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Background: The aim of this study was to compare outcome (clinical, patient-reported outcome measures, radiologic, joint motion and pedographic) of total joint replacement with Roto-Glide (RG) and arthrodesis (A) for severe osteoarthritis of the first metatarsophalangeal joint (MTP1). Methods: All consecutive patients with arthrodesis and RG from January 23, 2011, until September 18, 2019, at the authors' institution were considered for inclusion in the study. Preoperatively and at follow-up (FU), radiographs, and/or weightbearing computed tomographic imaging were obtained. Standard dynamic pedography was performed. Visual analog scale foot and ankle (VASFA), European Foot and Ankle Society (EFAS) score, MTP1 range of motion for dorsiflexion/plantarflexion (DF/PF) were registered and compared preoperatively and at FU. Results: Seventy RG and 72 arthrodesis patients were included. Preoperative VASFA and EFAS scores did not differ between the RG and arthrodesis groups (average scores: VASFA, 50.6 and 45.6; EFAS score, 10.7 and 10.6, respectively; each P >.05). Wound healing delays without further operative measures were registered in 4 patients (6%) for RG and 5 (7%) for arthrodesis (P =.67), and 5 revisions in 5 patients (7%) for RG and 12 in 8 (11%) for arthrodesis (P =.05). The longest available FU was higher in RG than in arthrodesis (47 vs 37 months on average, P <.001). Pedography showed higher first metatarsal head or sesamoids and lower great toe force percentage from force of entire foot in RG than in arthrodesis (P =.05) resulting in physiological pattern in RG only. VASFA and EFAS scores at FU was higher in RG than in arthrodesis (average scores: VASFA, 72.6 and 63.6; EFAS score, 16.1 and 14.1, respectively; each P <.05). DF/PF measurement was only possible in RG (average value: DF/PF, 36.1/14.0). Conclusion: We found marginally lower revision rates and higher patient-reported outcome measures, joint motion (DF/PF), and more physiologic force distribution at slightly longer FU for the RG group than the arthrodesis group. Longer follow-up and broader clinical reporting are needed to identify the potential deficits of RG. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]