A joint fusion operation is not as terrifying as one initially thinks, quite the opposite

October 27, 2016

As a specialist foot and ankle surgeon I carry out fusion (arthrodesis) operations every week for severe arthritis involving the big toe, midfoot, talonavicular, calcaneocuboid, subtalar and ankle joints.
Almost every one of these patients when I had told them in the consulting room that a fusion may be required, initially balked at the idea. And it is easy to understand why. After all joints exists to allow movement of body parts, so the idea of fusing them and obliterating movement quite understandably feels “unnatural”. But joints also exist to bear load and help with stabilising structures. A damaged arthritic joint fails to do any of these.
When a joint becomes arthritic it is the underlying damage to the cartilage which is the primary problem. Cartilage is a unique and remarkable structure. It has the following properties:
  • low-friction
  • wear-resistant tissue
  • designed to bear and distribute weight

It is a strong, rubbery, flexible tissue with the lowest coefficient of friction known to man. Thus when two bits of cartilage slide over each other there is practically no friction, which means no wear or tear. Unfortunately the cartilage that you have in your body was the cartilage you were born with and the cartilage you will take to the grave. Our bodies cannot make new cartilage. Damage to cartilage results in arthritis.

The natural history of arthritis is to develop increasing pain and stiffness. Initially only after exertion but then gradually over time these symptoms will become constant even at rest. The deterioration can be rapid over months but generally is over years, sometimes decades.
Patients often ask me “how quickly is my joint going to deteriorate?” or “how do i know whether it is getting worse?”. The simple answer is I don’t know. But… if you were to look back over the last 12 months and plotted your pain every month, and tracked the deterioration, well I would say project that forward in time and you will have an understanding of the rate of deterioration and where you might be in the future.
The problem with a severely degenerative joint is that it simply does not function properly. Your body will make compensations and adjust the way you walk and load other joints, typically offloading the damaged joint and overloading the normal joints around the foot and ankle but also including the knees, hips and backs. Adjacent joint disease will definitely set in at some point and deformity can result in many patients with joint subluxation which has a domino effect on the adjacent joints.

Patients with severe arthritis tend to be desperate, because chronic pain is a miserable thing and mentally wears one down. So there is always an abundance of people offering elixirs and miracle cures who are willing to take advantage of this vulnerable group and make a quick buck. Beware the person offering you something thats sounds too good to be true, it probably is!

Stem cell research is in its embryonic stage and decades away from a practical application for end stage bone on bone arthritis. Certain joints such as knees lend themselves better to treatments such as autologous chondrocyte implantation but even this is a new technique with very mixed results suitable really for people with small focal damaged areas in the knee and possibly the ankle. It has certainly not something that can be used for the smaller joints in the foot.

So is a fusion such a bad thing? Ask yourself what is it that you are apprehensive about?
Many patients are concerned they will never walk again properly, or that they will not be able to run or play sports. It could be that they think they will have a permanent limp. The reality is quite the opposite. The majority of patients will have very little restriction.


The pros and cons of a fusion procedure (rough guide as each joint is different) – 

Cons – 

Typically 6 weeks non weight bearing, then weight bearing in a boot for 4-6 weeks
Risk of non union and infection (main complication) around 1%
Potential risk for adjacent joint disease after 10 years (low but real)

Pros – 

Excellent pain relief
Allow for significantly improved gait
Able to return to sports and exercise
Prevent deformity
Prevent other joint problems due to abnormal loading patterns (You will almost certainly develop joint problems elsewhere if you do not have the arthritis treated whereas there is a small risk of developing arthritis in other joints after a fusion)

Patients are always surprised at how much movement they have in the foot and ankle after a fusion and that is because there are so many other joints in the foot and ankle that can take over some of the lost range of motion. If the foot and ankle is like a chain, a fusion will only stiffen one link, the rest will still function normally. For me as a dedicated foot and ankle surgeon, fusion operations are incredibly satisfying operations because of the massive improvement it allows in patients lives. And that is after all what it is all about.

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Comments

Andrew Hodge

Having had both ankles fused as a result of Avascular Necrosis of the Talus I am now pain free and wish I had not waited so long - I can walk, drive, cycle (not wild off roading as before). I cannot run distances so jogging for me is out. I have some tight feeling around the ankles but not pain. It is important to follow the recovery instructions and not go weight bearing until absolutely ready. You don't really have a second chance here but it was well worth it 12months in. Thanks Ahmad

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