What is it?

Cheilectomy is an operation to remove a bony lump on the top of the main joint of the big toe. This is almost always caused by arthritis of the great toe (sometimes known as “hallux rigidus”).

Why would it be performed?

This operation is performed either because the bony lump is pressing painfully on your shoes, or as a treatment for early arthritis of the big toe, when the joint is not yet badly affected. Some people have both reasons for surgery. If the lump is pressing on your shoes, you will probably have tried different shoes before coming to see the surgeon and there is usually no other option than surgery. If arthritis is the main problem, surgery would only be advised if other treatments, such as painkilling and anti-­inflammatory medicines, modifications to your shoes and injections had not helped.

What does the operation involve?

A cut is made on the side of the big toe. The lump is removed and the joint tidied. The joint is checked to see how bad the arthritis is. The joint is stitched up and dressings applied.  Sometimes the surgeon will recommend a ‘Moberg’s Osteotomy’ as well. This realigns the big toe a little so that it is more comfortable to walk. Some people will have been advised before surgery that, if the arthritis is worse than it appears on X­ray, another operation will be carried out. ­Your surgeon will discuss this with you before the operation. Surgery can sometimes be done using ‘keyhole’ techniques.

Can it be done as a day case operation?

If you are medically fit, have someone who can collect you and look after you after the operation and you are comfortable afterwards, the operation can be done on a day case basis. If you have other medical problems such as diabetes, asthma or high blood pressure, you may have to attend the preoperative assessment clinic 2­-6 weeks before your surgery. You may need to stay in overnight after your surgery. You must stay overnight in case of complications if there is no one to collect and look after you. The commonest reason for having to stay overnight after a cheilectomy is for pain control, as the operation involves cutting out a piece of bone. Local anaesthetic injections can help with this, but not everyone is comfortable to go home. The majority of people who have a cheilectomy are able to go home the same day.

Will I have to go to sleep (general anaesthetic)?

The operation can be done under general anaesthetic (asleep). Alternatively, an injection in the back, leg or around the ankle can be given to make the foot numb while you remain awake. Local anaesthetic injections do not always work and, in that case, you may have to go to sleep if the operation is to be performed. Your anaesthetist will advise you about the best choice of anaesthetic for you. In addition, local anaesthetic may be injected into your leg or foot while you are asleep to reduce the pain after the operation even if you go to sleep for the surgery. You will also be given pain­killing  tablets as required.

Will I have a plaster on afterwards?

No, you will not have a plaster on, just a firm bandage.

What happens afterwards?

You will usually come back to the clinic 2-3 weeks after surgery where a nurse will check your wound, remove sutures and you will be advised on exercises. You should then start to stretch your big toe up and down gently. This may hurt a bit, but it is important to get your toe moving early so it does not stiffen up. Obviously, we do not expect you to do this very vigorously at first, but, as the toe heals, you should be working harder and harder at it. Usually, you will be seen again about 6­-8 weeks after your operation and, if you are making good progress, then you need not come back. If the operation was done for the bony lump alone, it will almost never grow back. If the operation was done for arthritis, you will probably notice an improvement in the arthritic pain within a month.

How soon can I…

Walk on the foot?

You can do so immediately, but for the first 2-3 weeks you should avoid walking if possible and put all of your weight on the heel. When not walking you must rest with your foot elevated as much as possible to reduce swelling. When your stitches have been removed or trimmed you can be more mobile.

Go back to work?

This depends on what you do and how you get to work. If you have a sitting­ down job that you could do with your foot up most of the time and you can get to work, you could probably go back 3 weeks after surgery. If you have a heavy manual job, you may be away from work for up to 2 months. If you need to drive to work, this will affect when you can go back. Your surgeon or foot and ankle nurse will advise you about going back to work

Drive?

You can drive as soon as your foot is comfortable enough and you can wear a suitable shoe. Usually this is 3­-4 weeks after surgery. You must be comfortable and not too stiff before trying to drive. Start by sitting in the car and trying the pedals. Then drive round the block. Drive short distances before long ones. If you cannot safely make an emergency stop your insurance will not cover you in the event of an accident. Ask your surgeon or foot and ankle nurse when it is safe for you to drive again.

Play sport?

As the swelling in your foot goes down and it becomes less stiff, you can start gently  exercising your foot and walking further each day. When you are comfortable doing this you can start gentle running and stretching. Contact, twisting and impact sports can follow as comfort dictates. Everyone varies as to how quickly they can take up exercise again. Be guided by your own body’s reactions and the advice of your surgeon. Most people can return to most of their previous activities within 6 months of a cheilectomy.

Risks

• COVID-19 infection increases the risk of complications and we recommend you read the separate leaflet about this.  If you are in one of the vulnerable groups you should think very carefully about proceeding with surgery unless it is absolutely necessary.
• Chronic regional pain syndrome (CRPS).
• Some local skin infection can occur around the incision site. This is why it is important to elevate your foot as much as possible to prevent swelling which stretches the wound edges. There can be bleeding and bruising.
• Occasionally, the nerves to the top of the toe are bruised or stretched in the course of the operation, causing numbness or tingling on top of the big toe. This usually settles within about 6 weeks.
• The foot tends to swell up quite a lot after surgery. Swelling is part of your body’s natural response to any injury and surgery is no exception. In addition, your foot is at the bottom of your body so fluid tends to collect in its tissues (“at the bottom of the slope”) and cause swelling. People vary in how quickly this swelling disappears after an operation and 6 months is not all that unusual. Provided you are not having undue pain or inflammation there is probably nothing to worry about and you can afford to give it time.
• There are general risks with any operation that include blood clots (DVT & PE), anaesthetic complications and tourniquet complications. Generalised pain, swelling and stiffness can occur (CRPS). If the surgery is done for arthritis in the joint, this may progress over the next few years and you may eventually need further treatment, including possibly another operation.

Wellbeing advice

Patients that have a healthy diet, regular exercise and refrain from smoking prior to  surgery are more likely to experience quicker and better recovery and may also have a more successful outcome with their surgery. If you have any concerns about your general health and well being (diet, exercise, smoking cessation) you are encouraged to discuss this with your GP, who will be able to provide advise on the options available to you.