1st Metatarsophalangeal Joint Fusion

Your 1st Metatarsophalangeal Joint (MTP) is one of the joints in your big toe. This joint is involved in pushing your foot away from the ground as you take steps forward. It is therefore a very important joint for normal walking.

When this joint is affected by arthritis (see Hallux Rigidus or rheumatoid arthritis), it can become extremely painful and stiff. When pain becomes so severe that walking is difficult or impossible, a fusion operation or arthrodesis is recommended to reduce the pain.

A fusion is a procedure where the remaining damaged cartilage is totally removed and the two bones that form the joint are fused. This results in an irreversibly stiff joint that is stable and often completely painless. The lack of movement in this joint does however mean that the other joints in your foot will have to compensate for the loss of movement. This can result in a subtly abnormal walking pattern and arthritis in other joints.

The fusion is usually held by either 2 screws or a plate that remain in your toe permanently. After the operation you will not be able to put weight through your toe for six weeks (non-weight bearing), however during this time you will have crutches and can put weight through your heel. During the early period of your recovery, you should try to keep your leg elevated as much as possible.

Most people are satisfied with fusion, despite the loss of movement.

Who is this operation for?

When arthritis affecting the big toe is severe and walking is impossible, a fusion operation is recommended. This might be due to wear-and-tear in the joint (osteoarthritis, hallux rigidus) or to a general disease like rheumatoid arthritis or diabetes.

Fusion is sometimes used to correct bunions when other forms of bunion surgery either fail or are not appropriate (see Bunion Surgery).

What are the alternatives to this operation?

Usually, non-surgical treatments for pain and stiffness will be trialled first. These may include orthoses, physiotherapy and pain-relieving medications.

Another operation commonly used to treat osteoarthritis in the big is cheilectomy. When pain is severe, cheilectomy will often not succeed in eliminating pain.

Arthroscopy (key-hole surgery) and injections are sometimes used for the treatment of rheumatoid arthritis. If you are considering arthrodesis, you will probably have already tried these measures and found they have not been aggressive enough.

Other radial operations like Osteotomy (re-shaping of the bones) & Arthroplasty (replacing the joint with metal implants) are sometimes performed by some surgeons. Arthrodesis generally has better results than these operations in terms of reducing pain and stabilising the joint. It does however have the disadvantage of prohibiting movement and these alternative operations preserve motion in the joint.

Complications

Possible undesirable results of surgery include:

  • Pain
    • There may be some residual pain in the MTP joint.
    • Arthritis may develop in the rest of the foot. This is an unavoidable risk in arthrodesis as the normal walking pattern is necessarily changed by fusion. You may develop pain in the big toe or along the outer edge of your foot.
    • Arthritis in other joints involved in walking, like the knees, hips, lower back and other foot may develop later in life.
  • Infection. All invasive procedures carry a small risk of infection. These risks are higher if you are a smoker or diabetic, and in fusion operations where screws are used.
  • Swelling.
  • Bleeding and problems with wound healing. These tend to be more common in diabetics, but are fairly rare in hallux rigidus operations.
  • Injury to nerves – Numbness or tingling can occur at the wound or in the toe. This is usually temporary but in some it may be permanent.
  • Blood clots- Deep vein thrombosis (DVT) or pulmonary embolism (PE) are rare. You will be encouraged to walk around as soon as possible after your surgery to avoid the development of DVT. If you or your family have a history please let one of your treating doctors know.
  • Nausea, drowsiness or other discomfort associated with the anaesthesia.

For more information on the general complications associated with surgery, see Complications of Surgery.

When surgery is complicated or fails, you may need follow-up surgeries.

  • Re-positioning. Research has shown that 5-10% of cases do not fuse in the exact position intended. This may be due to the position not being achieved during surgery of movement of the bones following surgery. You will not be able to wear high heels following a fusion.
  • Removal of screws. Occasionally prominent screws or screws that cause irritation may need to be removed.
  • When the bone fails to heal around the screws, revision surgery is required. This is called ‘failed’ fusion. Research has shown that this occurs in approximately 10% of cases but is significantly greater if you smoke.

Before the operation

What do I need to do before the operation?

In most cases, you will not need to stay in hospital overnight for a big toe fusion.

It is a good idea to get things organised for when you get home. Below is a list of things it might be a good idea to organise:

  • Help with household tasks
  • Food cupboards stocked up
  • Help with shopping
  • Help with children, pets and relatives organised for your return home
  • Someone to bring you to and from the hospital

Preadmission Clinic | Preparing for Surgery

Before your operation, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.

During the visit, you will be seen by a

  • doctor
  • nurse
  • anaesthetist (if necessary)

Tests

Before your operation, your surgeon will have ordered X-Rays to assess your toe. He or she may also have ordered special tests to assess the blood vessels (angiography) and soft tissues (CT/MRI) in your leg.

Other tests that may be ordered for you to check you are ready for surgery include:

  • blood tests
  • Xray of your Chest
  • Urine Test
  • ECG

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.

Tip

Carry a list of your medications with you including the name, dosage and how often you take it.

Medications

Our doctors will advise you which medications you should stop or can continue taking before surgery.

If you have rheumatoid arthritis, you may need to see a specialist rheumatologist to review your medications.

About the Operation

You will be brought to the operating theatre where your surgeon and anaesthetist will check that you are ready. You will then be put to sleep (general anaesthetic).

Your surgeon will carefully position your toe before making an incision over the joint. From here, the surgeon is able to remove the ends of the bone that form the joint. Screws or a plate are then used to compress the two cut bones against one another. These will need to remain in your foot for life.

Over the following days the bones will grow and heal over the screws or plate. This turns the two separate bones into a single, painless unit.

Most surgical procedures are performed with a combination of local and general anaesthetic. This combination maximises the chances of returning home the same day following surgery.

After the Operation

What can I expect after the operation?

When you arrive back on the ward from theatre your leg will be in a bandage and a post op shoe. Your leg will be elevated to reduce swelling and your foot will be numb due to the local anaesthetic block. This will gradually wear off over 24 hours.

After you leave surgery, you will need to discuss with your doctor what kinds of activities you should avoid. This will often include:

  • Not wearing high heels
  • Avoiding running

You will be heel weight bearing in a post op shoe for 6 weeks after your operation or until the surgeon is happy that the joint is fusing. You may need crutches to walk safely but this will be assessed by a Physiotherapist prior to you leaving hospital.

You will be seen at the Dressing Clinic in the Orthopaedic department between 10 days to 2 weeks after your operation. At this appointment, the Nurses will check the incision and remove the dressing and stitches if required.

What about pain?

Whilst you are in hospital you will be monitored and the medical staff give you painkillers as needed (see Post-Operative Analgesia). The Nursing staff ensure that you know what medications to take for pain when you get home.

Keeping your leg elevated helps to control the pain and minimise the risk of your incision becoming infected. You will need to keep your leg elevated 50 minutes out of every hour for the first 2 weeks. This prevents your incision from leaking and becoming infected.

What should I do if I have a problem?

If you experience severe pain, excessive swelling, inflammation or discharge please report it to your GP. If you cannot contact your GP you should visit the emergency department as quickly as possible.

Recovery and Rehabilitation

You will need to keep weight off your toe for six weeks after your operation. At this time, you will be seen in Orthopaedic clinic to have follow-up X-Rays. Your surgeon will be able to tell you if your toe is healing well and if you can start walking.

A long period of physiotherapy is required to retrain the body to walk.

F.A.Q.s | Frequently Asked Questions

When can I return to work?

Your own circumstances will determine when you feel ready to go back to work. If you have an office-type job and you can elevate your leg then you should be able to return to work sooner. If your job requires a lot of walking or is strenuous then you may need more time off work. You will need to get a sick certificate from the staff at the hospital before you go home, or from your GP.

When can I return to driving?

You must be free of pain and able to perform an emergency stop. This will also depend on which foot was operated on (right or left). If you have had left sided surgery and drive an automatic car you may be able to drive 2-4 weeks following surgery. Your insurance company must be notified regarding the type of operation that you have undergone to ensure that cover is valid.

More information on arthritis, relevant treatments and support services can be found at the following sites:

Medical sources on First Metatarsal Fusion:

The latest research on first metatarsal joint fusion is accessible through the Cochrane Library and PubMed Database.

Some relevant articles include:

  • Mestiri, M. et al., “Retrospective study of the first metatarsophalangeal joint arthrodesis: 39 cases”, La Tunisie Medicale, 2010 Oct;88(10):725-30. PMID: 20890820
    • This article reviews a number of these surgeries and found that patients are generally very satisfied with the reduction in pain and ability to walk.
  • Lombardi, C.M. et al., “First metatarsophalangeal arthrodesis for treatment of hallux rigidus: a retrospective study”, Journal of Foot and Ankle Surgery. 2001 May-Jun;40(3):137-43. PMID: 11417595
  • Hawke F, et al., “Custom-made foot orthoses for the treatment of foot pain”, Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006801. DOI: 10.1002/14651858.CD006801.pub2.

References

Mann, R. A., Disorders of the First Metatarsophalangeal Joint, Journal of the American Academy of Orthopaedic Surgery, Vol. 3, No. 1, Jan/Feb 1995, pp. 34-43.

Yee, G., Lau J., ‘Current Concepts Review: Hallux Rigidus’, Foot & Ankle International, Vol. 29, No. 6, June 2008.