Cheilectomy Post Op: Patient Shares Post Op Course

    Comment Posted January-22-2014

      I am 2 weeks post opt rom having a cheilectomy done on left foot. I am pretty pleased with how it is going and am in a soft shoe most of the time. 13 staples taken out 3 days ago and this seems to be quite sensitive where these were taken out and healing is slow. Hoping in 2 weeks I have greatly improved by then. Less is more for this type of problem and my doctor feels a fusion is last option to consider.

 I'm 49 year old female very active and a runner so will keep you posted on my recovery. My hallux rigidus was quite bad and it was time to do something about it. Good luck everyone and if I can be of any help let me know.

Dr Blake's comment: This kind patient is post cheilectomy for Hallux Rigidus. She has agreed to respond to comments or questions. I am very appreciative. 

Hallux Rigidus: Email Advice

Hi there Doctor  Rich..... you earned it and I feel I need to address you appropriately),

Today, I just returned from yet one more podiatrist visit.  And now...I am thoroughly confused.  Let me back up a bit....I had been searching for foot help on the internet.  That's how I found your blog.  I also found Dr. Huppen of Seattle, WA.  You both have very extensive sites with great information.  Regarding Dr. Huppen who I found first...well, his site was so amazing and helpful about orthotics and showing foot anatomy and what happens when a flat foot walks without support that I actually called his office for a reference.  He publishes articles and speaks at conferences and I thought in his travels he might know someone in the Milwaukee area.  He did refer me to a Dr. Brant McCarten who was familiar with Dr. Huppen.  And then ....I found your blog which was so helpful. But I can't fly to Seattle or San Francisco, so I went to visit Dr. McCarten hoping that all I needed were the right orthotics and appropriate shoes and my hallux rigidus would stabalize and I could live without a chielectomy.

So my plan right now is this....I am having orthotics made with support under the middle of my foot to alleviate pressure on big toe and support my flat feet.  This orthotic...it will not be under my big toe...Dr M. wants my toe to move somewhat as that is what it is meant to do,so it will end before it hits the base of my toes.   But Dr. M outlined how he could very easily help my problem....do a cheilectomy.  

Why I am writing to you....I would like to hear your thoughts about the chilectomy procedure and it's ability to alleviate hallux rigidus. I have heard that having the cheilectomy is a slippery slope which ultimately leads to the fusion surgery.   I truly don't want to have the surgery that fuses it.  Can't wrap my head around that right now. I have read about folks that were very happy with the results after having the chilectomy.  I have also read about those that were unhappy with the results.  This doc has done many of these procedures....he works with lots of athletes.  

I have been very athletic ...for the past 33 yrs...running (which I stopped 14 yrs ago) biking, inline skating, cardio/stepping....racquetball.  And now my life is whittled down....mostly doing pool work....swimming into a stream (I don't know the exact name of it), and other water aerobics.  A little bit of inside biking and elliptical...but my heels are starting to hurt recently.    I have to walk very slowly in the orthotics that I have so my joint doesn't hurt...so I am even moving slower these days.  It's getting to me emotionally, I regret to say.  I know I have to wait till these orthotics come in and see if they need adjustment...then I have to wean into them.

And as I sit here...I can feel my heels talking to me....not sure if it's cause the Xelero sneakers which are new...and possibly are too dense and don't give enough.  I have been on a never ending search for comfortable work shoes (I am an elementary school teacher...walking on hard stone tiles all day).  

So Doc, I would appreciate your thoughts.  And suggestions for shoes.  I have very narrow feet as well.  

With respect,

Jenna (name changed due to witness protection)

Dear Jenna, 

     Thank you so very much for the wonderful email. Cheilectomy is a wonderful procedure, but can go wrong even in the best surgeon's hands. They need to have a feel on how much bone and good cartilage to remove from the top of the joint (typically as little as possible but still get the job done). Lack of pre-op MRIs are one of the major causes of poor results. The MRI should point to where all of the bone spurs to be removed are, and if removing them will lead to joint restrictions post op. The MRI will also tell the surgeon if there are significant cartilage damage deep within the joint that may warrant a joint replacement in the future, or at least micro fracture surgery at the same time of the cheilectomy. The standing AP foot x-rays should tell the surgeon if the first metatarsal also should be shortened at the time of the surgery with an osteotomy (surgical bone break with screw fixation). So, I am not afraid of cheilectomies. They work best with mainly medial and lateral spurring, and least with major dorsal (top) spurring with absence of dorsal cartilage. The more the dorsal bone needs to be removed, the more post op physical therapy is needed to attempt to get the range of motion back, and probably the more luck is needed. From 2 weeks, when the stitches come out, to 12 weeks, physical therapy is crucial in a lot of instances when the dreaded frozen toe syndrome is expected. Golden Rule of Foot: Go into a cheilectomy with Plan B as a joint replacement, not fusion. I hope this helps. I will have to discuss narrow work shoes at another time. Rich

Initial Workup Hallux Limitus for potential surgery

This wonderful young lady (my age) presented to the office to discuss surgery on her big toe joints. She has a bone spur on the top of the joint that is painful to wear shoes (especially non athletic). A surgeon had recommended removing the bone spur in a relatively simple procedure by shaving the top of her joint. Where this may be perfect, I have had too many patients that have problems when the joint itself is damaged. Removing the spurs from the top of the foot removes bump pain, but can increase bending pain. The shaving procedures typically cause scarring of the ligaments on top of the joint permanently limited the range of motion further. It is rare that patients get more range of motion after surgery, typically less, so jamming of the joint with bending can occur easier. 

Here are the x rays that she brought into the first visit. We are now going to get MRIs to look at the internal nature of the joints and see if they are damaged. Can you guess what joint has more damage and what joint has less range of motion because of that fact from looking at these photos? First 3 are the left side, and the second 3 are the right side.

It is the left side that is worse in range of motion and pain, but the x rays really can not say that for sure. There are suggestions that both joint surfaces will have too much damage (osteoarthritis) to qualify for this bone shaving. The decision may be to implant or fuse. I prefer to implant these joints, since there is no going back once it is fused. The patient has over 40 degrees of range of motion now on the left and 55 degrees on the right. 

Hallux Rigidus Post Cheilectomy: Email Advice

Hi Dr. Blake,

I am in tears at finding your blog site; I have been so frustrated and I realize that everything I’ve been told to do with my foot hasn’t helped. 

 My condition is I believe hallux rigidus, although it has been called “arthritis in great toe joint” by my podiatrist.  I am 45 years old, and love to run.  I am in a bit of a crisis with my left foot.  I had a cheilectomy in July of last year (big toe joint cleaning procedure), after suffering for 3 years with a bone spur on the top of my great toe joint.  The podiatrist I saw told me that orthotics would not help, and that surgery was the only option to remove the spur (I have always been very healthy, and never thought to question his prognosis; I know better now). 

 I did not want surgery, but could not walk or run anymore without significant pain.  I had the surgery.  Since that time, I have lived in what feels like a very painful nightmare.  My doctor told me that I would be running again within two weeks post-surgery.  The swelling after surgery was significant, and I knew something wasn’t right, so I requested physical therapy.  The physical therapist had me stretch my toe joint and get back hard into activity and I received very little relief.  At nine months post-surgery, the pain was still limiting, and I feared that my return to jogging and activity was exacerbating the problem, along with the stretching routine, so I requested more physical therapy.  The therapist worked hard on everything in my foot but my great toe joint, saying that I need to stretch it by placing the toe on a wall and bending in for 5 minutes at a time to keep it from stiffening up.  I have been doing that and jogging, and now I feel that I’m in a mess.  The pain is so severe I can barely get from place to place.  My podiatrist said it’s just arthritis and is talking more surgery, after giving me a cortisone injection last week, which didn’t help.  I bought dansko shoes for work, but even they hurt, and I fear that I’ll always be in pain and that I’ll never have any normal function in my foot.

I am a mother of two pre-teen children, just graduated from grad school and in August started my dream job of teaching, and I feel like I’m at square one in treating my foot pain.  I desperately need help to know what to do to first.  I have an appointment to see an orthopedic surgeon soon, but I feel I need to start somewhere now.  Where should I start?  I know now that “hitting it hard” physically has exacerbated my symptoms.  I will switch to biking, yoga, and swimming.  I can’t walk one step without pain, so should I try taping, inserts, etc., as well?  I feel that I’m at square one with very little guidance and no one to turn to. 

I would very much appreciate advice on where to start…insoles? More physical therapy? Taping?  The pain is excruciating when I walk, so I know to take it easy, but for how long and in what ways?

Thank you so much!

Gerry (name changed)

Dr Blake's response:

     Thank you so very much for the email. First of all, for the next 3 years, you need to create as much of a pain free environment as you can, and as quickly as you can. Please go into a removable boot, with EvenUp for the other side. This should be combined with icing 3 times a day to calm the joint down. After 1 month you will have a new outlook on this, and we can email more. There are 3 phases of Rehabilitation: Immobilization, Re-strengthening, and Return to Activity and you need to be in the first phase for now. As the joint calms down, you then begin  to wean off the cast which can take 2 to 6 weeks. You need to be in shoes and inserts that provide protected weight bearing. Do not mobilize the joint for the next several months at least. The information gained from an MRI would be wonderful to have. 

     I try to tell my patients that there are 3 basic types of surgery for this condition: clean out (cheilectomy or arthroplasty), toe implants, and toe fusion. I love to have patients have a cheilectomy if the spurring is superficial (which yours sounded like), but even before they have the cheilectomy they must be ready for the implant if it does not work. Unfortunately, you really should not run with an implant, so your doctor probably just did not want to go there in that discussion. So, no one would argue too much if you had the implant. 

     Bone surgery takes time to heal, and we must honor that. Following cheilectomies,  some runners can get back quickly (3 months or so), but others take 6-12 months. It is a Bell Shaped curve. Most times this is hard to predict. 

     For now, cross train as you mentioned, ice several times a day, move the joint gently, often, but never with pain (since you can not know if you are hurting it), use the boot, get a carbon graphite plate, get orthotics that off weight, learn how to do dancer's pads and spica taping, experiment with hiking boots and shoes with rockers (like New Balance 980 or 928), and come to peace now that running may be back in 2015 or 2016. 

     I definitely would love to see an MRI now and in 6 months. In that 6 month comparison, you can get a great idea how the joint is healing, or not. Good objective decisions can be made then, not now. Avoid any more cortisone shots since it can mask pain and weaken the joint, unless you have definitely made the decision to do surgery in the near future. Honor your pain now, it really is your friend, it is telling you something. I hope this helps some. Rich

Cheilectomy Post Op: Email Advice

Good evening, I had the cheilectomy surgery Nov 6 2013

Dr Blake's comment: A Cheilectomy (also known as an arthroplasty) is basically a joint cleanup of the big toe joint when arthritic spurs and cartilage damage is noted. Like meniscal repairs and cleanups of the knee, it may be the precursor of a partial or complete joint replacement. 

I was making good progress I thought. Recently, I am having a lot of soreness behind the big toe actually the entire toe is sore and nerve sensations are occurring.  I limp because of this soreness. 

Dr Blake's comment: If you read the post on Good vs Bad Pain, you are definitely in the Bad Pain side of things. What can you do to help this? Some common changes you can make are: daily ice pack for 10-15 minutes three times a day, learning spica taping, wearing a removable boot or another stiff sole shoe any time possible for the next several months, trying to make yourself dancer's pads to off weight, and going to PT for advice and anti-inflammatory treatments. 

 I went for my check up 6 months  he said to get some insoles for my sneakers but I  wear a 2 inch heel at work.

Dr Blake's comment: There is some many factors involved in finding a comfortable heel to wear. You definitely want to go shoe shopping. Try 20 different pairs of 2 inch heels and you will find some much more comfortable than others based on stiffness, padding, volume, flexibility, etc. 

  He said I was pushing my toe down causing pressure from wearing this small heel. He is a Orthopaedic surgeon for the foot and ankle.  I don't have much cartilage left by looking at my X-ray.   I am very active with weight lifting and stair stepping everything bothers my foot.  Further Surgery I don't think I want.  It's been 6 months and somewhat worse than 2 months ago for some reason.

Dr Blake's comment: When you are in a flare, which is very common for this and many surgeries during the first year, it is important to figure out how to get out of the flare as soon as possible. If that means a removable boot every weekend and evening after work for several weeks, so be it. If it means icing 5 times daily, and a good dose of oral meds, and shoe changes and physical therapy, so be it. See if you can begin to experiment and find what seems to help at least some, and then take the additive approach of finding multiple things. Hope it helps. Rich