1ST MTP (Big toe) Fusion surgery

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Expert Patient Guide · Foot & Ankle Surgeon · London & North London

First MTP Fusion (Big-Toe Joint Fusion)

A patient guide to big-toe joint fusion surgery (first MTP fusion) for hallux rigidus — by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, Royal National Orthopaedic Hospital (RNOH), Stanmore, London and North London.

First MTPJ fusion — also known as first metatarsophalangeal joint (MTPJ) fusion, big-toe joint fusion or first MTPJ arthrodesis — is one of the most reliable operations in foot and ankle surgery. It is performed for severe arthritis of the big-toe joint (hallux rigidus), advanced bunion deformity, and a range of other forefoot conditions where the joint can no longer be preserved.

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore, and Honorary Associate Clinical Professor at UCL. As one of the top foot and ankle surgeons in London and North London, he treats patients with specialist expertise in total ankle replacement, complex hindfoot and forefoot reconstruction, sports injuries, and Achilles tendon problems including Achilles tear and Achilles rupture. This guide explains what first MTPJ fusion involves, how to prepare, what recovery looks like, and the risks involved.

At a glance

AT A GLANCE

First MTPJ Fusion (Big-Toe Joint Fusion)
Procedure	Arthrodesis (fusion) of the first metatarsophalangeal joint
Main indication	Severe hallux rigidus (big-toe arthritis), failed bunion surgery, severe deformity
Anaesthetic	General or spinal, usually with ankle block for pain relief
Hospital stay	Day case or one overnight
Dressing & footwear	Wool and crepe dressing, flat-soled post-operative sandal
Elevation	Strict elevation for the first 2 weeks
Follow-up	2 weeks — wound check; 6 weeks — X-ray;
Return to desk work	2–4 weeks
Return to sport	3–6 months (low impact earlier)
Success rate	Union typically achieved in around 90–95% of patients

Section 1

1. Why have the surgery? (What are the benefits)

The big-toe joint takes around 40–60% of the load passing through the forefoot every step you take. When this joint becomes severely arthritic, painful or stiff, walking, standing and sport all become difficult. Conservative treatments — supportive shoes, stiff insoles, activity modification, anti-inflammatories and steroid injections — are tried first. When these no longer control symptoms, surgery becomes the next sensible step.

First MTPJ fusion is considered the gold-standard operation for severe big-toe arthritis. By permanently joining the two bones of the joint, the painful arthritic surfaces are eliminated. The aim is a stable, strong, pain-free big toe that allows you to return to a normal active life.

Key benefits

Reliable, long-lasting pain relief — typically the single most predictable outcome of any forefoot operation.
A strong, stable big toe that supports the forefoot properly when you walk, climb stairs and exercise.
Correction of deformity, including severe bunions and toes that have drifted out of line.
Improved ability to walk longer distances and stand for longer without pain.
Return to most sports, including hiking, cycling, gym work, golf and many racquet sports.
A durable result — once the bones have fused, the result generally lasts a lifetime, unlike joint replacements which can wear out.
Wider shoe choice for many patients, including normal everyday footwear after recovery.

Who is a good candidate?

Patients with painful end-stage hallux rigidus, severe or recurrent bunions, rheumatoid forefoot disease, or failed previous big-toe surgery are typically excellent candidates. Mr Welck will discuss whether fusion, joint preservation or another option is best suited to your particular foot, your activity level and your goals.

Section 2

2. Preparing for the surgery

Good preparation makes the recovery from first MTPJ fusion much smoother. The operation is normally performed as a day case, so a small amount of planning at home goes a long way.

In the weeks before surgery

Optimise your general health. If you smoke, stopping at least 6 weeks before surgery significantly improves bone healing — nicotine is one of the strongest risk factors for non-union (failure of the bones to fuse).
Keep active and maintain a healthy weight if possible. The fitter you are, the easier recovery tends to be.
If you take blood thinners (such as warfarin, rivaroxaban, apixaban or clopidogrel) or insulin, our team will advise on adjustments in advance.
Arrange someone to drive you home and ideally stay with you for the first 24 hours.
Plan a comfortable downstairs base if your home has many stairs, with everything you need (phone, charger, water, books, remote) within easy reach.

Useful equipment to purchase

A small amount of kit makes the first two weeks much easier and protects your wound and metalwork:

A foam leg-elevation cushion. Elevating your foot above the level of your heart for the first 10–14 days is the single most effective thing you can do to reduce swelling, pain and wound complications. A purpose-made foam wedge is far more comfortable and effective than stacked pillows.
A waterproof cast and dressing protector, such as a “Limbo” cover. This slips over your dressing or boot and allows you to shower normally without soaking the wound — essential for the first 2 weeks while the wound heals.
A post-operative stiff-soled shoe or walking boot — this is normally provided by the hospital, but check at your pre-assessment.
Crutches or a walking frame, again usually provided. A small backpack is helpful for carrying items while on crutches.
Loose, comfortable trousers or shorts that fit easily over the dressing.

Two helpful resources from the Stanmore Foot & Ankle Service explain how to prepare practically and which products are most useful:

Download our patient leaflet on preparing for foot surgery: Preparing for Foot Surgery (PDF)
Download our product guide for recommended recovery equipment: SFAS Product Guide (PDF)

Section 3

3. What does the surgery involve?

The aim of first MTPJ fusion is to remove the worn-out, painful joint surfaces of the big-toe joint and to join the two bones — the end of the long foot bone (the first metatarsal) and the base of the big-toe bone (the proximal phalanx) — so that they grow together into one solid, pain-free unit.

The operation is normally performed under a general or spinal anaesthetic, usually combined with an ankle block injection that keeps the foot numb for many hours afterwards and dramatically reduces post-operative pain.

Step by step, in simple terms

A single incision (around 5–7 cm) is made over the top of the big-toe joint.
The damaged cartilage is carefully cleared away from both sides of the joint, leaving healthy bone behind.
The big toe is then placed into the ideal position — slightly raised off the ground, with a small amount of outward angle — so it sits naturally in a normal shoe.
The bones are held together using a small low-profile metal plate and screws, or crossed screws, depending on what fits your foot best.
The wound is closed with dissolvable stitches under the skin and a layer of sticky strips, then dressed and bandaged.

Over the following weeks, your own bone grows across the join, and the two bones gradually become one. This is what gives the long-lasting pain relief. The metalwork stays in place permanently and almost always causes no problems — it is only removed in the small number of patients who feel it through the skin.

The operation typically takes around 45–75 minutes.

Section 4

4. How long will you be in hospital?

First MTPJ fusion is most often performed as a day-case procedure, meaning you arrive in the morning, have your surgery, and go home the same day once you are comfortable, eating and drinking, and have been seen by the physiotherapy team.

Some patients prefer to stay one night — for example if they live alone, live a long way from the hospital, or have other medical conditions. This is easily arranged in advance.

Before you leave, you will have:

Been fitted with a wool and crepe dressing and a flat-soled post-operative sandal.
Been advised on safe mobilisation, with the emphasis on strict elevation of the foot for the first 2 weeks.
Received a supply of pain-relief medication and, where appropriate, blood-thinning injections or tablets to reduce the risk of clots.
Been given written instructions on wound care, elevation and what to do if you have any concerns.
A follow-up appointment booked in clinic at around 2 weeks for a wound check and removal of sutures if needed.

Section 5

5. What does the recovery look like?

Recovery from first MTPJ fusion is staged and predictable. Following the protocol carefully is the single biggest factor in achieving a strong, solid fusion. The post-operative protocol below is what Mr Welck recommends for most patients undergoing first MTPJ fusion; your individual plan may be adjusted depending on bone quality, any additional procedures and your general health.

Early recovery (Weeks 0–2)

You go home in a wool and crepe dressing with a flat-soled post-operative sandal.
Strict elevation of the foot above heart level for the first 2 weeks — this is the single most important thing you can do to reduce swelling, pain and wound problems. Use a foam leg-elevation cushion as much as possible during the day, and elevate the foot on pillows overnight.
You will be able to mobilise short distances around the house in the flat-soled sandal, but movement should be kept to a minimum during the first 2 weeks. Keep the dressing clean and dry — a waterproof cover (e.g. Limbo) allows you to shower.
Pain is normally well controlled with simple oral analgesia after the first 48 hours.
At around 2 weeks you will be seen in clinic for a wound check, removal of sutures if needed, and a clinical review.

Mid-term recovery (Weeks 2–6)

Continue to mobilise in the flat-soled post-operative sandal. Activity can be gradually increased, but the foot should still be elevated for much of the day.
Swelling steadily improves, although mild swelling at the end of the day is normal for several months.
Most desk-based patients return to work between 2 and 4 weeks, working from home where possible. Driving an automatic car (if surgery was on the left foot) may be possible from 2 weeks; right-foot surgery normally requires 6 weeks off driving.
At 6 weeks an X-ray is taken to confirm the bones are healing. You remain in the post-operative shoe until X-rays show radiographic union, after which you transition into a supportive shoe or trainer.

Long-term recovery (6 weeks onwards)

Once radiographic union is confirmed, you transition out of the post-operative sandal into a stiff, supportive trainer or walking shoe.
Physiotherapy is started if needed — to mobilise the smaller toe joints, address gait and rebuild calf strength.
Low-impact exercise (stationary bike, swimming, cross-trainer) can usually be restarted from around 8–10 weeks.
At 16 weeks you are reviewed in clinic with a weight-bearing CT scan to confirm the fusion is fully solid. If all is well, you are discharged at this point.
Higher-impact sports — running, racquet sports, hiking, golf, gym work — are typically resumed between 3 and 6 months, once the imaging shows complete bony union and there is no tenderness around the fusion site. Approximately 75% of patients feel able to return to this.
Swelling continues to improve gradually for up to 12 months, and the final long-term result is reached by around 9–12 months.

It is important to understand that a fused big toe will no longer bend up and down — this is the trade-off that delivers the reliable pain relief. The smaller joint towards the tip of the toe still moves, and the great majority of patients find that everyday walking, sport and shoe wear feel natural and comfortable once recovery is complete.

Section 6

6. What are the risks?

First MTPJ fusion is one of the most reliable operations in foot and ankle surgery, but as with any surgery there are risks. The most important procedure-specific risks are explained below.

Main procedure-specific risks

Non-union — the bones fail to fully join. This happens in approximately 5–10% of patients and is more common in smokers, diabetics and those on certain medications. If the non-union is symptomatic, revision surgery with bone graft may be needed.
Malunion — the toe heals in a slightly imperfect position. Most patients tolerate this well; occasionally revision is needed if the position interferes with shoe wear.
Metalwork irritation — the plate or screws can occasionally be felt under the skin. A small proportion of patients (around 5–10%) request removal once the fusion is fully healed, normally at 12 months or beyond.
Stiffness of the small joint at the tip of the toe (the interphalangeal joint), which can occasionally become symptomatic later in life as it carries more load.
Altered sensation along the inside of the big toe, due to stretching of a small skin nerve. This usually settles but can occasionally be permanent.
Difficulty with very high heels or extremely flexible shoes — most patients adapt easily, but heels over around 4 cm are rarely comfortable.

There is also a small set of general risks common to all foot surgery — including infection, bleeding, swelling, blood clots (DVT and PE), wound healing problems, complex regional pain syndrome, and risks of anaesthesia. These are explained in detail in our dedicated risk leaflets:

Please read these in conjunction with this leaflet before signing your consent form. Mr Welck will discuss the risks that are most relevant to your individual case in clinic.

Section 7

7. Frequently asked questions

How successful is a first MTPJ fusion?

First MTPJ fusion has one of the highest success rates of any foot operation. Around 90–95% of patients achieve a solid bony fusion and report excellent or good pain relief and a return to normal activity. The result is durable — once fused, the joint should not deteriorate again.

Will I be able to walk normally after a fused big toe?

Yes. The vast majority of patients walk completely normally after recovery. The big toe is positioned to roll naturally as you step, so there is no limp and no obvious change in gait.

Will I be able to play sport again?

Yes. Cycling, swimming, gym work, hiking, golf, skiing and most racquet sports are all well-tolerated after first MTPJ fusion. Running is possible for many patients, although some find a stiff-soled trainer most comfortable. As a foot and ankle surgeon who treats many sports injuries in London and North London, Mr Welck routinely returns active patients to their chosen sports following this operation.

What shoes can I wear afterwards?

Most everyday shoes — including trainers, brogues, ankle boots, work shoes and most flat fashion shoes — are comfortable after recovery. Very high heels (above around 4 cm) and extremely flexible shoes such as flip-flops are less suitable. Many patients find their shoe choice actually widens after surgery, because the painful arthritic joint no longer dictates which shoes are tolerable.

How long will I need off work?

Office and desk-based workers typically return to work between 2 and 4 weeks, often working from home initially. Patients with jobs involving prolonged standing or walking usually need 6–10 weeks. Heavy manual workers may need 3 months.

Will the metalwork need to be removed?

Usually not. The plate and screws are designed to stay in place permanently and are made from low-profile titanium that is extremely well tolerated. Around 5–10% of patients elect to have the metalwork removed later if they can feel it through the skin, which is a small, straightforward day-case procedure performed only once the fusion is solid (typically beyond 12 months).

Could I have a joint replacement instead?

First MTPJ joint replacements (such as cartilage-substitute implants) are an alternative in selected patients, particularly those with lower demands. However, fusion remains the most reliable, longest-lasting option, especially for active patients, those with severe deformity or those who have had failed previous surgery. Mr Welck will discuss the pros and cons of every option that applies to your individual foot.

How do I book an appointment with Mr Welck?

Mr Matthew Welck consults privately across London and North London, and works at the Royal National Orthopaedic Hospital (RNOH) in Stanmore. To arrange a consultation, visit matthewwelck.com or contact his practice team for the next available appointment.

About Mr Welck

About Mr Matthew Welck

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore, and Honorary Associate Clinical Professor at UCL. He is widely regarded as one of the leading foot and ankle surgeons in London and North London, with specialist clinical interests in total ankle replacement, complex hindfoot reconstruction, flatfoot correction, forefoot surgery and the treatment of sports injuries. He has published over 50 peer-reviewed papers, received the European Foot & Ankle Society Best Scientific Paper Prize and the David Marsh Orthopaedic Research Prize, and completed double fellowship training including at the Foot and Ankle Institute in Baltimore, USA.

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