Pros and Cons of Big Toe Joint Fusion: The Best Surgery?

Pros and Cons of Big Toe Joint Fusion: This is the most predictable procedure available to the foot and ankle surgery. This is reliable and essential ensures you will only need one surgery if your life if all goes well. The down side is that it is very permanent and you will no longer have motion in the joint.



Pros and Cons of Big Toe Joint Fusion:


The big toe joint fusion is recognized as being the  “most permanent and satisfactory correction of hallux valgus(bunion)”. Numerous studies over the years have indicated that this is the most predictable and effective surgery for any type of bit toe joint deformity or arthritis.


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.



Pros of Big Toe Joint Fusion:


  • Better long term results and happiness.
  • More stable.
  • Better pushoff strength.
  • It will not shorten over time like a arthroplasty might(more chronic arthritis will develop).
  • Long term durability.



bilateral big toe joint fusion for halllux rigidus bunion
This is an example of a bilateral screw based MTPJ fusion patient. This patient had it done many many years ago when plates were not the standard. The downside of this approach is that you have to protect a little bit longer at the beginning. But the end result is just as good!



Cons of Big Toe Joint Fusion:


  • Longer recovery time.
  • No joint motion means less shoe options.
  • Shorter bone may mean less contact to the floor(more pressure on the 2nd metatarsophalangeal joint).
  • No going back unless you get more surgery.


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.




Frequently asked questions:


Primarily used for Hallux Abducto Valgus and Hallux Limitus:


  • The big toe fusion is called a McKeever bunionectomy. It is primarily used for both severe hallux abducto valgus deformities(bunions) and stiff big toe joints due to osteoarthritis termed hallux limitus and hallux rigidus.


great toe joint fusion recovery time great toe joint
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.




Secondarily used for Repair of Failed Surgeries


  • The big toe fusion is secondarily used to repair severe/recurrent hallux abducto valgus, failed implant joint arthroplasty (remodelling), hallux varus, primary first MPJ osteoarthritis, post traumatic arthritis, inflammatory and septic arthritis and various other neuromuscular conditions.


big toe joint hallux IPJ fusion surgery treatment hallux
This is technically a great toe joint fusion. But this is a fusion of the IPG joint, it is not a fusion of the metatarsal phalangeal joint. There are actually cases of NFL running backs playing while having the screw in their big toe joint! That’s how well you can move after one of these surgeries.





People are Usually Very Happy with the Operation


  • An appropriately fused big toe joint has shown to have the greatest long term patient happiness from a recurrence standpoint, a pain standpoint and a functionality standpoint.It seems that the only problem is the psychology behind telling a patient that their joint will be fused and they expect that it is much worse than it really is.



Big toe joint arthritis hallux rigidus
This is an example hallux rigidus or really bad arthritis formation in the big toe joint. Procedure like this needs. The bone removed, as well as the potential fusion of the joint.



Should I Remodel the Joint or Fuse the Big Toe?


  • The big toe joint fusion has the benefit of locking the toe in proper position as well as removing pain in the joint. The big toe joint arthroplasty (remodelling) procedure is beneficial in the case where the position is not a big problem such as in a straight joint with a mild amount of joint damage; the arthroplasty is also beneficial because it allows for more types of shoes to be worn. The benefits of the big toe joint fusion (arthrodesis) is that you will have a greater degree of pushoff strength in the joint and essentially guaranteed prevention of future pain and improper positioning if all goes well with the surgery. The arthroplasty has a quicker healing time but weaker pushoff strength (less of a problem if the patient is already apropulsive).


  • Pros: More stable, Better pushoff strength, Better long term results and happiness, will not shorten over time like a arthroplasty might(more chronic arthritis will develop).


  • Cons: Longer recovery time, No joint motion means less shoe options, shorter bone may mean less contact to the floor(more pressure on the 2nd metatarsophalangeal joint).


Pros and Cons 1st MTPJ metatarsal phalangeal joint fusion of the big toe joint
There are pros and cons to a first MTPJ fusion. The pros are that it is very predictable procedure that will get rid of your pain! This leads to excellent overall results. The downsides are you will never be able to bend your big toe joint again. But in most cases, if you’re considering this procedure, you probably can’t bend your big toe joint anyway.


Who should Avoid Big Toe Fusion



  • People who need to kneel and bend should choose remodeling over fusion. Bowlers and carpet layers need to bend their big toe joint every day, people like this should avoid it.


  • People who cannot tolerate being immobilized in a boot for any extended period of time(cast or CAM Walker).


  • Anyone who plans to wear heels larger than 1″ tall. This will basically cause you to develop hallux rigidus as the big to will press against the floor in its fused position, causing a callus to form on the inside of the big toe.


Big Toe Fusion Operation:


  • A detailed guide on the principles of the surgery and how it is performed by the podiatrist.


Big Toe Fusion Recovery Time :


  • A rough estimate on how long it will take for your joint to fuse and what you can do to speed that up.


Big Toe Fusion Complications:


-Nonunion and mal-position are the two major complications.


-Nonunion- this can be prevented by proper fenestration and ensuring that the patient does not have any systemic problems such as smoking or diabetes. If this does occur the painful non-union will need to be excised and then filled in with a bone graft.



Bone Spur on Top of the Foot Surgery Recovery Time Protocol:


This guide will detail the length of specific step by step bone spur surgery recovery time.


Day 1: Top of the Foot Spur Removal Surgery Day:


  • The actually surgery takes well under an hour, and your foot is usually numbed up for the rest of the day.
  • Some people don’t need much if any pain medication outside of anti-inflammatories. If you do have pain to this site, then it is normal to have a prescription for a narcotic pain medication for the days immediately after the surgery.
  • After surgery you will wake up with a dressing on your foot. Keep this dressing in place and your pain will be well under control with medication.
  • No implants or bone healing is necessary, except for the healing of bone pain.
  • You can wear a boot over your dressing almost immediately.
  • Most physically able people do not need crutches or a walker unless they have other health issues.
  • Usually there are about 2 sutures in the foot.


This is what your dressing will look like immediately after surgery. The best thing to do is to elevate it , keep it protected and get some rest!


Day 7:  Top of the Foot Bone Spur Removal Surgery Postoperative Visit #1:


  • Within about a week, we have the first postoperative visit.
  • You will have an X-ray at this visit and we will make sure there is no irritation or damage to your dressing.
  • With this dressing change some antibiotic ointment is applied, we make sure you are not having any problems at this time.
  • Sutures are not removed yet at this visit.


The incision site will stay covered with the stitches in place following the surgery.

Week 2-3: Top of the Foot Bone Spur Removal Surgery Postoperative Visit #2:


  • This can fluctuate depending your overall health needs, physical fitness and life needs.
  • If you are able to rest more, weight less and are really healthy, sutures can usually come out at 2 weeks. Some patients need to walk and be more active, if this is the case you will likely need sutures longer and have a larger dressing.
  • If you swell more and are more tender, they can stay in a little bit longer.
  • If you are a smoker or have decreased healing ability, we may need to keep your sutures in place longer.
  • At this point your incision site should be healed.
  • At this point you will wear a band-aid for 2 weeks and walk in a good supportive running shoe.



Week 5: Postoperative Visit #3:


  • This is what the incision site will look like after the sutures are removed at 2-3 weeks or so.
  • If everything looks good, you no longer need to wear a band-aid.
  • At this point you will still be sore but can transition back into



2 Months: Postoperative Visit #4:


  • At this point you continue wearing a good supportive orthotic and good shoe.
  • If everything is feeling well you should be close to healed.
  • Keep in mind that you will continue improving for about 6 months total. But at this point you should be feeling better than you did prior to when you have a heel spur.
  • Congratulations you



Treatment algorithm for bunion surgery:


  • Find out if a different procedure is best for you.
  • A metatarsal joint fusion may not always be worth it.
  • Many times other procedures are just as effective and the healing time can be much quicker.



Resources for Big Toe Joint Fusion:

Big Toe Joint Fusion.