There is a paucity of published literature regarding the long-term outcomes of the modern generations of total joint arthroplasty (TJA) of the first metatarsophalangeal joint. Between 1999 and 2001, we recruited 63 patients into a randomised controlled trial of arthrodesis vs TJA. The 2 year results were published in 2005.

At a mean follow-up 15.2 years (range 13.2–17.2), all patients from the original trial were contacted. Data were collected in the form of visual analogue score for pain (VAS), visual-Analogue-Scale Foot and Ankle (VAS FA) as well as information on any revision procedures.

Data were available from all surviving patients (66 toes 53 patients). There was no difference in pain scores between the arthrodesis group and arthroplasty group 7.4 ± 15.7 vs 15.7 ± 19.7 (p=0.06). There was also no difference in the VAS FA scores as a whole 88.9 ± 12.9 vs 86.1 ± 17.1 (p = 0.47), or when divided into its 3 components (pain, function and other complaints). There was however a significant difference with regards to patient satisfaction with the arthrodesis group outperforming the TJA group: 95.5 ± 10.4 vs 83.6 ± 20.9 (p<0.01). There was a significantly higher rate of revision surgery in the TJA group when compared to the arthrodesis group (p= 0.009).

At 15 years the patients that underwent arthrodesis were more satisfied and had a greater survivorship compared to TJA, however there was no difference in outcome with regards to pain or function between the two groups. Based on the results of this study arthrodesis remains the ‘gold standard’ due to excellent pain relief, high function and low risk of revision surgery.

A Morton's neuroma is a painful forefoot disorder characterised by plantar pain and toe paraesthesia. Many treatments have been tried including modification of shoe wear, injections and surgery. The results from different treatment modalities are extremely variable in the scientific literature.

We reviewed 79 patients who presented with an ultrasound proven Morton's Neuromata at an average of 60 months following treatment in a patient blind randomised trial.

35 had surgery with resection of the Morton's Neuromata. We compared the results of the patients who had had a steroid injection and surgery, a steroid injection alone, a placebo injection and then surgery and a placebo injection alone.

We looked at the requirement for further consultations, pain scores, activity restrictions, footwear restriction, overall satisfaction with their treatment and overall quality of life scores. We found no significant difference between the groups. Overall 80% of the surgical patients had a good or excellent result and 67% of the non- operatively managed patients had a good or excellent result. There was no difference in their quality of life scores.

Previous studies have shown little benefit in steroid injections in the treatment of Morton's Neuromata. We conclude at the five year mark there is no significant differences between operating on Morton's Neuromata and treating them conservatively.

Further research should focus on comparing operative vs conservative treatment in the short to medium term. In order to justify the risks and costs of surgery.

Joint arthroplasty is increasingly being promoted by commercial companies for hallux rigidus. We report the preliminary results of a randomised controlled trial comparing metatarsophalangeal joint arthroplasty with fusion.

63 patients, 14 with bilateral disease (39f, 24m; mean age 55, range 34–77) were recruited and assessed independently. They were then allocated by closed opaque envelope to receive either a condylar joint replacement (BIOMET®) or toe arthrodesis (circlage and oblique K-wire). Outcome assessments were repeated at 6 months, 1 and 2 years (2 fusion, 1 implant lost to follow-up at 1yr).

All 38 fusions finally united (3 were delayed > 4 months) at a mean angle of 26±7° dorsiflexion. Two patients were admitted for K-wire extraction under GA and seven required courses of antibiotics. Six of the first 30 arthroplasties had on-going pain and erythema following surgery. One had a sympathetic dystrophy but the remaining five had evidence of phalangeal component loosening and were readmitted for a one stage cemented revision (4 aseptic and 1 septic loosening). The phalangeal component was cemented on the final 9 occasions (Palacos® + Gentamicin). No further revisions have been required. At 1yr 80% of patients rated their fusion and 72% their arthroplasty good/excellent (VAS pain score: pre: 63±18 -v- 59±19, n.s; 1yr: 18±24 -v- 38±27 p< 0.05 means±SD).

Patients are generally pleased to retain joint mobility, but the high incidence of phalangeal component loosening probably will require a change in implant design / surface coating.