1st MTPJ FUSION
Big Toe Joint Fusion
1st MTPJ (Big Toe) 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.
Sometimes Mr Redfern may also recommend this operation for the treatment of a bunion in some patients.
The surgery involves removal of the joint surfaces via an incision over the 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 (<5% in Mr Redfern’s practice). 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. The toe is positioned for optimal function.
Once fusion is successful, you will be able to wear most shoes (but not necessarily all types and generally not more than a 2 inch/5 cm high heel. 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
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 if any 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 or no 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
2-6 weeks
Continued strict use of the stiff soled post-operative shoe provided whenever walking
Walking activity should be minimal - “slowly pottering around” rather than trying to return to activity
Patients may prefer to only use one crutch as a walking stick (and a reminder to themselves of the continued need for care)
Elevation is less important but still required sufficient to minimise swelling in the foot as much as possible
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 - this should be stiff soled and supportive such as a stiff walking trainer or similar
No sports until 3 months after surgery
No high heels to worn until 3 months after surgery
Remember the swelling is likely to persist (albeit slowly improving) until 4-6 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 4-6 months generally but sometimes up to year after surgery.
Infection – This is a small but important risk. The risk in Mr Redfern’s practice is less than 1%. You will be given intravenous antibiotics to help prevent infection. However, the best way to reduce your chances of acquiring an infection is to keep the foot elevated over the first 14 days. If there is an infection, it will generally resolve with a course of antibiotics. It is important you contact Mr Redfern’s team if you are concerned you may have developed an infection (increased swelling, redness, heat and/or any discharge in the surgical area)
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. This risk is 1% in Mr Redfern’s practice
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. This risk is 1% in Mr Redfern’s practice.
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 in a severe form (<1% in Mr Redfern’s practice)and is not properly understood. It is thought to be due to inflammation of the nerves in the foot and it can also follow an injury but we don’t fully understand 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– Delayed union is when he bones are slow to heal. This is not an exact science but generally, if the bones have not healed on an x-ray by three months then this is a delayed union - and often accompanied by persisting swelling in the foot. Non-union refers to failure of the bones to heal and this can sometimes only become apparent after a year following surgery. This is only a problem if there is swelling and discomfort (risk approximately 2%) in which further surgery may be needed.
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 for example. This rarely causes a problem that requires further surgery and can usually be accommodated with insoles. The risk of requiring further surgery to correct the position of the toe is 1% in Mr Redfern’s practice.
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 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 12 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 permanently stiff following this surgery as is the intention. Despite this, the vast majority patients do not report difficulty with footwear although a 2 inch (5cm) heel is generally a maximum. Published studies report approximately 90% of patients return to their pre-surgery sport (including running) without difficulty. If you are having the fusion to treat a bunion then one advantage is that the bunion will not recur with this technique.
Continuing symptoms – Most people (in the region of 90%) are happy with the results of their fusion surgery but you can appreciate that if any of the problems detailed above occur then this may require further treatment and could affect the end result.
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.