Toe joint replacement at Cambridge Hospital

What is toe joint replacement?

Toe joint replacement is an operation to remove a damaged joint in your toe, usually your big toe, and replace it with an artificial one. It's generally used to treat severe arthritis of the big toe joint, the joint where your big toe meets your foot, once other treatments haven't helped.

What conditions does toe joint replacement treat?

This operation is used to treat severe, worn joints in your big toe that haven't improved with other treatments, most often caused by:

• osteoarthritis – a condition where the joint's cushioning cartilage wears away
• hallux rigidus (a ‘stiff big toe’) – where arthritis makes the joint increasingly hard to bend
• bunions (hallux valgus) – a painful bony lump on the outside of your big toe
• rheumatoid arthritis – a condition causing joint swelling and pain
• injury – such as a bone fracture, or osteonecrosis, where part of the bone dies from a poor blood supply.

What are the benefits of toe joint replacement?

Removing the damaged joint and replacing it can relieve pain, reduce stiffness and swelling, and improve your range of movement. Unlike some other surgical options, it aims to maintain some natural movement in the joint, as well as the length of your toe.

Are there different types of toe joint replacement?

There are two broad surgical options for a severely arthritic big toe joint: joint replacement, which keeps some movement, or joint fusion, which permanently joins the bones so the joint can no longer move at all.

Some surgeons consider fusion the more established, reliable choice, while replacement aims to preserve movement, particularly for people who want to stay more active.

Toe joint replacements themselves come in different forms. Some use a simple silicone spacer, generally offered to less active people since it typically lasts around 10 years before it may need replacing.

Others use a metal implant that resurfaces one or both sides of the joint, aiming to more closely preserve your natural movement, though the long-term results of these newer designs are less well established.

What happens before toe joint replacement?

Toe joint replacement is only considered once other treatments, such as supportive shoes, insoles, activity changes, pain medication, physiotherapy or steroid injections, haven't given enough relief.

Your surgeon will ask about your general health and how your toe pain affects your life, examine your toe's strength and movement, and arrange X-rays and other tests to check you're fit for surgery.

Some centres carry out this operation under local anaesthetic as a day case, with numbing injections around your ankle or behind your knee, meaning you can eat and drink as normal beforehand. You'll also usually attend a pre-assessment appointment, where a nurse takes your medical history and answers any questions.

What happens during toe joint replacement?

The exact steps depend on the type of implant and anaesthetic used, but a typical operation using a full artificial joint follows this pattern:

1. You're given anaesthetic – this may be a local anaesthetic to numb your foot as a day case, or a general anaesthetic to put you fully to sleep
2. Your surgeon makes a cut on the top of your toe
3. The damaged joint, along with any damaged cartilage and bone, is removed
4. The artificial joint (prosthesis) is inserted and attached to the bones on either side using pins, screws or bone cement
5. Your surgeon checks the new joint is secure and moves properly, and that surrounding tendons and nerves are back in place
6. The cut is closed, usually with stitches, and your toe and foot are wrapped in bandages, sometimes with a cast or protective shoe.

An operation using a full artificial joint can take 2 to 3 hours, though simpler day-case procedures using a spacer may take around 40 minutes.

What does recovery from toe joint replacement look like?

You'll wake up with your foot bandaged, and possibly in a cast or protective shoe. For the first 2 to 4 days, you should rest with your foot raised to hip height, restrict walking to bathroom visits, and use crutches if you've been given them. Pain is usually worse for the first couple of days, so take your prescribed painkillers.

After about a week, you can gradually do a little more within your pain limits, and you may be shown exercises to keep your toe moving. Stitches are usually removed around 2 weeks, and once your wound has healed, you can get it wet and move into a supportive trainer-type shoe.

Between 2 and 6 weeks, your foot will start feeling more normal, though it may still be swollen, especially by the end of the day – you can return to normal shoes by about 6 to 8 weeks.

Between 8 and 12 weeks, swelling continues to settle, and sport can usually be considered from around 3 months, depending on your recovery.

By 6 months, swelling should be minimal and you should be feeling the full benefit of surgery, though healing can continue for up to a year. Your surgeon will also advise you on returning to work and driving, both of which depend on your job and how comfortable you feel.

What are the risks and complications of toe joint replacement?

All operations carry some risk, though serious complications from foot surgery are uncommon and most resolve without lasting problems.

Possible complications include:

• infection – around 2 in 100 people
• delayed wound healing – around 8 in 100
• ongoing swelling or a thickened, tender scar – each around 4 in 100
• The implant can loosen, move, shift the toe's alignment, or increase pressure elsewhere in the foot, sometimes causing new pain under the second toe – around 3 in 200 people
• Rarely, the body reacts to the implant material itself, which would need it to be removed, and there's a small risk of a blood clot (deep vein thrombosis).

Like any implant, a toe replacement can wear out over time, typically after around 10 years, or otherwise fail. If this happens, it may sometimes be replaced with a new implant, but if too much bone has been lost, the joint may instead need to be fused using bone grafts.