Cheilectomy

Cheilectomy
Cheryle E. Hartley, PA-C
St. Francis Foot & Ankle Center, St. Francis Orthopaedic Institute, Columbus, Georgia
A cheilectomy (pronounced k-eye-LECK-toe-me)
is a surgical procedure used to remove bone spurs
from the base of the big toe. The word comes from
the Greek word cheilo, meaning lip, and describes the
“lip” (spur) of bone caused by inflammation or arthritis
of the joint. This inflammation of the joint causes
degenerative changes that result in a stiff big toe, or
hallux rigidus. It is the second most common big toe
condition after hallux valgus (bunion). It occurs more
commonly in women than men (2:1) and usually occurs between the ages of 30 and 60 years.
Hallux rigidus can be disabling because motion is
limited and pain occurs in the metatarsophalangeal
joint at the base of the big toe. New growth of bone
around the dorsal articular surface of the metatarsal
head prevents the big toe from dorsiflexing, causing
pain and stiffness (Figure 1). Shoe-wear modification
does not decrease the pain, so the pain and disability
are typically greater with this condition than with hallux valgus.
A
B
C
Common symptoms include gradually increasing
pain and stiffness around the great toe that increases
with standing, walking up an incline, squatting, running, or walking in heels because forced dorsiflexion
of the big toe results in impingement or jamming. Occasionally, one might experience numbness or tingling
in the big toe because the nerve is being compressed
between the bony prominence and the shoe.
Physical examination might reveal swelling around
the joint; a palpable bony prominence on the dorsum
of the metatarsal; and decreased and/or painful range
of motion, mostly with dorsiflexion and sometimes
with plantar flexion. Radiographic findings for a
patient with hallux rigidus vary in degrees of abnormalities from minimal bony proliferation or spurring
to more advanced spurring with joint-space narrowing
and widening/flattening of the metatarsal head and to
great joint-space narrowing and extensive spurring
around the edges of the joint. Subchondral sclerosis or
cysts also might be seen around the joint.
Nonoperative treatment includes using nonsteroidal anti-inflammatory drugs, having an intra-articular
corticosteroid injection to decrease joint inflammation, wearing shoes with a wide toe box and low heel,
and wearing molded stiff inserts with a rigid bar or a
rocker bottom shoe. Repeated injections of intra-articular corticosteroids are not advisable.
Operative treatment might be indicated if the condition does not improve with nonoperative treatment.
The choice of surgical procedure depends on the degree of involvement, range-of-motion limitations, and
the patient’s age and level of activity. The main goals
are to relieve the dorsal impingement and decrease the
associated joint inflammation. No procedure can be expected to restore normal range of motion and anatomy.
Figure 1. Preoperative radiographs show bone spurs.
A, Lateral view. B, Anteroposterior view. C, Oblique
view.
Cheilectomy
The treatment for most patients with hallux rigidus
is a cheilectomy. Dorsal cheilectomy is indicated in
patients with mild to moderate arthritic changes. This
procedure is relatively simple to perform (Figures 2-6).
After surgery, the patient can bear weight on the heel
of the foot in a postoperative shoe for approximately 2
weeks. Next, he or she begins range-of-motion exercises, with gradual increase of activity and normal shoe
wear based on comfort level and resolution of swelling. Patients usually recover from surgery in 6 to 8
weeks and can return to exercise at 6 months. As with
any operation, cheilectomy has potential complications, including infection, damage to small nerves and
blood vessels that can lead to numbness and tingling
of the big toe, and progression of arthritis and stiffness.
As stiffening of the big toe joint increases, a cheilectomy might not be sufficient. An additional bone cut
on the big toe itself (osteotomy of the phalanx) might
be needed. This is called the Moberg procedure. In
more severe cases, fusion of the big toe (arthrodesis)
or removal of bone from the joint (arthroplasty) might
be indicated. The difference between a fusion and an
A
arthroplasty is movement of the big toe. Although
a fusion is a permanent correction with elimination
of the arthritis and pain, it restricts the motion of
the toe and is not recommended for the treatment of
uncomplicated hallux rigidus. The Keller procedure
(excisional arthroplasty) shortens the big toe slightly
but maintains some movement. It might be indicated
for older, sedentary individuals, but it is not generally
recommended because of its potential complications.
Capsular interposition arthroplasty can provide pain
relief in select individuals with advanced degenerative disease. Implant arthroplasty procedures have the
potential for implant failure and should be reserved for
older patients with few functional demands on their
feet.
Cheilectomy is the preferred treatment for most
patients with mild to moderate hallux rigidus. If the
results of cheilectomy are unsatisfactory, salvage with
an arthrodesis or resection arthroplasty procedure can
be performed. Therefore, it represents a “no bridges
burned” type of approach.
B
Figure 2. A, A 5-cm dorsomedial incision over the first metatarsophalangeal joint avoids the digital branch of the
medial cutaneous nerve. B, To expose the joint capsule, the nerve is retracted medially and the tendon, laterally.
Hartley CE
Figure 3. Microsagittal saw removes 25% of the articular surface of the metatarsal head.
Figure 6. Continue to smooth cut surfaces with rasp
until all bony overgrowth is removed to obtain full
range of motion.
Figure 4. Carefully rongeur the dorsal lip of the distal
metatarsal to smooth the cut surface.
Figure 5. If less than 75° of dorsiflexion is obtained,
then consider more aggressive release by removing
bony overgrowth of proximal phalanx.