Implants have been used to replace the metatarsophalangeal (1st MTP) joint of the big toe for more than a century. Although good early results have been reported with silicone implant arthroplasty, they were complicated by late failure. New designs of implants have evolved in the last two decades to replace the joint in severe arthritis. The functional requirements of the 1st MTP joint and the role of the soft tissue must be respected in order to achieve optimal results after implant arthroplasty. This article will discuss the development of implant arthroplasty of the 1st MTP joint, complications, the current status of the procedure and raise the question of what else can be done.