The first metatarsophalangeal (MTP) joint, located at the base of the big toe, is essential for walking, running, and maintaining balance. When the cartilage in this joint becomes severely damaged from arthritis or deformity, movement can cause significant pain and limit mobility. First MTP joint fusion, also known as arthrodesis, is a surgical procedure designed to eliminate pain by permanently joining the bones of the big toe joint into a stable, immobile position.
How Common It Is and Who Gets It? (Epidemiology)
First MTP joint fusion is one of the most frequently performed forefoot surgeries for end-stage hallux rigidus (arthritis of the big toe) and severe hallux valgus (bunion deformity). It is most commonly indicated in adults aged 40 to 70, especially women, and in patients with rheumatoid arthritis, prior failed foot surgeries, or traumatic joint injury. The procedure has become the gold standard for patients seeking lasting pain relief and restored walking function.
Why It Happens – Causes (Etiology and Pathophysiology)
The need for MTP fusion usually arises from progressive cartilage degeneration or joint instability caused by:
-
Hallux rigidus: Severe osteoarthritis that causes stiffness and bone spurs.
-
Hallux valgus: Large bunion deformity with joint subluxation or arthritis.
-
Rheumatoid arthritis: Chronic inflammation that damages cartilage and bone.
-
Post-traumatic arthritis: Cartilage loss following previous fracture or dislocation.
-
Failed previous surgery: When earlier bunion or joint procedures have not relieved pain or restored function.
These conditions result in pain, swelling, 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 (in the forefoot) to the proximal phalanx of the big toe. It allows up to 110° of motion during walking and push-off. The joint bears significant weight during each step, and when arthritis or deformity develops, it disrupts gait mechanics, shifting pressure to the smaller toes and leading to further discomfort.
What You Might Feel – Symptoms (Clinical Presentation)
Patients with advanced MTP joint disease often experience:
-
Chronic pain in the big toe joint, worsening with walking or tight shoes.
-
Swelling, stiffness, and decreased range of motion.
-
Difficulty wearing normal footwear.
-
Toe deformity, drifting, or crossing over the second toe.
-
Gait changes and pain under the ball of the foot.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is made through clinical evaluation and imaging studies:
-
Physical Exam: Reveals pain with movement, swelling, and reduced motion.
-
X-rays: Show joint space narrowing, bone spurs, or deformity.
-
MRI (if needed): Evaluates soft tissue or cartilage injury.
The diagnosis is confirmed when conservative treatments fail to relieve pain or restore motion.
Classification
Hallux rigidus (arthritis of the first MTP joint) is often graded by severity:
-
Grade I: Mild stiffness, minimal bone spurs.
-
Grade II: Moderate loss of cartilage and pain with motion.
-
Grade III: Severe arthritis with extensive spurring and minimal motion.
Fusion is indicated for Grade III or end-stage disease or for complex deformities unresponsive to other procedures.
Other Problems That Can Feel Similar (Differential Diagnosis)
-
Sesamoiditis or sesamoid fracture
-
Gout or pseudogout
-
Plantar plate tear or metatarsalgia
-
Morton’s neuroma
-
First tarsometatarsal joint arthritis
Treatment Options
Non-Surgical Care
Initial treatments aim to reduce pain and maintain mobility:
-
Orthotics: Custom insoles or rocker-bottom shoes reduce joint stress.
-
NSAIDs: Reduce inflammation and discomfort.
-
Corticosteroid injections: Provide temporary relief of pain and swelling.
-
Activity modification: Avoiding high-impact activities or prolonged standing.
If these fail to relieve symptoms, surgical fusion is the next step.
Surgical Care
Goal: To remove the damaged cartilage, correct alignment, and permanently join (fuse) the metatarsal and phalanx bones for a stable, pain-free joint.
Surgical Steps:
-
Incision: A small incision is made on the top or side of the big toe joint.
-
Joint Preparation: The surgeon removes all cartilage from the joint surfaces.
-
Bone Alignment: The bones are positioned in optimal alignment — typically with the toe elevated 10–15° relative to the floor for normal walking.
-
Fixation: The bones are secured using one of several fixation methods:
-
Crossed screws – provide compression and stability.
-
Dorsal plates with screws – ensure rigid fixation and allow early weight-bearing.
-
Compression staples or hybrid devices – offer continuous pressure across the fusion site for faster healing.
-
-
Closure and Dressing: The incision is sutured, and a boot or splint is applied.
Recovery and What to Expect After Treatment
Timeline:
-
0–6 weeks: The patient wears a postoperative boot and remains non–weight-bearing or partially weight-bearing as instructed.
-
6–12 weeks: Gradual transition to full weight-bearing with supportive footwear.
-
3–6 months: Most patients return to normal activities; full fusion is typically achieved by 12 weeks.
Physical Therapy:
Focuses on maintaining mobility in the surrounding joints, strengthening, and gait training once healing progresses.
Possible Risks or Side Effects (Complications)
-
Nonunion: Bones fail to fuse (1–5% of cases).
-
Malunion: Improper alignment of the fused joint.
-
Hardware irritation: May require screw or plate removal later.
-
Infection or wound complications: Especially in diabetic patients.
-
Transfer metatarsalgia: Increased pressure on the smaller toes.
Long-Term Outlook (Prognosis)
First MTP fusion is a durable solution with fusion rates of 90–95% and pain relief in over 90% of patients. The joint no longer moves but allows comfortable walking in standard shoes. Compared with joint replacement or resection arthroplasty, fusion provides superior long-term outcomes, stability, and durability.
Out-of-Pocket Costs for Treatment
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
Diana 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 Joint Fusion?
A. First MTP joint fusion is a surgical procedure to treat severe arthritis or deformities in the big toe by removing the damaged cartilage and fusing the bones together to create a stable, non-moving joint.
Q. Why is First MTP Joint Fusion needed?
A. It is needed for conditions like end-stage hallux rigidus, rheumatoid arthritis, severe hallux valgus (bunion deformity), or when previous surgeries have failed to address pain and dysfunction in the big toe.
Q. How is the First MTP Joint Fusion surgery performed?
A. The procedure involves making an incision over the MTP joint, removing damaged cartilage, and aligning the bones. The bones are then held together using screws, plates, or staples to ensure proper healing.
Q. What are the fixation techniques used in First MTP Joint Fusion?
A. Common fixation techniques include screws, plates, or titanium staples, which are used to stabilize the bones while they fuse together during the healing process.
Q. What is the recovery timeline for First MTP Joint Fusion?
A. Initial healing takes 0-6 weeks with a special boot, followed by 6-12 weeks of physical therapy. Full recovery may take 3-6 months, depending on individual healing.
Q. What are the risks and complications of First MTP Joint Fusion?
A. Potential complications include infection, nonunion (failure of the bones to fuse), hardware-related issues, and malunion (improper bone healing).
Q. How effective is First MTP Joint Fusion?
A. The procedure has a high success rate, with union rates of 90% or higher, providing significant pain relief and improved mobility for most patients with severe big toe arthritis or deformities.
Q. Can I walk immediately after First MTP Joint Fusion surgery?
A. No, you will need to refrain from putting weight on the foot for several weeks, typically using crutches or a walking boot to protect the joint during the early stages of recovery.
Q. Will I experience pain after First MTP Joint Fusion?
A. Some discomfort is normal after surgery, but most patients experience significant pain relief once the joint heals, particularly those who had chronic pain due to arthritis or deformities.
Q. Can First MTP Joint Fusion be done on both feet at the same time?
A. While it is technically possible, performing First MTP Joint Fusion on both feet simultaneously is generally not recommended due to the need for proper weight-bearing and rehabilitation after the procedure.
Q. Can I return to high-impact activities after First MTP Joint Fusion?
A. High-impact activities, such as running or jumping, are typically discouraged after fusion surgery, as the procedure limits motion in the joint, which is designed to provide more stability rather than flexibility.
Q. Is physical therapy necessary after First MTP Joint Fusion surgery?
A. Yes, physical therapy is often required to restore strength, flexibility, and mobility in the foot, as well as to ensure a full recovery and prevent complications like stiffness or muscle weakness.
Q. What are the long-term benefits of First MTP Joint Fusion?
A. The procedure provides long-term pain relief, improved stability, and better function for the foot. Most patients experience a significant reduction in pain and are able to resume daily activities without discomfort.
Q. Are there any alternatives to First MTP Joint Fusion?
A. Alternatives include joint replacement, cheilectomy (removal of bone spurs), and corrective procedures for bunions or hammertoes, but fusion is often recommended for severe cases of arthritis or deformity.
Q. How will the First MTP Joint Fusion affect my foot’s appearance?
A. After surgery, the joint will be immobile, and the appearance of the big toe may change slightly due to the fusion. However, the main goal is to relieve pain and improve function, not cosmetic appearance.
Q. What is first MTP joint fusion?
A. It’s a surgery to permanently fuse the bones of the big toe joint to relieve pain and improve stability when arthritis or deformity has damaged the joint.
Q. How successful is the surgery?
A. Fusion success rates exceed 90%, with lasting pain relief and improved function.
Q. Will I lose motion in my big toe?
A. Yes. The joint will not move after fusion, but most patients walk comfortably and adapt well.
Q. How long before I can walk again?
A. Limited weight-bearing may begin in a protective boot within weeks. Full walking typically resumes by 6–8 weeks.
Q. Will the hardware need to be removed later?
A. Only if screws or plates cause irritation after healing.
Q. Can I wear normal shoes after fusion?
A. Yes. Most patients can wear comfortable walking or athletic shoes but should avoid high heels.
Summary and Takeaway
First MTP joint fusion provides predictable pain relief, stability, and improved function for patients with end-stage arthritis or deformity of the big toe. The procedure eliminates painful motion while preserving a natural gait and ability to wear standard footwear. With modern fixation methods and careful rehabilitation, patients achieve long-term satisfaction and reliable outcomes.
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)
The surgery is performed by an orthopedic foot and ankle surgeon or podiatric foot surgeon specializing in reconstructive forefoot surgery. The care team includes anesthesiologists, surgical nurses, and physical therapists who assist with postoperative care and rehabilitation.
When to See a Specialist?
Consult a specialist if you have chronic big toe pain, stiffness, or deformity that limits walking or has not improved with non-surgical treatments.
When to Go to the Emergency Room?
Seek emergency care if you develop severe pain, swelling, redness, drainage, or fever after surgery, as these may indicate infection or complications.
What Recovery Really Looks Like?
The first few weeks focus on protecting the fusion site and managing swelling. Gradual improvement occurs as weight-bearing increases, and most patients return to daily activities within three months. Long-term, patients report lasting pain relief and stable function.
What Happens If You Ignore It?
Without treatment, arthritis or deformity may worsen, causing chronic pain, limited motion, and altered walking mechanics that can affect other joints in the foot or leg.
How to Prevent It?
While joint fusion treats end-stage disease, maintaining foot health through proper footwear, early arthritis management, and avoiding repetitive trauma can help delay progression.
Nutrition and Bone or Joint Health
A diet high in calcium, vitamin D, and protein supports bone healing. Avoid smoking and excessive alcohol, which can delay fusion.
Activity and Lifestyle Modifications
After recovery, most patients walk comfortably and can enjoy activities like hiking or cycling. High-impact activities or narrow, high-heeled shoes should be avoided. Supportive footwear and routine stretching help maintain comfort and prevent strain on the rest of the foot.
Dr. Mo Athar
