Joint fusion superior to watchful waiting for hallux rigidus 

1. In this randomized controlled trial, arthrodesis significantly reduced walking-related pain compared with watchful waiting in adults aged 40 years or older with hallux rigidus.

2. Arthrodesis also improved pain at rest and was associated with lower analgesic use.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Hallux rigidus, or osteoarthritis of the first metatarsophalangeal joint (MTPJ) at the base of the great toe, is a common degenerative joint disorder. Joint-space narrowing, osteophyte formation, and restricted dorsiflexion can lead to pain, difficulty walking, and discomfort with footwear. Evidence supporting conservative management remains limited, while recommendations for surgical intervention have largely been based on observational studies and case series. This study evaluated whether MTPJ arthrodesis, the gold-standard surgical treatment for hallux rigidus, is superior to watchful waiting. At follow-up, patients who underwent arthrodesis reported significantly less walking-related pain than those managed with watchful waiting. Arthrodesis was also associated with reduced pain at rest and lower analgesic use. No major adverse events or reoperations were reported. Notably, a substantial proportion of participants initially assigned to watchful waiting ultimately elected to undergo arthrodesis during the study period. The generalizability of these findings is limited by the study’s single-centre design, potential selection bias, lack of blinding, and exclusion of patients with conditions such as increased hallux valgus angle, rheumatoid arthritis, or prior foot and ankle trauma. Nevertheless, this trial provides higher-quality evidence supporting arthrodesis as an effective treatment option for adults with hallux rigidus who are seeking relief from walking-related pain.

Click to read this study in AIM

Relevant Reading: Functional Outcomes Following First Metatarsophalangeal Arthrodesis

In-Depth [randomized controlled trial]: This randomized controlled trial evaluated whether first MTPJ arthrodesis was superior to watchful waiting for painful hallux rigidus. Eligible participants were adults aged 40 years or older with walking-related pain rated at least 4/10 for more than 1 year and radiographic evidence of first MTPJ osteoarthritis (Coughlin-Shurnas grades I–III). Patients with hallux valgus angle greater than 15°, rheumatoid arthritis, peripheral neuropathy, or poorly controlled diabetes were excluded. The primary outcome was walking-related pain at 12 months, measured on a 0-10 numerical rating scale (NRS). Secondary outcomes included pain at rest, satisfaction, disability, foot function, quality of life, and use of analgesics and orthoses. Of 165 patients screened, 147 (89%) were eligible and 90 (61%) consented to participate. Participants were randomized to arthrodesis (n = 45) or watchful waiting (n = 45), with follow-up completed by 89 of 90 participants (99%). The mean age was 58 years, the median symptom duration was 60 months, 57% were women, and the median baseline walking pain score was 6/10. At 12 months, mean walking-related pain was 1.3 in the arthrodesis group compared with 5.7 in the watchful waiting group, corresponding to an adjusted mean difference of -5.0 points (95% confidence interval [CI], -6.1 to -3.9), substantially exceeding the minimal important difference (MID) of 1.7 points. Pain at rest was also lower following arthrodesis (0.6 vs. 3.6; adjusted mean difference, -3.5 [95% CI, -4.7 to -2.4]), again exceeding the MID. Most functional outcomes, including Manchester-Oxford Foot Questionnaire domains, also favored arthrodesis. No serious adverse events or reoperations occurred, although six minor adverse events were reported after surgery. Notably, 29 of 45 participants (64%) initially assigned to watchful waiting ultimately opted for arthrodesis during follow-up. Sensitivity analyses yielded similar results. Overall, arthrodesis was superior to watchful waiting for improving pain, function, and quality of life in adults with hallux rigidus.

Image: PD

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