First MTP Joint Interposition Arthroplasty

The first MTP, also called the first metatarsophalangeal joint, is the big toe joint. A first MTP joint interposition arthroplasty is a surgical procedure to treat arthritis of the big toe. The treatment can stop pain at the base of the big toe by preventing the surfaces of the bones from rubbing together. It also can preserve some motion in the big toe.

Symptoms

The main symptoms of arthritis are pain and loss of motion at the joint between the big toe and the foot. Your foot and ankle orthopedic surgeon will examine you and take X-rays to determine the extent of your arthritis. If it is severe, this procedure may be an option.

Patients with infection or blood vessel disease should not be considered for this surgery. Young age and poor skin around the joint or large deformities are sometimes barriers to surgery. Diabetics should consult their doctor before this surgery.

Treatment

An incision is made over the first MTP joint and carried down to the joint. The joint surfaces along with a small amount of bone are removed.

A newer technique uses a synthetic cartilage implant plug made out of polyvinyl alcohol as a spacer, without covering the surface area of the joint. This procedure requires less bone removal and is easier to convert to fusion if it fails. It also has shown to be as effective as fusion in relieving pain, while preserving motion of the joint. This is a newer procedure; however, current studies have demonstrated good results that appear likely to hold up over time. Many foot and ankle orthopedic surgeons find this procedure helpful but at present it is not universally accepted.

Recovery

After surgery, a gauze dressing and a wrap such as elastic bandages are placed over the toe and foot. The joint should be immobilized followed by early motion to prevent stiffness. Physical therapy may be used to improve motion and strength. Patients should keep their foot elevated as much as possible to reduce swelling. There may be a brief period of time where you should not weight bear but in general you will get back to limited walking within a few weeks of your surgery. Stitches generally are removed after 10 to 15 days, depending on the condition of the skin. Patients are encouraged to wear a hard-soled shoe.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

One of the most frequent complications of first MTP joint interposition arthroplasty is failure to relieve pain or preserve motion. Another complication is rejection of the tissue placed in the gap, which may require further surgery. Other complications can include pain at the base of the second toe, delayed wound healing, recurrent deformity, bony overgrowth, disintegration of bone around the graft, implant displacement, instability of the joint and injury to the nerves of the big toe.

FAQs

When can I return to work?

It depends on the physical requirements of your work and your individual pain tolerance. When you can tolerate pain without pain medication and you can walk without assistive devices you can return to a sedentary occupation (desk work, etc.). For more physically strenuous occupations, it could take as much as 12 weeks to safely return to work. You and your orthopedic foot and ankle surgeon can decide when it is right for you to return to work.

Can I play sports after first MTP joint interposition arthroplasty?

Strenuous physical activity such as running, jumping and rock climbing is thought to lead to early failure of the procedure. Light activity, such as walking and cycling, can be performed after the initial healing without significant risk of early failure. Again, this is a matter to be discussed with your orthopedic foot and ankle surgeon.

Will first MTP joint interposition arthroplasty improve my range of motion?

It is unlikely that you will regain more motion than you had prior to surgery.

First Metatarsophalangeal Joint

The first MTP, also called the first metatarsophalangeal joint, is the big toe joint. A first MTP joint fusion is a surgical procedure to treat arthritis of the big toe. This condition can cause pain and swelling and lead to difficulty walking, running, and wearing shoes. Arthritis develops when the cartilage on each bone wears away and the two bones that make up the big toe joint rub against one another.

In a first MTP joint fusion, the bones are joined (fused) together permanently so they cannot rub against each other and cause pain.

Diagnosis

The need for surgery depends on how bad the arthritis is and how much pain you are experiencing. Surgery is recommended for those with pain and stiffness in the big toe joint. Some patients are unable to wear certain shoes (dress shoes, high heels and boots) and can’t participate in activities due to pain. If the condition exists in both feet, the more painful foot is operated on first.

A foot and ankle orthopedic surgeon can determine the severity of the condition. Before deciding on surgery, patients should try non-surgical treatment such as changes in activity and footwear or steroid injections. Patients also can try wearing a shoe with a rounded bottom or using carbon shoe inserts that limit joint motion.

You should avoid surgery if you have an active infection or severe narrowing of the arteries. You must be able to manage a recovery period that can last six months or more.

Treatment

In this procedure, the damaged cartilage is removed and the two bones are fixed 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.

Specific Technique

An incision is made on top of the big toe. Any cartilage is cleared away to allow the two bones to heal together. Your foot and ankle orthopedic 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. In some cases, two screws can be placed across the joint without using a plate. After the hardware is placed, the incision is closed with sutures and the foot is placed in a dressing or splint.

Recovery

After surgery, you will likely be examined at two weeks, six weeks, three months and six months intervals. X-rays may be taken at each visit to evaluate the bone healing and the position of the big toe. Weight bearing status will be determined by your surgeon. After a first MTP fusion, you should not wear shoes that put extra stress on the joint.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Common 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.

FAQs

If I have a first MTP fusion, will I have a limp when I walk?

Most people with a first MTP fusion do not have a limp after it is fully healed.

First MTP Cheilectomy

The first MTP, also called the first metatarsophalangeal joint, is the big toe joint. A first MTP cheilectomy is a surgical procedure that removes bone spurs on the top surface of the big toe joint. Bones spurs develop due to arthritis of the big toe, also known as hallux rigidus. The spurs block the toe’s motion, which causes pain. A first STMP cheilectomy relieves pain and improves range of motion in the big toe.

Symptoms

Pain with limited motion of the big toe or pain with direct pressure from shoes could be signs that surgery is needed. However, patients should first try non-surgical treatments, such as wearing a stiff shoe or a rigid insert, and/or taking anti-inflammatory medications. Surgery is indicated when these efforts fail to provide good pain relief. If you do not have relief of symptoms, a cheilectomy may be right for you.

Treatment

Your foot and ankle orthopedic surgeon will remove the spurs on the top of the metatarsal and phalanx bones and clean out the joint. Any free-floating debris in the joint is removed. This may allow the joint to have more range of motion and should decrease pain with walking and standing. No metal, implants or other hardware are put in the foot.

Specific Technique

An incision is made over the top of the first MTP joint. Care is taken to avoid the tendon that extends the big toe. Any bone spurs are removed. If there is inflamed joint tissue or debris, these are removed as well. The cartilage on the joint surfaces is inspected. Approximately 30 percent of the top portions of the head of the metatarsal bone and corresponding bone spurs are removed.

Recovery

After the surgery, your foot is put in a soft dressing. Your doctor will encourage you to keep your foot elevated for a few days to minimize swelling. You normally can bear full weight on the foot immediately after surgery in a post-op shoe or walking boot. The sutures will be removed once the incision has healed. Your doctor may have you perform range of motion exercises on the toe. As the swelling goes down, you will be able to transition back into a regular shoe, usually two to four weeks after the procedure.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. With a cheilectomy, there is a risk of numbness along the big toe, a painful scar or an incision that does not heal properly. Arthritis is a progressive problem, and you may have continued pain after the surgery. While most patients do well with a cheilectomy for more than 10 years, some may need additional surgery, such as a fusion. This can occur in 20 to 30 percent of patients with big toe arthritis.

Tailor’s Bunion

A bunionette (also known as a tailor’s bunion) is a painful bony prominence, or bump, on the outside of the fifth (pinky) toe. Over time, the bunionette may worsen as the fifth toe moves inward and the fifth metatarsal (the bone connected to it) moves outward. Rubbing between the bump and tight shoes may also cause a callus to grow over the fifth toe area. All bunionettes can cause pain and pressure on the outside of the foot, though often they do not cause symptoms.

An osteotomy is a surgically performed cut of the bone. A fifth metatarsal osteotomy refers to a cut in the head, neck, or shaft of the bone to make it straighter and the bony prominence smaller. This reduces rubbing on the outer side of the foot and decreases or eliminates the pain.

Symptoms

Your foot and ankle orthopedic surgeon may recommend surgery if your bunionette (bump) is painful, does not improve with non-surgical treatment, and prevents you from wearing comfortable shoes. Non-surgical treatment options include wearing wider shoes, shaving the callus on the outer side of the fifth metatarsal, padding the area, removing pressure from the bump by using a donut pad, or using a pre-made or custom orthotic device.

Surgery should never be chosen before non-surgical measures have been tried. Surgery should be avoided if you have an infection at the fifth toe or around the surgical site, or if your toe has poor circulation. Poor circulation can be caused by smoking and diabetes and can lead to problems with wound healing after surgery. A fifth metatarsal osteotomy is not needed if the bone is well-aligned. Surgery should not be considered for ease of shoe wear if you are not having pain.

Treatment

This is an outpatient procedure, meaning the patient can go home the same day as surgery. The bump in the bone is cut down and the fifth metatarsal is cut, repositioned, and fixed in position to corrects its deformity and decrease pain.

Specific Technique

The location where the bone is cut varies depending on the shape of the bone. This procedure often is done along with shaving the outer side of the bump itself. The far end of the bone is then shifted inward, and held in place using sutures, wires, screws, or screws and a plate.

Recovery

The recovery will depend on the specific surgical technique used. After surgery, the patient may not be allowed to bear weight for up to six weeks, which will require the use of crutches or a knee walker. For the first two weeks after surgery, a splint with a bandage is worn, and the foot cannot get wet. For several weeks after surgery, the patient may have to elevate his or her foot above chest level to decrease swelling. Swelling may last for several months after surgery.

After a couple of weeks, the stitches are removed. In the following few weeks, the patient wears a boot to protect the foot. After another few weeks, the patient progresses to weight bearing and possibly physical therapy. The boot may be removed several weeks after surgery.

Sometimes, a bunionette is fixed as the same time as a bunion (a bump at the big toe). In that case, the recovery is determined by the procedure on the bunion.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications that may occur from a fifth metatarsal osteotomy include the bone taking a long time to heal or not healing at all. It is uncommon for the bunionette to come back.

Chevron Osteotomy

A Chevron osteotomy is a common surgery to treat a bunion. A bunion (also known as hallux valgus) is a misalignment of the knuckle of the big toe. This misalignment causes the big toe to turn toward the smaller toes. It often creates a bump at the base of the big toe. Bunions are not always painful, but this deformity generally will increase over time.

In a chevron osteotomy, the foot and ankle orthopedic surgeon cuts the end of the long bone leading to the big toe (metatarsal) and rotates the end of the bone to straighten the big toe. This procedure may be performed in conjunction with soft tissue adjustments around the joint. This osteotomy is mostly performed for mild to moderate bunion deformity. This bunion correction surgery relieves pain by restoring normal straightness to the first toe joint.

Diagnosis

Bunion surgery may be needed if your bunion has a painful bump or skin irritation over the bump. You may have already tried non-surgical treatments such as splints, toe spacers, and wider shoes without pain relief. While bunion surgery may improve the cosmetic appearance of the foot by making the toes straighter, it should never be performed primarily for this reason.

Bunion surgery also should not be performed if the bunions are painless and do not cause problems. You should avoid surgery if you have an active infection, poor blood flow, or uncontrolled diabetes. If you have a severe deformity or extensive arthritis in the affected joint, a Chevron osteotomy may not be the correct procedure for you.

Treatment

A Chevron osteotomy is performed as an outpatient procedure, meaning patients generally go home a few hours after surgery. The first toe joint is straightened and the painful bump at the base of the big toe is filed down. This generally relieves the pain associated with the bunion and gives the foot a more normal appearance.

Specific Techniques

An incision is made on the inside of the foot over the joint of the big toe. The inflamed fluid sac between the skin and bone is removed. The end of the first metatarsal is cut in a V-shape and the head is moved toward the second toe. In some cases, the orthopedic surgeon may use removable wires or permanent screws to hold the end of the bone in its new place. The bony prominence on the inside of the foot is shaved to remove the painful bump. An additional procedure to tighten the soft tissue on the inside of the toe is performed with the osteotomy. Sometimes another procedure will be done to loosen the soft tissue on the outside of the joint. Orthopedic surgeons often use an X-ray machine in the operating room to verify that the toe is correctly aligned.

Recovery

A dressing will be applied by your surgeon in the operating room, and you will be given a special shoe or boot. You will have to avoid putting weight on the foot or only put weight on the heel for a period of time determined by your surgeon. The dressings are applied to hold the big toe in the straight position, so you should not change the dressings unless told to by your surgeon. Also, the dressings cannot get wet.

You will elevate your foot to chest level for the first few weeks after surgery. You may need to use crutches or a walker the first few days after this surgery, which help to reduce complications as well as pain and swelling. Your doctor may ask you to do range-of-motion exercises (bending the knee, hip, or ankle) to maintain flexibility and to avoid stiffness.

Stitches usually are removed two weeks after surgery. Your surgeon will discuss whether physical therapy is needed.

Prolonged swelling and challenges with reasonable shoes are very common following foot surgery and may last several months. Compression stockings and physical therapy can be helpful in reducing the swelling.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Potential complications with Chevron osteotomy include the bone failing to heal or disruption of the blood supply to the cut bone. Surgically corrected bunions have the potential for recurrence, even when the procedure was performed correctly. Patients can help prevent this by following their doctor’s post-operative instructions.

FAQs

Is it better to have my bunion fixed now, or should I wait?

When the pain of a bunion interferes with daily activities or shoe modification options don’t help you, it’s time to discuss surgical options with your foot and ankle orthopedic surgeon. Together you can decide if surgery is best for you. How long will I have to be off of my foot? For a brief period of time after surgery, you should not put weight on the foot. In some cases, your surgeon may allow you to walk on your heel only.

What do I do if my bunion comes back?

No matter how well your surgery may have gone, there is always the chance that your bunion may recur. Often the new bunion is not painful and surgery is not needed. However, if your bunion comes back with pain, then you should talk to your foot and ankle orthopedic surgeon about revision surgery.