Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Fellow of the American College of Foot and Ankle Surgeons. Updated April 2026.

What Is First MTP Joint Fusion?

big toe joint best treatment
big toe joint best treatment

First metatarsophalangeal (MTP) joint fusion—also called first MTP arthrodesis or hallux rigidus surgery—is the gold-standard surgical treatment for severe arthritis of the big toe joint. It permanently eliminates motion at the first MTP joint by allowing the metatarsal bone and the proximal phalanx (the first bone of the big toe) to grow together into a single fused unit. The goal is eliminating pain from the arthritic joint while maintaining a stable, functional foot for walking, standing, and many athletic activities.

First MTP fusion is most commonly performed for advanced hallux rigidus (Grade III–IV arthritis) that has failed conservative treatment (orthotics, rocker-bottom shoes, cortisone injections). It is also used for failed previous big toe surgery (including failed implant arthroplasty), severe hallux valgus (bunion) with first MTP arthritis, rheumatoid arthritis affecting the first MTP joint, and avascular necrosis of the metatarsal head.

The Procedure

The surgery is performed under regional or general anesthesia, typically as an outpatient procedure. An incision is made over the top of the big toe joint, the remaining cartilage is removed, and the bone surfaces are prepared to allow bone-to-bone contact. The position of fusion is critical—the toe is placed in a slight amount of dorsiflexion (5–10 degrees upward) to allow normal push-off during walking. Fixation is achieved with a plate and screws, two crossing screws, or a combination. The fixation holds the joint in position while healing occurs over 8–12 weeks.

Recovery Timeline

Week 1–2: Non-weight-bearing or heel-weight-bearing only in a surgical boot, with the foot elevated as much as possible to control swelling. Sutures removed at 2 weeks with wound assessment. Week 2–6: Progressive weight-bearing in a flat surgical boot, transitioning from minimal to full weight-bearing by week 6 as comfort allows. Week 6–10: X-rays confirm early fusion progress; transition to a stiff-soled postoperative shoe. Month 3–4: If X-rays show solid fusion, transition to regular supportive shoes. Return to low-impact activities at 3–4 months. Return to running and impact sports at 4–6 months when fusion is solid. Full comfort with all activities may take 6–12 months as the foot adapts to the new mechanics.

Life After Big Toe Fusion: Activity and Function

Many patients are surprised by how well they function after first MTP fusion. The adjacent interphalangeal joint (between the first and second bones of the toe) compensates for some lost motion, and the rocker-bottom effect of a slightly rigid forefoot during walking is minimized with appropriate shoes. Patients return to walking, hiking, cycling, golf, tennis, swimming, and even running after fusion. High heels above 2–3 inches are generally not comfortable. Studies consistently show that patient satisfaction after first MTP fusion for hallux rigidus is approximately 90%, with most patients recommending the procedure to others.

Frequently Asked Questions

Does big toe fusion affect walking?

Most patients walk comfortably and near-normally after first MTP fusion. The key is proper surgical positioning—fusing the toe in the correct amount of dorsiflexion and neutral valgus/varus. With ideal positioning, the gait pattern adapts well because the opposite limb’s push-off compensates and the remaining IP joint provides some motion. Patients should wear shoes with a slightly rocker-bottom or cushioned sole, which reduces the demand for toe dorsiflexion during the toe-off phase of walking. Initially, some patients walk with a slightly modified gait, but by 4–6 months most have adapted to a comfortable near-normal walking pattern. Long-term gait studies show that first MTP fusion patients walk with adequate speed and symmetry compared to non-operated controls.

What is the success rate of big toe joint fusion?

First MTP fusion has excellent outcomes, with fusion rates of 90–95% and patient satisfaction rates of approximately 90% in most series. Failure to fuse (non-union) occurs in 3–5% and may require revision surgery. Malposition (incorrect fusion angle) is the most important technical complication—too much or too little dorsiflexion affects walking mechanics. Smoking significantly increases non-union risk and is a relative contraindication to elective fusion surgery. When performed by experienced surgeons with appropriate fixation, first MTP fusion reliably eliminates big toe joint pain and allows return to most activities. Long-term follow-up studies show maintained outcomes at 10+ years in the vast majority of patients.

Can the hardware be removed after big toe fusion?

The hardware (plates and screws) used for first MTP fusion is typically left in place permanently unless it causes problems. Hardware removal is performed in approximately 5–15% of patients—usually for hardware prominence causing shoe irritation, palpable or painful hardware under the skin, or infection. Once fusion is solid (usually by 3–4 months), the hardware is no longer needed for structural support but its removal requires another surgery and additional recovery. Most patients with well-positioned hardware and no symptoms elect to leave it in place indefinitely. If hardware removal is needed, it is a relatively straightforward procedure with a shorter recovery than the original fusion surgery.

Medical References & Sources

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Dr. Tom Biernacki, DPM is a board-certified podiatric surgeon at Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan. He performs first MTP joint fusion for hallux rigidus and other indications, with individualized surgical planning to optimize postoperative function.

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Medically Reviewed by: Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Balance Foot & Ankle Specialists

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Clinical References

  1. Coughlin MJ, Shurnas PS. Hallux Rigidus: Grading and Long-Term Results of Operative Treatment. J Bone Joint Surg Am. 2003;85(11):2072-2088.
  2. Raikin SM, et al. Comparison of Arthrodesis and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint. J Bone Joint Surg Am. 2007;89(9):1979-1985.
  3. Goucher NR, Coughlin MJ. Hallux Metatarsophalangeal Joint Arthrodesis Using Dome-Shaped Reamers and Dorsal Plate Fixation. Foot Ankle Int. 2006;27(11):869-876.

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