Osteoarthritis is a common degenerative condition, as data from Van Saase et al. showed that approximately 20% of the general population by age 40 exhibit radiographic signs of first metatarsophalangeal joint osteoarthritis. In cases of end-stage osteoarthritis or hallux rigidus that are refractory to conservative management, surgical treatment typically involves joint-destructive procedures, most commonly arthrodesis, and in select cases, arthroplasty of the first metatarsophalangeal joint. Nonunion following first metatarsophalangeal joint arthrodesis occurs in 12–13% of patients, ^, with 11% of cases requiring additional intervention and revision procedures. Revision procedures for failed arthrodesis or arthroplasty may result in metatarsal shortening, which can lead to lesser metatarsal stress fractures, lateral column overload, hammertoe deformity, and transfer metatarsalgia. Additionally, large osseous defects can further contribute to overload and deformity and often require a structural graft to restore the metatarsal parabola. Structural grafts are most commonly autogenous bone grafts, however, 3D-printed or prefabricated truss implants may be an effective alternative. In this case series, we evaluate the use of titanium trusses during revision forefoot procedures for failed first metatarsophalangeal joint arthrodesis or arthroplasty procedures.

The current gold standard in bone grafting is an autogenous bone graft—often obtained from the iliac crest or fibula—due to its osteoconductive, osteogenic, and osteoinductive properties. ^, However, autogenous bone graft harvest has been associated with several inherent risks, such as donor site morbidity, hematoma, pain and neurovascular injury. Dimitriou et al. reported a 19.37% overall harvesting complication rate in a study of 6449 patients who underwent autologous iliac crest graft harvesting. Similarly, Conti et al. observed osteolysis or graft collapse in 50% of 32 patients who underwent calcaneocuboid arthrodesis using autologous iliac crest grafts.

In contrast, truss implants—also described in the literature as titanium wedges, titanium scaffolds, or porous metal implants—are mechanically robust, providing the most strength with the least mass, and do not exhibit resorption or collapsing complications often associated with allografts and autografts. In addition, the lattice design and roughened surface of the truss facilitate osteoblast attachment. Truss implants can be either custom-made, patient-specific, or prefabricated. They are available in various materials that are designed to optimize stability while minimizing the risk of rejection and infection. Custom implants are created by using preoperative CT imaging to match the patient’s specific anatomy and defect geometry. Prefabricated trusses, on the other hand, are manufactured in a range of standardized sizes and configurations to accommodate osseous deficits. These implants can be stored on-site and are readily available for use at the surgeon’s disposal. However, because they are produced in standardized sizing, they may not conform as well as a custom implant.

There are several reports highlighting the successful use of titanium trusses for revision procedures in the hindfoot and ankle, however, there are only a few studies evaluating the effectiveness of trusses in the forefoot. Furthermore, there is limited literature comparing both clinical outcomes and cost analyses between custom and prefabricated implant options. In this study, we retrospectively evaluated the success of titanium trusses in revision forefoot procedures within our institution to restore length and provide structural stability in cases of failed first metatarsophalangeal joint arthrodesis or arthroplasty. We also compared the costs of prefabricated and custom titanium trusses at our institution.

We retrospectively identified patients who underwent revision first metatarsophalangeal (MTP) arthrodesis for failed prior arthrodesis or arthroplasty at a single institution. All procedures were performed by a single surgeon between October 1, 2017 and January 1, 2024. Inclusion criteria consisted of patients undergoing revision first MTP arthrodesis utilizing a titanium truss implant with available postoperative follow-up. All revision surgeries utilized either a custom, patient-specific (3D-printed) titanium truss implant or a prefabricated titanium truss. Implant selection was made at the treating surgeon’s discretion based on patient-specific factors and imaging findings. Surgical technique was not standardized across all cases. The use of supplemental fixation, as well as the addition of adjunctive graft material (including autograft, allograft, or other biologics), was determined at the discretion of the treating surgeon based on intraoperative findings and defect characteristics. However, all cases utilized a titanium truss implant in conjunction with a dorsal plate spanning the first metatarsophalangeal joint ( Fig. 1 ).

Patient 3. From left to right: preoperative anteroposterior (AP) and lateral radiographs with first metatarsophalangeal (MTP) joint implant arthroplasty; postoperative AP and lateral radiographs following revision first MTP arthrodesis utilizing a prefabricated titanium truss; and an intraoperative image of prefabricated truss packed with bone graft.

The primary outcome assessed was successful osseous union. Union was evaluated using either postoperative computed tomography (CT) or plain radiographs. When CT imaging was obtained, union was determined by a radiologist and defined as greater than 50% osseous bridging across the bone–implant interface. In cases where CT imaging was not obtained, union was assessed by the operating surgeon using plain radiographs using the same criteria. CT imaging was used to confirm union in 6 of 8 cases, while the remaining 2 cases were assessed using plain radiographs.

The timing of union was defined as postoperative imaging demonstrating osseous consolidation based on chart review of clinical documentation and imaging reports. Radiographic union was identified based on terminology such as “fusion,” “consolidation,” or “osseous bridging” at the bone–truss interface with maintained alignment. CT scans were interpreted by radiologists and described union using terms such as “healed” or “fusion.” Due to variability in follow-up intervals, imaging timing, and documentation, exact time to union was not uniformly standardized across all cases.

Additional variables collected included patient demographics, smoking status, prior surgical history, implant type, and postoperative outcomes, including need for hardware removal. Implant cost data for both custom and prefabricated titanium trusses were obtained directly from surgical billing records at our institution.

A total of seven patients (eight feet) underwent revision first metatarsophalangeal (MTP) arthrodesis and met the inclusion criteria. Of the eight cases, four were performed for failed prior arthrodesis and four for failed arthroplasty. All patients in this cohort were female. The mean age at the time of surgery was 47 years (range: 32–57 years), with a mean body mass index (BMI) of 27.71 kg/m² (range: 23.5–36.5 kg/m²). Three patients were former smokers, and five were never smokers.

Preoperatively, seven of eight feet were evaluated with computed tomography (CT) to assess the extent of osseous involvement, including bone loss and cystic changes. In one case, a preoperative CT scan was not obtained at the discretion of the treating surgeon due to clear radiographic evidence of nonunion and metatarsal shortening necessitating revision and restoration of length. One case required hardware removal and bone biopsy before definitive revision surgery.

A custom titanium truss was utilized in five cases, while a prefabricated titanium truss was used in three cases. The mean duration of follow-up was 25.5 months (range: 4–72 months). All patients maintained clinical and radiographic union without evidence of hardware failure or need for further revision at the latest follow-up. Detailed patient demographics and procedural characteristics are summarized in Table 1 .

Table 1

Patient demographics, surgical characteristics, and postoperative outcomes for revision first metatarsophalangeal arthrodesis utilizing titanium truss implants, including implant type, cost, time to weightbearing, time to union, imaging modality, follow-up duration, and need for hardware removal.

Patient	Age at surgery (years)	BMI Kg/m 2	Surgery revised	Smoking status	Laterality	Implant used	Cost US dollar	Gender	Weeks NWB	Time to normal shoe (weeks)	Imaging and time to union (months)	Follow up duration (months)	Hardware removal performed
1	56	24	Implant	Former	Left	Custom	$13,500	Female	7	13	XR- 16	36	No
2	57	26	Implant	Former	Right	Custom	$13,500	Female	10	12	XR- 14 CT- 8	26	No
3	52	36.5	Implant	Former	Right	Prefabricated	$1825	Female	9	11	XR- 4	4	No
4	38	32	Arthroplasty	Never	Left	Prefabricated	$1825	Female	7	12	XR- 6 CT- 6	6	No
5	39	30	Arthrodesis	Never	Right	Custom	$13,500	Female	8	13	XR- 12 CT- 18	24	Yes
6	57	24.5	Arthroplasty	Never	Right	Prefabricated	$1895	Female	8	14	XR- 4 CT- 26	72	Yes
7	45	23.5	Arthrodesis	Never	Right	Custom	$11,500	Female	7	10	XR- 4 CT- 6	16	Yes
8	32	25.2	Arthrodesis	Never	Left	Custom	$11,500	Female	8	14	XR- 8 CT- 14	20	Yes

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