1st MTPJ FUSION

Big Toe Joint Fusion

Hallux Metatarsophalangeal Joint Fusion (MTPJ fusion)

This operation is intended to glue (fuse) the big toe joint together and is usually performed as a day case operation. It is also called an arthrodesis of the big toe joint (metatarsophalangeal joint). It is usually performed for painful arthritis of this joint (hallux rigidus) which has not responded to other non-operative treatment.

The surgery involves removal of the joint surfaces via an incision over the upper or inside surface of the foot. The two ‘raw’ bone surfaces are then compressed together using titanium screws and a plate to stabilise the joint in the desired position. This metalwork does not usually need to be removed subsequently although it can be removed if required. Holding the prepared joint still allows the bone to knit up across the joint as if healing a broken bone. This is called fusion.

Once fused, the big toe does not move except at the end joint (interphalangeal joint) and this should greatly improve / abolish the painful symptoms from this joint. The toe is positioned according to the need to roll off the big toe, exercise, or wear higher heeled shoes.

Once fusion is successful, you will be able to wear most shoes (but not necessarily all types). There are no limits to the amount of type of exercise activities allowed subsequently.

Big Toe Fusion surgery performed by Mr Redfern. The x-ray on the left was before surgery. The patient complained of painful hallux rigidus (arthritis), hallux valgus (bunion) and painful lesser toe deformities (2nd and 3rd toes) with metatarsalgia. The problems were solved with fusion of the big toe joint combined with state-of-the-art minimally invasive surgery to correct the lesser toes. Final x-ray on the right

Big Toe Fusion surgery performed by Mr Redfern. The x-ray on the left was before surgery. The patient complained of painful hallux rigidus (arthritis), hallux valgus (bunion) and painful lesser toe deformities (2nd and 3rd toes) with metatarsalgia. The problems were solved with fusion of the big toe joint combined with state-of-the-art minimally invasive surgery to correct the lesser toes. Final x-ray on the right

General Recovery Facts Big Toe Fusion

  • Operation performed under general anaesthetic or regional anaesthetic

  • You are able to walk on the foot immediately after the surgery (day of surgery) 

  • You must wear your surgical shoe (post-op shoe) at all times including in bed at night 

  • You may not walk on the foot without this shoe at all, even in the house  

  • You may not drive after the surgery for six weeks unless you have an automatic vehicle and only the left foot has undergone surgery

  • The surgical shoe is worn for 6-8 weeks 

  • Usually patients can manage a 2 inch heel height once everything has settled (occasionally more-discuss with Mr Redfern)

Post-operative Course: Big Toe Fusion

Day 1 

Foot wrapped in bandage and surgical shoe

Start walking on the foot in surgical shoe only

Strict elevation of the foot (elevate foot for 50 minutes out of every hour)

Take pain medication for the first 2 days regularly (usually very little pain however)

Expect numbness in foot 12-24 hours 

Some blood drainage through bandage may occur  - do not change bandage 

Do not remove surgical shoe - even at night

Day 7

Do not remove surgical shoe - even at night

Continue to strictly elevate the foot (elevate foot for 50 minutes out of every hour)

Usually very little pain - continue pain medication if required  

Keep bandaging dry and do not remove (do not change dressing unless instructed)

May drive with caution in surgical shoe ONLY IF surgery to left foot only and automatic vehicle (otherwise return to driving at 6-8 weeks post surgery)

10-14 Days 

Follow-up review by Mr Redfern in the outpatients for wound review & removal stitches

Shower when incision dry 

6-8 weeks 

Follow-up in the outpatients with xray on arrival

Remove surgical shoe if satisfactory xray 

A regular shoe may be worn as comfort allows 

No sports until 3 months after surgery 

No heels to worn until 3 months after surgery

Main Risks of Big Toe Fusion Surgery:

Swelling – Initially the foot will be very swollen and needs elevating.  The swelling will disperse over the following weeks and months but will be apparent for up to 6-9 months.

Infection – This is the biggest risk with this type of surgery.  Smoking increases the risk 16 times.  You will be given intravenous antibiotics to help prevention.  However, the best way to reduce your chances of acquiring an infection is to keep the foot elevated over the first 10 days.  If there is an infection, it may resolve with a course of antibiotics.

Wound problems – Sometimes the wounds can be slower to heal and this does not usually cause a problem but needs to be closely observed for any infection occurring.

Scar sensitivity – The scars can be quite sensitive following surgery but this usually subsides without treatment. If persistent sensitivity occurs then this can be treated.

Nerve Injury – The risk of the small nerves in the area being directly injured by the surgeon is approximately 1%. However, the nerves can become bruised by the surgery as a result of the swelling (10%). Whilst this usually recovers, you could end up with some permanent numbness over the big toe area, which might cause irritation. 

CRPS – This stands for complex regional pain syndrome. It occurs rarely (1%) in a severe form and is not properly understood. It is thought to be inflammation of the nerves in the foot and it can also follow an injury. We do not know why it occurs. It causes swelling, sensitivity of the skin, stiffness and pain. It is treatable but in its more severe form can takes many months to recover.

Delayed and non union– This is when the bones fail to join and bone has not grown across the cut bone.  If this is painful then further surgery may be needed. The risk of this is approximately 10%.

Malposition – ideally the toe is fused in a position that allows optimum function and gives the best appearance. We will try to fuse the joint in the best position, using a flat panel to simulate the normal standing posture of the foot.  However, as you are asleep and lying down, it is not always possible to achieve this best position.  The toe may be either too high or too low.  This rarely causes a problem that requires further surgery and can usually be accommodated with insoles.

Deep Vein Thrombosis (DVT) – This is a clot in the deep veins of the leg and the risk of this occurring following foot and ankle surgery is low (generally< 1%). The fact that you are mobile after surgery and able to take weight through the heel of the operated foot helps to minimise this small risk. However, it is sensible to try and move the toes and the ankle regularly following the surgery and probably also sensible to avoid a long-haul flight in the first 4 weeks following surgery. If a deep vein thrombosis (DVT) occurs then you will require treatment with heparin and Warfarin to try and prevent any of the clot travelling to the lungs (pulmonary embolus / PE) which can be much more serious).

Stiffness – The big toe joint is almost always more stiff following this surgery because of the scar tissue that forms. The stiffness can be minimised by beginning to move the big toe after 2 weeks from surgery and your surgeon will advise you regarding this. Most of the movement usually returns but some stiffness may remain permanently.

Continuing symptoms – Most people (90%) are very happy with the results of their bunion surgery but you can appreciate that if some of the above problems occur then this may affect the end result. Occassionally (5%) the bunion may recur although not usually to the same degree. This is more likely in patients who have more lax ligaments in their feet. If there is a recurrence then you don’t necessarily require any further surgery – this will depend upon your symptoms.

Sick Leave

In general 2 weeks off work is required for sedentary employment, 6 weeks for work involving standing or walking, and 8 to 10 weeks for manual labour work.  We will provide a sick certificate for the first 2 weeks; further notes can be obtained from your GP.

Driving

May return to driving after outpatient review at 2 weeks post surgery ONLY IF left leg surgery only and automatic vehicle – otherwise unable to drive until 2 months post surgery.

These notes are intended as a guide and some of the details may vary according to your individual surgery or because of special instructions from your surgeon.