Toe joint fusion at Haywards Heath Hospital

Toe joint fusion joins the two bones of your big toe joint together permanently, so they can no longer rub against each other and cause pain. Doctors may also call this an arthrodesis, and it's used when arthritis or a severe deformity in the big toe hasn't responded to other treatment.

What conditions does it treat?

Toe joint fusion is most often used for:

• hallux rigidus, the medical name for arthritis in the big toe joint, where the cartilage has worn away and the bones rub together
• arthritis that affects the whole foot, such as rheumatoid arthritis
• a severe bunion (hallux valgus) that has badly deformed the toe
• problems left over from an earlier toe operation, such as a toe that is deformed, weak, floppy or painful.

It's usually only considered once the joint is badly damaged, or once non-surgical treatment, such as painkillers, supportive footwear, or insoles, has failed to control the pain.

What are the benefits of having toe joint fusion?

The main benefit is a big reduction in pain, since the arthritic joint surfaces no longer grind against each other.

Removing the bony bump that often forms with arthritis also means footwear tends to fit more comfortably, and many people find their general mobility improves as a result.

Because the bones are held straight while they join together, fusion also corrects the deformity in the toe, easing the visible bump as well as the pain.

Are there different types of surgical approach?

Fusion is one of three main surgical options for a badly arthritic big toe joint.

Cheilectomy is a smaller operation that trims away bony overgrowth and can suit milder arthritis, though it does not treat the underlying arthritis and further surgery may be needed later.

Joint implants aim to ease pain while keeping some movement in the toe, though results tend to be less predictable than fusion.

Within a fusion, surgeons fix the bones together with screws, a small plate, staples, or a combination, depending on what will hold your toe securely in position.

Sometimes another procedure is done during the same operation, such as straightening a hammer toe, removing a Morton's neuroma, or a Weil's osteotomy to ease pressure under the ball of the foot.

What happens before the operation?

Before your operation, you'll be invited to a pre-operative assessment appointment, usually a few weeks beforehand. A member of the team will check your general health, discuss the anaesthetic that's right for you, and answer any questions.

To prepare, you'll usually need to:

• bring a list of any medicines you're taking
• stop smoking well in advance if you can, ideally 6 weeks before and 6 weeks after too – please speak to your team about arranging support for this
• arrange for a friend or family member to collect you and stay with you for the first night
• stop eating and drinking (fast) for around 6 hours beforehand if you're having a general anaesthetic
• sign a consent form once you're happy to go ahead, after discussing the procedure and any questions with your surgical team.

What happens during the procedure?

The operation usually takes around 45 to 60 minutes, though it can take longer if another procedure is done at the same time.

In general, it follows these steps:

1. You have your anaesthetic: either a general anaesthetic so you're asleep, or a local or regional anaesthetic (such as an ankle block) so your foot is numb while you stay awake
2. Your surgeon makes a cut over the joint, usually on the top, side, or inside of the big toe
3. Bony lumps are trimmed away and the worn cartilage is removed from both bone surfaces
4. The bone ends are shaped so the toe will sit in a good position, roughly straight with a slight upward angle
5. The two bones are compressed together and fixed in place with screws, a small plate, staples, or a combination of these
6. The wound is closed, usually with dissolvable stitches, and a bulky dressing or bandage is applied to your foot.

What does recovery look like?

Many people go home the same day, since this is usually done as day case surgery. You may need to stay overnight if you don't have someone to look after you at home, or occasionally for extra pain relief, since cutting into bone can be quite sore at first.

For the first 2 to 4 days, rest with your foot raised above hip height as much as possible, and keep to crutches with only short trips to the bathroom. You'll be given pain relief to take home, since this early period tends to be the most uncomfortable.

You'll usually be seen in clinic at around 2 weeks, when your dressing comes off and any stitches are checked. From here you can gradually build up your activity, though you'll normally stay in a protective boot or sandal for around 6 weeks in total, wearing it whenever you're weight-bearing. If an X-ray shows the bone hasn't fully joined yet, your team may ask you to continue a little longer.

A follow-up X-ray, usually around 6 to 8 weeks after surgery, checks that the bones have joined properly. Many people return to desk-based work by around 6 weeks, though a manual job may mean staying off for up to 3 months. Medically and legally, don’t drive until you can comfortably manage an emergency stop and your post-operative boot has been removed, usually from 6 weeks. Speak to your surgeon and medical insurer first before returning to driving. Most sport is best delayed until around 12 weeks.

Swelling and some stiffness can continue for several months, and it may take up to a year for the foot to fully settle. Most people are back to their usual day-to-day activities within about 3 months, although high-impact sport takes longer.

What are the risks and complications?

As with any operation, there are risks to be aware of. Your surgical team will talk you through these in detail before you decide, but the ones reported most often include:

• Non-union, where the bones don't join properly – reported rates vary between around 5 and 10 in 100 people having their first fusion, rising to around 15 to 20 in 100 for a repeat operation
• Infection, in around 1 to 10 in 100 people, depending on the source – rarely, this can spread to the bone and need further surgery or a longer course of antibiotics
• Numbness or altered sensation in the toe, if a small nerve is bruised or damaged during surgery, which usually settles but can occasionally be permanent
• A stiff joint, which is expected after fusion and may limit high heels or very active sports
• Swelling and bruising, which is common and can take many months to fully settle
• Prominent or loose metalwork, which occasionally needs a small further operation to remove
• Pain or stiffness in nearby joints, from changes to the way you walk or extra pressure under the ball of the foot
• A blood clot (deep vein thrombosis), which is uncommon after foot surgery but can be serious