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Fusing an arthritic big toe cut walking pain from 5.7 to 1.3 in the first trial to test it
Hallux rigidus is common and its main operation had never been compared against simply waiting. A Finnish randomized trial of 90 adults found fusion beat watchful waiting by 5 points on a 10-point walking pain scale at 12 months.
- Fusing an arthritic big toe cut walking pain from 5.7 to 1.3 out of 10.
- That is about three times the improvement agreed in advance as meaningful.
- The comparison was watchful waiting, which is what many patients are offered.
- This common operation had never been tested against simply waiting before.
- 90 adults at a single Finnish center, randomized, followed a year.
Orthopedic surgery has a long history of operations that turned out to work no better than waiting. Keyhole surgery for knee arthritis, vertebroplasty for spinal fractures, and shoulder decompression all survived for years on surgeon confidence before a trial with a proper comparison arm arrived and found nothing.
So the interesting thing about hallux rigidus, arthritis in the joint at the base of the big toe, is that its standard operation had never faced that test. Miettinen and colleagues, writing in Annals of Internal Medicine, note that no randomized trials have compared surgery with the natural course of the disease.
They ran one. At 12 months, the observed mean walking-related pain was 1.3 in the arthrodesis group and 5.7 in the watchful waiting group.
Why the size of that gap is the story
Five points on a ten-point scale is a very large difference for any intervention.
What makes it interpretable is that the team said in advance how much would count. The prespecified minimal clinically important difference was 1.7 points, meaning the smallest change a patient would actually notice. The result came in at three times that.
Setting the threshold before seeing the data matters more than it sounds. A trial that decides afterwards what counts as meaningful can always find a bar its result clears. This one committed first.
What fusion actually does
Arthrodesis is not a repair. It is the deliberate abolition of a joint.
The surgeon strips the worn cartilage from both surfaces and fixes the bones together, here using a lag screw and dorsal plating, and over the following months they knit into a single bone. The joint no longer bends. It also no longer grinds, and grinding is what hurts in an arthritic toe.
That trade is the whole clinical question. A fused first metatarsophalangeal joint changes how a foot pushes off, rules out heels, and cannot be undone. Against that, this trial puts a five-point reduction in walking pain sustained across a year.
What the trial measured, and what it did not
The primary outcome was walking-related pain on a numerical rating scale, and that is a narrower thing than “did surgery help”.
Pain and function come apart in foot surgery more than elsewhere. A stiff, painless toe can still change a gait, and a patient can be delighted with the pain relief and frustrated by what they can no longer wear or do. The abstract reports the pain result; the broader function and satisfaction picture is where a reader should want more.
Twelve months is also a first look rather than a final one. Fusion is permanent, and the questions that matter for a permanent operation, whether neighboring joints wear faster and whether the relief holds at five and ten years, are not answered here.
Who was in it
Osteoarthritis is a common form of arthritis in which cartilage in a joint breaks down over time, and it most often occurs in the hands, knees, hips and spine. Feet get less attention, which is part of why this operation went untested.
The trial enrolled adults aged 40 or older with radiographically confirmed hallux rigidus, symptoms for over a year, and walking pain of at least 4 out of 10. It excluded type 1 diabetes, rheumatoid arthritis, and a bunion angle over 15 degrees. So this is a result about established, painful, X-ray-confirmed disease in otherwise reasonably healthy feet.
It also ran at one orthopedic department in Finland, which the authors list as their limitation. Single-center trials carry the technique and the case selection of one surgical team, and both travel imperfectly.
What a person with a painful big toe should take from it
The honest headline is that an operation many people are offered has, for the first time, been shown to beat doing nothing, by a lot.
That is not the same as saying everyone should have it. Watchful waiting in this trial meant genuinely waiting, and most people with a sore toe try stiff-soled shoes, rocker soles, orthotics and anti-inflammatories first. None of those was the comparison here.
What changes is the conversation. A patient weighing a permanent fusion against carrying on can now be told what the difference looked like in a randomized trial, rather than what a surgeon believes. Regular exercise is one of the best things you can do for your health, and a foot that hurts every time it pushes off is a reason people stop.
People also ask
What did the trial find?
At 12 months, the observed mean walking-related pain was 1.3 in the arthrodesis group and 5.7 in the watchful waiting group (adjusted mean difference, -5.0 points [95% CI, -6.1 to -3.9 points]), exceeding the prespecified minimal clinically important difference and favoring arthrodesis.
What is hallux rigidus?
Osteoarthritis of the joint at the base of the big toe, the first metatarsophalangeal joint. The cartilage wears, the joint stiffens, and pushing off while walking hurts. It is one of the most common arthritic conditions of the foot.
What is arthrodesis?
Fusion. The surgeon removes the damaged joint surfaces and fixes the two bones together, here using a lag screw and a plate along the top of the foot, so they heal as one bone. The joint stops moving, and stops hurting.
Does a fused toe still work?
It walks. Losing motion at that joint changes push-off and rules out high heels, and the trial's primary outcome was walking pain rather than a full function or satisfaction measure, so this result speaks to pain specifically.
Why is a minimal clinically important difference worth knowing?
Because statistical significance says a difference exists, not that a patient would notice it. The team set 1.7 points in advance as the smallest change a person would feel. The observed 5.0 points is nearly three times that, which is what makes this a large result rather than merely a detectable one.
Why had nobody run this trial?
The authors note that no randomized trials have compared surgery with the natural course of the disease. Established operations are difficult to randomize against no operation: surgeons believe they work, patients want them, and a waiting arm is a hard sell.
Who should not read this as advice?
Anyone whose situation differs from the trial's. It excluded type 1 diabetes, rheumatoid arthritis and significant bunion deformity, ran at a single Finnish hospital, and enrolled people with symptoms for over a year and a walking pain score of at least 4 out of 10. This is general information rather than medical advice.
References
- Miettinen, M., Sirola, T., Lahdeoja, T., Sandelin, H., Nummela, M., Repo, J. P., Ponkilainen, V., Ramo, L. Surgery Versus Watchful Waiting for First Metatarsophalangeal Joint Osteoarthritis: A Randomized Controlled Trial. Annals of Internal Medicine, 2026.
- MedlinePlus. Osteoarthritis. US National Library of Medicine.
- MedlinePlus. Exercise and Physical Fitness. US National Library of Medicine.