pain and swelling after fusion of big toe joint

On Sept 9th 2014 I had toe fusion on my R big toe. I am a 51 year old male that walks about 10 miles a day at work. The doctor stated I would be out of work for 3 months. It has now been 6 months and the toe is still very sore and swells up a lot after it has been used (walked on). Even hurts at night time if sheet lays on it. The doc say I am cleared for work and that it is fine. Obviously it is not. Work won't let me return due to icing restrictions she has indicated. She has not commented on the swelling, just says I can return to work. The doctor has done several x-rays and states it looks good. Why does it swell up and hurt as bad as it did before surgery. Actually swells up more after the surgery. I have already been on medicine for an infection. Used an "ice" machine and bone stimulator.

Any ideas would be appreciated.
Thank You
Larry

RESPONSE

Hi Larry,

What I am about to say, I am not saying for convenience sake, as I have said it numerous times on this site. I do not particularly like fusions of the big toe joint.

There are plenty of surgeons who perform them and many swear by them.

Keep in mind the comments I am about to make are based on the fact that I have never examined you, never seen your x-rays, no nothing about your medical history and would not know you if I fell over you.

But, what I do know is that you are someone who walks about ten miles a day at work. That should have raised a red flag. When this type of procedure is performed, the joint is being fused, generally because it is worn out from arthritis or perhaps a serious trauma and in the surgeon's mind fusing the joint is the only option. This means there will never be motion in the joint again. The problem is, in order to walk, particularly ten miles a day, you need to be able to transfer body weight from your first metatarsal bone to the big toe so that you can "push off" in your gait in order to keep moving forward.

When the joint is fused, the two bones have to be lined up in a certain manner that will essentially let you "roll" from the first metatarsal to the big toe. What this means is that the big toe has to be fused, not in a direct straight line, but with the big toe slightly angulated upwards from the first metatarsal, so that you can accomplish that "roll".

The only way to know if the toe was fused in the proper angle would be too look at a lateral view (side view) of an x-ray. A less accurate way would be for you to stand flat on the ground. If the big toe is lifted up somewhat from the floor then the angle might be fine; if however, the toe is flat on the floor that might be a good part of the problem.

Knowing that you have to walk ten miles a day, I would assume your surgeon would have weighed the various surgical options which would have included an implant or just plain remodeling of the joint, to essentially remove bone spurs that were limiting your motion and creating pain.

So, obviously, I do not know how the decision to fuse the joint was made. You are right, by six months you should at the very least be well on your way to healing, maybe not 100 percent, but you should be functioning with "some" discomfort, not a lot of discomfort, and obviously you are not.

What are your options? I am always a little skeptical of surgeons who tell the patient that everything looks fine, so if you are still having pain, it must be your fault. Look, I have operated on patients, who have not responded in a time line I would have expected; I do not dismiss them, I try and work with them to get them back to normal.

For those reasons, it sounds to me that perhaps your surgeon just wants you out of the office or even worse, has no idea on a "plan B". Please keep in mind, I am just guessing here as I know nothing about your relationship with your surgeon.

The best advice I could possibly give you is to get a second opinion by another surgeon in your area, as a second set of independent eyes on your problem could be very helpful.

From a surgical stand point, you are greatly limited in your options since the cartilage from both the head of the first metatarsal bone and the base of the toe bone has been removed. I would think the only option would be a total implant for the joint encompassing both bones, but I am on the other side of the internet, so I do not know for sure.

From a conservative standpoint an orthotic with a built in Morton's extension or other modification, might be helpful as it would better distribute your body weight and perhaps allow you to walk a little better.

At six months down the road, I am not sure if any physical therapy would be of much value, but you could consider it.

Lastly, there is always the possibility that you do not have a complete fusion, or perhaps even a small fracture in one of the bones. If you have not had an MRI, that might be an option as it would give you a better picture of what is going in your foot and might pick up some pathology that is causing your ongoing pain.

Marc Mitnick DPM
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