Fusion of the meatatarso phalangeal

Podiatric Surgery

Fusion of the Metatarso Phalangeal (Big Toe Joint) Introduction

This leaflet will explain what will happen when you come to the hospital for surgery to fuse the big toe joint.

What is a fusion of the metatarso phalangeal joint of the big toe?

The metatarso phalangeal (MTP) joint of the big toe is the main joint at the base of the toe. A fusion is a surgical procedure where the joint is permanently stiffened, creating a fusion between the two bones adjacent to the joint.

The procedure can be performed under local anaesthetic whereby you are awake but the foot is numbed.

Why do I need this surgery?

This joint might become painful and stiff as a result of arthritis, a longstanding bunion deformity or previous injury. The need for surgery is usually indicated by pain in the joint, significant enough to interfere with activities of daily life. A bony ridge around the joint might also become prominent enough to interfere with the comfort of your footwear.

The surgery is performed to reduce pain and discomfort and to improve shoe-fit by eliminating painful movement and removing any bony ridges adjacent to the joint. Mobility of the joint is permanently sacrificed in the process.

Arthritis or damage to the joint is not in itself a reason for surgery, but it might be needed if pain becomes so bad that a completely stiff joint with less pain would be preferable.

What are the alternatives?

Most mild cases of toe joint damage do not need any treatment. If it should become too uncomfortable then wide wellfitting shoes with low heels and relatively stiff soles are recommended. High heels and pointed shoes should be avoided.

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It might also help to add a rounded sole to the shoe. A cobbler should be able to do this for you. This encourages a rolling action when walking to help limit the upward bending of the painful big toe. Artificial stiffening of the sole of the shoe might also be considered.

If shoe changes prove inadequate, a steroid injection in the joint can be considered, although this does not always help, and is not likely to have any significant long-term effect.

If the joint remains not too damaged, but movement is restricted by bony ridges on top of the joint, then an operation where the bony ridges are smoothed down, without stiffening the joint might be considered. This procedure is not always successful, and further surgery might be required. This procedure is not recommended if there are significant arthritic changes to the joint, or if the big toe is not reasonably straight.

Sometimes, the joint is removed leaving a gap to heal with scar tissue, forming a ‘false’ joint. This shortens the big toe significantly and is rarely suggested for active patients.

Replacement with an artificial joint (prosthesis) has been performed for many years, usually for young, active patients.

However, eventual failure due to wear and tear, loosening of the prosthesis or infection has been documented.

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Fusion of the Metatarso Phalangeal (Big Toe Joint) What does surgery involve?

On the day of surgery you will be admitted to the ward and one of the nursing staff will check you in, take your blood pressure and perform any other tests that may be required. Your surgeon will remind you of the surgical process and possible complications and will ask you to sign a consent form.

At some point during the morning/afternoon you will be escorted to theatre.

The surgeon will make a cut over the joint, so the bony ridges next to the joint and the remaining joint cartilage can be removed. The big toe is placed in the most comfortable position next to the second toe and stabilised, usually with small metal plates or screws to hold the bones in place until fused together. The procedure takes around 60-90 minutes. You will be in a below-knee cast for up to eight weeks.

After the operation you will be taken back to the ward and once able you should start taking your painkillers. One of the team will see you on the ward after the operation to answer any questions that you might have and make sure that you are fit to leave hospital. You will be shown how to use crutches.

You should not drive after foot surgery and should be accompanied home by a responsible adult.

You will be advised of your follow-up appointment date, either on the day or by letter in the post.

How will I feel afterwards?

Although long-acting local anaesthetic administered during the procedure should control most of the pain for about eight to 10 hours, you can expect some pain or discomfort after the operation. Painkillers will be discussed with you prior to your operation and you should bring these with you on the day of surgery.

Recovering from surgery

X-ray of foot with plate and screws after fusion operation

The first two days Restrict your activity to going to the toilet only. Bend your knee regularly to stimulate circulation. Most people are able to stop taking their painkillers after 48 hours. Do not leave the house, drive or get the foot wet. You must not take any weight on the foot. Use the crutches for support.

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Two to seven days You should aim to be moving around the house for 20 minutes in each hour, resting with your foot elevated for the remaining 40 minutes. Do not go out of the house, drive or get your foot wet. Do not bear weight through the foot.

Use the crutches.

At seven days Your foot will be checked in the outpatient clinic. Sometimes, the cast is left on and sometimes it might be changed. remain at home, do not drive, and keep your foot dry. Use crutches as required.

At 14 days At the second post-operative appointment you will have the cast changed and probably have the stitches taken out.

An X-ray may be taken of your foot to establish how well the bone is fusing. You will be advised to gradually increase your activity and gently exercise. Another cast will be applied for up to an additional four weeks. Continue to stay off this foot and use crutches for support.

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Fusion of the Metatarso Phalangeal (Big Toe Joint) At six to eight weeks The cast will be removed and an X-ray will be taken. If the fusion appears to be progressing well, your surgeon might ask you to use a replaceable aircast walker boot. This can be removed at night and you can bathe. You can start bearing weight through the foot using the walker boot.

At 12 weeks You should be moving around more comfortably. Swelling around the surgical site will normally be reducing and the scar line will be fading. You will normally be back to wearing normal shoes.

What are the possible risks and complications?

No surgery can guarantee to be successful, but the vast majority of people are satisfied with the outcome of their surgery. This information tells you about the more common complications relating to foot surgery in general and more specifically to this type of operation.

General complications of foot surgery Pain: There will be post-operative pain. For most people the pain passes after 24-48 hours and is tolerable with regular painkillers (following dosage recommendations).

Swelling: This is a normal outcome of any operation. The extent of post-operative swelling varies and cannot be predicted. In some people the swelling reduces within a matter of weeks and in others could take many months. Application of an ice pack greatly reduces the swelling.

Infection: There is a small risk of infection with all surgery. This would be treated with relevant antibiotics. Look out for redness and discharge from the wound.

Deep vein thrombosis (DVT): Also known as venous thromboembolism (VTE), this is a rare complication of foot surgery under local anaesthetic. The risk increases if you are having a general anaesthetic. There is also an increased risk if you smoke, take the contraceptive pill, or HRT. Immobilising the leg in a cast also increases the risk of a DVT. If you have had a DVT in the past, please tell your surgeon. If you do have certain risk factors you will have an injection to thin your blood on the day of surgery. This might need to be repeated for up to seven days following surgery.

Complex regional pain syndrome (CRPS): This is a rare but difficult complication. This is an abnormal response of the nervous system to surgery but can happen after simple trauma. This can lead to a variety of painful sensations in the foot, which require medical and pain relieving techniques.

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Scarring: As a result of your surgery you will have a scar on your foot. To begin with the scar will be raised, red and sensitive but with time it will usually settle.

Specific complications of fusion surgery About 8% of patients experience a delay in the time it takes for the bones to join together, or a failure to form a bony fusion. Smoking and the daily intake of anti-inflammatory, or certain anti-arthritic medication can have a negative effect on bone healing. Excessive walking, especially in a loose or broken cast, can also contribute to delayed or failed fusion. A significant proportion of unsuccessful fusions need further surgery.

Stiffness of the big toe should be expected after a fusion. For most people this does not matter, but it might be important for people involved in activities where mobility of the big toe is important. You should consider and discuss this with your podiatric surgeon before the operation. It might affect the judgement on whether you will benefit enough from surgery, or on the type of operation.

The position in which the toe is stiffened is important because mobility will be permanently restricted. If the big toe points up, down or sideways too much, or too little, increased pressure on the toe might cause discomfort.

Although fusion in a comfortable position should be achievable in the vast majority of patients, a perfect position cannot be guaranteed in every case.

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Fusion of the Metatarso Phalangeal (Big Toe Joint) A mild-to-moderate alignment problem should not cause any significant symptoms, but a further operation might be necessary if it is too uncomfortable. Gradual improvement in the ability to roll over the stiffened big toe during walking can be expected for several months after this operation.

Damage to the small nerves under the skin can occur in any foot surgery resulting in tingling, numbness and ‘pins and needles’. However, it is uncommon, rarely serious and tends to recover.

Removal of the metalwork fixtures introduced at the time of surgery is only considered if they should cause discomfort. This might become necessary in approximately 10% of patients.

Most patients find it difficult or impossible to work, or do some daily activities, for six or eight weeks.

You should not drive while your foot is immobilised in a cast and until you can control your vehicle safely and effectively.

Patients can usually wear normal, comfortable shoes after a successful fusion of this joint. Swelling during the first three months or so, and discomfort for up to six months, might make it difficult or impossible to wear certain shoes. High heels and pointed shoes might cause discomfort and should be avoided.

Useful numbers Braintree Community Hospital Podiatric Day Surgery Unit

01376 555 900

01376 555 908

If you have any concerns during the first 24 hours following your discharge from hospital, please telephone the ward you were on. After 24 hours, please seek advice from your GP. This document can be made available in other languages and formats upon request.

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