A Patient information guide to

Big toe Fusion (1st MTPJ Fusion)

Foot and Ankle Unit

Mr Ali Abbasian

Mr Amit Amin

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• What does the surgery involve? A big toe fusion is performed as a definitive procedure to treat painful hallux rigidus

(big toe arthritis) or sometimes for severe bunions. It is usually performed as a day surgical procedure. This means that you are able to go home on the same day after your surgery.

During the surgery your surgeon will make a small incision around 5cm long on the back of your big toe to expose the arthritic joint (see pictures).

The joint is cleared from any bone spurs that often grow around the big toe joint. The remaining joint cartilage is then removed to expose the undersurface of the joint. This surface is then perforated and thus “prepared” for a fusion. The aim is to encourage bleeding and stem cells at the end of the bones to facilitate healing or union. Just like when a fracture or break heals.

After the surfaces are ready they are held in a functional position for the big toe and fixed rigidly using small plates (see picture) and screws. The joint will then heal into one solid bone.

Very occasionally bone graft or bone graft substitutes may be used.

• What are the risks of the surgery?As with any surgery, a 1st MTPJ fusion can have risks. Fortunately these occur rarely

in this type of surgery but are important for you to be aware of. Your surgeon will discuss

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these further with you during the consent process. Below we have listed some of the complications associated with this type of surgery.

Nerve Injury or Numbness

Sensory nerves around the big toe can occasionally be bruised or damaged during the surgery. This can give you an area of numbness on the back or one side of the big toe. In most instances this resolves over a few weeks however on occasions it may be permanent. These nerves are very small and the area of numbness is normally also small and generally is of no consequence. On occasions a regrowth of the nerve within the scar can become sensitive and this may need further minor surgery to excise.

Infection

Wound or deep infection is uncommon after this surgery and occurs in less than 1-2 in 100. The risks can be higher in those with diabetes or in smokers. If infection occurs you may need further surgery to remove the hardware and may require prolonged intra-venous antibiotics. If you feel unwell, have a fever, there is oozing from the surgical incisions; or your leg feels hot and is red; then you need to seek medical attention as soon as possible.

Thrombosis

A clot in the calf veins, ‘deep vein thrombosis or DVT’ may rarely occur after foot surgery. Occasionally the clot can break off and travel to the lungs (Pulmonary embolism).

The risk of thrombosis varies from person to person. We assess your individual thrombosis risk pre-surgery and will provide you with blood thinning injections if your individual risk is thought to be high. Due to the very rare occurrence of DVT in those with a low individual risk, these medications are not routine for this procedure. We thus avoid their routine prescription, as they themselves have serious risks and side effects.

Tendon injury

The tendons to the big toe are at risk of injury during the procedure. In particular the extensor tendon (EHL) that helps turn up the end of the big toe. If this occurs it is usually repaired at the time and no functional deficits is likely to result.

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Malunion

This means healing in the wrong position. We aim to put the joint in the most functional position. This generally means that the toe is put nearly straight and flat to the ground but with a slight bend inwards (valgus) and upwards (dorsiflexed). This has been shown to be the best position to allow good function. On occasions the position may not be achieved. If the toe is bent too inwards or outwards it may rub against shoes or the other toes and become symptomatic. Fortunately, malunions are very rare in our practice, as we take utmost care to achieve the perfect position. If they occur and the symptoms are not acceptable then secondary surgery to “change” the position may become necessary.

Non-union

This means a lack of healing. A 5% rate has been listed in the literature. Various factors can lead to the fusion ‘not taking’ and for healing to not complete. Smoking is a big risk factor and smokers’ risk of non-union is much higher than the above figure. We therefore advise against having this operation unless you have been a non-smoker for at least 3 months. In the presence of a symptomatic non-union then revision surgery to get the joint fused may be necessary. Painful Hardware

The plates and screws used in our practice are incredibly low profile and thin and are of the latest generation. The rates of symptoms from the hardware is therefore very low in our practice. Should the hardware be palpable and rub agains shoes then it may be necessary to remove them after the fusion is complete. This is a relatively minor procedure with a rapid recovery.

• What happens on the day of the surgery?The surgery is performed as a day surgical procedure and you are often able to go

home on the same day. Occasionally if the procedure takes place late in the afternoon or early evening then it may be advisable for you to stay for one night.

We perform the surgery under a general anaesthetic and you will meet and discuss your anaesthetic needs or concerns with our anaesthetist prior to surgery.

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The surgery can take between 45-60 mins depending on the complexity. At the start of the procedure we will infiltrate a local anaesthetic “block” around the ankle. This will make the foot numb and help with post surgery pain. This lasts a few hours after the operation. so don’t worry if you cannot feel your toes when you wake up.

The incision are closed with dissolvable stitches in most but not all cases. You are likely to ‘wake up’ with needles in your arm for the anaesthetic agents (cannula) and a big bandage around the foot.

The surgery is done using a tourniquet around the thigh. This is to prevent blood getting into the operative field. This does means that occasionally your thigh might feel bruised and a little sore after the surgery. This is normal and usually settles in a day or two.

• What happens after the surgery? You will be transferred back to the ward where you will be seen by one of our

physiotherapists. You will be shown how to use crutches and will usually be allowed to fully weight bear on the operated foot wearing a special shoe (see pictures). You will be allowed to weight bear on the heel with a foot-flat-gait and will be asked to avoid ‘toeing off’ on the front of the foot. Once you are safely moving around and your pain is controlled you are discharged home. It is a good idea to have a friend or relative with you as an escort and to help during the first night at home. The pain is usually controlled because of the local anaesthetic in your ankle. Do take painkillers before this wears off to pre-empt the pain.

Weeks 0-2Take it easy - It is best to avoid too many work or social activities and have time to

rest and elevate the foot. You can use ice packs to control the pain and swelling.The bandaging should be left undisturbed in this time. The wound should be kept

dry for the first 2 weeks.

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It is a good idea to do gentle exercises of the ankle and try and get around to allow circulation in your leg but need to spend regular periods elevating your foot. We recommend 30-40 minutes of elevation in every hour.

You will be reviewed by your surgeon at around 2 weeks to check the wound and remove any stitches.

Weeks 2-6You will be able to continue with heel weight bearing in the post op shoe. The time

spent with the foot elevated can be relaxed, however, you must still avoid long journeys and prolonged periods with your foot down.

You will be assessed by your surgeon at six weeks with X-rays to assess the fusion and confirm that it is healing.

Months 2-4Swelling, especially with use and the end of the day may continue during this time.

You can now resume most of your usual day to day activity. We recommend that high impact activity such as jogging should be avoided in this time although some low impact activity such as swimming can start.

Months 4-6

In this period a gradual return to exercise is possible but usually under the supervision of a physiotherapist and in small increments. Expect ongoing swelling after use.

When can I start my routine?

Work

This depends on the type of work you do and the complexity of your ankle arthroscopy. As a general rule however, sedentary and desk based jobs can commence within 7-14 days. Following the 2 week visit most office based jobs can commence however we do recommend that long commutes on public transport are avoided and alternative transport used or working from home chosen. If your work is more physical or requires prolonged walking or standing then it is best to delay for 6 weeks.

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Driving

This depends on how painful and swollen the foot is. You should feel safe and in control of the car before you consider driving. As a general rule we always say that you must be able to perform an emergency stop without undue pain in your ankle.

The Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. Motor insurance companies vary in their policies, It is best to discuss your circumstances with your insurance company. If you drive an automatic car and the surgery is in your left foot then you can start driving as soon as a few days after the surgery. If not then driving should not be contemplated for the first 6 weeks when the post operative shoe is on.

Shower or Bath

We recommend no baths (this applies to hot tubs or swimming pools too!) for the first 6 weeks. A shower can be used from 24 hours using waterproof coverings to protect the bandaging.

Sports

This is very variable and depends on the condition of your ankle and on the particular sport. However most sports should be avoided for the first 2 months and only very low impact sports during the 2-4 month period. Higher impact activity is gradually introduced from 4 months and most actives are resumed by 6 months.

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