Big Toe Fusion - Guy's And St Thomas' NHS Foundation Trust

Big toe fusionThis leaflet answers some of your questions abouthaving big toe fusion surgery. It explains thebenefits, risks and alternatives, as well as what toexpect when you come to hospital. If you have anyquestions, please speak to a doctor or nurse caringfor you.

What is big toe fusion surgery?This operation fixes the bones together at the base ofthe big toe (first metatarsophalangeal joint).What happens during the surgery?This can be done as a day surgery procedure, unlessyou have other significant medical problems that meanyou may need to stay in hospital overnight. You willusually have a general anaesthetic (be asleep). A cut ismade over the joint. The joint surfaces are cut out andprepared so that the big toe sits in a good position. Thebones are then fixed together with metalwork (screws,or a plate and screws). The wound is closed withstitches. Procedures for the smaller toes may beperformed at the same time, but you would haveseparate cuts over those toes.Why should you have this surgery?The most common reason to have this surgery is forsevere arthritis of the big toe, where the toe is alreadystiff and painful. In the fusion operation, the jointsurfaces are removed so that the two bones will healtogether. If there is no movement at the joint there willbe no pain. However, the joint will be permanentlystiff. People can walk fairly normally with a stiff toe as itdoes not hurt, but women will notice a difficulty inwearing a heel higher than 1 inch.2

What are the risks?In general, the risks of any operation relate to theanaesthesia and the surgical procedure itself.In most cases you will have a general anaesthetic. Youwill be able to discuss this with the anaesthetist beforesurgery and they will identify the best method foryou. For more information about this please see ourleaflet, Having an anaesthetic. If you do not have acopy, please ask us for one.The main surgical risks are listed below. The full list ofrisks will be explained by the surgeon treating you.Swelling. Your foot will swell after surgery as part of theresponse to surgery and the healing process. It maytake more than 6 months for the swelling to go downcompletely. It is important to elevate (raise) your foot inthe early stages, when not moving.Non-union. There is a one in 10 (10%) chance that yourbones will not heal together (unite). This may need moresurgery. This risk can go up to one in 2 (50%) if yousmoke, and can be higher in patients with diabetes.Mal-union. This is when your bones have healedtogether but not in the correct position, causing your bigtoe to point inwards, outwards or be slightly raised. Thiscan cause the toe not to work correctly. If this happensyou might need revision surgery to break the boneagain and realign it. The chance of this happening israre.3

Stiffness. The big toe will be stiffer than before surgery.This will limit the size of heel you can wear on yourshoe. The surgery will allow for a small heel. If this is notacceptable, you should discuss with your surgeonbefore booking the surgery.Infection. The cuts usually heal within 2 weeks, but mayleak a small amount of fluid. In a small number of cases(less than one in 10 patients), the wounds may becomeinfected and need antibiotics.Pain. Some patients experience pain under the smallertoes after big toe fusion surgery, as the weight istransferred this way (metatarsalgia). This is often helpedwith a special shoe insole. A small number of patientsmay experience chronic regional pain syndrome, adisease characterised by severe pain, swelling andchanges in the skin, which may persist beyond the firstfew weeks after surgery.Metalwork. You may be able to feel the metalwork inyour foot. If this happens, after six months you mayhave a smaller operation to remove it. By then the fusionwill be solid so the screws are no longer needed as thebone will have bridged the site of the joint.Shoes with a soft upper or even a rocker sole shoe canhelp.4

Are there any alternatives?Simple non-surgical measures, such as a stiff-soled orsoft shoe should be tried before having surgery. If thejoint damage is not too severe, sometimes acheilectomy may be performed before fusion surgery.This is where the joint is cleared of excess bone to tryto maintain movement and improve the pain. Often, thedamage is too severe to be treated with a cheilectomy,and fusion surgery is the best option.How can you prepare for the surgery?Please refer to one of these leaflets which will give all ofthe information you will need before your operation: Having surgery at Guy’s and St Thomas’ Hospital Having an anaesthetic.If you do not have a copy, please ask us for one.You should make arrangements to be collected from thehospital. Someone should stay with you overnight if youhave a general anaesthetic and your operation is a daycase. You will need some time off work after thesurgery. This will be 2-6 weeks, but it may be longer ifyou have a manual job. Your surgeon will discuss thiswith you. We advise that you speak to your employerbefore surgery to make plans.5

Consent – asking for your consentWe want to involve you in decisions about your care andtreatment. If you decide to go ahead, you will be askedto sign a consent form. This states that you agree tohave the treatment and you understand what it involves.If you would like more information about our consentprocess, please speak to a member of staff caring foryou.Will you feel any pain?There will be some pain after the surgery. During youroperation local anaesthetic may be injected into yourfoot to reduce the pain after the operation. You will begiven medicines to take home to control the pain. Thenurse will go through the medicines with you, includinghow often and when to take them. There will be acombination of strong and weak painkillers.It is important that you continue to take painkillers asadvised after your surgery. If you have little or no painyou may not need to take the painkillers.If your pain does not settle, you can be reviewed in yourscheduled outpatient appointment, or you should getadvice and management from your GP.6

What happens after this surgery?The day of your surgeryWhen you have recovered from the anaesthetic, thephysiotherapists will give you crutches and a specialorthopaedic shoe. This will allow you to put weight onthe back/heel of your foot, but not on the front/ball. Thiswill protect the area that has been operated on. Mostpatients can go home on the same day as the surgery.What do you need to do after you gohome?This is a general guide only. Patients will progress andrecover from their surgery at different rates. If yoursurgeon gives you different advice, please follow that.Days 1-7 after surgeryThe local anaesthetic in the joint will start to wear off theday after surgery, so you will need to start takingpainkillers. You should keep the foot elevated when notwalking for 2 weeks after surgery. Whenever the foot isput down, it will swell and become sore.It is normal to see mild bruising and some dry blood onthe foot. Your foot and ankle will be heavily bandaged toprotect it and to help reduce the swelling. The gauzebandage which is applied in the operating theatre willstay on for 2 weeks. There will not normally be a plastercast. Do not get your bandaged foot wet.7

Days 8-14 after surgeryContinue to elevate the foot as much as possible, whennot moving. You can walk short distances in your homeor to a car from this week, but make sure you arewearing the orthopaedic shoe. In week two you can startworking from home but you must try and keep the footelevated. By the end of this week the post operativepain will have significantly reduced.You will be seen about 2 weeks after your operation inthe nurse dressing clinic in the orthopaedic outpatientclinic. This appointment will be made and posted to you.During this appointment the wounds will be checked andany stitches removed. We can advise you at thisappointment about returning to work.Days 15-21 after surgeryIf you have a sedentary desk (job) and can elevate yourleg, you will be able to return to work 2 weeks after yoursurgery. If you have a heavy manual job it will be atleast 8 weeks, and possibly 3 months, before you canreturn to work.You should not drive, unless surgery was on your leftfoot and you have an automatic car. If surgery was onyour right foot or you have a manual car, it will be 6weeks before you can drive. Motor insurance companiesvary in their policies, so check with them first.8

Days 22-28 after surgeryYou should remove all the remaining wound dressingsat home by soaking the dressings off in the bath orshower. You should apply moisturiser around thehealing wound. Once the wound is completely healed,you should apply the moisturiser over the wound aswell. You can massage the scar to soften it and make itless sensitive. Keep wearing your orthopaedic shoe andwear a large sock to stop it rubbing on the scar.At this stage, your foot will still be swollen. Do notexpect to fit into your normal shoes.5-6 weeks after surgeryYou will have another appointment to see a member ofthe team in clinic. You may have an X-ray at thisappointment to check the bones are healing.You can start wearing a pair of wider, looser fittingshoes after this appointment. A good option includestrainers, with loosened laces, croc style shoes or softsuede boots. Bring a pair with you to your clinicappointment.6-12 weeks after surgeryYour mobility will continue to improve although youshould avoid walking long distances. You can usuallyreturn to work after 6 weeks if you have a light manualjob. Discuss this with the doctor during your outpatientappointment. You may start driving again, but checkwith your insurance company first.9

You can start gentle, low impact exercise and activities,for example, cycling, exercise bike and cross training.Gradually increase your activity level with time. Highimpact exercise, for example running, can start at 12weeks. You should speak to your surgeon about this ifyou are unsure.3-12 months after surgeryIt may take 6 months to return to your normal sportingactivity level.Your foot may continue to be swollen for up to a yearafter this surgery.Patients are advised to not fly within 12 weeks of footsurgery. This is due to the increased risk of blood clotsduring this time.What should you do if you have aproblem?If you experience any of the following symptoms, pleasecontact your GP or go to your nearest EmergencyDepartment (A&E): increasing pain increasing redness, swelling or oozing around thewound site fever (temperature higher than 38C).If you have an infection at any time during yourrecovery, either suspected by you or diagnosed by yourGP or an Emergency Department doctor, please contactyour consultant’s secretary, t: 020 7188 4443.10

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