What are the pros and cons of joint fusion versus joint replacement for the big toe? I have had bunion surgery that didn't work. Now I'm faced with one of these two choices as the next surgery.
Standard of care for a painful big toe is conservative care first. Medications (e.g., pain relievers, antiinflammatories), physical therapy, and orthotics (special shoe inserts) are the main stays of nonoperative care. Even after a failed surgery, conservative care is advised. Once you have reached the maximum benefit from conservative care, then additional surgery is often the next step. Arthrodesis (joint fusion) or osteotomy are the most common choices offered. Fusion is accomplished with pins, screws, wires, and/or metal plates. The advantage is a stable joint that stops hurting. The disadvantage is an immobile joint that doesn't move. You will be unable to push off with the big toe when you take a step. The foot and ankle will make the necessary changes but it will affect the biomechanics of the entire chain from foot up the leg. Still, the results are fairly positive with 90 per cent of patients expressing satisfaction with the results. Osteotomy is a procedure to realign the toe. The surgeon removes a wedge-shaped piece of bone from the toe and straightens the remaining bones in a midline position. This might have been the surgery you already had. Joint replacement for the big toe (metatarsophalangeal joint) is still fairly "new". The idea has been around for 50 years but finding an implant that works well is still a challenge. Surgeons along with the help of companies that make the implants are working to find a design that will last with few if any problems. Results of the current total toe arthroplasty (another term for big toe joint replacement) in use compared with arthrodesis don't favor the arthroplasty just yet as a long-term solution for joint degeneration of the big toe. Some patients do report decreased pain. But the overall satisfaction rate is only around 77 per cent after five years. That doesn't begin to compare with the 90 per cent rating for arthrodesis. Nor does it measure up to 98 per cent rating for other joint replacements like for the hip or knee. For patients willing to try this approach, the implant can always be removed and the toe fused if it doesn't work out. But there is usually bone loss with this type of revision surgery, so it isn't done routinely. Be sure and go over the pros and cons with your surgeon to make certain you understand all the advantages and disadvantages of both procedures. Your decision should take into consideration your age, activity level, weight, and any other health problems that can affect healing and recovery.