The joint at the base of the big toe can become painful and stiff as a result of arthritis. This may be caused by an old injury, previous surgery or simply be due to a pre-disposition to arthritis. Pain at the joint can start to affect your daily activities and even your sleep pattern. In addition, the joint itself can develop a bony ridge over the top of the joint, from the arthritis, and this can affect your ability to wear certain shoes.
A 1st MTP joint replacement is carried out to put a metal surface on the two bones with a specialised plastic separator in between, thereby replacing the diseased joint surfaces and allowing movement at the joint.
This surgery can be done as a day case but may involve an overnight stay, depending on your circumstances and the Surgeon’s preference. It may depend on your recovery, general condition, home circumstances and mobility. The procedure
is usually performed under general anaesthesia but may be carried under local anaesthetic with sedation, spinal or epidural anaesthetic. You would have an opportunity to discuss these options with your Anaesthetist and Surgeon before your
operation.
A cut is made over the joint area and the ridges of bone next to the joint and cartilage are removed. The new joint surfaces are then inserted into the bones and the bone grows into the implants over time.
The aim of the procedure is to reduce pain and discomfort and allow movement of the joint. This surgery should allow you to wear your footwear more comfortably.
Wound infection. All surgical procedures carry this small risk and sometimes the infection can be treated with additional wound care and antibiotics. However, if infection gets onto the implants then failure of the implant can occur with pain and loosening occurring requiring further surgery and treatment (see later).
Damage to the small nerves of your toes could also occur, which may leave you with numbness or possibly a painful scar.
The bone may fail to join onto the implant. This is more common if you are a smoker and so, if you are about to undergo surgery, we strongly advise you to stop smoking for at least two weeks before surgery and for around six weeks after your surgery. By doing this you will find the healing process similar to that of a non-smoker. Smoking can also delay wound healing as well.
Blood clot (deep vein thrombosis and pulmonary embolus) is a rare complication caused by being less mobile following your foot surgery. You can help to prevent this by elevating your foot when you sit (with your heel above your hip level) keeping gently mobile, wearing your surgical sandal and using crutches (as instructed by the ward physiotherapist) plus carrying out frequent ankle exercises and knee bending exercises to keep your circulation moving. In addition, with this operation, you are encouraged to walk straight after surgery, and undertake toe exercises, which also helps. Depending on your risk factors, Surgeon’s and hospital’s preference, you may also be offered additional antibiotics.
Foot swelling, pain and bleeding can occur if you sit with your leg down and are not moving which is why we advise you to move around regularly every hour or so, during the day.
Implants can loosen over time and sometimes may need to be removed. If this happens then occasionally another joint replacement can be inserted but, more often, the joint will need to be fused (stiffened) using additional bone graft taken from the edge of your pelvis.
If you decide not to proceed with surgery, you may receive advice regarding more suitable footwear. If appropriate, your surgeon may refer you to the orthotist for an assessment with a view to supplying special insoles, which may also help you to manage your symptoms. Your surgeon may advise you to have a steroid injection into the joint itself, under imaging guidance, to help to reduce your pain.
An alternative surgical procedure is a 1st MTP joint fusion to permanently fuse (stiffen) the two bones adjacent to the joint, thereby preventing any movement at the joint. If a joint replacement or fusion procedure has been recommended to you then the arthritis is too advanced for a cheilectomy procedure, where the prominent bone ridge on the top of the joint is shaved off in order to stop pain over the top of the joint when walking.
If you decide not to proceed with any treatment, then it is likely your symptoms and condition will continue and is likely to may become worse. Occasionally the joint may become less painful if it becomes so stiff it can’t move very much, but that only happens to a relatively small number of patients. If you have a large bump over the top of the joint then that will continue to cause problems with footwear.
The staff will ask routine questions about your health, the medicines you take at the moment and any allergies you may have.
You will be given instructions on eating and drinking and when to stop before your operation.
You will be asked to sign a consent form to say that you understand the procedure, and what the operation involves. You will be able to discuss the operation with a doctor and it is important you ask any questions you wish to have answered.
This will vary between hospitals but usually, after your operation, you will be kept in the theatre recovery room before being transferred back to the ward. During the operation you will usually have been given some local anaesthetic (LA) to make your foot numb after the surgery, this helps to control your pain. The effects of this will wear off approximately 8 to 10 hours after your operation, but the length of time the numbness lasts can vary. It is important that as soon as you start to feel a tingling sensation you inform the nursing staff so that suitable painkillers can be given to you, before the pain progresses. Pain is difficult to control if you wait until your pain is more severe.
The first time you get out of bed, you should make sure you ask a nurse for assistance / supervision. This is in case you feel dizzy or unsteady. It is also important that you don’t put your operated foot to the floor until the physiotherapist has assessed you using crutches and provided you with a surgical sandal, which you will have to wear every time to get up to walk. You will need to use this sandal for 4 to 6 weeks depending on instructions from your specialist and outcome of your clinic reviews. The physiotherapist will assess and advise you of the safest way to use your crutches, especially if you have stairs to manage at home. You will also be given instructions on the special exercises you will need to undertake from the day of one, after surgery. These are very important to ensure the new joint moves properly. Once your flexible surgical sandal has been fitted, you will be advised to put your weight carefully through your foot so that you don’t overload your operation site.
You should:
You will be followed up in outpatient clinic after your surgery when your wound will be checked and any sutures/steri-strips are removed. You will then have a physiotherapy appointment made for you to ensure you are doing your exercises properly after the surgery. You will return to follow-up clinic six weeks after your surgery when you will hopefully be re-introduced to normal footwear again, depending on your X-ray result and the opinion of your specialist. The shoes you need to bring with you should be flat, roomy with a thick sole e.g., trainers or flat trekking type sandals which can be adjusted easily to allow for swelling. A degree of swelling can last for quite some months after your surgery.
