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 http://www.podiatrytoday.com/blogged/why-i-prefer-first-mpj-implants-bei... . Published Aug 10, 2013. Accessed Aug 20, 2013.
2. Richie Jr. D. Who is fact checking the podiatric profession? Podiatr Today. Available at http://www.podiatrytoday.com/blogged/who-fact-checking-podiatric-profession . Published Sept 27, 2012. Accessed Aug 20, 2013.
3. Richie Jr. D. Assessing recent systematic reviews on surgical treatment of hallux rigidus. Podiatr Today. http://www.podiatrytoday.com/blogged/assessing-recent-systematic-reviews... . 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.



Kevin A. Kirby, DPMsays: August 23, 2013 at 11:53 pm

Doug:

I'm glad you spoke up about this since Dr. Raducanu's article bothered me also. What's another phrase for listing research to support a position but then only reporting a limited part of the study? Cherry-picking!

I prefer first metatarsophalangeal arthrodesis procedures over any implant procedures available and, in fact, I have athlete-patients doing marathons and iron-man triathlons after I have fused their 1st MPJs. If these procedures are done correctly, I have not seen any biomechanical abnormalities develop.

The idea that the 1st MPJ fusion procedure creates more abnormal biomechanics than does the best 1st MPJ implant arthoplasty procedure is yet another podiatric myth that has been passed on from one generation of podiatrists to another. Glad to see this one coming to an end ... finally.

Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine

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Ron Raducanu, DPMsays: August 25, 2013 at 8:55 pm

Wow.

Cherry picking? Jeez. You interpret things differently, I guess. But that's not cherry picking, is it?

I'm glad you have positive results with MPJ Fusions.

When was the last time you tried an implant?

Also, you allude to the fact that there is a "podiatric myth" about the alteration in biomechanics passed on from generation to generation. Where is your literature to prove one vs. the other? None of the studies I've cited say anything about mechanics at all. Please provide me a research study that shows these biomechanics you claim are preserved with one procedure vs. the other.

Come on, guys. It's my opinion based on my experience. You can argue EBM all you want but the data doesn't necessarily support your stance either.

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Ron Raducanu, DPMsays: August 24, 2013 at 2:07 pm

I'm curious Dr. Richie. How many of each have you done and what were your outcomes?

Although I appreciate your take on evidence-based medicine (EBM), it is merely a tool. I taught a course on EBM at a medical school and all the professors involved agreed that simply using EBM as the only route to guiding treatment may indeed be more harmful than it seems.

I admitted that I don't do 1st MPJ arthrodeses as I have had great success with my patients with the 1st MPJ implant. With the very short postoperative period before return to activity and the satisfaction my patients have relayed to me after having the procedure, I think it's a no brainer.

Again, I appreciate your insight a great deal but would prefer to hear your experience at this point. I looked over the studies before writing my blog and found that there was a sore lacking of good literature with respect to the 1st MPJ implant. Not that it was a bad procedure or a description of why per se, but very little out there. What does that say about EBM? It means more need to be done before a conclusion can be made.

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Doug Richie D.P.M. F.A.C.F.A.S.says: August 25, 2013 at 1:53 pm

Ron,

When I started my surgical residency over 30 years ago, I trained with a group of surgeons who performed total implant arthroplasty with the old Swanson silastic implant routinely on all stages of hallux rigidus. I noted that only the 70+ year old patients did well since they had a sedentary lifestyle, and also appreciated the dismal options available for salvage when the implant failed.

Over the years, I tried newer implants, including metal hemi-implants and once tried a two-piece metal implant. In every case, the results were marginal in terms of patient satisfaction. I soon realized that the vendors for these implants promised fantastic results and assured me that these implants were safe and reliable for running patients. Fortunately, I had learned from past mistakes to be skeptical of these new technologies and was wise enough to avoid implants in any of my active, athletic patients.

In the meantime, I saw many athletic patients present to my office who had undergone implant arthroplasty of the 1st MPJ who had their running careers cut short due to complications from this procedure. I remain convinced that implant arthroplasty is an absolute contraindication in any patient who wants to participate in running sports.

Fifteen years ago, I heard Rich Bouche, DPM, FACFAS, present the findings of his series of active patients who had undergone successful arthrodesis of the 1st MPJ for hallux rigidus. I was impressed with the long-term results and began doing the procedure on my own athletic patients who presented with Grade 3 and Grade 4 hallux rigidus. Since that time, I have performed arthrodesis of the 1st MTP on over 30 active runners and the results have been extremely favorable with fewer complications than any other procedure I have done for this same condition in this type of patient. Having performed surgery on hundreds of patients with hallux rigidus over the years, arthrodesis has become my procedure of choice for nearly all patients with Grade 3 or 4 hallux rigidus.

But I would caution any colleague why reads my anecdotal evidence of surgical outcomes. Systematic reviews of studies of hundreds of patients from multiple surgeons, as cited in my blog, are far more reliable than reports from a single practitioner. Yes, we need more quality Level 1 and 2 evidence to substantiate ALL of the surgical procedures we do on the 1st MPJ. In the meantime, the available evidence is quite clear that arthrodesis is the procedure of choice over implant arthroplasty in the surgical treatment of hallux rigidus.

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Ron Raducanu, DPMsays: August 25, 2013 at 9:53 pm

I've done many Implants on athletes all of which very much appreciated that I didn't recommend a fusion as had several other doctors they visited before seeing me. They were very happy to have had an option and happily, in my hands, I've had excellent results.

Once again, I take issue with your claim that EBM is a panacea and should be followed without question. I just posted a study that disagrees with your assertion and proves it with research. Tell me I'm cherry picking all you like but the fact remains that there is no black and white, but shades of grey. You paint the shade more black and I paint it more white, depending on our beliefs and experience. That's what being a clinician is, is it not?

What I don't like is your comment about those that don't follow EBM either aren't familiar with the research or the procedures. Maybe those of us that don't follow what many of these articles claim to prove read with a little more of a critical eye and realize that just because something can be shown effective doesn't mean it will be for everyone.

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Ron Raducanu, DPMsays: August 25, 2013 at 9:39 pm

This article just came out and is available online:

Hállux Rígidus: prospective study of joint replacement with hemiarthroplasty

Alexandre Leme Godoy dos Santos; Fernando Aires Duarte; Carlos Augusto Itiu Seito; Rafael Trevisan Ortiz; Marcos Hideyo Sakaki; Túlio Diniz Fernandes

Institute of Orthopedics and Traumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – FMUSP, São Paulo, SP, Brazil

ABSTRACT

OBJECTIVE: To report the results of medium-term follow-up after deploying Arthrosurface-HemiCap® in patients with diagnosis of Hállux Rigidus (HR).

METHOD: Eleven patients underwent partial Arthroplasty of the first metatarsal-phalangeal joint. Six women and five men with an average age 51.9 years (46 to 58 years) and average postoperative follow-up of 3.73 years (3-4 years); were classified through the Kravitz system and evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) scales for hállux, Visual Analogical Scale (VAS) – analog functional pain - and range of motion in the first metatarsal joint in preoperative, postoperative after six months and present post-operative.

RESULTS: The results show significant improvement of the three analyzed parameters, both for overall analysis and for pre and post-operative comparisons individually. The comparative analysis of each variable in the six months and the current postoperative periods do not show statistically significant differences, indicating maintenance of parameters during this interval.

CONCLUSION: hemiarthroplasty of first metatarsophalangeal joint is a reproducible and safe option for the surgical treatment of hállux rigidus II and III, with significant improvement of the evaluated parameters for the studied population. Level of Evidence IV, Case Series.

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Doug Richie D.P.M. F.A.C.F.A.S.says: August 27, 2013 at 12:24 am

Ron,
You now cite a Level IV case series in support of your position? If you want to use EBM to promote the value of implant arthroplasty, could you find a study with comparative groups and at least a 24month follow up?

If you want to do some further reading on this subject, see my original blog and references which show the clear superiority of arthrodesis over implant in the surgical treatement of hallux rigidus.

If this is the best you can come up with, naive readers must rely on your suggestion to "give it a go and decide for yourself" and wait to see if proven shortcomings of 1st MPJ implant surgery are going to haunt their patients for the rest of their lives. For me, this question was answered years ago when I experienced the failures of joint implants for the 1st MTP after vendors and paid consultants urged me to "go for it."

The choice of relying on paid consultants versus evidence-based medicine is clear and simple. How could anyone see this any different?

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Ron Raducanu, DPMsays: August 27, 2013 at 12:28 pm

Doug,

The idea of these blogs is to relay information. This isn't a scientific exercise in EBM to satisfy you nor am I trying to claim it is. There is nothing "clear" about the superiority of anything as far as I'm concerned based on the data available.

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Ed Davis, DPMsays: September 2, 2013 at 6:02 pm

The comparison of first MTP joint arthrodesis vs. implant arthroplasty satisfaction rates in the studies listed do not completely take into account what we now know after several decades of first MTP joint implant use.

Bruce Lawrence, DPM, designed and marketed first MTP joint implants, and had made a number of obervations of why such implants may work or not. The following is not an attempt to quote him but to list several areas of consideration.

1) An implant of the first MTP joint is designed to restore motion at the joint but not necessarily fix the pathomechanics that led to hallux rigidus formation. Forefoot supinatus, first ray hypermobility and first ray elevatus have been suggested as etiologic factors. Such factors may be mitigated surgically or biomechanically via orthotic devices. Do studies attempting to compare arthrodesis to implants consider implants used in conjunction with control of such etiologic factors?

2) There have been and remain a diversity of first MTP joint implants from hemi implants and flexible stemmed implants to two-part unconstrained implants. It has been my experience based on communication with colleagues such as Dr. Lawrence and teaching residents that the two-part unconstrained implants have been most problematic. The hinged silicone devices appear to have the highest success rate but we must be more specific in how we define success.

To illustrate this, Dr. Lawrence related a story to me about a patient whom he placed a hinged silicone implant successfully but returned about 20 years later with another foot problem. Radiographs revealed that the hinged of the implant has broken and he discussed removal of the device with the patient. The patient replied, "Why ... it does not bother me." Apparently, broken hinges of such implants may allow the two portions to become pseudo-encapsulated and continue to function.

One myth promoted by arthrodesis advocates is that when a hinged implant breaks at the hinge, that constitutes a failure. Not necessarily so. Two options may exist upon such breakage.
A) If there is no pain nor loss of function at the joint, surgical treatment may not be needed.
B) It is often possible, if not desirable, to simply remove the old implant and place a new one in its place.

Studies comparing arthrodesis to first MTP joint implants may be using the entire spectrum of implant placement as a comparison including two-part unconstrained implants, implants placed without mitigation of pathomechanics and so on.

3) A number of studies reviewed look at patient satisfaction over a period of time in which it may not be possible to measure the various long-term sequelae of both types of procedures.

Certainly, a successful arthrodesis means there is no joint pain as the joint no longer exists. Understandably, longer-term studies are harder to perform and may involve the inclusion of more variables. Longer-term sequelae of first MTP joint arthrodesis (or failed implant arthroplasty) may include lesser metatarsal pain, iliotibial band pain, hip pain and exacerbation of sprains in patients with preexisting lateral ankle instability. Such sequelae are ones that I have encountered and have discussed with colleagues. We can discuss how gait alterations which shift propulsion laterally across the forefoot could relate to such issues at another venue.

Surgical studies often involve numbers that are small, not of long duration and with limited variables. We need not get into a contest here to see which side is more consistent with principles of EBM.

Ed Davis, DPM, FACFAS
San Antonio, TX

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