What is a big toe fusion?
A big toe fusion is an operation for severe arthritis of the big toe that is painful and already stiff (hallux rigidus). The technical term is a first metatarsophalangeal joint arthrodesis. It is a well-established surgical treatment and has been proven to be effective. The goals are to permanently stiffen the main joint of the big toe and the lack of movement alleviates pain.
An operation is only recommended as a last resort, once non-operative treatment measures for hallux rigidus have been exhausted and if your symptoms remain significant. A big toe fusion is not recommended for cosmetic reasons or to avoid problems that are not yet present.
What happens during a big toe fusion?
In most cases the operation is performed under general anaesthetic (whilst you are asleep). Alternatively, you can have a regional anaesthetic, which just numbs the leg.
A surgical cut (3-5cm) is made on top of the main joint of the big toe. The bony bumps and remaining cartilage are cleared from the two joint surfaces. The two bones (first metatarsal and proximal phalanx) are placed in the correct position, then rigidly held together using metal screws and possibly a plate. This allows natural bone healing, to fuse your big toe.
Once the operation is completed the wound is closed with stitches, local anaesthetic is given to provide pain relief for the first few hours after surgery then a bulky bandage along with a surgical sandal is applied.
What are the limitations of a big toe fusion?
A big toe fusion makes your big toe stiff. It will limit the heel height you can wear on your shoes, usually a maximum of a one-inch heel. A big toe fusion may alter the way you walk, but most people do not have a limp after it has fully healed. If you cannot accept these limitations, you should not have a big toe fusion.
What are the risks of a big toe fusion?
The risks of any operation generally relate to the anaesthetic and the surgical procedure.
You will be able to discuss your anaesthetic options and associated risks with the anaesthetist before your surgery. With a general anaesthetic, the risks will vary depending on your general health.
The main surgical risks of a big toe fusion are listed below, but it is not exhaustive. These will be further explained in the outpatient clinic.
Swelling– The foot will swell after surgery in response to the surgery and the healing process. It will take more than six months for the swelling to settle.
Failure of fusion – There is a 5-10% risk your big toe will not fuse together and may need to be rectified with a second operation. Patients who smoke are at a much higher risk of this complication. We will therefore ask you to stop smoking (including nicotine vapes) before surgery and while your big toe is fusing together. We can direct you to services that can help with smoking cessation.
Mal-position– When the big toe is fused it may not be in the correct position. If the position of the big toe fusion is problematic some patients may consider further surgery to adjust this. Great care is taken during surgery to avoid this complication.
Pain– Some patients may experience pain under the second toe (metatarsalgia), due to weight transfer changes after a big toe fusion. Careful surgical technique can reduce this risk, but it cannot be completely avoided. This may require further surgery in the future.
Prominent metalwork– If the metalwork in your foot becomes a problem, you can have another operation to remove it. After six months the big toe fusion will be solid so the screws and / or plate can be removed.
Nerve injury – With an operation there is always a small risk of injuring or stretching the surrounding nerves, which can lead to numbness. These symptoms mostly resolve in time, but they can persist.
Infection– The wound usually heals within two weeks. In a small number of cases the wounds become infected. The majority are minor infections that can be simply treated with antibiotics. Occasionally, some patients can develop a deeper infection that might require another operation.
Blood clots (leg or lung) – There is small risk of developing a blood clot after foot surgery. Measures are taken to reduce the chance of this happening but cannot be completely avoided.
Chronic regional pain syndrome – Following foot and ankle surgery a small proportion of patients can develop chronic regional pain syndrome. Your foot becomes indefinitely painful, swollen and sensitive. If you develop this, you may require specialist care from a pain consultant.
What happens after my operation?
When will I go home after surgery?
Most patients can go home on the same day of surgery. You may require an overnight hospital stay if you have other significant medical problems.
Can I walk on the foot?
After the operation you can fully weight bear through the operated leg. Before you go home, the physiotherapist will make sure you are safe to get around on crutches. It is important to wear the surgical sandal continuously for six weeks to protect the operated area.
In the first few weeks, keep your leg elevated as much as possible to help reduce the swelling and aid wound healing. It is important that your bandage remans dry and you may find using a waterproof cover helpful (www.limboproducts.com).
When will I be followed-up in clinic?
You will be seen two weeks after surgery in the outpatient clinic. Your wound will be checked, the stitches removed and the surgical sandal re-applied. You are required to wear the surgical sandal continuously for a further four weeks.
You will then be seen six weeks after surgery with an X-ray to confirm your big toe has fused. If everything is progressing well, you will can then start wearing your own footwear. An accommodative soft trainer is best. You can be referred to our specialist physiotherapists and further appointments will depend on your individual progress.
When can I go back to work?
If you have a sedentary job (desk based) and are able to elevate your foot, you can return to return to work two weeks after surgery. If you have a more physically strenuous job, you may need longer off work.
When can I drive?
You can start driving when you are comfortably walking in your own footwear. If you cannot safely make an emergency stop, your insurance will not cover you in the event of an accident. Start by sitting in the car and trying the pedals, then drive round the block. Drive short distances before long ones. If you are having surgery on your left leg and drive an automatic car, you could consider to start driving sooner, but only if you are safe to do so.
When can I return to full activity levels?
It varies how quickly people can take up exercise again. You should though avoid high impact exercises for 12 weeks and return gradually as your comfort levels allow.
When can I fly after surgery?
If you are flying after recent surgery you are at an increased risk of developing a blood clot in one of the deep veins in your body, usually the leg (deep vein thrombosis or DVT). Please ask your surgeon for individual guidance on how long to delay flying after your surgery. Also, each airline has its own regulations about flying after surgery and you will need to check with your airline before flying.
Patients that have a healthy diet, take regular exercise and refrain from smoking are more likely to experience a quicker recovery with a more successful outcome from their surgery.
Taking vitamin C supplements for six weeks before surgery and six weeks after surgery can also be beneficial. You can purchase them from your local pharmacy or supermarket.
If you have any concerns about your general health and well-being (diet, exercise, smoking cessation) you are encouraged to discuss this with your GP, who will be able to provide advice on the options available to you.
We hope this leaflet has answered any questions you might have. If you have any further queries, please feel free to discuss them with any of the medical or nursing staff.