Big Toe Fusion Operation: Surgical Technique

A Big Toe Fusion Operation has many PROs and CONs: Generally it is a very reliable but more permanent, fused procedure.

 

Big Toe Fusion Overview:

  • This page will focus on the surgical technique of performing the big toe fusion operation from skin incision, proper technique through to recovery time.

 

big toe joint fusion with a plate 1st MTPJ fusion
This is an example of a six hole plate with one crossing screw. This procedure was performed for hallux rigidus, which is end-stage big toe joint arthritis. This is different than a really bad bunion, this is when you have really bad arthritis.

 

Big Toe Fusion Skin Incision:

  • -Dorsomedial incison at the 1st MTPJ- just medial and parallel to the extensor hallucis longus tendon.
  • -Extend incision just proximal and distal to the 1st MPJ joint and release the periarticular soft tissues from the joint margins.
  • -If this is for Hallux Abducto Valgus- do not bother with a lateral capsule release as this will correct itself when shortening and fusing the 1st MPJ
  • -Use a T-shape for the joint capsule and extend the vertical arm plantarly.
  • -The sesamoids are not generally arthrodesed to the 1st ray, but if painful they can be(quantify if severe pain ahead of time).
  • If there is a significant callus under the sesamoids, if there is a hypertrophied sesamoid or if they are fractured, they are then routinely excised.

 

1st MTPJ fusion healing time fluoroscopy surgery correction
This patient with a metatarsal phalangeal joint fusion had a recovery time of 1 month in a surgical shoe and dressing. Sutures came out at 3 weeks. The patient was then walking for 4 weeks.

Big Toe Joint Fusion Surgical Technique

  • -All cartilage must be resected from the 1st MPJ until bleeding bone is present, if the bone is extremely arthritic (subchondral sclerosis), then it is necessary to fenestrate the bone further to encourage healing.
  • -The joint can be cut in a cup-in-hole (only really practical for screw fixation- not plate or staples) configuration or left flat (need flat if using staples or plate fixation). Can use an interpositional bone graft to maintain the joint space.
  • -Reciprocal planing-hold the joint in the desired final position- then use the saw blade to section the joint until it fits together properly. The problem with this is excessive shortening and if a graft is not possible – then the ball in cup fusion may work much better.
  • -A ball in cup arthrodesis is made possible through the use of reamers to shave down the cartilage surface. It is also possible to change the positioning of the ball in cup 1st MPJ before it is fused without extra cutting. Be careful because a change in position can occur with ball in cup rather than planar positioning!
  • -Typically the sesamoids are left intact to aid with the fusion, but if calluses, hypertrophy, fracture or severe pain they can be resected.

 

Big Toe Joint Fusion Recovery Time
This a fracture of both the great toe and the 5th metatarsal. The big toe joint fusion recovery time on this patient was 4 weeks in a surgical shoe and bulky dressing, then a protective shoe for 4 more weeks.

 

 

First Metatarsophalangeal Joint Position:

  • -Sliding the joint both dorsally and laterally is possible to limit plantar pain and hallux interphalangeus abductus, but the majority of the position should be accomplished by angling not through sliding.
  • -There is no exact position- but generally dorsiflex slightly and abduct slightly but not to the point of touching the 2nd toe. Temporarily fixate the position with 2 crossing K-wires (these can be done percutaneously) before permanently fixating to check for patient satisfaction.
  • -Confirm position and screws with the C-arm. Mimic weight-bearing with a flat board to see what happens.
  • -The exact angular position is not the most important thing, but how it looks on mimicked weight bearing.

 

big toe joint fusion great toe joint fusion
On these x-rays, the plate and the screws look huge. We have to remember that this is a very thin plate, it is extremely rare for patients to ever feel this plate. I would say that only about 5% of the time in very thin patients do people feel this plate. These are locking screws, so they rarely if ever back out.

 

First Metatarsophalangeal Joint Fixation:

  • -Any technique can but used, but usually the most often employed and proven technique is percutaneous pins. They can be inserted 2 at an angle to prevent rotation, they can then be easily pulled out. The buried K-wire technique can be utilized to prevent unsightly pin protrusion from the digit for the patient.
  • -Plates are used usually only when a bone graft is employed for length, lower profile plates are utilized to prevent irritation in the shoe gear. A second procedure will usually be used to remove the plate at a later point.
  • -Screws are difficult to use due to the lack of bone stock in the 1st MPJ. They greatly reduce the bone surface for arthrodesis.
  • -External fixators are used to prevent deforming forces, but are usually employed for the compression of sharp bone segments.
  • -Staples are good for planar surface apposition of the 1st MPJ.

 

big toe joint fusion with a plate 1st MTPJ fusion
This is an example of a six hole plate with one crossing screw. This procedure was performed for hallux rigidus, which is end-stage big toe joint arthritis. This is different than a really bad bunion, this is when you have really bad arthritis.

 

Big Toe Joint Fusion Recovery Time:

  • -Follow this link to see what helps with recovery time and how long it will take to get better.