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Clinical Question: In patient with end-stage hallux
rigidus which has a better outcome artrodesis or total replacement
arthroplasty?
Bottom Line: Outcomes after arthrodesis were better than
those after arthroplasty. The results were partially attributable to an
unacceptably high incidence of loosening of the phalangeal components, which
resulted in removal of the implants. However, even when data from the
failures were excluded, arthrodesis was clearly preferred by most patients.
Reference: Arthrodesis or total replacement arthroplasty
for hallux rigidus: a randomized controlled trial.Gibson JN, Thomson CE.Foot
Ankle Int. 2005 Sep;26(9):680-90
Study Design: Randomized Controlled Trial
Synopsis: One problem that afflicts the big toe is called
hallux rigidus, a condition where movement of the toe is restricted to
varying degrees. This disorder can be very troubling and even disabling,
since we use the all-important big toe whenever we walk, stoop down, climb
up, or even stand. If you have pain and/or stiffness in your big toe, you
may have this condition.
Arthrodesis is the current treatment for end-stage hallux rigidus, although
there are many reports advocating total joint replacement arthroplasty. The
aim of this randomized controlled trial was to evaluate clinical outcomes
after first metatarsophalangeal joint (MTPJ) arthrodesis and replacement
arthroplasty. Between November, 1998, and January 2001, 63 patients between
the ages of 34 and 77 years, with unilateral or bilateral MTPJ arthritis
were recruited and randomly selected to have either MTPJ arthrodesis or
arthroplasty. Twenty-two patients (38 toes) had arthrodesis and 27 patients
(39 toes) had arthroplasty. A single surgeon performed all surgery. The
primary outcome measure determining successful surgery was a decrease in
pain as measured on a Visual Analogue Scale (VAS). Functional outcome was
assessed at 6 months and 1 and 2 years. Cost data were simultaneously
collected. At 24 months, pain improved in both groups (p < 0.001), but there
were significantly greater improvements after arthrodesis (p = 0.01). All 38
arthrodeses united at a mean dorsiflexion angle of 26 degrees, with few
complications. In contrast, in the arthroplasty group, six of the 39
inserted implants had to be removed because of phalangeal component
loosening. In the remainder the range of motion gained was poor, and the
patients tended to bear weight on the outer border of their foot. The cost
ratio was 2:1 in favor of arthrodesis.
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