FAI January 2026 Podcast: Outcomes Following First MTPJ Replacement Using the Roto-Glide Prosthesis

Summary

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Podcast Summary

FAI January 2026 Podcast: Outcomes Following First MTPJ Replacement Using the Roto-Glide Prosthesis

Host: Mark Easley (A)
Guest: Dr. Rohan Rajan (B), Consultant Trauma and Orthopedic Surgeon and Professor of Orthopedics, University Hospitals of Derby and Burton, UK

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Overview

This episode delves into the lead Foot & Ankle International paper on outcomes following first metatarsophalangeal joint (MTPJ) replacement using the Roto-Glide prosthesis. Dr. Rohan Rajan discusses his consecutive single-surgeon series, providing mid- to long-term results, clinical takeaways, technical pearls, the unique biomechanics of the Roto-Glide device, patient selection, revision strategies, and broader debates about motion-preserving surgery versus fusion in advanced hallux rigidus.

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Key Discussion Points & Insights

Study Summary & Outcomes

• Study Design:
  • Prospective, single surgeon, 6-year series (2014-2020)
  • 40 joint replacements in 35 patients, after exclusions 35 joints in 30 patients analyzed
  • Mean follow-up: 95 months (~8 years)
• Patient Data & Results:
  • Mean age: 57.9 years
  • Significant improvement in the Manchester Oxford Questionnaire (MOxFQ):
    • Preoperative score: 47
    • Final follow-up score: 6.3
  • Implant survivorship ~89.2% at 8 years
  • Complications included:
    • Joint stiffness (4 patients)
    • Flexor hallucis longus tendon rupture (1)
    • 5 converted to fusion (1 infection, 3 aseptic loosening, 1 persistent subluxation)
• Conclusion:
  • First MTPJ replacement is an option for end-stage hallux rigidus patients wishing to retain motion ([01:42], [02:50]).

Overcoming Skepticism: Replacement vs. Fusion

• Historical Skepticism: Many foot and ankle surgeons remain wary that MTPJ replacements “simply do not work.”
• Dr. Rajan’s Perspective:
  • Acknowledges a learning curve but stresses that teaching/mentorship can mitigate complications
  • Compares advances in hips and knees: “Have we not made strides in improvement of the design of implants, patient outcomes and satisfaction?” ([03:52])
  • Biomechanical studies (his and others) show improved gait, foot pressure, and satisfaction
  • While implants are costlier, long-term benefits up the kinetic chain may be more cost-effective ([04:30])
  • “We are at the threshold… of realizing that joint preservation of motion… now applies to the first MTPJ as well.” ([05:23])

Prosthesis Design & Surgical Technique

• Roto-Glide Prosthesis:
  • No design changes in 30 years
  • US surgeons favor dorsal approach; UK prefers medial
  • Teaching both approaches to expand global expertise ([05:50], [06:00])
• Expected Arc of Motion:
  • Can’t reproduce the 40-50° arc from initial studies; in Rajan’s series, mean is ~14.7° (range 5-30°)
  • This arc preserves the windlass mechanism, normalizing foot pressures and improving gait parameters ([07:18])

Addressing Sesamoid Arthritis

• Procedural Details:
  • No alteration of the sesamoid articulation by the implant
  • Essential to remove marginal osteophytes on/around the sesamoids for adequate symptom relief ([08:35])

Global Perspective: Implementing in Low-Resource Settings

• Nepal Experience:
  • Would not introduce Roto-Glide unless adequate follow-up is possible
  • In such settings, fusion is preferred due to reduced ability to manage complications or revisions ([09:44])

Challenges of Revision Arthroplasty

• Complexity:
  • Arthrodesis easier to revise than failed arthroplasty
  • Conversion from arthroplasty to fusion may require structural grafts and longer constructs
  • “Ultimately… what would I prefer as a patient? I would prefer a total joint replacement.” ([11:39])

Management of Concomitant Deformity

• Hallux Valgus
  • Roto-Glide meniscus available in standard and 3° angled (“anatomic”) options
  • Correction of significant valgus is limited; up to 3° can be fine-tuned intraoperatively
  • Combining with first TMT fusion/lapidus not done by Dr. Rajan; advocates for joint replacement over arthrodesis in stiff TMT scenarios ([13:13], [14:25])

Postoperative Rehabilitation & Function

• Activity:
  • Allows all exercises (including barefoot ones) by 2 weeks post-op
  • No dislocations observed with well-placed prosthesis ([15:17])
  • One subluxation case was iatrogenic and revised to fusion

The MOxFQ Outcome Measure

• Description:
  • 16-item, 3-domain (pain, walking/standing, social interaction) patient-reported metric
  • Scored 0-4 per item, summarized for domains, scaled 0-100
  • “Excellent psychometric properties in terms of reliability, validity, and responsiveness.” ([17:44])

Surgical Tips & Tricks

• Dr. Rajan’s Top Three Tips:
  1. “Choose the right patient.”
  2. “Perform an adequate exposure to allow removal of osteophytes and positioning of the jigsaw. Do not overstuff the joint.”
  3. “Choose the correct meniscus that allows a decent passive arc of motion. Lastly, close meticulously with a prayer.” ([19:16])

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Notable Quotes & Memorable Moments

• On the Need for Motion Preservation:
  • “I feel that we are at the threshold, very much as we were in the early part of the 20th century, of realizing that joint preservation of motion in the larger joints is advantageous, and this also now applies to the first MTPJ as well.” — Dr. Rajan ([05:23])
• Comparing Outcomes:
  • “Ultimately the question is what would I prefer as a patient? I would prefer a total joint replacement.” — Dr. Rajan ([11:59])
• On Low-Resource Setting Practice:
  • “If I’m not available there, as I am readily available here in the UK, I would not perform that surgery.” — Dr. Rajan ([09:58])
• Surgical Wisdom:
  • “Choose the right patient… Perform an adequate exposure… Do not overstuff the joint… Choose the correct meniscus… close meticulously with a prayer.” — Dr. Rajan ([19:16])
• Perspective on Progress:
  • "Grasp the nettle, read the published evidence which has demonstrated the advantage of joint motion over fusion in biomechanics, foot pressures, push off, and of course patient satisfaction.” — Dr. Rajan ([19:56])

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Timestamps for Important Segments

• [01:42] – Dr. Rajan summarizes study design and major findings
• [03:52] – Addressing replacement skepticism and motion preservation parallels with hips/knees
• [05:50] – Discussion of prosthesis design, surgical approach differences
• [07:18] – Realistic expectations for postoperative range of motion
• [08:35] – Addressing sesamoid arthritis intraoperatively
• [09:44] – Deploying advanced procedures in low-resource settings (Nepal perspective)
• [11:39] – Complexity of arthroplasty-fusion conversion/revision
• [13:13] – Managing hallux valgus in joint replacement and combining with other procedures
• [14:25] – Polyethylene component options: anatomic vs. standard
• [15:17] – Postoperative rehabilitation and exercise guidance
• [17:44] – Details on the MOxFQ outcome measure
• [19:16] – Dr. Rajan’s three surgical pearls
• [19:56] – Final reflections on the future of motion-preserving surgery in foot & ankle

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Tone & Style

The conversation is collegial, open, and pragmatic, blending technical insight with clinical wisdom. Dr. Rajan's candor about challenges, failures, and learning curves is matched by his advocacy for continuing innovation and patient-centered care. The hosts keep the discussion focused yet personable, rounding out the clinical content with anecdotes and friendly banter.

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Summary prepared for listeners and readers who want a comprehensive understanding of the episode’s essential content and clinically relevant insights, skipping non-content segments.

Transcript

[A]

This is Mark Easley and I have the distinct honor of talking with Dr. Rohan Rajan, the first author of January's lead paper in Foot and Ankle International. This paper is titled outcomes following first MTP joint replacement using the rotaglide prosthesis. Dr. Rohan Rajan is a Consultant Trauma and Orthopedic surgeon and professor of Orthopedics Gait in Biomechanics at the University Hospitals of Darby and Burton University of Darby University and the National University of Malaysia. He has numerous special interests in foot and ankle surgery including forefoot deformity and hallux rigidus. He started using the first MTPJ total joint replacement nearly 20 years ago and has distinguished himself as a thought leader for first MTP joint replacement. In addition, Dr. Rajan serves on the UK National Steering Group for Clubfoot Management, is a UK Clubfoot Network Deputy Chairman, established the Midlands Clubfoot Pathway and has been influential in creating a two University Clinical Movement Analysis Society UK accredited Gate Laboratories. Also, Dr. Rajan established a Never Rest Orthopaedics foundation charity to support and treat patients in Nepal which includes a women's refuge, an orphanage and an adult spine rehabilitation unit. Dr. Saltzman and I selected this article to highlight a single surgeon consecutive series of mid to long term outcomes of the ROTOR Glide first MTP Joint Replacement for Advanced Hallux Rigid as Failing Non operative measures welcome to the program Rohan.

[B]

Thank you.

[A]

Rohan, as lead author would you please give the listeners a brief summary of your paper and its major findings?

[B]

This was a single surgeon prospective follow up of the rotor glide first MTPJ total joint replacement. There were 40 joint replacements using the Roto Glide prosthesis which were performed in 35 patients over a six year period from 2014 to 2020. Two patients were lost to follow up and two died because of unrelated causes. One patient had the prosthesis removed in the first month because of infection and subsequently got lost to follow up. This left 35 total joint replacements in 30 patients who were included in this study. The mean age was 57.9 years. The mean follow up period was 95 months. There was a statistically significant improvement in the Moxford score. This is the Manchester Oxford Questionnaire where preoperatively it scored 47 and post operatively at the final follow up it was 6.3. At the average follow up of 8 years the implant survivorship was 89.2%, nearly 90%. Sadly we had several post operative surgical complications which I expect were part of the learning curve such as joint stiffness in four patients and one patient had a flexor hallucis longus tendon rupture. Furthermore, five patients were converted to fusion, one for infection, three for aseptic loosening and one for persistent subluxation with a reduction in surgical complications. I feel the first MTP J replacement may be considered an alternative for patients with end stage halox rigidus who want to retain joint motion.

[A]

Thank you very much, that's great. Let's get more into the details and just more broad strokes a little bit too. But there's a general sentiment among many foot and ankle surgeons that total joint replacement for the first metatarsal phalangeal joint simply does not work. You have nearly 20 years experience with more than one type of implant for this procedure. Please share why the skeptics should not shy away from this procedure.

[B]

Well Mark, I am the first to admit that there is a learning curve as with many and any new procedures. However, I am prepared to teach and coach others so that they do not make the mistakes I have made over the years. In this very paper it refers to the surgical complications I have encountered. In the final analysis, a joint needs to retain its motion. Look at the larger joints that we use to fuse, such as the hip and the knee. Have we not made strides in improvement of the design of implants, Patient outcomes and satisfaction? In previous published papers of mine in other learned journals, I have demonstrated an improved biomechanical spatiotemporal outcome, improved peak pressure changes towards a normal foot, and improve patient satisfaction following total joint replacement for the treatment of end stage hallux rigidus. Although the cost of the implants may be more substantial than that for fusion, the benefits of improved biomechanics up the kinetic chain affecting the proximal joints may in the longer term prove to be more beneficial and cost effective. In a recently submitted paper, I have shown that the first MTPJ replacement allows for a better function of the foot's windless mechanism by sparing the sagittal plane motion when compared to fusion, leading to improved foot biomechanics and pressures. I feel that we are at the threshold, very much as we were in the early part of the 20th century, of realizing that joint preservation of motion in the larger joints is advantageous, and this also now applies to the first MTPJ as well.

[A]

Great, great answer and I'm here to learn more too, so let's get more into some further questions. Rohan Hakan cofed designed and then introduced the Rotaglide total joint replacement in 1994. Have there been any design changes or surgical technique modifications over the past 30 years.

[B]

As far as I know there have not been any design changes, but I know that our American colleagues prefer the dorsal approach whilst we here in the UK we use the medial approach. I shall be hoping to teach the dorsal and the medial approaches with several key opinion leaders in the new year to our new colleagues both in Europe and in the States.

[A]

Perfect. Yeah, I'm very interested. So you mentioned we really have an obligation or advances should drive us toward taking where we have success in the larger joints two smaller joints as the first MTBJ so in total ankle replacement, a stiff ankle prior to surgery rarely leads to much improvement in ankle motion after ankle replacement. Despite this, in general total ankle outcomes are markedly improved for the first metatarsal phalangeal joint. Many foot and ankle specialists believe that the marginal improvement in first MTP joint motion with first MTP joint replacement is not worth the risk in favor of first MTP arthrodesis. You and your colleagues have a strong background in gait analysis. As you've already mentioned and as you referenced in your paper, you, Martinez, Richter and others have performed biomechanical analyses of first MTP joint arthroplasty, including comparing it to first MTP joint arthrodesis for advanced stiff hallux rigidus as you studied in your investigation. What first MTP joint motion can really be expected?

[B]

To be honest, I have not been able to reproduce Hakon Kofit's results of an arc of motion of 40 to 50 degrees following this replacement with the rotor glide. The mean arc of motion I have been able to achieve in my cohort of patients post operatively after swelling has settled is about 14.7 degrees with a range from 5 to 30 degrees. This, I feel is a realistic arc of motion. But importantly, this arc of motion preserves the windless mechanism and allows for a more normalized foot pressure with improved medial loading and push off reflected in improved spatio temporal parameters such as velocity, stride and cadence. Findings that I've already published. Great.

[A]

So Rohan, one of the greatest concerns for foot and ankle specialists considering first MTP joint arthroplasty is sesamoid arthritis. In looking at Figure 4, it appears that the rotor glide implant does not address the first metatarsal head sesamoid articulation. How can this procedure adequately relieve first MTP joint symptoms without addressing the first metatarsal head sesamoid articulation? Or does a surgical technique include any procedures to the sesamoid complex?

[B]

That's a good question. It is down to surgical technique and adequate attention to Removal of marginal osteophytes, something I've learned along the way. I perform an adequate exposure which allows me to deliver the whole metatarsal head and the whole base of the proximal phalanx and allows good vision of the tibial and fibular sesamoids. I then spend some time trimming the marginal osteophytes away from the sesamoids.

[A]

Great. Thank you. So Rohan, you take care of patients in Nepal and I want to compliment you on your amazing orthopedic work that you've done in that part of the world. But my question here is, in Nepal you may have patients who do not have the same access to medical advances or regular follow up as the patients you treat in the uk, with access to resources being equal. So, say you could bring the rhodaglide to Nepal, which you may be able to Would you perform first MTP joint replacement for your Nepali patients who may have some more challenges in the terrain they have to navigate than your patients in the uk? Those patients that have advanced hallux rigidus, would you bring the rotaglide to those patients?

[B]

First of all, thank you for referring to my charity, the Neverest foundation in Nepal, but as a background, this charity treats street orphans with neglected trauma. But coming back to your question, this rotaglide joint replacement is a relatively new procedure, although it's been around for about 20 years, but in Nepal it would be a brand new procedure. I think it's beholden upon a surgeon who introduces a new implant to be available to follow up his patients. Accordingly, to answer your question, if I'm not available there, as I am readily available here in the uk, I would not perform that surgery. Most likely if I have a patient with advanced painful hallux rigidus, I would probably go on to fuse it simply because I cannot follow them up.

[A]

Thank you. That's amazing work you do and so I admire what you've been able to accomplish, really working in two different parts of the world. Rohan, provided I properly position the hallux, I'm generally pleased with how well my first MTP joint arthrodesis performed for patients with hallux rigidus. Moreover, first MTP joint arthrodesis is a relatively reliable and reproducible procedure. In looking at the case example of an MTP joint arthroplasty failure in Figure 5, do I really need to consider MTP joint arthroplasty removal of a large volume of subchondral and cancellous bone needed for healing of an arthrodesis to accommodate a large stem in the first metatarsal and relatively large stem in the proximal phalanx poses challenges to revision surgery including the need for structural graft and extended internal fixation construct. And even in the rare event of non union with primary arthrodesis or need for revision surgery due to malunion, repeat surgery after primary arthrodesis will be far less complex. In that case you present on Figure 5 do the benefits really outweigh the risks?

[B]

Well Mark, you are correct on both accounts in that arthrodesis is a reliable operation and that revision of a non union is far easier than converting an arthroplasty to arthrodesis. What I would say is that the biomechanical advantage of a mobile joint has been proven with several published papers, mine included. I think ultimately the question is what would I prefer as a patient? I would prefer a total joint replacement.

[A]

Great. I like your succinct answer. That really simplifies my more than necessary complex question. So well, well done. Rohan, you excluded patients with hallux valgus from this investigation or at least patients with greater than 25 degrees of Hallux valgus. Figure 1 shows a central rail in the metatarsal implant that articulates with a groove in the polyethylene component. In your experience, can the rotaglide implant be successfully implanted and balanced in patients with concomitant first MTP joint, arthritis and hallux valgus? And how much stability does the central rail or this poly interface add? And taking this question one step further, do you believe it's safe to combine first MTP joint arthroplasty Alex valgus correction and a first TMT joint arthrodesis or lapidus procedure? Or do you believe that preserving the modest natural first TMT joint flexibility is important to the success of first MTP joint replacement?

[B]

This is a very complex question mark, so I'm going to break it down. The meniscus provided can be either a standard one or a very slightly angled one which will accommodate for up to 3 degrees of varus or valgus. Accordingly, if there is a very significant valgus, although the hellux rigidus may be corrected with an arthroplasty, the valgus may not be corrected adequately. Next, combining a lapidus with hallux rigidus and valgus. Personally I have never done that. However, I would suggest that a well positioned first MTPJ replacement allowing for good arc of motion would compensate for stiff TMT and biomechanically would be superior to an arthrodesis of this first MTPJ in this condition.

[A]

Great, thank you. And I'm going to take that question a little bit farther and you may have answered it with what you described. I just want to make sure the readers understand. In your manuscript you and your co authors mentioned the rotaglide polyethylene component or meniscus has both an anatomical and standard option. What is the difference?

[B]

Well, this is provided to give the surgeon options to fine tune the alignment of the joint. Think of it as the poly in the knee to correct the varus or the valgus. The anatomic meniscus allows for minor malalignments to be corrected intraoperatively such as 3 degrees of varus or valgus since the articular surface is generated at 3 degrees while the standard meniscus does not have the 3 degree tilt. Perfect. Yeah.

[A]

Thank you very much for clarifying. Rohan. In this age of fitness awareness and patients wanting to continue to do their planks and lunges and barefoot exercises that require considerable hallux MTP joint dorsiflexion, would you or do you allow your patients with first MTP joint replacements to perform these exercises or do the stresses without supportive shoes concern you?

[B]

Absolutely. I allow them to carry out all the exercises fully after two weeks. I have not found any dislocations to date of a well placed prosthesis. You will note that in this series of patients I had a patients with persistent subluxations which was iatrogenic which I then removed and fused. Great.

[A]

All right, we talked a little bit about your experience in Nepal. Let's bring you back to where you live in the uk. So correct me if I'm wrong, but the term Darby is a match between two local rivals from the same city or region. Your practice in Darby in the uk, where you're located and where you also spend much of your time. So is there a Darby for the local Darby County Football Club or perhaps with a neighboring Nottingham Forest? Or is that currently not possible with Nottingham Forest being in the Premier League? And do you really even care when you have the first class Derbyshire County Cricket Club and neighboring Nottinghamshire County Cricket Club? I mean, is cricket more your focus? Or maybe even rugby? Or do you even care about Premier League soccer?

[B]

Again, you are correct about the two rivals, Derby City, Nottingham. When we first moved to Derby from London and took up my consultant's job, my wife Kate told me an amusing story. She was at the school car park waiting to collect our three sons. And there she asked some of the mothers where should she go shopping. My wife suggested that she went to Nottingham as Nottingham was a bigger city. The other mothers immediately told her not to spend any money in Nottingham and to do so only in Derby because of this rivalry in football. And again, you are right, I prefer cricket and rugby over football, but this is not because of the lowly position Derby County Football Club finds itself in at the moment.

[A]

I love that. That's good. Well, thanks for sharing a little local color. We have the same Just not to bore you, but where I am in Durham, North Carolina, which is near Chapel Hill, North Carolina. So we have a big rivalry between Duke University and the University of North Carolina. So someday we'll have to compare notes a little bit more carefully. So back to your paper, Ron, you and your colleagues use a mocks fq. You mentioned that already in assessing your outcomes. It's a validated patient reported outcomes measure. For listeners who may not be as familiar with this particular outcomes measure, would you briefly explain its advantages in assessing results, especially for assessing the success of first MTP Joint Arthroplasty?

[B]

The Manchester Oxford Foot Questionnaire, or abbreviated to moxford, is an established validated patient reported outcome measure for foot and ankle surgery. It comprises three pain, walking and standing, and social interaction. It is a 16 item instrument answered on a 5 point Likert scale. Each item is scored from 0 to 4, with 4 denoting most severe. Scores for each item are then summed to form three separate subscales representing the underlying domains already mentioned, that's Walking or standing problems, of which there are seven items foot pain, of which there are five items and issues related to social interactions, of which there are four items. The raw scale scores are then each converted to a metric from 0 to 100, where 100 denotes the most severe. The three domain scales, I.e. walking, standing, pain and social interaction, have been shown to have excellent psychometric properties in terms of reliability, validity and responsiveness, and this has been published in many peer reviewed journals.

[A]

Perfect. Thank you very much for sharing those details. So as we get closer to the end of the podcast, to me it's clearly you're a master surgeon. So would you Please describe your three most important tips and tricks for successful 1st MTP Joint Arthroplasty?

[B]

Mark, I wouldn't describe myself as a master surgeon. We are all jobbing surgeons. However, my three top tips are the following. Choose the right patient Perform an adequate exposure to allow removal of osteophytes and positioning of the jigsaw. Do not overstuff the joint choose the correct meniscus that allows a decent passive arc of motion. Lastly, close meticulously with a prayer.

[A]

All right, very nicely done. So again, excellent work and excellent paper. As our podcast comes to its conclusion, is there anything else you would like to share with the listeners?

[B]

Well Mark, first it has been a total pleasure and an honour speaking with you, a like minded surgeon. So thank you so much for this opportunity. Secondly, I truly believe we are where our predecessors were in the early 20th century when they decided to go for preservation of motion instead of fusion with people such as Sir John Charnley and the rest. I would say grasp the nettle, read the published evidence which has demonstrated the advantage of joint motion over fusion in in biomechanics, foot pressures push off and of course patient satisfaction. So with that I thank you again Mark for this opportunity.

[A]

Oh gosh, it's my pleasure and very well said as far as your summary points, so thank you so much. I'd like to thank Dr. Rajan for discussing insights on his and his co author's foot and ankle international publication outcomes following first MTPJ replacement using the rotor glide prosthesis. And I would like to thank everyone for participating in this month's FAI podcast. This is Mark Easley and I look forward to next month's podcast.