A guide for patients

Big toe joint fusion operation

An arthrodesis (ar-thro-de-sis) of the big toe joint (1st metatarsal phalangeal joint) involves removing the arthritic surfaces of the joint and compressing the two bony surfaces together. The arthrodesis (fusion) is then held in position by either screws or plates. The screws and plates prevent any movement and allow the bony surfaces to fuse together. Infrequently the screws or plate may need to be removed at a later date.

It is important to realise that once the joint is fused there will be no movement at the big toe joint.

The procedure may be relatively restrictive for people who need to squat for their work as you will not be able to bend through your big toe joint. This will also have an effect on the heel height of your shoe; up to two centimetres is tolerable.

Treatment options

An arthrodesis is an end stage procedure; this means that there are no further surgical options from this group of procedures. Therefore, if you wished to delay surgery the procedure would not change but your pain would continue.

Conservative options include insoles and a rigid soled walking shoe but at this stage it is unlikely that they will provide any long-term benefit. Unfortunately, when the joint is severely arthritic steroid injections have very limited, if any, benefit.

Day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic, and you will be able to leave hospital the same day. This means that you are awake during the operation but a screen will prevent you from seeing the operation. To numb your foot, you will either be given some injections around your ankle (ankle block) or behind the back of the knee (popliteal block).

You can eat and drink on the day of surgery; there is no need to fast.

The operation may take approximately one hour but you should be prepared to be at the hospital for longer than this, as you need to stay for an hour after the procedure.

If you decide on surgical management you will be invited back to attend a pre-surgical clinic. A member of the nursing team will take your medical history. If you are on any medication please bring a list of these with you. This is also a good opportunity to ask questions and discuss any concerns you may have about the procedure.

You must have a competent adult at home for the first day and night after surgery.

Recovery after your operation

Following this procedure, you will be in a post-operative sandal or Aircast walker boot for two–six weeks, fully weight bearing.

The first two to three days

• You must rest, with your foot elevated to hip level. You should restrict your walking to bathroom visits and when getting about you must use your crutches.
• You should take the pain killers that have been prescribed and if you experience pain it is usually worse for the first two
• After three to four days if you are still experiencing pain that is not relieved by the pain killers you should contact the department.

If you have any concerns over your foot you should contact the department directly. The department is closed at the weekend. Out of hours you should contact your GP or attend your local accident and emergency (A&E)

Two weeks after surgery

• If you have been placed in a post-operative sandal or Aircast walker boot, you will continue wearing this for four weeks.
• Dressings and sutures will be removed.

Between six and eight weeks after surgery

• An X-ray will be taken to see how well the bone is.
• You can begin to return to low impact activities as advised by your surgeon.
• You can now drive; however, you must feel able to perform an emergency stop without hesitation or pain. (It is advisable to check with your insurance company about your cover).
• You may return to work but this is dependent on the type of work and footwear required for your job. For certain jobs returning to work in less than 12 weeks is not.

12 weeks after surgery

• Although the foot should now be comfortable and returning to normal there will still be noticeable swelling, particularly towards the end of the day, this is.
• You can gradually return to high impact activities.

Between six and nine months after surgery

• The residual swelling should now be slight although the healing process continues for 12 months.
• You should be getting the full benefit of the surgery.

Twelve months after surgery

• All healing is now complete.

Specific risks or serious occurring risks

All operations carry a small risk of complications. In foot surgery complications are uncommon and most resolve without permanent disability or pain.

General and specific complications of this procedure can include:

• infection (incidence: two in 100)
• delayed healing of the skin (incidence: eight in 100)
• non-compliance of patients (incidence: four in 100)
• prolonged swelling post operatively (incidence: four in 100)
• thick or sensitive scar formation (incidence: four in 100)
• loosening or movement of the screws or plates used to fix the bones (incidence: two in 100)
• the toe may be malaligned (poor positioning)
• increased pressure beneath the joint of the big toe
• development of secondary pain or tenderness under the second toe knuckle joint (incidence: three in 200)
• delayed or non-union of the fusion site
• blood clot deep vein thrombosis (DVT)
• arthritic changes of the joint of the big toe itself (56 per cent chance).

Complications following foot surgery are rare events but can occur. Please also read the “Your pre-operative information” booklet issued to you by your podiatric surgeon, which discusses potential complications further. It is important to remember that if a complication arises you will be required to visit the hospital more frequently and there could be a significant impact on your recovery and return to work time. Therefore, foot surgery should be considered carefully if it is only for cosmetic reasons.