Joint replacements of the first metatarsophalangeal (MTP) joint have traditionally had limited success. Joint replacements designed to date can be subdivided into hemiarthroplasties and total joint replacements. Despite ongoing requests from patients to have a joint replacement to preserve shoe wear options, many have failed to meet expectations because of loosening, implant wear, osteolysis, or loss of motion. Fusion has therefore remained the gold standard for treatment of end-stage MTP joint arthritis. A polyvinyl alcohol hydrogel implant shows promise. The Cartiva implant is a 8 or 10 mm disk of durable hydrogel material shown to resist compression and shear with exceptional wear characteristics. It is implanted with approximately 1 to 1.5 mm protrusion and acts as a spacer for the first MTP joint. This implant is commercially available in Europe and Canada. A prospective, randomized, multicenter clinical trial is underway in the United Kingdom and Canada to assess outcomes with this implant. This article outlines the indications for surgery, surgical technique, and potential complications for hemiarthroplasty of the great toe.