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

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.

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])

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])

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

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.

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.