Surgical Overview
The first MTP joint, also known as the great toe joint, is a joint comprising the head of the first metatarsal and the base of the proximal phalanx of the big toe. This joint allows the great toe to bend up (dorsiflexion) and bend down (plantarflexion). The great toe motion is very important in normal push-off during the gait cycle. The end of the two bones creating the first MTP joint are covered with a thick, smooth material called articular cartilage. Articular cartilage allows the two bones to move/glide against one another and also distribute load across the entire joint surface, thus absorbing shock.
Osteoarthritis is a degenerative joint disease in which the articular cartilage (tough but flexible tissue covering the articulating surfaces of the bones) gradually wears away and thins. X-rays help determine the severity of the first MTP joint arthritis. In a normal XR the articular cartilage creates the appearance of a symmetric joint space between the two bones (picture A). As the articular cartilage wears away, the joint space decreases progressing to bone on bone contact (picture B).
Other imaging studies such as a CT scan or MRI also assist the physician in determining the amount of joint space narrowing, joint surface positioning and the overall degree of arthritic change to surrounding/adjacent joints.
The main symptom usually associated with osteoarthritis in the first MTP joint is pain. In the early stages of disease, pain is present with movement or activity (walking). As osteoarthritis (OA) progresses, the pain can be present even at rest. Other common symptoms of first MTP OA include: joint stiffness, loss of motion, swelling, and difficulty walking (or walking with a limp).
Treatment for first MTP joint OA is focused on controlling pain, limiting motion that causes pain, and assisting in increasing walking tolerance. Non-surgical treatment approaches are usually tried first. Non-surgical treatment options include: medications (NSAIDs), custom foot orthotics, carbon fiber Morton’s extension, physical therapy, dietary supplements and/or cortisone/PRP injections into the joint.
Once conservative treatment options have been exhausted or the degree of OA is very severe, surgical intervention is usually necessary. The surgical option to treat first MTP joint OA is a joint arthrodesis (fusion). A first MTP joint fusion is the gold standard treatment for pain relief due to first MTP joint OA (picture below). This is performed through small incisions in a minimally invasive fashion allowing for a quicker recovery than traditional open surgery.
great toe fusion
Great toe fusion, or arthrodesis, is a surgical procedure for the treatment of disabling arthritis of the first metatarsophalangeal (MTP) joint when conservative measures have failed to relieve pain. With this surgery, the great toe MTP joint is permanently stiffened by removing the degenerated cartilage and fusing the bones together. This can usually be performed in a minimally invasive fashion.
The vast majority of patients will walk better, almost normal.
Not much, but you will notice that you will retain motion in the interphalangeal joint at the end of the toe.
Generally no, but you will be more comfortable in a shoe with a cushioned, rocker type sole. A heel height of about one inch can be worn.
With a successful fusion, most patients can walk for distance, ride a bike, perform hiking activities, swim, and golf. Tennis is often possible. Most patients can jog, downhill and cross-country ski.
Most patients cannot participate in high velocity jumping sports, such as basketball. Other patients have difficulty with activities that require extreme flexibility of the forefoot, such as yoga and ballet dancing.
Obviously, the fusion does not restore you to normal, and there are some limitations as mentioned above. Alternatives to fusion include non-surgical treatments such as activity modification, NSAIDs (e.g. Advil, Aleve), cortisone/PRP injections, and orthotics (shoe inserts). Surgical alternatives, including bone spur removal or arthroplasty, either with artificial joints or soft tissue interposition, have not been shown to out-perform a fusion.
Typically screws are used to hold the bones in position until the fusion is solid. Occasionally, bone graft is necessary if bony defects are present. Your own bone (autograft), cadaver bone (allograft) or synthetic bone graft may be used.
Your surgery generally takes place in a surgical outpatient setting.
The procedure generally takes about an hour and you will go home the same day.
Either a foot anesthetic block with sedation, or general anesthesia, will be offered.
Yes. You will get a dose of antibiotic before surgery.
No. Bleeding is minimal with use of a tourniquet during surgery.
Read the surgical folder carefully. The American Orthopedic Foot and Ankle Society (aofas.org) website is a helpful resource as well as FootcareMD website.
After surgery, you will be placed in a sterile bandage with a short medical boot and will recover in the outpatient post-anesthesia area (PACU). When you have adequately recovered and have passed the criteria, including weight-bearing in the medical boot with crutches, you will be discharged home.
For the first two weeks you must rest, get sleep, eat well, and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. You will be weight-bearing as tolerated in the medical boot, using crutches as needed. Keep your boot on at all times, including sleep, for the first two weeks to protect the fusion site. Keep the bandage clean and dry. Drink plenty of clear fluids, keep your foot elevated to the level of your heart, and take the pain medication prescribed as needed.
Discuss this with your rheumatologist, but it is generally recommended that you stop immune suppressive modulators (eg. Methotrexate, Enbrel, Humira) for two weeks before and two weeks after surgery.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
This is an important question because it impacts home and work situations. After your sutures are removed, you may increase your day-to-day activities, always using the medical boot and a clean sock. If your incision is well healed, you may wash the surgery site after sutures are removed. Use crutches as you feel necessary for balance and comfort. Try to keep your foot elevated when sitting. Typically, it takes about 6 weeks to heal the fusion. Once x-rays show a solid, stable fusion, you may transition into a roomy, comfortable shoe, usually a half size larger, to accommodate the typical post-surgical swelling. This is often necessary for a few months after surgery. In most patients, dress shoes can be worn between three and six months after surgery.
Download the Great Toe Fusion Post-Operative Guidelines for full details.
With a great toe fusion, many patients drive by two weeks when they are off the pain medications.
That depends on what you do. Sedentary desk workers may return as soon as one to two weeks. On the other end of the spectrum, construction laborers are typically out of work for three months. You will be provided out of work notes, or restricted duty notes, as necessary during your recovery. Family leave paperwork can also be submitted.
About three to five percent of patients will have a delayed union or non-union. This can be even greater in patients who have additional medical problems, have poor bone healing factors, or are smokers. To enhance your chances of healing, you should not smoke. For a delayed union you may be prescribed bone healing adjuvants, such as a bone stimulator, and prolonged immobilization. For an established non-union, you may require revision surgery and bone-grafting to try to get the fusion to heal.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, delayed union, non-union, or chronic pain and swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome.
Get ready for it! Optimize your physical and mental state, and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions. More information can be obtained from the American Orthopaedic Foot and Ankle Society website (www.aofas.org).
