Lifetime cost-effectiveness of first metatarsophalangeal joint fusion using patient reported outcomes from National Foot and Ankle Registry data in the UK

Background: Hallux rigidus is a common and debilitating condition that increasingly impacts UK healthcare resources. First metatarsophalangeal joint (MTPJ) fusion is a widely performed intervention with excellent clinical outcomes; however, its commissioning has faced restrictions in some regions in the UK due to perceived limited value. Robust national cost-effectiveness evidence is needed to guide policy and ensure equitable access to care. Methods: A cost–utility analysis was conducted using British Orthopaedic Foot & Ankle Society (BOFAS) Registry data for patients undergoing primary 1st MTPJ fusion. EuroQol-5 Dimension (EQ-5D-5L) outcomes at baseline and 1 year were utilised to estimate quality-adjusted life year (QALY) gains. A lifetime Markov model over 20 years simulated costs, utilities, and complication pathways from the UK NHS perspective. Costs were derived from national tariffs and discounted at 3.5 % per annum. Incremental cost-effectiveness ratios (ICERs) were calculated relative to conservative management, and deterministic sensitivity analysis tested uncertainty across cost and utility assumptions. Results: Out of 1199 patients, 202 had completed full PROM datasets for cost-utility modelling. EQ-5D-5L improved from 0.53 pre-operatively to 0.77 at one year (p < 0.001), exceeding the MCID by six months and sustained thereafter. The base-case model demonstrated a discounted lifetime QALY gain of 3.331 and cost of £ 4698.15, yielding an ICER of £ 1410.58 per QALY gained. Across all sensitivity scenarios, including increased costs, reduced utility gains, and shortened duration of benefit, the ICER remained well below accepted NICE thresholds (£20,000–£30,000/QALY). In the low-cost scenario, 1st MTPJ fusion became cost-saving (negative ICER) by year 18. Conclusion: 1st MTPJ fusion is a highly cost-effective intervention for hallux rigidus, delivering clinically significant and durable improvements in quality of life at very low cost per QALY gained. This procedure provides greater value for money than many widely commissioned major orthopaedic operations, including hip and knee arthroplasty. Current NHS restrictions on access are not supported by health-economic evidence. These findings reinforce the essential role of 1st MTPJ fusion in value-based foot and ankle surgical care.