Cheilectomy for big toe arthritis

What will surgery involve?

In this operation a small cut on the top of your Big toe is made taking care to protect the big toe tendon. The joint is then inspected. The bone spur on the back of the joint is resected with a saw. The cartilage of the main joint can also be cleaned out. Any other bone spurs from the joint will be removed at the same time and any loose cartilage or bone fragments washed out.

The wound is closed with dis-solvable sutures and dressing applied.

You would have had local aneasthetic block to the foot prior to the surgery. This means that when you wake up the foot should be reasonably comfortable and pain free.

What are the benefits of the surgery?

1. Increase motion – by removing the bone spurs the range of dorsiflexion (banding up) of the toe increases although it may not return to a normal range and some restriction will persist depending on the degree of the disease.
2. Reduce pain from impingement: When the toe moves up the bone spurs may impinge on each other causing pain. this can be reduced following the surgery.
3. Reduce friction in shoes: If the bone spur is very large it can cause friction in shoes causing pain. this can be alleviated after surgery.

What are the risks of surgery?

1. Swelling : this is common and will affect almost everyone. This will reduce gradually but it may take more than six months for the swelling to go down completely. It is important to elevate your foot in the early stages.
2. Infection: Wound or deep infection is uncommon after this surgery and occurs in less than 1-2 in 100. The risks can be higher in those with diabetes or in smokers. If infection occurs you may need further surgery to remove the hardware and may require prolonged intra-venous antibiotics. If you feel unwell, have a fever, there is oozing from the surgical incisions; or your leg feels hot and is red; then you need to seek medical attention as soon as possible.
3. Tendon injury: The tendons to the big toe are at risk of injury during the procedure. In particular the extensor tendon (EHL) that helps turn up the end of the big toe. The occurrence is however extremely rare.
4. Nerve injury or numbness: Sensory nerves around the big toe can occasionally be bruised or damaged during the surgery. This can give you an area of numbness on the back or one side of the big toe. In most instances this resolves over a few weeks however on occasions it may be permanent. These nerves are very small and the area of numbness is normally also small and generally is of no consequence. On occasions a regrowth of the nerve within the scar can become sensitive and this may need further minor surgery to excise.
5. Paradoxical deterioration of pain: On occasions gaining more motion in an arthritic joint may cause it to hurt more. This may mean that a fusion operation is necessary.

What happens on the day of surgery?

The surgery is performed as a day surgical procedure and you are often able to go home on the same day. Occasionally if the procedure takes place late in the afternoon or early evening then it may be advisable for you to stay for one night.

We perform the surgery under a general anaesthetic and you will meet and discuss your anaesthetic needs or concerns with our anaesthetist prior to surgery.

The surgery can take between 20-30 mins depending on the complexity. At the start of the procedure we will infiltrate a local anaesthetic “block” around the ankle. This will make the foot numb and help with post surgery pain. This lasts a few hours after the operation. so don’t worry if you cannot feel your toes when you wake up.

The incision is closed with dissolvable stitches in most but not all cases. You are likely to ‘wake up’ with needles in your arm for the anaesthetic agents (cannula) and a big bandage around the foot.

The surgery is done using a tourniquet around the thigh. This is to prevent blood getting into the operative field. This does means that occasionally your thigh might feel bruised and a little sore after the surgery. This is normal and usually settles in a day or two.

What happens after the surgery?

You will be transferred back to the ward where you will be seen by one of our  physiotherapists. You will be shown how to use crutches and will be allowed to fully weight bear on the operated foot wearing a sandal.  Once you are safely moving around and your pain is controlled you are discharged home. It is a good idea to have a friend or relative with you as an escort and to help during the first night at home. The pain is usually controlled because of the local anaesthetic in your ankle. Do take painkillers before this wears off to pre-empt the pain.

Weeks 0-2

Take it easy – It is best to avoid too many work or social activities and have time to rest and elevate the foot. You can use ice packs to control the pain and swelling.

The bandaging should be left undisturbed for the first 2-3 days and then reduced to the adhesive dressing over the cut. At this stage you may be able to convert to a pair of wide fitting shoes.  The wound should be kept dry for the first 2 weeks.

It is a good idea to do gentle exercises of the ankle and try and get around to allow circulation in your leg but need to spend regular periods elevating your foot. 

You will be reviewed by Mr Abbasian at around 2 weeks to check the wound and remove any stitches.

Weeks 2-6

You will be able to continue with a wide fitting shoe. Exercises of the big toe can commence. 

Months 2-4

Swelling, especially with use and the end of the day may continue during this time. You can now resume most of your usual activities including sports but these need to be introduced gradually. 

Months 4-6

 Expect ongoing swelling after heavy use.