What is it?

Fusion of the great (or big) toe is an operation to stiffen the joint at the base of the great toe (first metatarsophalangeal joint), removing bony bumps and correcting any deformity.

Why would it be performed?

The commonest reason for fusing the great toe is arthritis of the big toe joint. This may be isolated arthritis of the big toe (“hallux rigidus”) or part of a generalised arthritis of the foot (usually rheumatoid arthritis). It would only be performed if the arthritis had severely damaged the joint. If hallux rigidus is at an early stage, or the symptoms are mild, it is best to avoid surgery or another operation, called a cheilectomy, may be advised.

The toe may also be fused to correct a severe deformity of the toe, usually a bunion (“hallux valgus”). Severe deformities tend to recur if a lesser form of treatment is used and a fusion will virtually guarantee this will not happen.

A fusion may be used to treat problems after failure of another operation on the big toe, especially if the toe is deformed, weak, floppy or painful. If the toe has been left very short by the previous operation, a piece of bone may be inserted into the fusion to lengthen the toe.

Limitations of surgery

A fusion makes your big toe quite stiff. It will limit the height of heel you can wear on your shoes, usually a maximum of 1 inch heel. The stiff joint may alter the way you walk. Most people do not find this much of a problem (if you have severe arthritis, removing the pain by a fusion will usually make walking so much more comfortable that the stiffness is a small price to pay). Nevertheless, a few people have to use an insole in their shoes or have alterations to their shoes. If you cannot accept these limitations, you should not have a fusion. 

What does the operation involve?

A cut is made along the side of the toe and the joint is opened. Any large bony lumps are trimmed. The joint surfaces are cut out, trimmed to enable the toe to sit in the right position and fixed together with two screws, staples or a small plate. The wound is stitched up and a soft, bulky dressing applied.

Can it be performed as a day case operation?

If you are medically fit, have someone who can collect you and look after you after the operation and you are comfortable afterwards, the operation can be done on a day case basis. If you have other medical problems such as diabetes, asthma or high blood pressure, you may have to attend the preoperative assessment clinic 2-­6 weeks before your surgery. You must stay overnight in case of complications or if there is no one to collect and look after you. The commonest reason for having to stay overnight after great toe fusion is for pain control, as the operation involves cutting through a bone. It may be quite painful immediately afterwards. Local anaesthetic injections can help with this, but not everyone is comfortable to go home.

Will I have to go to sleep (general anaesthetic)?

The operation can be done under general anaesthetic (asleep). Alternatively, an injection in the back, leg or around the ankle can be given to make the foot numb while the patient remains awake. Local anaesthetic injections do not always work. In that case you may have to go to sleep if the operation is to be performed. Your anaesthetist will advise you about the best choice of anaesthetic for you. Local anaesthetic may be injected into your leg or foot while you are asleep to reduce the pain after the operation even if you go to sleep for the surgery. You will also be given pain­killing tablets as required.

Will I have a plaster on afterwards?

You do not usually need a plaster after a big toe fusion. Usually, we will put dressings and a bandage on your foot and you can walk on your heel in a protective sandal with a stiff sole. However, if your bone is particularly soft or the soft tissue repair of the joint needs extra protection, a plaster will be put on which you would usually wear for 6 weeks. This is also necessary if you have a bone graft operation for a short floppy toe.

What will happen afterwards?

• You can go home when comfortable and safe. An x-­ray may be taken before you go home.
• For the first 2 weeks, you should avoid walking if possible and only put your weight through the heel. Rest with your foot elevated to reduce swelling.
• Avoid Ibuprofen if possible.
• You will be seen in the clinic 2-3 weeks after your operation. The dressings will be removed, the wound examined and the stitches removed if necessary. 
• You may then have a splint put on your toe to hold it in position. You will then be more mobile and able to walk on your heel using crutches to support you. We still recommend, however, that, when not active, you elevate your foot on a stool to help reduce the swelling. You will be able to remove the splint for bathing and showering.
• Another clinic appointment will be made for 4-6 weeks later. At this time the splint will be removed, the toe will be examined and an x-­ray will be taken. If this shows the toe is fused, you can leave the splint off. If the fusion is not yet solid, you may need to continue using the splint for another 3-­4 weeks. The process will then be repeated.

How soon can I....

Walk on the foot?

You can do so immediately, but for the first 2-3 weeks you should avoid walking if possible and put all of your weight on the heel. When not walking you must rest with your foot elevated as much as possible to reduce swelling. After this you can be more mobile but you must still walk on your heel.

Go back to work?

This depends on what you do and how you get to work. If you have a sitting­ down job that you could do with your foot in bandages and you can get to work, you could probably go back to work 2 to 3 weeks after surgery. On the other hand, if you have a heavy manual job you may be off for up to 3 months. If you need to drive to work, this will affect when you can go back. Your surgeon will advise you about going back to work.

Drive?

Once your splint has been removed you may be able to start driving again. You must be comfortable and not too stiff before trying to drive. Start by sitting in the car and trying the pedals. Then drive round the block. Drive short distances before long ones. If you cannot safely make an emergency stop your insurance will not cover you in the event of an accident. Ask your surgeon or foot and ankle practitoner when it is safe for you to drive again.

Play sport?

After you are out of the splint you can start gently exercising your foot and walking further each day. When you are comfortable doing this you can start gentle running and stretching. Contact, twisting and impact sports can follow as comfort dictates. Everyone is different in how quickly they can take up exercise again: be guided by your own body’s reactions and the advice of your surgeon. Obviously, the stiffness of your toe may affect your ability to play sport, but most people can run, swim and cycle as much as they were doing beforehand within six months of surgery.

What are the risks?

• One problem after a fusion is failure of the joint to fuse. This occurs in about 5-10 in 100 people. Half of these will have no problems from their joint, as the scar created by surgery holds the bones together as firmly as a proper fusion. However, some will need to have the operation done again. If you are having a re-fusion, lengthening fusion or fusion for previous failed surgery, the rate of failure is higher at 15-­20 in 100 people and, again, about half will be painful. Diabetes, rheumatoid arthritis, poor circulation and smoking increase the risk of failure.
• COVID-19 infection increases the risk of complications and we recommend you read the separate leaflet about this. If you are in one of the vulnerable groups you should think very carefully about proceeding with surgery unless it is absolutely necessary
• Chronic regional pain syndrome (CRPS)
• Infections in the wound, plaster problems and minor damage to the nerves of the toe can occur in any foot surgery. Usually these are minor problems that get better quickly.
• The foot tends to swell up quite a lot after surgery. Swelling is part of your body’s natural response to any injury and surgery is no exception. In addition, your foot is at the bottom of your body so fluid tends to collect in its tissues and cause swelling. People vary in how quickly this swelling disappears after an operation. Provided you are not having undue pain or inflammation you can afford to give it time. If you are concerned, contact your surgeon for further advice.
• Rarely, the fusion itself becomes infected. This would require a further operation to clear the infection, antibiotics, and usually a repeat fusion when the infection has         settled.
• Deep vein thrombosis/pulmonary embolus (clots in your legs or lungs).
• There are general risks with any operation that include anaesthetic complications and tourniquet complications. 

Wellbeing advice

Most patients find that simple measures can make a big difference to the outcome of surgery. The evidence from studies and our experience supports this:

• Take simple Vitamin C and vitamin D tablets for healing
• Stop smoking, smoking slows down healing and is linked to increased complications
• Keep fit and a healthy weight, many foot problems are improved by losing weight