Big toe joint replacement operation

A joint replacement is a surgical option for severe arthritis of the big toe joint (first metatarsal phalangeal joint). The procedure involves removing the arthritic bone and inserting a silastic (silicone) joint/spacer. By removing the arthritic bone the pain associated with the condition is reduced. The implant allows motion at the joint and also maintains the length of the toe.

The silicone is an inert (non-reactive) material and is rarely rejected by the body. The silastic joint does allow some movement, but this will not be the same as a normal joint.

Joint replacement is generally an option for people who are less active. The reason is that the lifespan of the silastic joint will be reduced as it is unable to withstand the stresses placed upon it by a more active patient. Under normal circumstances, the implant’s lifespan is about 10 years. After this, the implant may need to be removed and replaced with a new implant.

Treatment options

An implant for an arthritic big toe joint is an end stage procedure. This means that there are no further surgical options from this group of procedures. 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 benefit. Unfortunately, steroid injections have limited, if any, benefit. From here, the only available option is manage as you are, or surgery.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation but a screen will prevent you from seeing the surgery.

To numb your foot, you will be given some injections around your ankle or behind the back of the knee. You can eat and drink on the day of surgery; there is no need for fasting.

The operation may take up to forty minutes, but you should be ready to be at the hospital longer than this to allow for preparation and recovery.

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

If you decide to progress with surgery, 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 with you. This is a good opportunity to ask us any questions and discuss any concerns you may have about the procedure.

Recovery after your operation

First two to four days

• You must rest with your foot elevated to hip level.
• You should restrict your walking to bathroom visits only. If you have been given crutches, you must use them. You may be able to bear a little weight on the foot.
• If you experience pain, you should take the prescribed painkillers. The pain is usually worse for the first two days.
• If you are still experiencing pain after three to four days that is not relieved by the painkillers, you should contact the department directly.
• 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 go to your local A&E department.

One week after surgery

• You may start to do a little more within the limits of your pain. Pain means you are doing too much.
• You may be asked to move your toe through a range of motion to maintain mobility.

Two weeks after surgery

• The stitches/sutures will be removed, if necessary.
• You will not need a bandage. If the wound has healed you can get it wet.
• You will be asked to start wearing a running trainer-type shoe.

Between two and six weeks after surgery

• The foot starts to return to normal and you can return to shoes (six to eight weeks).
• The foot will still be quite swollen, especially at the end of the day.
• You may return to work, but may need a longer respite if you have an active job.
• You may return to driving if you can perform an emergency stop. Please check with your insurance company about when your policy covers you to drive.
• While normal activity will be resumed, sport should be avoided.

Between eight and twelve weeks after surgery

• The foot should continue to improve and begin to feel normal again.
• There will be less swelling.
• Sport can be considered after three months, depending on your recovery.

Six months after surgery

• The swelling should now be slight and you should be getting the full benefit of surgery.

Twelve months after surgery

• The foot has stopped improving with all healing complete.

Specific risks or serious 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 include:

• infection (two in 100)
• delayed healing of the skin (eight in 100)
• non-compliance of patients (four in 100)
• prolonged swelling post operatively (four in 100)
• thick or sensitive scar formation (four in 100)
• loosening, movement or reaction of the implant
• the toe may be malaligned
• increased pressure beneath the joint of the big toe
• development of secondary pain or tenderness under the second toe knuckle joint (three in 200).
• delayed/Non-union of the fusion site
• blood clot deep vein thrombosis (DVT)
• arthritic changes of the distal joint of the big toe itself
• reaction to the implant – this will require removal.

Complications following foot surgery are rare, but can happen. It is important to remember that if a complication arises you will need to visit the hospital more frequently and there could be a significant impact on your recovery and return to work time. Foot surgery should be avoided for cosmetic gains.