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Big Toe Joint Fusion (1st MTP Fusion)

Big toe joint fusion, also known as 1st Metatarsophalangeal (MTP) Joint Arthrodesis, is a surgical procedure that permanently joins (fuses) the bones of the big toe joint. It is primarily performed for:

  • Severe arthritis (hallux rigidus) where the joint is painful and stiff.

  • Failed previous bunion or big toe surgeries with persistent pain.

  • Severe deformities (e.g., recurrent bunions, rheumatoid arthritis, or neuromuscular conditions).

  • Chronic instability or pain that has not responded to other treatments.

Fusion is a well-established and highly successful procedure, as it removes the damaged joint, eliminating pain while maintaining a stable, weight-bearing position of the toe.

What Does the Surgery Involve?

1st MTP fusion is performed under regional or general anesthesia and typically takes 60–90 minutes. The procedure includes:

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  1. Removal of Damaged Cartilage – The surfaces of the 1st metatarsal and proximal phalanx are shaved to create a healthy bone surface for fusion.

  2. Joint Positioning – The toe is aligned to allow for comfortable walking and footwear use.

  3. Fixation with Screws or Plates – The bones are held together with screws, a plate, or both, ensuring they fuse over time.

  4. Closure and Bandaging – The incision is closed, and a postoperative dressing is applied.

 

A surgical boot is worn to protect the fusion while it heals.

Alternative Treatments

Before considering fusion, non-surgical options may help manage symptoms:

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  • Footwear Modifications – Stiff-soled shoes with a rocker bottom can reduce pain.

  • Orthotics (Insoles) – Custom insoles may provide joint support.

  • Pain Management – NSAIDs, steroid injections (short-term relief).

  • Big Toe Joint Replacement – An alternative for selected patients, but has a higher failure rate than fusion.

  • Big Toe Cheilectomy – Removal of bone spurs for milder arthritis cases.

 

Fusion is recommended when these options fail or when arthritis is too advanced for joint-preserving procedures.

Risks and Complications

1st MTP fusion has a high success rate, but some risks exist:

 

General Surgical Risks:

  • Infection (1–3% risk) – More common in diabetics and smokers. Usually treatable with antibiotics.

  • Blood Clots (DVT/PE) – Prolonged immobility may increase risk, especially in high-risk patients.

  • Nerve Injury – Temporary or permanent numbness around the incision site.

 

Procedure-Specific Risks:

  • Nonunion or Delayed Healing – The bones may fail to fuse (5–10% risk), particularly in smokers or patients with poor bone quality.

  • Malposition (Improper Alignment) – If the toe is fused at an uncomfortable angle, revision surgery may be needed.

  • Prominent Metalwork – Some patients feel discomfort from screws/plates, requiring removal.

  • Fracture – The metatarsal or phalanx may crack during surgery or later if excessive stress is placed on it too soon.

  • Scar Sensitivity – The surgical site may remain tender for several months.

  • Transfer Pressure to Other Joints – Loss of motion in the big toe can increase strain on the lesser toes or midfoot, sometimes causing new pain.

 

Fusion eliminates movement in the joint, so running and certain high-impact activities may feel different, but most patients adapt well.

Recovery and Rehabilitation

Time Off Work

  • Desk jobs: 2–4 weeks

  • Manual labor: 8–12 weeks

 

Return to Driving

  • 6–8 weeks, depending on swelling and healing.

 

Return to Activities & Sports

  • Walking unaided: 6–8 weeks

  • Low-impact activities: 3–4 months

  • Full sports participation: 6+ months

 

Rehabilitation Timeline:

  • Weeks 0–6:

    • Non-weight-bearing or partial weight-bearing in a surgical boot or cast.

    • Keep foot elevated to reduce swelling.

  • Weeks 6–12:

    • Gradual return to normal footwear.

    • Start physiotherapy to maintain foot strength.

  • 3–6 months:

    • Return to full function and activities.

    • Swelling may persist up to 12 months.

 

With proper healing, most patients experience significant pain relief and improved foot stability.

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