Fusion of Joint in the First Toe Appears Superior than Replacement for Treatment of Osteoarthritis
People with severe arthritis in the first metatarsophalangeal joint, or big toe, can find it difficult and painful to walk. To treat this, surgeons have been fusing the bones together, a procedure called arthrodesis. Arthrodesis does have a fairly good rate of keeping the bones together, called a union rate, at between 77 percent to 100 percent, but there are drawbacks to the surgery. The fixed bone can make it hard to walk because the toe does not bend, causing problems with other bones and joints in the foot.
A replacement to the joint has been tried in a few different forms. In this study, the authors wanted to see if a metallic replacement (hemiarthroplasty of the toe joint had a better outcome than the fusion.
The authors looked at 46 patients who had had either surgery; 21 feet in 20 patients (6 men) had had a replacement and 27 feet in 26 patients (10 men) had fusions. The ages ranged from 32 to 73; the average age of the patients with the replacement was 60 years and for the fusion was 54 years.
The average time for follow up for the replacement patients was 79 months, ranging from 68 to 86 months. Among the replacement group, 5 patients had to have follow up surgery because the replacement did not work properly. Four of the patients ended up with a fusion. Among the patients who had fusions, the follow up was between 13 and 67 months after surgery. All fusions were healed and no revisions were needed. Two patients complained of problems with one of the screws, which was corrected with a local anesthetic while in the doctor's office. When asked to rate their pain at the follow up visits, using the visual analog scale (VAS), which is a scale of 1 to 10, with 10 being the worst pain, the replacement group reported an average of 2.4.
When the researchers looked at the comparisons between the groups regarding surgery outcome, they found the patients with the replacement saw significant improvements in pain and in motion. Sixty percent of the patients said that they would do the same procedure again if needed given the same situation. Twenty-four percent rated the results as excellent, 33 percent as good, 10 percent as fair, and three remaining as poor. Among the fusion group, there was also improvement noted in pain and movement. As well, 85 percent of the patients said that if they had to do the procedure again for the same problem, they would. Seventy-eight percent of the patients rated their results as excellent, 4 percent as good, 15 percent as fair, and 1 patient rated it as poor. Pain, measured by VAS, after surgery was lower (0.7) than that of the replacement group.
The authors conclude that although the particular type of replacement they were investigating did appear to offer some advantages over the previously used ones, at this point, fusion appears to be the most effective technique for osteoarthritis of this toe joint.
Steven M. Raikin, MD et al. Comparison of Arthrodesis and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint. In The Journal of Bone and Joint Surgery. September 2007. Vol. 89-A. No. 9. Pp. 1978-1985.