DOI: 10.1177/24730114261466656 ISSN: 2473-0114

Primary vs Revision and Salvage First Metatarsophalangeal Joint Arthrodesis: A National Database Study of Utilization, Complications, and Cost Analysis

Jacob W. McDevitt, Eric H. Durudogan, Frederic J. Washburn, Milap S. Patel, Anish R. Kadakia, Muhammad Y. Mutawakkil
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Background:

First metatarsophalangeal joint (MTPJ) arthrodesis is the gold standard for end-stage hallux rigidus and a salvage option for failed hallux valgus correction. Although complication rates for primary and revision fusion have been reported separately, no large-scale study has directly compared outcomes between these cohorts.

Methods:

Primary and revision first MTPJ arthrodesis cases were identified using the PearlDiver Mariner national administrative claims database. The revision and salvage cohort was defined as first MTPJ arthrodesis performed ipsilateral to any prior hallux procedure, including hallux valgus correction, cheilectomy, arthroplasty, or prior fusion, and is not limited to revision of a failed prior first MTPJ arthrodesis specifically. Cases involving trauma, infection, malignancy, or fewer than 2 years of follow-up were excluded. After 1:1 propensity score matching on demographics and comorbidities, 2099 patients remained in each cohort. Thirty-day complications, 2-year reoperations and failure-related diagnoses, postoperative opioid use, and cumulative health care expenditures were compared between cohorts.

Results:

Early postoperative complication rates were low and comparable between groups (revision 3.7% vs primary 3.1%, P  = .30), with no significant differences in infectious, medical, or surgical complications. At 2 years, revision arthrodesis was associated with significantly higher rates of any reoperation (12.6% vs 8.2%, P  < .001), repeat fusion (7.2% vs 4.4%, P  < .001), hardware removal (5.4% vs 2.1%, risk ratio 2.51, P  < .001), nonunion diagnoses (9.9% vs 4.1%, P  < .001), infection-related diagnoses (10.1% vs 6.6%, P  < .001), and wound complications (6.7% vs 4.2%, P  < .001). Postoperative opioid fill rates were higher in the revision cohort at all evaluated time points, including within 30 days (38.7% vs 34.4%, P  = .003) and at 1 year (56.7% vs 51.5%, P  = .001).

Conclusion:

Revision first MTPJ arthrodesis is associated with similar short-term perioperative risk but significantly greater long-term failure burden compared with primary fusion. These findings emphasize the importance of durable primary correction and suggest that salvage cases may warrant heightened attention to patient optimization. Although fixation strategy and biologic augmentation were not directly evaluated in this study, these represent plausible clinical considerations for mitigating reoperation risk and downstream resource use that merit prospective investigation.

Level of Evidence:

Level III, retrospective cohort study.

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