Brewster M. “Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature”

Abstract

Dear Editor: I read with interest the recent review article by Mark Brewster, MBChB, comparing the functional results of total joint replacement versus arthrodesis of the first metatarsophalangeal joint.1Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature.J Foot Ankle Surg. 2010; 49: 546-552Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar After reading the systematic review, I think several points need further clarification. First, the title of the article is too broad. The author does not include total joint replacements using Silastic or silicone implants, and specifically excludes articles on these implants from the systematic review. The title does not let the reader clearly know this. The title would have been better stated as “dual component total joint replacement versus arthrodesis” or wording to let the reader know that Silastic and silicone implants were excluded from the study. Second, the author states in the review’s abstract, “This systematic review reveals that arthrodesis achieves better functional outcomes than total joint replacement.” Although this statement may or may not be true, the results of the review do not support the statement. In fact, in the body of his article, the author states near the end of the review (next-to-last paragraph), “This systematic review revealed many things. Primarily, it appears that arthrodesis and total joint replacement have similar functional results.” This is the statement that should have been made in the abstract as well, based on the data provided from the author’s systematic review. Although a scoring system of acknowledged limitations (ie, AOFAS-HMI) was used for comparison, the comparison performed by the author revealed that the functional outcomes between total implant arthroplasty and arthrodesis were almost identical (83/100 for total implant replacement and 82/100 for arthrodesis). How then can the author justify the statement made in the abstract? Third, the author states in his article that the median revision rate in total joint replacements was 7% (range 0%–10%) and 0% (0%–12%) for arthrodesis. If one strictly looks at the numbers reported, there were 6 revisions in arthrodesis cases out of 158 fused joints reviewed. This is a revision rate of roughly 4%. The review suggests that the 12% rate reported in one study was an “outlier,” when in actuality it may not have been. I am not advocating any preference between total joint replacement and arthrodesis for the first metatarsophalangeal joint. However, when a systematic review is done, one must be careful to avoid statements that may lead a reader to potentially incorrect conclusions. Does Total Joint Replacement or Arthrodesis of the First Metatarsophalangeal Joint Yield Better Functional Results? A Systematic Review of the LiteratureThe Journal of Foot and Ankle SurgeryVol. 49Issue 6PreviewAs first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5 featured arthrodesis and 5 featured total joint replacement. Full-Text PDF ReplyThe Journal of Foot and Ankle SurgeryVol. 50Issue 2PreviewThank you for your interest and detailed analysis of my article published in The Journal of Foot & Ankle Surgery (Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature. J Foot Ankle Surg 49:546–552, 2010). I shall address each point you raised in order. Full-Text PDF