What are the symptoms? 

Pain: Pain is the commonest and most troublesome symptom. This is usually made worse  by walking. It may disturb sleep. Simple ways to see if your pain is getting worse is to  record whether your walking distance is decreasing, or whether you need more painkillers  to ease the pain. 
Stiffness: With osteoarthritis, stiffness or reduced movement is common. With  inflammatory arthritis, stiffness can often be worse first thing in the morning. 

Cracking/popping: There may be little pieces of loose cartilage or bone caught within the  joint causing this sensation. 

Giving way: This may be due to looseness of the ligaments, or secondary to pain. 

Swelling: Swelling may be as a result of extra bone, or fluid within the joint. The soft tissues can also inflame and swell.

Pain relief 

Pain killers such as Paracetamol can be effective. Non-steroidal anti inflammatories  (NSAID), such as Brufen, Ibuprofen and Diclofenac can reduce inflammation. Patients  need to check with their general practitioner or pharmacist that NSAID's are suitable for  them, as they can have side effects, especially if you have asthma or stomach ulcers.  Physiotherapy and hydrotherapy can help with pain and stiffness. Patients with  inflammatory arthritis are usually looked after by a rheumatologist. Disease modifying anti-rheumatoid drugs (DMARD’s) are used to treat these conditions, in conjunction with  painkillers and NSAID's. 

Operative treatments 

Steroid injection 

Steroid injection of the affected joint or joints may be an option that may provide temporary  relief from pain (depending on the joints involved). It may be possible for the injection to  occur under ultrasound guidance within the x-ray department. Often, the procedure will  require admission to hospital usually as a day case with the injection taking place in an  operating theatre with x ray facility to identify the affected joint/s for injection. Injection is  not a cure for the condition but can provide temporary relief of pain. 

Midfoot fusion surgery 

Midfoot fusion, also referred to as arthrodesis, is a procedure in which the separate bones  that make up the arch of the foot are permanently fused into a single mass of bone. Fusion  eliminates the normal motion that occurs between these bones.  

What are the goals of a midfoot fusion? 

The primary goal of midfoot fusion is to decrease pain and improve function. Eliminating  the painful motion between arthritic joint surfaces and restoring the bones to their normal  positions achieves this. Other goals include the correction of deformity and the return of  stability to the arch of the foot. A successful midfoot fusion can achieve these goals and  restore more normal walking ability. 

When should I avoid surgery? 

Midfoot fusion should not be performed if there is active infection or if the patient’s health is  poor enough that the risk of surgery is too high. Conditions such as uncontrolled diabetes  and blood flow problems may make a patient a poor candidate for surgery. Other reasons  to not perform midfoot fusion include osteoporosis and poor skin quality. Smoking  significantly increases the risk that bones will not fuse.  

General details of procedure 

Successful midfoot fusion depends on complete removal of all joint surfaces (cartilage) and  stable fixation of the joints being fused. 
Midfoot fusion is generally accomplished using one or two incisions on the top of the foot.  The length of the incision and how many incisions are necessary is determined by the  number of joints to be fused. Careful attention is paid to protecting tendons and nerves. 

Stability is achieved during midfoot fusion using metal implants such as screws and plates.  These are designed to immobilize the joints and allow for the formation of bone across the  joint space. This process may involve the addition of bone graft material to fill any gaps  that might exist between the bones after the cartilage has been removed. This bone graft  material may be taken from another location in the patient’s body (autograft). It may also  come from donated bone (allograft) or from a synthetic material. A combination of these  materials may be used. 

The potential complications of midfoot fusion include 

1. Failure of the pain to resolve: This is usually because of one of the reasons outlined  below - occasionally no cause can be found. 

2. Failure of the bones to heal: In smokers the complication rate is increased by a factor  of five. For this reason it is advisable to stop smoking 3 months before surgery. In  smokers, nicotine is the cause of the problem and thus nicotine patches should also be  avoided. If the bones fail to heal, this may require a second operation. 

3. The bones not healing in the correct position (malunion): This can usually be rectified  by a second operation. 

4. Infection. 

5. Bleeding. 

6. Blood clots in the leg and, rarely, on the lung (deep venous thrombosis and pulmonary  embolus). 

7. Wound healing problems. 

8. Nerve and blood vessel damage leading to numbness, pain or weakness in the foot. 9. Prominent metalwork requiring the screws to be removed at a small second operation. 

10. In some people, over the longer term arthritis can develop in other joints in the foot, as  a result of the excess strain placed on them by the fusion of the Midfoot joint/s.  Treatment with further fusion (depending upon the first procedure) may be possible.  Obviously, further fusions can lead to an excessively stiff foot. 

Most problems can be treated by medications, therapy and on occasions by further  surgery, but even allowing for these, sometimes a poor result ensues.

How long will it take to recover? 

After the operation you will have your foot in a plaster cast. To minimize swelling the foot  must be kept up most of the time. When the foot is lowered it will throb and swell. This  should be avoided. Over time you will be able to increase the time that your foot is lowered.  After two to three weeks you will be able to keep your foot down most of the time. 

You are likely to spend about 1-3 days in hospital.  

As this is the period when your bones are in the process of fusing together you will wear a  plaster cast for the first 12 weeks following surgery. During this time you must not weight  bear on the operated foot for the first 6 of these weeks. You will then commence partial  weight bearing for the second six weeks. Your plaster will typically come off permanently at  about twelve weeks. 

From three to six months post-surgery, you will gradually start to build up your mobility and  strength. Full recovery will take 6 months to one year, (depending on your type of surgery). 

Activity and time off work 

In general, 6 weeks off work is required for sedentary posts; 12 weeks for standing or  walking posts; 16 weeks for manual / labour intensive posts. 

It can take several months (9-12) for swelling to settle. Continue to elevate your foot as  needed. 

Once your fusion is achieved you should be able to return to wearing normal shoes and  resume exercise. 

Follow up clinic appointments 

∙ 2 weeks clinic: removal of sutures and change of plaster 

∙ 6 weeks clinic: change of plaster to partial weight bearing cast or walker boot. X-ray of  foot. 

∙ 3 months clinic: removal of cast / X-ray foot, mobilise full weight bearing (may continue  with supportive boot if necessary) 

∙ 6 months clinic: for final assessment if no complications

How will I know if I have a complication? 

You may be experiencing a complication if you bleed or experience an increase in pain or  swelling after you go home. If these symptoms continue after you have elevated the leg  and taken painkillers you should notify the hospital as this could indicate the early onset of  infection or possible deep vein thrombosis. (See contact numbers below) 

Post-operative Venous Thromboembolism (VTE) prophylaxis 

Whilst your leg is being stabilised within a plaster cast (up to 12 weeks)you may be  required to take an injected blood thinning medication every day to prevent the formation of  a blood clot in your leg and associated complications. This information will be provided to  you during your inpatient stay.