First MTP joint arthrodesis is a surgical procedure that fuses the first metatarsal head to the proximal phalanx of the great toe. First introduced by Clutton in 1894 as a treatment for severe hallux valgus, the technique has evolved into the gold standard for managing end-stage arthritis (hallux rigidus), severe deformities, and post-traumatic or rheumatoid joint destruction. The procedure reliably relieves pain, restores alignment, and improves function for patients with advanced forefoot pathology.
How Common It Is and Who Gets It? (Epidemiology)
First MTP arthrodesis is most commonly performed in middle-aged to elderly adults, particularly women, who experience degenerative arthritis, severe bunion deformities, or rheumatoid arthritis. It is also a preferred salvage operation for patients with failed previous forefoot surgeries such as joint replacements or osteotomies. The procedure is performed worldwide, with high patient satisfaction and consistently favorable outcomes.
Why It Happens – Causes (Etiology and Pathophysiology)
The need for first MTP arthrodesis typically arises from end-stage joint degeneration or deformity. Common causes include:
- Hallux rigidus: Advanced osteoarthritis with cartilage loss and painful stiffness.
- Hallux valgus: Severe bunion deformity, often accompanied by instability or arthritis.
- Rheumatoid arthritis: Progressive synovial inflammation causing deformity and collapse of the joint.
- Post-traumatic arthritis: Degeneration following previous fractures or dislocations.
- Failed prior surgery: Including unsuccessful joint-preserving procedures or implants.
The joint loses its smooth cartilage surfaces, resulting in pain, stiffness, and deformity that interfere with normal gait and shoe wear.
How the Body Part Normally Works? (Relevant Anatomy)
The first MTP joint connects the first metatarsal bone and the proximal phalanx of the great toe. It allows dorsiflexion (upward motion) and plantarflexion (downward motion) critical for push-off during walking. Stability is provided by the joint capsule, plantar plate, and surrounding tendons. When arthritis or deformity disrupts this alignment, pain and mechanical imbalance develop, often forcing the patient to walk abnormally.
What You Might Feel – Symptoms (Clinical Presentation)
Typical symptoms include:
- Persistent pain in the big toe joint.
- Swelling and stiffness, limiting movement.
- Difficulty wearing shoes or walking long distances.
- Deformity of the toe (valgus or rigid position).
- Pain under the lesser metatarsals due to transfer of weight (metatarsalgia).
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a thorough clinical examination and review of imaging studies.
- Physical Exam: Reveals reduced joint motion, tenderness, swelling, and deformity.
- X-rays: Show loss of joint space, bone spurs, and cystic changes.
- CT or MRI: Occasionally used to evaluate joint integrity or prior surgical hardware.
The diagnosis is clinical in most cases, confirmed by radiographic evidence of joint degeneration or deformity.
Classification
Commonly classified by pathology or underlying diagnosis:
- Primary (degenerative) arthritis.
- Post-traumatic arthritis.
- Rheumatoid arthritis-related destruction.
- Severe deformity (hallux valgus, hallux varus, or failed prior surgery).
Other Problems That Can Feel Similar (Differential Diagnosis)
- Sesamoiditis or sesamoid fractures.
- Gout or crystal arthropathy.
- Plantar plate tears.
- First tarsometatarsal joint arthritis.
- Morton’s neuroma.
Treatment Options
Non-Surgical Care
Before surgery, conservative management aims to relieve symptoms and preserve motion:
- Orthotics: Custom insoles with stiff soles or rocker-bottom shoes.
- Activity modification: Avoiding high-impact activities.
- NSAIDs: For pain and inflammation.
- Corticosteroid injections: Temporary relief in mild to moderate arthritis.
When pain persists despite these measures, arthrodesis (fusion) becomes the definitive treatment.
Surgical Care
The goal is to eliminate pain by permanently fusing the joint in proper alignment.
Surgical Steps:
- Incision and Exposure: A dorsal incision over the first MTP joint.
- Joint Preparation: Removal of residual cartilage. The cup-and-cone technique is the gold standard—concentric reaming creates complementary surfaces for stable fusion while preserving bone stock.
- Fixation: Several constructs are used to secure the fusion:
- Crossed screws (traditional technique).
- Dorsal locking plates for added rigidity and early weight-bearing.
- Hybrid fixation (plate + compression screw or memory staple) for continuous compression and enhanced stability.
- Alignment: The toe is positioned with 10–15° dorsiflexion and 5–10° valgus relative to the floor for optimal function and footwear compatibility.
- Closure and Immobilization: The incision is closed, and a postoperative boot or cast is applied.
Postoperative Care and Recovery
- Weight-Bearing: Early weight-bearing in a stiff-soled shoe or boot is often possible with modern fixation systems.
- Immobilization: Usually 4–6 weeks in a postoperative boot, followed by transition to regular footwear.
- Physical Therapy: Focuses on gait training and strengthening once fusion is confirmed radiographically.
- Return to Activity: Most patients return to normal daily activities within 8–12 weeks, with gradual return to sports thereafter.
Possible Risks or Side Effects (Complications)
- Nonunion or Malunion: Improper fusion or misalignment (1–5% of cases).
- Hardware irritation: May require removal if painful.
- Infection or wound healing problems: Particularly in diabetic or vascular patients.
- Transfer metatarsalgia: From altered weight-bearing mechanics.
- Persistent pain: Rare when alignment and fusion are optimal.
Long-Term Outlook (Prognosis)
First MTP joint arthrodesis yields fusion rates of 90–95% and patient satisfaction exceeding 90%. Most patients report substantial pain relief and improved gait mechanics. Compared with alternatives such as hemiarthroplasty or resection arthroplasty, fusion offers superior long-term stability and function.
Out-of-Pocket Cost
Medicare
CPT Code 28750 – First MTP Joint Arthrodesis (Fusion of the Great Toe Joint): $178.82
Medicare Part B typically covers 80% of the approved cost for this procedure after your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These supplemental plans work together with Medicare to close the coverage gap and reduce patient financial responsibility.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans generally cover any remaining coinsurance or small deductibles, which typically range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your First MTP Joint Arthrodesis is needed due to a work-related injury or deformity, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and follow-up visits. You will not have any out-of-pocket expenses, as the employer’s insurance carrier pays all approved costs directly.
No-Fault Insurance
If your MTP joint fusion is related to an automobile accident or trauma, No-Fault Insurance will generally cover the full cost of treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your policy.
Example
Michelle Andrews suffered from severe arthritis in her big toe joint and underwent First MTP Joint Arthrodesis (CPT 28750). Her estimated Medicare out-of-pocket cost was $178.82. Since Michelle had supplemental insurance through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q.What is first MTP arthrodesis?
A. It’s a surgical fusion of the big toe joint to relieve pain and correct deformity caused by arthritis or severe bunions.
Q. How successful is the surgery?
A. Success rates exceed 90%, with high fusion rates and excellent pain relief.
Q. Can I walk normally after the surgery?
A. Yes. After fusion, patients can walk comfortably in regular shoes. High heels and excessive toe bending are limited.
Q. How long does recovery take?
A. Most patients are walking in a postoperative shoe within weeks and resume normal activities in 2–3 months.
Q. Will I lose motion in my toe?
A. Yes, the fused joint no longer bends, but most patients adapt easily and walk pain-free.
Q. Can the hardware be removed later?
A. Yes, if screws or plates cause discomfort, they can be removed after complete healing.
Summary and Takeaway
First MTP joint arthrodesis is the most reliable surgical treatment for severe arthritis and deformities of the big toe joint. It provides durable pain relief, stability, and improved gait alignment, allowing patients to return to daily activities with confidence. With modern fixation techniques and early weight-bearing protocols, recovery is faster and outcomes are excellent.
Clinical Insight & Recent Findings
A recent study from Bradford Royal Infirmary reviewed outcomes of the continuous compression implant (CCI) for first MTP joint fusion — a modern alternative to traditional plate-and-screw fixation.
Among 27 patients (36 feet), the fusion success rate reached 94.4%, with nearly all patients reporting significant pain relief and satisfaction. The CCI device provided uniform compression across the fusion site, reduced soft-tissue irritation, and allowed for earlier weight-bearing. The study also noted lower implant cost and shorter operative times compared with standard constructs.
Overall, CCI fixation proved to be a reliable, cost-effective, and patient-friendly option for treating severe arthritis and deformities of the big toe joint. (“Study on continuous compression implants for first MTP joint fusion – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
First MTP arthrodesis is performed by an orthopedic foot and ankle surgeon or podiatric surgeon specializing in reconstructive forefoot procedures. The surgical team includes anesthesiologists, nurses, and rehabilitation therapists.
When to See a Specialist?
Consult a specialist if you have persistent pain, stiffness, or deformity in the big toe joint that limits walking or shoe wear despite conservative treatments.
When to Go to the Emergency Room?
Seek emergency care for severe swelling, redness, fever, or drainage after surgery — signs of infection or wound complications.
What Recovery Really Looks Like?
Initial swelling and stiffness gradually subside within weeks. Fusion typically consolidates within 8–10 weeks. Most patients return to full function by three months with little to no residual pain.
What Happens If You Ignore It?
Untreated hallux rigidus or arthritis can lead to worsening deformity, gait imbalance, and chronic pain that eventually affects other parts of the foot.
How to Prevent It?
Use supportive footwear, avoid high-impact activities if painful, and manage underlying conditions like arthritis early to prevent progression.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and protein supports bone healing. Avoid smoking and maintain healthy blood sugar levels to improve fusion rates.
Activity and Lifestyle Modifications
After fusion, patients can resume walking, hiking, and most activities comfortably. Avoid high heels and ensure shoes have stiff soles or rocker bottoms for optimal gait efficiency.
Dr. Mo Athar
