Inter-phalangeal joint arthrodesis (big toe) surgery: A guide for patients

Before surgery

Surgery

After surgery

What treatment is available?

Treatment can consist of conservative and surgical options:

Non-surgical treatment

• Alteration of footwear: Changing to a wider/deeper fitting shoe can reduce pressure on the toe
• Protective padding and silicone toe moulds.

If conservative treatment fails and the toe continues to be a problem surgery would be recommended.

Surgical treatment

• Fusion, known medically as an arthrodesis, is an option when the joint is too worn/damaged or deformed to preserve and too painful to leave without surgery.
• The operation does not aim to correct the underlying joint degeneration nor restore it to normal. Instead, the aim of surgery is to remove the joint surfaces and surrounding prominent bony bumps and to fuse the joint rigid (for instance, stopping the bending movement of the small joint in the big toe). This is achieved with a large screw, or wires.
• The surgery also aims to correct any positional deformities of the joint at the same time.
• Up to 95 per cent of patients report joint pain improvement.
• Throughout the operation you will have a tight band (called a tourniquet) around the ankle to keep the blood away from your foot. This is sometimes uncomfortable but is released immediately after the operation.
• The skin layers are often stitched together with stitches that dissolve. Occasionally, if your skin is very sensitive, or you are prone to problem scarring, you may require stitches that need to be removed two weeks later.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation but a screen will prevent you from seeing anything.

To numb your foot, you will either be given some injections around your ankle or behind the back of the knee. You can eat and drink on the day of surgery; there is no need for fasting.

The operation may take up to 40 minutes, but you should be prepared to be at the hospital for some time before the surgery and afterwards to allow for preparation and recovery.

You will be invited back to attend a pre-surgical clinic if you decide on surgical management. A member of the nursing team will take a medical history. If you are on any medication, please bring a list with you. This is a good opportunity to ask questions and discuss any concerns you may have about the procedure.

You must have a competent adult at home for the first day and night after surgery.

Recovery after your operation:

The first two to three days

• You must rest with your foot elevated to hip level.
• You should restrict your walking to bathroom visits only. If you have been given crutches, you must use them in the way shown. You may be able to bear a little weight on the foot.
• If you experience pain, you should take the prescribed painkillers. Any pain is usually worse for the first two days.
• If you are still experiencing pain after three to four days that is not relieved by the painkillers, you should contact the department directly.
• If you have any concerns over your foot you should contact the department directly.
• The department is closed at the weekend. Out-of-hours, you should contact your GP or go to your local accident and emergency (A&E) department.

Two to six weeks after surgery

• Two weeks after the operation you must attend for removal of the dressing.
• The skin should be healing well by this time and any non-dissolvable stitches will be removed.
• You should no longer need a bandage but should continue to wear your surgical shoe until your next appointment. At this stage, you can gradually and gently increase your activities. You will still need to rest between your activities.
• One to two days after the stitches have been removed you can start bathing the foot normally.

Six weeks after surgery

• At six weeks after surgery a further X-ray of the foot is required and you must return to the clinic for a review.
• There will still be noticeable swelling especially towards the end of the day. This is quite normal at this stage.
• You can return to normal shoes such as roomy trainers.
• You will be given post-operative exercises to undertake regularly.

Between eight and 12 weeks after surgery

• You may return to work around this time (depending on the type of work and footwear in which you are allowed to return). For heavy jobs, returning to work in less than 10 weeks is an unrealistic expectation.
• You can return to driving. However, you must feel able to perform an emergency stop. (Check with your insurance company when you policy covers you to drive.)
• Although normal everyday activities will be possible, sporting activities will still be restricted at this stage.

12 weeks after surgery

• The foot should now be comfortable and returning to normal but there may still be some slight swelling.

Six to 12 months after surgery

• The residual swelling should now be very slight, if not completely resolved, and you should be getting full benefit from the surgery. After 12 months, all healing is complete.

Intended benefits of the procedure

• The aims of surgery are to stop movement, improve position and reduce pain in the small joint of the big toe, thus making walking and wearing footwear more comfortable.

Serious or frequently occurring risks toe joint fusion

• Infection (two in 100)
• Delayed, or non-healing of the bones, which might require further surgery. Smoking increases the risk of this complication considerably (eight in 100)
• The toe may not be completely straight
• Shortening of the big toe length
• Prolonged/chronic swelling of the toe (four in 100)
• Continued joint pain
• Screw irritation (can be removed via a second small operation)
• Irritation of the bigger big toe joint causing pain and/ or osteo-arthritic changes
• Transfer of pressure onto the ball or outside of the foot causing pain (metatarsalgia)
• Development of deformities/pain with the toe next to the big toe
• Alteration of gait pattern causing other joint/muscular pain
• Thickened scar and/or tender scar (may reduce over 12 months) (four in 100)
• Areas of numbness (may reduce over 18 months)
• Complex regional pain syndrome (increased sensitisation and chronic pain from the foot)
• Deep vein thrombosis (a blood clot in the leg)
• Rarely, you may feel the foot is worse after surgery than it was before.

You should be aware that these complications are relatively uncommon. They mostly resolve without permanent disability or pain using medications, therapy and on occasions further surgery. But even allowing for these, sometimes you may not achieve the result that you want.

For these reasons we do not advise surgery purely for cosmetic reasons. We also advise against prophylactic surgery (which is preventative surgery to avoid problems that are not yet present).