Introduction
If a patient has severe arthritis or deformity in the main big toe joint, then a fusion of this joint can provide excellent pain relief and maintain very good function of the foot. The idea of eliminating all movement in what seems like such an important joint can seem overwhelming for many patients, but there is a large body of evidence and long history of success with this surgery that make it the “gold standard” by which all other options for these conditions are judged.
Patients can expect to have (near) complete resolution of their pain in most cases, be able to walk unlimited distances, and return to many other activities they’ve given up because of their toe. The main limitations are an inability to run, being limited to flat shoes rather than heels, or difficulty manipulating the foot down into tight high-top boots.
Indications
In most cases the reason for surgery is severe pain caused by arthritis. This may be due to degenerative osteoarthritis, rheumatoid, gout or other causes. In some cases surgery is performed to straighten a severe deformity or stabilize an unstable joint. Surgery should not be considered until all appropriate non operative treatments have been explored.
Patients with diabetes, rheumatoid arthritis, or who smoke, are at a much higher risk of complications from surgery and may choose to avoid an operation at all
Preoperative Instructions
You will be given a full briefing of how to prepare for your procedure well in advance of the day of surgery. In very general terms you will need to...
- Let our team know what other medication you are taking and follow our guidelines on taking these medications in the days/weeks before surgery.
- This is particularly pertinent to blood thinning medications such as aspirin, warfarin, clopidogrel and Xarelto.
- Let our team know if you develop symptoms of any illness (including a cold or fever) or if you believe you may be pregnant.
- If you smoke, stop smoking ideally several days or weeks ahead of the procedure, but at the very least not smoke after midnight the night before surgery.
- Maintain your strength and mobility as best as possible.
- Ensure the foot is clean, do not use moisturizer on the day of the surgery.
- Not eat or drink anything for a minimum of 8 hours prior to admission.
- Bring all available and relevant imaging with you to hospital.
Procedure
A general anaesthetic is typically used with a local nerve block. An incision is made on the inner side of the joint and the remaining cartilage and bone surfaces are removed with a burr. The ends are roughened and the two bones are put in position and held firmly together with plates and screws. The concept is to try to “trick” the body into thinking it is healing a fracture, such that the bones knit together into one mass of bone. The incision is closed with dissolving stitches under the skin. Dressings and bandages are applied.
Postoperative Instructions
Immediately after surgery, the foot must be kept elevated (above the level of the heart) to reduce swelling. This is especially important over the first 2 weeks. Patients also receive pain medication at this time. Patients typically stay in hospital for one night.
You may walk on the foot. A post-op shoe will be provided to wear over the bandages when walking. The bandages are to be left in position until your review appointment. This will mean having to use plastic bags and tape to protect the dressings when showering.
At 10-14 days you will be seen and the wounds checked, any external sutures and dressings are removed. You are to continue wearing the post op shoe for another 4-5 weeks after this time. Although it is possible to start returning to activity after this point, it is important to remember that the toe will still swell and ache if you do too much.
At around 6 weeks after the surgery, an x-ray is undertaken to ensure the bones are knitting together well, and if so, it will be possible to start wearing normal shoes hereafter. The toe will remain swollen for at least another month, and it will usually take about 3 months from the date of surgery for full recovery.
Risks
All surgery carries with it some form of risk. Common risks that apply to all surgery, including toe fusion, are...
- Bleeding.
- Formation of a blood clot (“DVT” or deep vein thrombosis) Pieces of clot in the leg can break off and lodge in the lungs causing a pulmonary embolism. This can be very serious, and in rare cases even cause death.
- Infection.
- Nerve damage.
- Difficulty getting the wound to heal.
- Abnormal pain reactions or nerve hypersensitisation known as complex regional pain syndrome (CRPS).
Risks specifically related to this procedure include...
- Malposition of the toe. – It is possible to misjudge exactly the best position to fix the toe joint. Too far up it could rub on shoes, too down it could cause pressure on the end, across too far it could rub on the next toe. This occasionally requires a second operation for adjustment.
- Non-union - if the bones don’t fuse together, the toe remains painful and the hardware can loosen or fail. This would mean having to do the surgery all over again
- In the long term, having a stiff joint can have impacts on, and cause arthritis in adjacent joints. This usually takes many years, but could require further surgery later on.
Treatment Alternatives
Depending on the severity of your arthritis and functional needs there may be other surgical options, including:
Please discuss the pros and cons of each of these procedures and which is most likely to be appropriate in your case with Mr Callahan.