Hallux rigidus: arthrodesis reduced walking pain more than watchful waiting

Polish version: Paluch sztywny — artrodeza zmniejszała ból bardziej niż obserwacja

For symptomatic hallux rigidus, first metatarsophalangeal joint arthrodesis reduced walking pain substantially more than watchful waiting. In the first randomized comparison of fusion with the natural course of the condition, the 12-month difference exceeded both statistical significance and the prespecified threshold for clinical importance.

Why this study matters

Osteoarthritis of the first metatarsophalangeal joint may cause pain and restricted dorsiflexion that interfere with walking, footwear and activity. Arthrodesis is an established option for painful, more advanced disease, but randomized evidence against watchful waiting had been lacking. Miettinen and colleagues’ trial, published in Annals of Internal Medicine on 11 August 2026, examined the benefit of choosing fusion rather than comparing two operative techniques.

Study design

The single-centre randomized trial followed patients for 12 months. Eligibility required age ≥40 years, radiographic Coughlin–Shurnas grade I–III disease, symptoms for more than 1 year and walking pain ≥4 on a 0–10 scale. Exclusions included type 1 diabetes, rheumatoid arthritis and hallux valgus exceeding 15°.

Ninety patients were randomized 1:1 to arthrodesis or watchful waiting without surgery; 89 attended the 12-month assessment. The primary endpoint was walking pain on a 0–10 scale, with a prespecified clinically important difference of 1.7 points.

Main result

Mean walking pain at 12 months was 1.3 after arthrodesis and 5.7 with watchful waiting. The adjusted difference was −5.0 points (95% CI −6.1 to −3.9), favouring surgery. This substantially exceeded the 1.7-point threshold and represented a large clinical effect.

Clinical interpretation for an orthopaedic surgeon

The trial supports fusion for carefully selected patients with longstanding, clearly symptomatic hallux rigidus and substantial walking pain. The comparator was watchful waiting, however, rather than a standardised active nonoperative programme. It also did not compare fusion with cheilectomy, implants, interposition arthroplasty or other motion-preserving procedures, so it cannot determine the best operation for every stage.

Limitations

• A single-centre study limits generalisability across populations and services.
• Twelve-month follow-up does not establish long-term results, adjacent-joint loading or late reoperation.
• Patients were selected by age, symptom duration, pain severity and radiographic stage.
• The control was observation, not a structured active nonoperative programme.
• Other surgical treatments were not compared.

Implications for practice

Discussion of expected pain relief from fusion can now draw on direct randomized evidence against watchful waiting, in addition to case series and technique comparisons. The trial does not imply that every patient needs surgery, that arthrodesis is best at every stage or that nonoperative care should be omitted. Comparative effectiveness against other procedures and long-term consequences of losing first-joint motion remain unresolved.

References

• Miettinen M, Sirola T, Lähdeoja T, Sandelin H, Nummela M, Repo JP, Ponkilainen V, Rämö L. Surgery Versus Watchful Waiting for First Metatarsophalangeal Joint Osteoarthritis: A Randomized Controlled Trial. Ann Intern Med. Published August 11, 2026. DOI: 10.7326/ANNALS-26-00710. PubMed: PMID 42574728.

This summary is based on the publicly available abstract and publication metadata.

Related resources

For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.