Background Information:

What are the other Names for the Procedure?

• Arthrodesis of the Big Toe Joint
• Big Toe Fusion
• First MTP Joint Fusion

What is Big Toe Fusion surgical procedure?

• A Big Toe Fusion is a surgical procedure that is performed to treat arthritis of the big toe. In some cases, it is also performed to treat severe bunions
• Arthritis of the big toe is a joint disorder characterized by an abnormal inflammation of the first metatarsophalangeal joint. The symptoms of the condition include stiffness, swelling, and inflammation of the joint

What part of the Body does the Procedure involve?

The Big Toe Fusion surgical procedure involves the tissues and bone of the big toe (first metatarsophalangeal joint). The procedure can be performed on one toe or both toes.

Why is the Big Toe Fusion surgical procedure Performed?

There could be various reasons for performing a Big Toe Fusion Procedure. Some of these include:

• Treating severe arthritis of the big toe
• Occasionally, in the treatment of bunions

What are some Alternative Choices for the Procedure?

Big Toe Fusion is a unique procedure for treating arthritis. Currently, there are no suitable alternatives for the same.

What are the Recent Advances in the Procedure?

Currently, no significant advances specific to Big Toe Fusion Procedure are reported. 

What is the Cost of performing the Big Toe Fusion surgical procedure?

The cost of the Big Toe Fusion Procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Big Toe Fusion Procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.guysandstthomas.nhs.uk/resources/patient-information/surgery/orthopaedics/big-toe-fusion.pdf (accessed on 2/08/2021)

https://www.fortiusclinic.com/conditions/big-toe-joint-fusion-surgery (accessed on 2/08/2021)

https://arizonafoot.com/first-metatarsal-phalangeal-joint-mtp-arthrodesis/ (accessed on 2/08/2021)

Prior to Big Toe Fusion surgical procedure:

How is the Big Toe Fusion surgical procedure Performed?

The Big Toe Fusion Procedure is performed as follows:

• An incision is made by the surgeon on the medial (inside) aspect of the front of the foot, at the base of the big toe; and, about 3 cm (2-3 inches) long, towards the heel
• Two screws are drilled into the two adjacent bones. The screw that starts nearest to the big toe goes through the bone nearest the toe and is aimed at an angle back towards the heel
• The tip of that screw ends up in the same bone the next screw starts in. The other screw starts closer to the heel, and the tip then ends up in the same bone the other screw started in
• The surgeon has to make sure the screws are offset a little, so they do not strike each other half way through. So, the previously mobile joint will no longer move because the two screws hold it stiff
• On a post-operative X-ray, the two crossed screws are checked for proper placement. The incision(s) is/are closed with sutures, a dressing applied, and the foot wrapped up
• No plates are used in this procedure, just the two screws. The screws stay in place for the duration of the patient’s life

Prior to the surgical procedure, the following may be necessary:

• Preoperative physical examination to evaluate the patient is fit to undergo the procedure
• Preoperative laboratory testing
• Evaluation of medication history and safety of anesthesia planned
• Arrival at surgery location fasting

Where is the Procedure Performed?

The Big Toe Fusion Procedure is usually performed in an outpatient surgery center facility or a hospital.

Who Performs the Procedure?

The Big Toe Fusion Procedure is usually performed by a podiatrist, an orthopedic surgeon, or a general surgeon.

How long will the Procedure take?

The surgical procedure may take 45 to 60 minutes to perform.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Big Toe Fusion Procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician performing the procedure will evaluate the patient prior to procedure and discuss procedure details with risks for complications and obtain his/her permission (termed informed consent). 
• If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
• Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
• It is strongly advised not to use any cocaine about 7 to 14 days before procedure; and if so, it is important to discuss the same with the physician and anesthesia team
• Smoking should generally be avoided prior to procedure
• Generally, the patient is required to be on fast (no solids or liquids) for at least 8 hours prior to the procedure
• Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications taken) with their attending physician well in advance

What is the Consent Process before the Procedure?

The physician will obtain permission for the Big Toe Fusion Procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the procedure?

Before the procedure, an X-ray of the foot is taken. Additional tests may be necessary based on the healthcare provider’s evaluation of the patient.

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Big Toe Fusion Procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?

During the Big Toe Fusion surgical procedure:

What kind of Anesthesia is given, during the Procedure?

A Big Toe Fusion surgical procedure is performed under general anesthesia by injection and inhalation with a local anesthetic administered after surgery around the wound.

How much Blood will you lose, during the Procedure?

The amount of blood loss is generally minimal since the procedure requires only a small incision. But, if complications arise during the procedure, it could lead to further loss of blood.

What are the possible Risks and Complications during the Big Toe Fusion surgical procedure?

The possible risks or complications that may arise during the surgery include:

• Infection
• Accidental injury to the neighboring tissue, nerve, or bone
• Excessive bleeding
• Anesthetic complications, such as respiratory depression, the need for mechanical ventilation, allergic reactions, etc.

What Post-Operative Care is needed at the Healthcare Facility after the Big Toe Fusion surgical procedure?

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise.

After the Big Toe Fusion surgical procedure:

What are the possible Risks and Complications after the Big Toe Fusion surgical procedure?

The possible risks and complications that may arise after the Big Toe Fusion surgical procedure include:

• Swelling of the foot after surgery
• Malunion: A serious complication that might occur, if the first metatarsophalangeal joint heals in an improper position
• Nonunion: Another serious complication, when the bones does not heal adequately, shifts to an improper position, receives an inefficient supply of blood flow, or becomes infected
• Stiffness with the big toe
• Uncomfortable pain under the smaller toes

What is the Prognosis after the Surgery?

• A complete recovery from a Big Toe Fusion Procedure is usually achieved without any serious complications being observed
• About six months after surgery, individuals may return to some form of activity and sports
• In rare cases, prolonged swelling of the ankle may occur following the procedure

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Pain around the surgical wound
• Swelling and redness
• Numbness, tingling sensation, or loss of feeling in the foot or toe
• Bleeding or fluid drainage
• Loosening stitches
• Fever
• Dizziness
• Signs of infection

What Post-Operative Care is needed at Home after the Big Toe Fusion surgical procedure?

At home, the following post-operative care may be recommended, after a Big Toe Fusion Procedure:

1 to 7 days after the procedure:

• Begin the course of prescribed medication to reduce pain, as advised by the physician
• Elevate the foot while resting, to prevent formation of blood clots and reduce the possibility of swelling
• Keep the wound bandaged for about 2 weeks post-surgery. It is applied in the operating room and is used to help reduce swelling. Avoid getting the gauze bandage wet

8 to 14 days after the procedure:

• Continue to elevate the foot while resting
• By this time, individuals may be able to walk short distances. Make sure to continuing wearing the orthopedic walking boot, prescribed by the healthcare provider
• Avoid smoking and taking anti-inflammatory medications during the first few weeks after surgery as this may delay or prevent the bones from fusing together

15-21 days after the procedure:

• Recovering from Big Toe Fusion surgery differs from one individual to another. After about 2 weeks post-surgery, individuals with a sedentary job may return to work, if elevation of the foot is possible
• It may take about 2 to 3 months for individuals with labor-intensive type jobs to return to work

1 month after the procedure:

• If a medical professional prescribes an antibiotic ointment, apply the ointment to the healing wound. Continue to apply the ointment to the wound once it is completely healed
• Wash the surgical wound with mild soap while bathing; keep it clean and dry thereafter

2 to 3 months after the procedure:

• At this point, an individual’s mobility will be improved. However, it is recommended to avoid walking long distances
• Individuals with a job that is more labor-intensive should discuss with their healthcare professionals about returning to work
• Individuals may slowly resume low impact exercises, such as cycling, exercise bike, and cross training. High impact exercises, such as running may begin about 3 months after surgery, as advised by the surgeon

3 months to 1 year after the procedure:

• 6 months after surgery, individuals can probably return to normal sports activities
• Individuals are advised to refrain from flying in the first 3 months after surgery due to the increased risk of developing blood clots during this time frame
• Swelling of the foot may still be noticeable for up to a year after surgery

In general, the following post-operative instructions may be given by the surgeon/healthcare expert:

• Leave the dressing applied in the OR intact until suture removal visit, which may be after 10-14 days, or as advised
• Painkillers may be prescribed, which may be required for a few days after surgery
• Partial weight bearing as tolerated may be considered after 24 hours (next day) following surgery
• Crutches or walker may be used for support
• A stiff flat-soled Velcro mini-boot on each foot may be used, to keep the foot and toe joints from moving for about 6 weeks, or as recommended
• A follow-up X-ray may be then taken to assess healing, following which one may use regular shoes
• Physical therapy visits may be needed and planned
• The physiotherapist will advise when normal physical activities, such as walking, tennis, or swimming, may be resumed

How long does it normally take to fully recover, from the Procedure?

It may take about 6 weeks to recover from the Big Toe Fusion surgical procedure. At this time, individuals may be able to participate in low impact sports.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The tissue is taken for further examination and later disposed, as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Big Toe Fusion surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• The orthopedic surgeon, a podiatrist, or a general surgeon
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing, before Big Toe Fusion surgical procedure is performed.