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Hallux Rigidus

Cheilectomy

CHEILECTOMY

Cheilectomy in Greek means ‘excision of lips’. The excision of the extra bone around the edges of an arthritic joint is a cheilectomy. In the big toe a cheilectomy has an 85% success rate. This means 15% of patients have on going symptoms and likely progress to a fusion.

 

I will also discuss with you a Cartiva implant to cushion the joint and possibly fill any cysts in the bone

What can I expect on the day of surgery?

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  • The surgery will normally be under a general anaesthetic.

  • Normally this is a day surgery case.

  • I will numb the ankle with local anaesthetic so that you will be comfortable when you wake.

  • There will be a bulky bandage on your foot and ankle which you will keep dry.

  • The outer bandage will be removed after 48 hrs but the adhesive dressing underneath must be kept clean.

  • You will be given crutches and a post op shoe to wear

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What are the risks and complications?

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The vast majority of patients do extremely well. A small group of patients need extra physio due to swelling or extreme stiffness. Rare complications include infection, DVT, nerve damage, fracture, recurrence, deformity, further surgery ( fusion of the joint) and CRPS.

 

The success rate of a cheilectomy is 85%. This means that 15% of patients having a cheilectomy will continue to pain and may opt to proceed to a fusion

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Clear Advice About DVT

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A DVT is a Deep Vein Thrombosis or a blood clot in the leg. A blood clot occurs after forefoot surgery for about 1 in every 400 patients. You can help prevent a blood clot by keeping your knee and ankle and toes moving. Keeping yourself hydrated is also helpful to prevent a DVT. Finally elevating your leg to the level of your heart will minimise the amount of swelling you have which will also help to prevent a DVT.

 

If you were the unlucky patient who developed a DVT you would likely have some symptoms:

  • The leg (above the dressing/foot) would become hard, heavy, swollen, painful and/or red

  • If you were to have any of the above symptoms you would have to have a scan to look for a blood clot and then be treated with blood thinners

If the blood clot were to move to the lungs you would have a pulmonary embolism which is a medical emergency

  • The symptoms of a pulmonary embolism are breathless & chest pain- Call 911

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When can I drive?

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The best guide that you are safe to return to driving is that you are able to walk well without crutches and without the surgical shoe. The usual time scale also depends on whether you had surgery on your right or left foot and whether you drive a manual or an automatic.

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  • Right side surgery and all car types: 2-3 weeks

  • Left side surgery and manual car:     2-3 weeks

  • Left side surgery & automatic car:     2 weeks

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How long will I need to off work?

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The time you require off from work depends on what type of job you do. The first two weeks of healing are critical and so you must have this time off work. Many people are able to work from home and so if you avoid commuting in the first three weeks, you will find that your foot does better. If you work on your feet all day, do a manual job, or are required to wear dress shoes you may need 4 weeks before you are back at work.

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What instructions will I have for the first 2 weeks after surgery?

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  • Elevate leg level to heart (above if swollen)

  • Keep foot dry for 2 weeks

  • Reduce Bulky dressing at 48 hours

  • Keep adhesive dressing intact for 2 weeks

  • Move Toes and Ankle

  • Weightbear in post-op shoe

  • Keep the big toe flat and don’t walk with the toe sticking up in the air

  • Please remember that standing and walking in the first 2 weeks puts pressure on the healing wound. The more you stay off your foot, the better your wound will heal.

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SELF EXERCISES

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Start immediately (Day 1) post op and repeat as often as you can.

(Please don’t remove your dressing these photos are just to illustrate clearly what you should do)

  1. In your dressing wiggle your toes up and down as much as you are able to do

  2. Grip the entire big toe and move the toe as far down as it will go and then as far up as it will go

      Passive Dorsiflexion                                                                                    Passive Plantarflexion

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What happens at 2 weeks in clinic?

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  • You will attend my foot & ankle clinic to check your wound

  • It is crucial that you learn how to do special exercises in this clinic appointment to teach the big toe to work normally (see below)

  • Reteach your big toe to rest on the floor (and not stick up in the air)

  1. Sit in a chair no splint THEN:

  2. Practice pushing your whole hallux down into the floor (Figure1)

  3. Once you are doing this well, lift your heel and start to push up onto tip toes (Figure 2)

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   FIGURE 1                                                                   FIGURE 2

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Physiotherapy and instructions for the period from 2 weeks to 6 weeks following surgery

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  • You may start to wear a roomy shoe

  • A lace-up shoe which you can loosen with a stiff sole will be better for you

  • Gradually increase the amount of time you spend standing and walking

  • Continue to elevate your foot when it is swollen

  • Continue to do the exercises to move the toe up and down regularly

  • Now add in exercises (shown to you in clinic) which work on ensuring your big toe can push down into the floor and then lift your heel off the floor

  • You may do pilates exercises/ abdominals and core (but only those where you are laying on a floor mat and no standing exercises)

  • Also stretch gastrocs, & hamstrings with theraband or towel wrapped around foot

  • Contrast bathing in hot and cold bowls of water

  • If K-wires, clean foot with a moist flannel but do not wet the wires

  • Wound massage with Bio Oil

  • Work on walking slowly but well

  • Walk Heel to Toe: heel contact, foot onto ground, move over your foot and make sure you use your big toe to push off off

  • Your physio can help you with developing a good gait

  • Walking speed will come over time

Clinic Appointment 6 weeks following surgery

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  • You will have a set of weightbearing radiographs

  • This clinic appointment is to check the function of your foot and to make sure you are on track for a good result

Physiotherapy and instructions 6 weeks+ following surgery

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‘SURREY STAGES’

The Surrey Stages is a Foot & Ankle Rehabilitation Program designed to continue to strengthen the healing tissues while preventing injury as healing takes place

 

BRONZE AWARD

  • DOUBLE HEEL RISES (DHR)

  • You can go up and down on tiptoes in sets of 3, slowly and 15 reps in each

  • You are working towards a normal gait (perhaps slightly slower to start)

  • All pilates exercises & gym equipment with foot plate (bike, rowing machine, X-trainer)

  • Note: If you and your physio are struggling to help you progress past the bronze award, start to wear a backpack and slowly increase the weight/ number of books in the back pack. Eventually you will be able to discard the back pack and progress to the Silver Award

 

SILVER AWARD

  • DOUBLE HEEL RISES WITH A LIFT

  • You go up on both feet but lift unoperated leg and lower slowly only on operated leg

  • 3 sets, working to 15 reps in each

  • You can stand both feet on a wobble board

  • You can hold a solid DHR for 20 seconds

  • You can skip on the spot (low height) with both legs

 

GOLD AWARD

  • SINGLE HEEL RISES

  • 3 sets, working to 15 reps in each

  • You can stand on one foot on wobble board

  • You can hold a solid DHR for 40+ seconds

  • Very gentle jogging

 

PLATINUM AWARD

  • Progress to hopping in all directions

  • Double and Triple Hops

More information

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Links to the Cartiva Website: http://www.bio-vation.co.uk/

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What is Cartiva made from?

A Cartiva implant is made from the same material as a contact lens but it is designed to be a thick plug that mostly is implanted into the bone. The plug sits proud within the joint so that it can act as a cushion to replace the action of the missing cartilage. There is now concern that the implant fails in women with weak bone and growing numbers of surgeons are concerned that the cartiva may fail more often then first thought.

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What is the International study which showed the Cartiva to be as successful as a 1st MTPJ fusion?

http://www.bjjprocs.boneandjoint.org.uk/content/97-B/SUPP_14/26

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What if the implant fails?

If the Cartiva fails, you will need to discuss your options about further surgery. There may be the option to replace the Cartiva implant with a new one but it may also be that the best decision is to fuse the joint.

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