Great Toe Fusion vs. Joint Replacement Surgery

Arthritis and degenerative joint disease (DJD) can cause problems with shoes and limitations with activity choices for many patients.  The most common presentation is in the bunion region of the foot, however there are cases when the great toe (big toe) of the foot, is involved and becomes arthritic as well.

Damage to the joint can be caused by mechanical injury (trauma), repetitive stress type injuries (athletic activities that are extreme and stress the joint), or secondary to compensation in the region due to biomechanics and related issues. Ultimately the break down of the cartilage of the joint at the great toe causes limitation of movement, pain and needs to be corrected with either fusion or joint replacement.

Conservative solutions can include things like changes in shoes, inserts or local anti inflammatory injections.  This often eliminates pain, but the treatments can be temporary and require a more aggressive surgical intervention if they do not provide comfort or solve the problem well for the patient.

The Procedure

The procedure has two potential end points:  1. Fusion of the joint, with removal of the arthritic surfaces, and fixation of the two bones of the great toe (IPJ) with a screw of other type of stabilization; or 2. Replacement of the great toe joint with a synthetic Joint Replacement Implant.

Hallux surgery is much like bunion surgery with the incision on the side of the great toe.  The first step is dissection and exposure of the bony deformity.  This step requires and incision on the medial side of the foot over the IPJ.  This incision is then deepened to the level of the joint capsule.  This is a layer of ligamentous tissue that is thick and covers the entire joint.  The capsule is incised to expose the joint (it will be repaired later).  At this time, the arthritic changes and exostosis (extra bone) are removed .  If a fusion is being performed the surface is flattened out and the edges of the two bones are fit and confirmed to align well and prepared for the fusion and fixation.

The site is then fixated with a compressive screw or staple.  The tissues are repaired and the skin is closed.

If during the pre operative consultation the patient has voiced a concern with fusion and would like to attempt joint replacement a synthetic Total Joint Replacement will be placed in between the two bones of the great toe.  This implant will replace the joint surfaces that have been destroyed beyond repair by the arthritic nature of the problem.

Possible Complications Related to Great Toe Fusion/Joint Replacement

Implant Complications
The screws, implants, or other fixation devices used in the surgery may cause discomfort, become loose, or break sometimes requiring removal.    This can also cause dislocation of the osteotomy or fusion site, which can require revision surgery.  There may also be premature breaking or wear of the Joint Replacement Implant. Prudent care of the surgical region during recovery will ensure that dislocation does not happen.  Continued awareness of your new joint will ensure you do not break it.  All synthetic materials wear with time, and although the percentage is low, it may be necessary to consider replacement of the implant in 10-15 years if there is evidence of wear, or sustained damage or dislocation.

Stiffness of Joint
There are instances that the joint can become stiff after surgery.  This can be due to a variety of reasons and usually manageable with physical therapy, and conservative treatment.  If the region remains stiff after treatment, surgical treatment could be an option.  It is also important to acknowledge and understand that great toe joint replacement surgery has a potential for failure in developing the expected range of motion.