Jump to Treatment options / Cheilectomy / Fusion

Introduction

The knuckle joint at the base of the big toe is known as the first metatarsophalangeal joint or 1st MTPJ.

It takes considerable load throughout our lives, bearing all of our weight when running, walking and standing on tiptoe. It is commonly affected by wear and tear arthritis. The medical name for this condition is hallux rigidus. 

Hallux rigidus results in stiffness, pain, bony prominences which may rub on shoes. Sometimes the toe may become crooked and deformed.

 

 

Treatment options

Non-surgical

Patients with hallux rigidus should initially try wearing more supportive stiff-soled shoes which are large enough to prevent rubbing. A rigid insole may help by preventing excessive movement of the painful toe.

Avoiding activities such as running may also help. If the toe is very stiff, a shoe with a slight rocker bottom may help. There are several of these on the market, known as FitFlops and MBT trainers.

Injections

If these measures fail, the joint can be injected with steroid. This offers some short-term pain relief, but is not a long-term solution. Repeated injections can damage skin and soft tissues and are not recommended.

 

Surgical Options

There are two operations available. The amount of arthritis in the joint will determine which option is best.

 

Cheilectomy

If there is limited arthritis, but large bone spurs which limit movement and cause pain, the bone spurs can be removed.

This involves making an incision on the top of the toe and removing excess bone. This is called a cheilectomy. The advantage is that movement of the toe is maintained. The disadvantage is that the joint is left intact. Arthritis may progress, resulting in ongoing pain.

Recovering from a cheilectomy

After the operation, the toe is protected with a bandage. This should be left undisturbed and kept dry until you are seen in clinic at two weeks. At this stage, if the wound has healed, it is very important to get the toe moving. It will be sore at first, but gentle manipulation will prevent the toe from becoming stiff. You will be able to fully weight bear, although it will be swollen and sore for several weeks. Keeping the foot elevated is the best way to reduce this.

You should be able to return to work after two weeks for office-based work. If you have to stand for long periods or wear work boots you may need up to six weeks off.  

Most people are able to return to driving after four weeks, although this can be longer in some cases. You must make sure you are in full control of the car before you drive, and let your insurance company know you have had an operation. 

Risks and complications

The main complication is ongoing stiffness. Manipulation of the joint is usually successful in treating this. You may need physiotherapy. 

The joint will have been left intact, and sometimes arthritis can progress, resulting in ongoing pain. If this is the case, a future fusion may be required. Infection, nerve injury and blood clots are other potential risks.  The ‘Preparing for Foot Surgery’ information sheet has more information.

 

First MTPJ Fusion

If the entire joint is affected with arthritis or the toe is bent, the best option is to surgically fuse the joint.

An incision is made on the top of the toe, the joint is exposed and the damaged bone surfaces removed. The adjacent bones are then fused together with screws, staples or a metal plate.

The objective is to achieve solid bone healing so that there is no movement across the joint. This eliminates pain and corrects deformity. The disadvantage is that there will be no movement at the joint which will make wearing very high-heeled shoes impossible. Running long distances may be difficult.

 

Recovering from first MTPJ fusion

After the operation you will be in a stiff-soled shoe which allows you to bear weight through your heel but not the front of your foot. This protects the bone whilst it heals. In some cases a small plaster cast may be applied.

Dressings should be undisturbed and kept dry for the first two weeks until you are seen in clinic. You will need to wear the special shoe for at least six weeks. Your foot will be swollen and must be elevated most of the time. An X-ray after six weeks will confirm that the bone has healed. You can return to normal footwear at this stage, although your foot may be swollen for up to six months. Broad supportive flat shoes are best.

Most people can return to work and driving after six weeks. Some people require longer, particularly if they have a job which requires standing for long periods.

 

Complications

The main risk is of the bone failing to heal. This is much commoner in diabetics and smokers. If you smoke, you must stop before surgery.

When the joint is fused, the toe will be slightly shorter afterwards. This is normal.

Occasionally the screws, staples or plate may be felt under the skin when the swelling has subsided. If this causes irritation they can be removed after six months. There are risks of infection, nerve injury, blood clots and ongoing pain. The ‘Preparing for Foot Surgery’ booklet has more information. 

 

A note on joint replacement

In the past surgeons have tried replacing the first MTPJ with an artificial joint. The results have generally been poor. The artificial joint wears quickly and can come loose, resulting in recurrence of pain and deformity. Correction is difficult and often unsuccessful. Currently I do not recommend this treatment for most patients.

 

 

 

Who should you contact if you have a problem after surgery?

  

You will have clinic appointments two and six weeks after the operation. It is often helpful to write down any questions beforehand so you don’t forget them.

 

If you have a problem at any other time, please contact your consultant’s secretary on

 

(01424) 755470

 

In an emergency contact your GP

or attend the A&E department.