Great Toe Cheilectomy

(Bone Spur Removal)

Indications

A cheilectomy involves removal of bone spurs that involve the top part of the big toe joint (1st MTP joint). These bone spurs occur as a result of early arthritis of the joint and can cause pain and limited motion of the big toe. The word “cheilectomy” means “the cutting away of a lip of bone.”

This procedure is indicated in those with painful, limited motion of the big toe that does not respond to non-surgical treatment. This is done to allow increased motion through the big toe MTP joint, to decrease shoe wear irritation from the prominence (bump), and to eliminate some early arthritis on the upper surface of the joint. This procedure is effective only for patients who have arthritis involving the top part (dorsal aspect) of the great toe joint (first MTP joint). While older patients more commonly have arthritis of the big toe, it can be seen in younger adults due to sports trauma or other conditions. In all age groups, the bone spur removal is designed to improve mobility of the joint. Some occupations and recreational activities may require this joint mobility, so it is important to advise your surgeon of all activities to discuss realistic expectations of this procedure. The cheilectomy procedure is not indicated in patients with extensive arthritis involving the entire joint (i.e. more severe or end/late-stage hallux rigidus).

Procedure

A cheilectomy does not involve metal or other implants, it is a trimming of bone from the area of the bump or spur (Figure 1). The procedure is performed by making an incision centered over the top of the 1st MTP joint. The tendon that extends the big toe is protected. The cartilage of the joint is inspected. Typically, the top third of the first MTP joint has arthritic changes. This bone spur and arthritic area is removed in order to allow increased motion and improvement in symptoms. The incision is typically about 5-7 cm long, and sutures or surgical clips are used to close the incision. A sterile bandage or wrap is used to protect the area after surgery. The procedure is performed as day surgery in almost all cases. Many surgeons will offer an option of local anesthesia for the procedure. The most common reasons for overnight hospital stays are related to management of other medical conditions such as diabetes, high blood pressure or asthma. In some patients, pain control can be an issue that is best handled prior to going home.

Figure 1: Great Toe Cheilectomy (bone spur removal) for treatment of mild Hallux Rigidus (arthritis of great toe)

Great Toe Cheilectomy (bone spur removal) for treatment of mild Hallux Rigidus (arthritis of great toe)

Recovery

Patients are typically able to rapidly remobilize with weight bearing as tolerated in a stiff-soled shoe almost immediately after surgery. Instructions for bandage and wound care are given. Some patients prefer to use crutches or a cane for a few days after surgery for comfort. Most patients will take a few days off from work or school in order to have the freedom to elevate the foot frequently to control swelling. Sutures are removed as soon as the incision heals, usually about 2 weeks after surgery. Range of motion exercises and occasionally physical therapy are started once the wound has healed. A simple exercise of gently moving the great toe up and down is important to prevent stiffness. Normal walking helps to promote the upward motion, although some patients subconsciously walk temporarily on “the outside border” of the foot to decrease pressure on the big toe. Using a mirror to walk ‘Heel-to-toe’ can help to improve confidence to put normal pressure on the big toe.

Most patients are able to resume their usual lifestyle within a few weeks, although certain high-intensity activities will not be possible right away. Residual pain and swelling can be expected to limit some activities or even work for about three months post-operatively. Return to intensive sports or demanding physical situations is usually possible by six months. Each person’s recovery will depend on a number of factors so these timelines are estimates only.

Driving must not be attempted while “impaired” so pain and stiffness should be resolved before returning to safe operation of a motor vehicle. This is usually 2-4 weeks after surgery, possibly longer in some individuals.

Footwear may be an issue in the recovery period due to swelling of the toe and possibly the surrounding area. Most patients report relief in their old footwear given that the uncomfortable bump has been removed.

Arthritis symptoms usually resolve about one month after surgery. Patients can experience relief for up to 10 years following the surgery. Actual mobility of the joint varies from patient to patient, but most report a satisfactory improvement, with gains in mobility continuing up to a year after surgery.

Potential Complications

Progression of arthritis: There is the very real potential for a recurrence or persistence of symptoms after a great toe cheilectomy. This can occur relatively quickly if there was more wear and tear arthritis in the great toe joint than expected. In addition, this surgery does not fully correct the underlying biomechanical forces that caused the arthritic changes in the first place. Therefore, over time the great toe symptoms may have a tendency to recur. If the symptoms recur, it may be necessary to perform a more definitive procedure, such as a great toe fusion or a 1st MTP joint replacement.
Local nerve irritation: Irritation to the nerves supplying the big toe can occur as a result of this procedure. In some patients, a partially “numb” area of the big toe results from the surgery. Most nerve problems resolve in about six weeks.
Wound healing problems: In most patients, the wound heals with no problems. In patients with medical conditions such as diabetes or inflammatory arthritis, the surgeon may give special postoperative instructions. Smoking may interfere with wound healing, and all advice regarding management of smoking should be carefully followed. In physically active patients, returning “too soon” to regular footwear, or high-intensity activity, can result in unwanted irritation of the wound, even after the wound has healed and the sutures have been removed.
Infection: A sharp increase in pain, accompanied by redness and tenderness of the skin may indicate infection. If infection occurs it is usually related to the surface of the wound and is easily recognized and treated, usually with oral antibiotics. If a deeper infection is suspected, intravenous antibiotics may be necessary. Seek a medical opinion if there is a concern about infection (painful redness of the wound, possibly associated with fluid leaking from the wound). Be sure advise of any unusual exposures to soils, fungus, pets or travel if an infection is suspected or diagnosed.
Blood Clots (DVT): In any foot surgery, there is a small risk of developing a blood clot. Since a cheilectomy procedure allows for early mobility, the risk of blood clot is very low. If the lower leg becomes swollen and sore, this should be investigated. If you have had a blood clot in the past, or have risk factors for blood clots, advise your surgeon. Medication to thin the blood may be prescribed around the time of surgery and may need to be taken for a number of weeks after surgery.

Edited on January 24, 2017

(Originally edited by Daniel Cuttica, DO)

mf/ 10.22.18