiner-rated alignment with patient-reported pain and has a known ceiling effect, and some arthrodesis series rescaled its maximum because a fused joint cannot earn motion points.(27) The Manchester-Oxford Foot Questionnaire, the Self-reported Foot and Ankle Score, the Foot and Ankle Ability Measure, and the PROMIS instrument are psychometrically stronger but were each used by only one or two studies, so they cannot be compared directly across procedures.(19,47) Nonunion was defined heterogeneously, with some series reporting only symptomatic nonunion and others counting radiographic gaps, which partly explains the wide range of 0% to 30%.(31,33) These measurement differences, more than any clinical difference, are likely responsible for the apparent spread in reported complication rates.

The Swefoot registry series illustrates what registries add to this question. It captured 419 consecutive arthrodesis procedures with a standardized patient-reported outcome set and showed that the one-year Self-reported Foot and Ankle Score approached the population norm, a stronger statement about the external validity of arthrodesis than any single-center series can make.(19) Registries could answer the comparative question more efficiently than a trial if they recorded arthroplasty procedures in the same data model, and the HARD trial protocol shows that a pragmatic randomized comparison is feasible in this population.(48) The present review found no equivalent registry infrastructure for arthroplasty outcomes, which is a gap that limits the precision of the arthroplasty arm.

Device-specific and activity-related studies complete the picture. A comparison of the Cartiva implant, allograft interposition arthroplasty, and arthrodesis compared pain relief across the three procedures,(49) and a matched cohort described comparable outcomes among Cartiva, cheilectomy, and fusion.(50) Sports participation after capsular interposition arthroplasty and arthrodesis was compared in one retrospective cohort.(51) Patient-reported outcomes measured with the PROMIS instrument were compared between arthrodesis and polyvinyl alcohol hemiarthroplasty.(47) A comparative analysis of the randomized cohort documented differences in operative and recovery time between implant hemiarthroplasty and arthrodesis, a logistic consideration for scheduling and rehabilitation that does not offset the durability difference.(52)

The choice is also not strictly binary, because joint-preserving procedures such as cheilectomy and decompression osteotomy remain options for earlier disease and were present among the retrieved records.(2,41) This review focused on arthrodesis and arthroplasty, but a surgeon treating grade II disease should still weigh cheilectomy before either destructive procedure, and the long-term comparison of cheilectomy, Keller arthroplasty, and arthrodesis indicates that arthrodesis becomes the more reliable choice as disease severity advances.(41)

Several strengths of this review should be weighed against its limitations. The search was performed in Scopus as the primary source and covered the full publication window through 2026, and every included study was verified against its DOI. The synthesis separated comparative from single-cohort evidence, and the arthroplasty arm was reported by implant type, which most prior reviews did not do. The review also reports the screening method transparently and avoids inflating the certainty of its conclusions beyond what retrospective and uncontrolled evidence can support.

Several limitations condition the interpretation of this review:

Only 14 of 32 potentially eligible reports had retrievable open-access full text, so 18 reports, including several comparative series, could not be assessed beyond their abstracts; a future update with institutional access would strengthen the comparison.(53,54)

All included studies were observational and most were single-arm, which restricts causal claims; this limitation is best overcome with a registry-based or randomized comparison such as the HARD trial design.(48)

Follow-up was short in several series, which underestimates late implant failure; registries with prolonged surveillance are the appropriate corrective measure.(19)

Publication and language restrictions, although limited to four languages, may exclude nonindexed evidence.

The included studies came from a limited set of health systems, and the fixation methods and implant choices reflect local practice, so the revision rates reported here may not transfer to settings with different surgical training or implant availability.

For the treating surgeon, the practical reading is that arthrodesis should remain the default recommendation for end-stage hallux rigidus, and arthroplasty should be reserved for the patient who explicitly prioritizes motion and accepts revision risk.(5,13) For the podiatrist and the primary care provider, the implications are narrower but concrete: patients who report persistent pain, swelling, or progressive stiffness after implant arthroplasty should be referred for early radiographs, because subsidence and osteolysis can precede clinical failure.(8,20) For researchers, the priority is a comparative study with a common outcome set and at least five years of follow-up, because the current literature cannot yet distinguish equivalent pain relief from durable pain relief.

Patient selection therefore becomes the operative variable. Younger and more active patients who place a premium on footwear and sport are the group for whom motion preservation is most attractive, and they are also the group in whom a failed implant is least acceptable, because salvage arthrodesis in the presence of bone loss is technically more demanding and carries a higher nonunion rate.(18,34) The kinematic and gait evidence supports the functional rationale for motion preservation but does not yet demonstrate that this advantage survives to the long term.(35,43) For the older or less active patient, in whom the priority is a single operation and early return to weight bearing, arthrodesis is the more defensible choice.(37,41) The phrase selected patients, which appears throughout the arthroplasty literature, deserves a concrete definition: a candidate with no inflammatory arthropathy, no hallux valgus beyond mild deformity, intact bone stock, and realistic expectations about the possibility of conversion to arthrodesis.(5,13) When those conditions are not met, the motion-preserving advantage of arthroplasty is outweighed by the risk of early failure and a more difficult salvage.

These trade-offs translate directly into a concrete consent script for the outpatient consultation. A patient offered arthrodesis should be told that pain relief and satisfaction are high and durable, that the procedure stiffens the joint permanently, that metalwork removal is sometimes needed, and that nonunion occurs in a minority of cases. A patient offered arthroplasty should be told that motion may be preserved but that pain relief is no better than arthrodesis in the available comparisons, that the implant can fail within the first two years, and that revision usually means conversion to arthrodesis with the added difficulty of bone loss.(20,26,34) Device surveillance data support this caution, because adverse-event reports for first metatarsophalangeal implants concentrate in loosening, fracture, and revision.(8)

A common outcome set would amplify the value of any future study, because the current fragmentation of instruments is a direct obstacle to pooling and to comparison across implants. Pain on a visual analog scale, one validated patient-reported function measure, a standardized definition of nonunion and of implant failure, and a minimum follow-up of five years would together provide the denominator that this review could not reconstruct from the primary literature.

A definitive answer will require a comparative design that the current evidence lacks. A randomized comparison of a single modern arthroplasty device against arthrodesis, with a common patient-reported outcome set, blinded radiographic adjudication of nonunion and subsidence, and a minimum follow-up of five years, would settle the question of durability. Until such evidence exists, registries that capture both procedures under one data model offer the most efficient route to long-term revision denominators.(19,48)

CONCLUSIONS

Arthrodesis of the first metatarsophalangeal joint achieves predictable pain relief, restores a stable first ray, and carries the lowest revision burden among the options reviewed, with nonunion as its main specific complication. Arthroplasty preserves motion and produces pain and function gains comparable to arthrodesis in the short term, but implant arthroplasty, and the polyvinyl alcohol hydrogel device in particular, carries a higher and earlier revision risk.

The choice between the two procedures is therefore a decision about trade-offs rather than superiority: arthrodesis for durability, and arthroplasty for the selected patient who accepts revision risk in exchange for preserved motion. Evidence of higher certainty, ideally a randomized or registry-based comparison with a common outcome set and long follow-up, is still required to refine patient selection.

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