Surgical Overview
The first MTP joint is made up of two bones: the first metatarsal head which articulates with the base of the proximal phalanx. The great toe joint moves mainly in one direction like a hinge allowing your toe to move up and down. Inside the toe joint the bones are covered with a thick, smooth material called articular cartilage. The articular cartilage allows the two bones to move/glide against one another.
Hallux rigidus is a disorder that affects the first metatarsophalangeal (MTP) joint – the big toe. It causes pain and stiffness in the joint, and with time it gets increasingly harder to bend the toe. ‘Hallux” refers to the big toe and “rigidus” indicates that the toe is rigid/stiff and cannot move normally. Hallux rigidus is actually a form of degenerative arthritis.
This disorder can be very painful and even disabling as we use the big toe as our main push-off during walking. We rely on normal, pain-free bending of the big toe at the MTP joint to walk normal, stoop down, go up on our toes to reach high. Many patients confuse hallux rigidus with a bunion. The same joint is affected but they are different conditions requiring different treatments.
The diagrams below show normal dorsiflexion (upward bend) of the great toe and the limited bend with hallux rigidus.
The main symptom of hallux rigidus is pain in the big toe with push-off of walking. As the disorder progresses swelling can occur around the first MTP joint and a progressive bony bump (bone spur) like a bunion develops on the top of the foot on both sides of the joint. The great toe becomes stiff and motion of the toe decreases in both directions.
Non-surgical treatment of mild or moderate cases of hallux rigidus may include the following:
Shoe modifications: Shoes with a large toe box put less pressure on your toe. Stiff or rocker-bottom soles may also be recommended.
Orthotics: Custom orthotics with a Morton’s extension (stiff extension under the great toe) may improve foot function.
Carbon fiber Morton’s extension: To stiffen push-off of the great toe.
Medications: Oral non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help reduce pain and inflammation.
Corticosteroid Injections: Injections of corticosteroids may reduce inflammation and pain
PRP Injection: Injections of PRP may reduce inflammation and pain and improve the articular cartilage
Physical therapy: Physical therapy may provide some relief.
Surgical treatment for hallux rigidus is usually explored once conservative options have failed and the disorder is affecting a person’s normal activities. The surgical technique of choice is a cheilectomy.
cheilectomy
Cheilectomy is a minimally invasive (<5mm) surgical removal of the bony prominence on the top of the first metatarsophalangeal (MTP) joint of the great toe when hallux rigidus has developed. It is performed when conservative measures have failed to relieve pain. It is typically seen as a "non-bridge-burning" procedure in hopes of decreasing pain and improving motion in the mild to moderate arthritic toe.
The vast majority of patients will walk better, almost normal.
With a successful cheilectomy, most patients can walk for distance, ride a bike, perform hiking activities, swim, and golf. Tennis is often possible. Many patients can run, downhill and cross-country ski.
Obviously the cheilectomy does not restore you to normal, or remove the arthritis that is present. Most patients are better, but not perfect. Alternatives include non-surgical treatments such as activity modification, NSAIDs (eg. Advil, Aleve), cortisone/PRP injections, and stiff orthotics (shoe inserts) to limit motion.
Your surgery generally takes place in a surgical outpatient setting.
The procedure generally takes about an hour and you will go home the same day.
A foot anesthetic block with sedation will be offered.
You will get a dose of antibiotics before surgery. Patients are started on one 325 mg aspirin once a day for 4 weeks.
Your surgery generally takes place at the New England Baptist Outpatient Center and is an outpatient procedure.
No. Bleeding is minimal with use of a tourniquet during surgery.
Read carefully the information in the surgical folder.
After surgery, you will be placed in a bandage with a stiff surgical shoe or boot and will recover in the outpatient post-anesthesia area. When you have adequately recovered and have passed the criteria, including weight-bearing in the surgical shoe/boot with crutches, you will be discharged home.
No. Bleeding is minimal with use of a tourniquet during surgery.
Read carefully the information in the surgical folder.
After surgery, you will be placed in a bandage with a stiff surgical shoe or boot and will recover in the outpatient post-anesthesia area. When you have adequately recovered and have passed the criteria, including weight-bearing in the surgical shoe/boot with crutches, you will be discharged home.
For the first two weeks you must rest, get sleep, eat well, and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. You will be weight-bearing as tolerated in the surgical shoe/boot. Keep the bandage clean and dry. You may remove the shoe/boot at night for sleep. Drink plenty of clear fluids, keep your foot elevated to the level of your heart, and take pain medicine as prescribed.
Discuss this with your rheumatologist, but it is generally recommended that you stop immune suppressive modulators (eg. Methotrexate, Enbrel, Humira) for two weeks before and two weeks after surgery.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
This is an important question because it impacts home and work situations. After your sutures are removed, you may increase your day-to-day activities. If your incision is well healed, you may wash the surgery site after sutures are removed. Try to keep your foot elevated when sitting. After suture removal, you should begin bending the toe by hand, for about five minutes every hour, while awake. Soak the foot in warm water and Epsom salts and move the toe up and down. This will decrease swelling and avoid adhesions. Physical therapy may be prescribed as well. After two weeks, you may transition into a roomy, comfortable shoe to accommodate the typical post-surgical swelling.
Download the Cheilectomy Post-Operative Guidelines for full details.
Many patients can drive by 1-2 weeks.
That depends on what you do. Sedentary desk workers may return as soon as one to two weeks. You will be provided out of work notes, or restricted duty notes, as necessary during your recovery. Family leave paperwork can also be submitted.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, or chronic pain and swelling. In about ten percent of patients, the arthritis will progress. In this situation, a fusion may be required. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome.
Get ready for it! Optimize your physical and mental state, and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions. More information can be obtained from the American Orthopaedic Foot and Ankle Society website (www.aofas.org). FootcareMD.com is another helpful online resource.
