Is Cheilectomy An Option For End-Stage Hallux Rigidus?
- Neal Blitz DPM FACFAS
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Foot surgeons are well aware of the various surgical procedures that address the various stages of degeneration of the big toe joint. As the severity of arthritis becomes more involved, so do the surgical interventions.
Surgeons generally perform cheilectomy for mild stages of arthritis when there is a bone spur on the top of the big toe joint. When it comes to patients with moderate arthritis, one may “decompress” the joint by performing an osteotomy to shorten and plantarflex the first metatarsal. In regard to end-stage arthritis, surgeons “classically” manage this with a joint destructive procedure: fusion, implant or resection. There are studies that support each procedure and their indications.
However, the idea of performing a cheilectomy for end-stage arthritis is not often a first-line option. This is largely due to the pre-determined surgical algorithms that are based on textbook knowledge, “experience” passed down from surgeon to surgeon and research studies.
Early in my professional career, I leaned heavily on these algorithms for hallux limitus/rigidus and achieved successful outcomes. In recent years, I have moved away from more aggressive (or “more permanent”) procedures as a first-line option and found a simple cheilectomy to be a more universal procedure in the management of end-stage hallux rigidus. If patients fail cheilectomy, then the surgeon still has options to perform joint destructive procedures.
Indeed, this approach is not for every patient. You should examine each and every patient individually, and develop an appropriate surgical plan based on the clinical scenario, age, medical comorbidities and, most importantly, patient expectations.
I have found that the dorsal “bump pain” is responsible for a majority of patient symptoms. By the time a patient presents with end-stage arthritis, there is little to no motion of the big toe joint and there is significant (dorsal) osteophytosis. These patients have already functionally compensated for having a stiff non-mobile joint. Their lifestyles long ago adjusted to accommodate the degenerated big toe joint.
In general, patients with severe end-stage arthrosis do not expect the joint to become a normal joint again. They tend to ask for pain reduction/resolution. It is important to try to differentiate the patient’s pain from the arthritic degeneration of joint (i.e. bone-on-bone grinding pain) versus the dorsal bump pain.
Further Insights On The Advantages Of Cheilectomies
In clinical practice, I tell patients that the big toe joint has degenerated and discuss both cheilectomy and whatever joint destructive procedure I think will be the best option for the end-stage arthrosis for their particular situation. While the joint destructive procedure is “permanent” and offers the potential for 100 percent pain relief, there are secondary factors/complications that may come into play, resulting in a painful outcome.
Cheilectomy, if nothing else, has a chance to alleviate or lessen the patients’ pain with a relatively non-cumbersome postoperative course (weightbearing as tolerated immediately after surgery). Cheilectomy also avoids some of the pitfalls (i.e., malunion, nonunion, bone loss, etc.) that destructive procedures may cause.
It is extremely important to inform patients with end-stage arthrosis who undergo cheilectomy that the joint may become more painful after the surgery. Once the surgeon removes the bony blockade, this arthritic joint will have more motion, allowing for increased bone-on-bone contact, which may be painful. I found that patients with eburnated joints have less of this problem. Nonetheless, the pain from the increase motion is usually short-lived and subsides within six weeks or so.
I also clearly indicate to patients who choose cheilectomy that they may not be 100 percent pain-free but achieving a significant amount of pain relief may suffice. Patients who complain of continued pain worthy of another surgical intervention can then have that joint destructive procedure.
Lastly, recurrence of the dorsal osteophyte is not uncommon. Re-growth occurs over a few years but it is indeed possible to have the recurrence sooner. If this should occur and is symptomatic, I have had patients simply request to have the bone spur removed again.
While cheilectomy is not for every patient with end-stage arthrosis, it may be a viable treatment option that you may have not strongly considered before.