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Big toe fusion (1st MTPJ arthrodesis)
Fusion of the main joint of the big toe is often performed to treat painful arthritis or severe bunion deformities and it is a very effective operation in managing the symptoms.
What is big toe arthritis?
Arthritis of the big toe or hallux rigidus can present many years after trauma or can be secondary to other inflammatory disease such as rheumatoid arthritis or gout. It is common in those participating ‘kicking sports’ in the past. It results in a stiff and painful joint as the articular cartilage of the joint is slowly lost and large bone spurs form around the joint.
What is done during a big toe fusion operation?
I commonly performed the procedure under a general anesthetic which means you will be “asleep” during the whole procedure. Occasionally the operation may be performed under a local aneasthetic and this can be decided on an individual basis. Regardless you will have a local aneasthetic block which is performed under ultrasound guidance to numb the entire foot.
The aim of the surgery is simply to remove the diseased and painful joint and fix the bone ends so that the body heals the interval into one solid bone. The is done through a small cut or incision over the top of your big toe. Usually there are large bone spurs which are removed, and any remaining joint cartilage is also removed. The resulting bone ends are prepared by making multiple small holes to encourage bleeding and then fixed together with metal screws and/or plates. The surgical incision is closed with absorbable sutures and dressing in the form of a bulky bandage is applied to the foot and ankle.
How long does the operation take and do I need to stay overnight?
The surgery is performed as a day surgical procedure. You are normally expected to come in at the beginning of the list which may mean early in the morning. This is so that you are checked in and seen by all the relevant people. Surgery itself will take around 60 minutes however you may be under the anesthetic for longer. Most of my patients can leave the hospital on the same day fully weight bearing on the operated foot. The aneasthetic block also means that the pain cannot be felt post operatively.
What alternatives are there to big toe fusion surgery?
There are various surgical and non-surgical options to treat arthritis of the big toe. Please do refer to the information I have on this website to read about other available treatments and their indication. I can discuss the pros and cons of each in your case. Some of the more common ones are listed below:
What are the risks of the surgery?
Other than the general risks associated with any foot surgery that are described in a separate leaflet, there are some risks and complications that are specific to a big toe fusion and you need to be made aware of them and are listed below. . Fortunately, these are infrequent events, and the greater majority of my patients go through this surgery without any problems.
This is when the bones that are meant to heal together fail to do so. There will be a persisting gap at the joint and may lead to ongoing pain and sometimes to the metalwork to break. This happens rarely and in my experience with modern plates and screws the rates are as low as 1%. I have published my results in a peer reviewed article. This is lower than the higher rates of around 5-10% which has been reported in the literature.
If you suffer with a painful non-union then the treatment would be revision surgery and re-doing the operation to help it to heal. Certain patient factors such as medical co-morbidities and especially smoking can be risk factors for non-union. You must consider stopping smoking if you are undergoing this surgery.
This is when the toe is fused in the wrong position and as a result you are having problems with footwear or with walking. The aim is to fuse the toe slightly off the floor (dorsiflexion) and slightly turning inwards. If this is not the case and the toe is too elevated or too depressed, then this may cause secondary problems. The modern plates tend to help dictate the position and problems with malunion are now very rare in my practice. If a malunion becomes very symptomatic then you may need surgery to break the bone and realign it.
Occasionally the screws or plates can be prominent, and you may feel them. If this was the case and after the fusion has taken place the hardware can be removed in a relatively simple operation and without any damage to the fusion. The literature again reports rates as high as 10-15% especially for plate fixation. In my experience and in my series of patients the rates of hardware removal with modern low-profile plating systems has been very low and in the region of around 2-3%.
The main tendon to the big toe is near the surgical field and can get injured during the procedure. This is called the extensor hallucis longus tendon or EHL and its job is to life the end of the toe up. Injury to this tendon is again a rare event and if it occurs it can be sutured at the same time.
When the main joint of the big toe is fused the smaller joint at the end of the big toe works harder to compensate. This means that in the distant future there may be secondary arthritis in that joint. Whilst this does occur after first MTPJ fusion surgery the rates are low. However, it is important that this joint is free from arthritis before you undergo a big toe MTPJ fusion.
