Breaking the Stiffness: Functional and Radiological Results of Three Fixation Approaches in First MTP Arthrodesis

Objectives: This study aimed to compare the clinical, functional, and radiological outcomes of three different fixation techniques-dorsal locking plate, crossed cortical screw, and a combination of both-used in first metatarsophalangeal (MTP) joint arthrodesis for advanced-stage hallux rigidus. The goal was to provide evidence-based guidance for surgical technique selection. Methods: This retrospective cohort study included 52 patients with advanced hallux rigidus (stage III-IV, Coughlin-Shurnas classification) who underwent surgical treatment between 2023 and 2025 at the Department of Orthopedics and Traumatology of Ankara Etlik City Hospital, with a minimum follow-up of one year. Patients were categorized into three groups according to the fixation technique used. Visual Analog Scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Foot Function Index (FFI) were assessed using validated Turkish-language versions of the questionnaires. Radiological parameters included hallux valgus angle, first toe dorsiflexion angle, distal interphalangeal (DIP) arthritis, and radiographic union-defined as trabecular bridging across at least three cortices on weight-bearing anteroposterior and lateral radiographs. ANCOVA was performed with age as a covariate. Results: A total of 52 patients were included: Group 1 (dorsal plate fixation, n = 19), Group 2 (crossed cortical screw fixation, n = 16), and Group 3 (combined fixation, n = 17). Group 1 patients were significantly older (mean age: 64 ± 6 vs. 55 ± 6 and 59 ± 5 years; p < 0.001). After age adjustment, VAS pain scores were significantly higher in Group 1 compared to Group 3 (mean VAS: 2.8 ± 0.6 vs. 1.9 ± 0.5; p = 0.010). AOFAS scores did not differ significantly (p = 0.166), although Group 2 showed the highest median value (90 [70-93]). FFI scores differed significantly (p < 0.001), with Group 1 reporting worse outcomes (19 [17-31]) than Group 2 (15 [13-22], p = 0.03) and Group 3 (15 [11-16], p = 0.01). Dorsiflexion angle was significantly lower in Group 2 than Group 1 (median 19° vs. 27°; p = 0.04), though all remained within the physiological range. Radiographic union was achieved in 50/52 patients (96.2%), without significant intergroup differences (p = 0.612). Complications included two cases of wound dehiscence in Group 1; no infections, symptomatic non-union, malalignment, or hardware irritation were observed. Conclusions: Crossed cortical screw fixation yielded the most favorable functional outcomes, whereas the combined technique achieved the lowest postoperative pain scores. Dorsal plate fixation alone consistently underperformed. While outcomes were adjusted for age, residual confounding cannot be excluded. These results highlight the importance of tailoring fixation strategy to patient profile, with crossed screw and combined methods representing reliable choices for optimizing postoperative outcomes in advanced hallux rigidus.