Regaining Mobility: A Comprehensive Guide to Learning to Walk After Big Toe Fusion

Big toe fusion, also known as great toe fusion or first metatarsophalangeal (MTP) joint fusion, is a surgical procedure designed to alleviate pain and restore function in individuals suffering from disabling arthritis of the big toe joint. This article provides a detailed overview of the procedure, recovery process, and what to expect when learning to walk again after surgery.

Understanding Great Toe Fusion

What is Great Toe Fusion?

Great toe fusion, or arthrodesis, is a surgical procedure performed to treat disabling arthritis of the first metatarsophalangeal (MTP) joint when conservative measures have failed to relieve pain. The first metatarsophalangeal (MTP) joint is the joint in your big toe. Big toe arthritis (also known as hallux rigidus) can cause pain and swelling and lead to difficulty walking, running, and wearing shoes. With this surgery, the great toe MTP joint is permanently stiffened by removing the degenerated cartilage and fusing the bones together. This can usually be performed in a minimally invasive fashion. In a first MTP joint fusion, the bones are joined (fused) together permanently so they cannot rub against each other and cause pain.

Why is it Performed?

Surgery is typically recommended if you have pain and stiffness in the big toe joint. shoes, high heels, and boots) and can't participate in activities due to pain. the condition. Before considering surgery, you should try non-surgical treatment such as modifying your activities or taking steroid injections. motion.You should avoid surgery if you have an active infection or severe narrowing of the arteries.

How is the Fusion Achieved?

Typically screws are used to hold the bones in position until the fusion is solid. Occasionally, bone graft is necessary if bony defects are present. Your own bone (autograft), cadaver bone (allograft) or synthetic bone graft may be used. In an MTP joint fusion, your foot and ankle orthopaedic surgeon removes the damaged cartilage and fixes the two bones together with screws and/or plates to enable them to grow together. This is routinely performed as an outpatient procedure. Most patients go home the same day of the surgery unless they need to be monitored in the hospital overnight.

Specifically, your surgeon will make an incision on top of the big toe. Any cartilage is cleared away to allow the two bones to heal together. Your foot and ankle orthopaedic surgeon may use a combination of tools to shape each bone for a perfect fit. Once prepared, the two bones are positioned and a metal plate is placed to hold both bones together. An additional screw is set across the joint for extra stability and compression, which aids in healing. the joint without using a plate. Hallux Metatarsophalangeal Joint Fusion (MTPJ fusion)This operation is intended to glue (fuse) the big toe joint together and is usually performed as a day case operation. It is also called an arthrodesis of the big toe joint (metatarsophalangeal joint). It is usually performed for painful arthritis of this joint (hallux rigidus) which has not responded to other non-operative treatment. Sometimes Mr Redfern may also recommend this operation for the treatment of a bunion in some patients.The surgery involves removal of the joint surfaces via an incision over the inside surface of the foot. The two ‘raw’ bone surfaces are then compressed together using titanium screws and a plate to stabilise the joint in the desired position. This metalwork does not usually need to be removed subsequently although it can be removed if required (<5% in Mr Redfern’s practice). Holding the prepared joint still allows the bone to knit up across the joint as if healing a broken bone. This is called fusion.

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The Surgical Experience

Where and When?

Your surgery generally takes place in a surgical outpatient setting. This is routinely performed as an outpatient procedure. Most patients go home the same day of the surgery unless they need to be monitored in the hospital overnight. The procedure generally takes about an hour and you will go home the same day.

Anesthesia and Antibiotics

Either a foot anesthetic block with sedation, or general anesthesia, will be offered. Yes. You will get a dose of antibiotic before surgery.

Preparing for Surgery

Read the surgical folder carefully. Get ready for it! Optimize your physical and mental state, and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions.

What to Expect Immediately After Surgery

Day 1: Foot wrapped in bandage and surgical shoe, start walking on the foot in surgical shoe only, strict elevation of the foot (elevate foot for 50 minutes out of every hour), take pain medication for the first 2 days regularly (usually very little if any pain however), expect numbness in foot 12-24 hours, some blood drainage through bandage may occur - do not change bandage, and do not remove surgical shoe - even at night. When you have adequately recovered and have passed the criteria, including weight-bearing in the medical boot with crutches, you will be discharged home.

Initial Recovery Phase

At-Home Care

For the first two weeks you must rest, get sleep, eat well, and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. You will be weight-bearing as tolerated in the medical boot, using crutches as needed. Keep your boot on at all times, including sleep, for the first two weeks to protect the fusion site. Keep the bandage clean and dry. Drink plenty of clear fluids, keep your foot elevated to the level of your heart, and take the pain medication prescribed as needed.

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Medications

Discuss this with your rheumatologist, but it is generally recommended that you stop immune suppressive modulators (eg. Methotrexate, Enbrel, Humira) for two weeks before and two weeks after surgery. Your doctor will tell you if and when you can restart your medicines. Be safe with medicines. Read and follow all instructions on the label. Store your prescription pain medicines where no one else can get to them. When you are done using them, dispose of them quickly and safely.

Managing Bleeding and Wound Care

Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.

Follow-Up Appointments

After surgery, you will likely be examined at two-week, six-week, three-month, and six-month intervals. X-rays may be taken at each visit to evaluate the bone healing and the position of the big toe.

Learning to Walk Again: A Gradual Process

The Phases of Walking Recovery

The Non-Weight-Bearing Phase: Immediately after surgery, most patients must avoid putting any weight on the affected foot. Crutches or other walking aids may be necessary to keep pressure off the healing area. This phase typically lasts 2-6 weeks, depending on the procedure. Yes, learning to walk after big toe fusion is possible, but the recovery process is gradual. First, you’ll need to use crutches or a walker to avoid putting weight and pressure on your foot.
The Partial Weight-Bearing Phase: As healing progresses, you may be allowed partial weight-bearing using a walking boot, brace, or supportive shoe. This phase helps the foot gradually adjust to movement without overloading the surgical site. Physical therapy may begin to improve strength and flexibility.
The Full Weight-Bearing Phase: When it is determined to be safe according to your postsurgical instructions, you can transition to full weight-bearing, often starting with short, controlled walks. Physical therapy plays a crucial role in restoring balance, coordination, and proper walking mechanics. Over time, as your bones heal and fuse, you’ll regain the ability to walk normally, although you might feel some stiffness in your toe.

Week-by-Week Progression

10-14 Days: Follow-up review by Mr Redfern in the outpatients for wound review & removal stitches and shower when incision dry.
2-6 weeks: Continued strict use of the stiff soled post-operative shoe provided whenever walking, walking activity should be minimal - “slowly pottering around” rather than trying to return to activity, patients may prefer to only use one crutch as a walking stick (and a reminder to themselves of the continued need for care), and elevation is less important but still required sufficient to minimise swelling in the foot as much as possible.
6-8 weeks: Follow-up in the outpatients with xray on arrival, remove surgical shoe if satisfactory xray, a regular shoe may be worn as comfort allows - this should be stiff soled and supportive such as a stiff walking trainer or similar, no sports until 3 months after surgery, and no high heels to worn until 3 months after surgery.

Tips for a Faster and Safer Recovery

Follow Post-Surgical Instructions: Strictly adhere to your surgeon’s guidelines regarding weight-bearing, wound care, and activity modifications to prevent complications.
Use Supportive Devices as Needed: Crutches, knee scooters, or walking boots help protect the foot during early recovery. Transition gradually to normal footwear under medical supervision.
Prioritize Physical Therapy: Targeted exercises restore strength, flexibility, and stability, helping you walk confidently and reduce the risk of re-injury. You may need to do regular rehabilitation (rehab) exercises to strengthen your foot and improve movement.
Manage Swelling and Pain: Elevate your foot, apply ice as directed, and follow a pain management plan to stay comfortable during recovery. Pat the incision dry. Put ice or a cold pack on your foot for 10 to 20 minutes at time. Try to do this every 1 to 2 hours for the next 3 days (when you are awake). Prop up your foot and leg on a pillow when you ice it or anytime you sit or lie down during the next 3 days. Try to keep it above the level of your heart.
Choose the Right Footwear: Supportive, cushioned shoes are essential when transitioning back to normal walking. After a first MTP fusion, you should not wear shoes that put extra stress on the joint. Your surgeon may recommend custom orthotics for additional support. You must wear your surgical shoe (post-op shoe) at all times including in bed at night You may not walk on the foot without this shoe at all, even in the house.

Life After Fusion

Walking and Mobility

The vast majority of patients will walk better, almost normal. Most people who have a first MTP fusion do not have a limp after the toe is fully healed.

Activities You Can Enjoy

With a successful fusion, most patients can walk for distance, ride a bike, perform hiking activities, swim, and golf. Tennis is often possible. Most patients can jog, downhill and cross-country ski. After a first MTP fusion, most people are able to return to an active lifestyle - including walking, hiking, biking, swimming, and jogging - without pain in their toe.

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Activities to Avoid

Most patients cannot participate in high velocity jumping sports, such as basketball. Other patients have difficulty with activities that require extreme flexibility of the forefoot, such as yoga and ballet dancing.

Footwear

Generally no, but you will be more comfortable in a shoe with a cushioned, rocker type sole. A heel height of about one inch can be worn. After a first MTP fusion, most people are able to wear sneakers, sandals, dress shoes that do not have a high heel, and boots. Usually patients can manage a 2 inch heel height once everything has settled (occasionally more-discuss with Mr Redfern). Once fusion is successful, you will be able to wear most shoes (but not necessarily all types and generally not more than a 2 inch/5 cm high heel.

Returning to Work and Driving

Sedentary desk workers may return as soon as one to two weeks. On the other end of the spectrum, construction laborers are typically out of work for three months. You will be provided out of work notes, or restricted duty notes, as necessary during your recovery. Family leave paperwork can also be submitted. With a great toe fusion, many patients drive by two weeks when they are off the pain medications. You may not drive after the surgery for six weeks unless you have an automatic vehicle and only the left foot has undergone surgery. May drive with caution in surgical shoe ONLY IF surgery to left foot only and automatic vehicle (otherwise return to driving at 6-8 weeks post surgery).

Potential Downsides and Complications

Alternatives to Fusion

Alternatives to fusion include non-surgical treatments such as activity modification, NSAIDs (e.g. Advil, Aleve), cortisone/PRP injections, and orthotics (shoe inserts). Surgical alternatives, including bone spur removal or arthroplasty, either with artificial joints or soft tissue interposition, have not been shown to out-perform a fusion.

Potential Complications

Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, delayed union, non-union, or chronic pain and swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome. Complications specific to MTP fusion include poor or delayed bone healing, infection, and stiffness in neighboring joints. The metal plate used during surgery can sometimes cause irritation. In this case it can be removed after the bone has healed. Finally, scarring within the joint can limit neighboring tendons.

Addressing Non-Union

About three to five percent of patients will have a delayed union or non-union. This can be even greater in patients who have additional medical problems, have poor bone healing factors, or are smokers. To enhance your chances of healing, you should not smoke. For a delayed union you may be prescribed bone healing adjuvants, such as a bone stimulator, and prolonged immobilization. For an established non-union, you may require revision surgery and bone-grafting to try to get the fusion to heal.

Main Risks of Big Toe Fusion Surgery:

Swelling - Initially the foot will be very swollen and needs elevating. The swelling will disperse over the following weeks and months but will be apparent for up to 4-6 months generally but sometimes up to year after surgery.
Infection - This is a small but important risk. The risk in Mr Redfern’s practice is less than 1%. You will be given intravenous antibiotics to help prevent infection. However, the best way to reduce your chances of acquiring an infection is to keep the foot elevated over the first 14 days. If there is an infection, it will generally resolve with a course of antibiotics. It is important you contact Mr Redfern’s team if you are concerned you may have developed an infection (increased swelling, redness, heat and/or any discharge in the surgical area)
Wound problems - Sometimes the wounds can be slower to heal and this does not usually cause a problem but needs to be closely observed for any infection occurring. This risk is 1% in Mr Redfern’s practice
Scar sensitivity - The scars can be quite sensitive following surgery but this usually subsides without treatment. If persistent sensitivity occurs then this can be treated. This risk is 1% in Mr Redfern’s practice.
Nerve Injury - The risk of the small nerves in the area being directly injured by the surgeon is approximately 1%. However, the nerves can become bruised by the surgery as a result of the swelling (10%). Whilst this usually recovers, you could end up with some permanent numbness over the big toe area, which might cause irritation.
CRPS - This stands for complex regional pain syndrome. It occurs rarely in a severe form (<1% in Mr Redfern’s practice)and is not properly understood. It is thought to be due to inflammation of the nerves in the foot and it can also follow an injury but we don’t fully understand why it occurs. It causes swelling, sensitivity of the skin, stiffness and pain. It is treatable but in its more severe form can takes many months to recover.
Delayed and non union- Delayed union is when he bones are slow to heal. This is not an exact science but generally, if the bones have not healed on an x-ray by three months then this is a delayed union - and often accompanied by persisting swelling in the foot. Non-union refers to failure of the bones to heal and this can sometimes only become apparent after a year following surgery. This is only a problem if there is swelling and discomfort (risk approximately 2%) in which further surgery may be needed.
Malposition - ideally the toe is fused in a position that allows optimum function and gives the best appearance. We will try to fuse the joint in the best position, using a flat panel to simulate the normal standing posture of the foot. However, as you are asleep and lying down, it is not always possible to achieve this best position. The toe may be either too high or too low for example. This rarely causes a problem that requires further surgery and can usually be accommodated with insoles. The risk of requiring further surgery to correct the position of the toe is 1% in Mr Redfern’s practice.
Deep Vein Thrombosis (DVT) - This is a clot in the deep veins of the leg and the risk of this occurring following foot and ankle surgery is low (generally <1%). The fact that you are mobile after surgery and able to take weight through the operated foot helps to minimise this small risk. However, it is sensible to try and move the toes and the ankle regularly following the surgery and probably also sensible to avoid a long-haul flight in the first 12 weeks following surgery. If a deep vein thrombosis (DVT) occurs then you will require treatment with heparin and Warfarin to try and prevent any of the clot travelling to the lungs (pulmonary embolus / PE) which can be much more serious.
Stiffness - The big toe joint is permanently stiff following this surgery as is the intention. Despite this, the vast majority patients do not report difficulty with footwear although a 2 inch (5cm) heel is generally a maximum. Published studies report approximately 90% of patients return to their pre-surgery sport (including running) without difficulty. If you are having the fusion to treat a bunion then one advantage is that the bunion will not recur with this technique.

When to Seek Professional Help

While discomfort is expected, contact our office if you experience:

Severe pain or swelling that worsens
Signs of infection, such as redness, warmth, or drainage
Difficulty moving your toes
New or worsening instability when walking

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