Advanced stages of first metatarsophalangeal joint (MTPJ) arthritis have traditionally been treated with various arthroplasties or arthrodesis. A recent study suggests that the outcomes of arthrodesis are superior to those of metallic hemiarthroplasty; however, complications and poor outcomes still remain with arthodesis of the first MTP joint. This study reports two year follow-up in patients with advanced MTPJ arthritis who underwent prosthetic inlay resurfacing for the metatarsal side of the MTPJ. From January 2005 to October 2006 patients with stage II or III hallux rigidus underwent inlay resurfacing of the first MTPJ (Arthrosurface HemiCAP® prosthesis). Fourty-seven patients (51 implants) were willing to participate at two institutions in a follow-up study comparing preoperative and postoperative radiographs, range of motion, AOFAS scores and SF-36 scores. The average age of the patients was 51 years. At a mean follow-up of 27 months (range: 12–38), the postoperative assessment demonstrated statistically significant improvements in range of motion (passive mean preop: 280 – postop: 660), AOFAS scores (mean preop: 510 – postop: 940) and SF-36 scores (mean preop: 81, postop: 96) (P< 0.05) when compared to baseline. There were no clinical or radiographic failures of the implant with all patients being satisfied and willing to undergo the procedure again. Although longer term follow up is still lacking the two year results are very promising. As minimal joint resection is necessary, conversion to arthrodesis or resection arthroplasty is relatively simple.