A cheilectomy is performed with use of regional anesthesia. The patient is
positioned on the operating table in the supine position. The leg is
exsanguinated with an Esmark bandage (Medline Industries, Mundelein,
Illinois), which is used as an ankle tourniquet. A dorsal longitudinal
incision is centered over the first metatarsophalangeal joint, extending from
the middle of the proximal phalanx 3 cm proximally. The dissection is deepened
on the medial aspect of the tendon of the extensor hallucis longus. The
extensor hood and joint capsule are incised. The capsule is preserved for
later repair (Fig. 1). The
joint is inspected, a complete dorsal synovectomy is performed, and any loose
bodies are removed. The percentage of remaining viable cartilage on the
metatarsal head is then estimated (Fig.
2). (If it comprises <50% of the metatarsal articular surface,
a cheilectomy is contraindicated.) Any dorsal osteophytes on the base of the
proximal phalanx are removed with a rongeur
(Fig. 3). The proximal phalanx
is plantar flexed to aid in the exposure of the metatarsal head. With a 6-mm
osteotome, an oblique osteotomy is performed, and dorsal, medial, and lateral
osteophytes as well as up to 25% to 33% of the metatarsal head are removed
(Figs. 4-A and
4-B). This resection is begun
just dorsal to the edge of the remaining viable metatarsal head articular
cartilage; thus, in cases of more severe arthritis, a more extensive
metatarsal head resection is performed. Too aggressive a resection may
increase the risk of metatarsophalangeal joint subluxation, and, thus, a
resection of >33% of the metatarsal head is discouraged
(Fig. 5). Typically, all or
almost all of the metatarsal head that is denuded of articular cartilage is
resected. At the conclusion of the resection, dorsiflexion of at least 70°
should be achieved (Figs. 6-A and
6-B). Any irregularities on the metatarsal articular cartilage,
including loose cartilaginous fragments, are removed. Should a small area of
denuded cartilage remain, it can be perforated with a small drill. The joint
is then lavaged. Bone wax is applied to raw bone surfaces to impede further
bleeding (Fig. 7). The capsule
is repaired beneath the tendon of the extensor hallucis longus with
interrupted absorbable sutures, and the skin is closed in a routine fashion
(Figs. 8-A and 8-B).
INDICATIONS FOR CHEILECTOMY:
Grade 1 (mild), Grade 2 (mild+), or Grade 3 (moderate) hallux rigidus.An enlarged dorsal prominence on the metatarsal head that restricts shoe
wear.Restricted range of motion of the first metatarsophalangeal joint that is
characterized by pain at the extremes of dorsiflexion and plantar flexion.A relative indication is a patient's desire to maintain active motion at
the first metatarsophalangeal joint despite substantial degenerative arthritis
of the joint. A thorough discussion, however, should cover the fact that, with
progressive arthritis, pain relief in this circumstance may not be complete
following cheilectomy.
Grade 1 (mild), Grade 2 (mild+), or Grade 3 (moderate) hallux rigidus.
An enlarged dorsal prominence on the metatarsal head that restricts shoe
wear.
Restricted range of motion of the first metatarsophalangeal joint that is
characterized by pain at the extremes of dorsiflexion and plantar flexion.
A relative indication is a patient's desire to maintain active motion at
the first metatarsophalangeal joint despite substantial degenerative arthritis
of the joint. A thorough discussion, however, should cover the fact that, with
progressive arthritis, pain relief in this circumstance may not be complete
following cheilectomy.
CONTRAINDICATIONS:
Extensive degenerative arthritis of the first metatarsophalangeal joint for
which an arthrodesis is preferable.Articular cartilage degeneration that extends over >50% of the
metatarsal head articular surface.A patient's desire simply to retain metatarsophalangeal joint motion (see
above).
Extensive degenerative arthritis of the first metatarsophalangeal joint for
which an arthrodesis is preferable.
Articular cartilage degeneration that extends over >50% of the
metatarsal head articular surface.
A patient's desire simply to retain metatarsophalangeal joint motion (see
above).
PITFALLS OF THE PROCEDURE:
The major pitfall with cheilectomy is pushing the indications for this
procedure too far. Adherence to the grading system as described in the
original article leads to a reliable result.With more extensive joint arthritis, pain relief is frequently
inadequate.Inadequate bone resection from the metatarsal head may prevent restoration
of adequate metatarsophalangeal joint motion. If impingement persists, the
cheilectomy may be unsuccessful.Excessive resection may destabilize the metatarsophalangeal joint.
The major pitfall with cheilectomy is pushing the indications for this
procedure too far. Adherence to the grading system as described in the
original article leads to a reliable result.
With more extensive joint arthritis, pain relief is frequently
inadequate.
Inadequate bone resection from the metatarsal head may prevent restoration
of adequate metatarsophalangeal joint motion. If impingement persists, the
cheilectomy may be unsuccessful.
Excessive resection may destabilize the metatarsophalangeal joint.
AUTHOR UPDATE:
The procedure has not changed at all since we first described it in
19791.
INDICATIONS FOR ARTHRODESIS OF THE FIRST METATARSOPHALANGEAL
JOINT:
End-stage Grade-4 degenerative arthritis or <50% of the articular
cartilage of the metatarsal head remains, which precludes an adequate
cheilectomy.Previous failed cheilectomy.Severe hallux valgus.Recurrent hallux valgus.Rheumatoid arthritis with forefoot deformity.
End-stage Grade-4 degenerative arthritis or <50% of the articular
cartilage of the metatarsal head remains, which precludes an adequate
cheilectomy.
Previous failed cheilectomy.
Severe hallux valgus.
Recurrent hallux valgus.
Rheumatoid arthritis with forefoot deformity.
CONTRAINDICATIONS:
Patients in whom the absence of metatarsophalangeal joint motion is
unacceptable.Severe osteopenia precluding adequate internal fixation.Recent joint infection.Less severe hallux rigidus with >50% of the metatarsal head articular
surface remaining.Vascular insufficiency that might impair adequate healing.Substantial interphalangeal joint arthritis with restricted range of motion
(<30°).
Patients in whom the absence of metatarsophalangeal joint motion is
unacceptable.
Severe osteopenia precluding adequate internal fixation.
Recent joint infection.
Less severe hallux rigidus with >50% of the metatarsal head articular
surface remaining.
Vascular insufficiency that might impair adequate healing.
Substantial interphalangeal joint arthritis with restricted range of motion
(<30°).
PITFALLS OF THE PROCEDURE:
Malalignment after the arthrodesis. It is critical to achieve neutral
rotation, adequate dorsiflexion, and adequate valgus. On the other hand, too
little valgus places the interphalangeal joint at risk of degenerative
arthritis while excessive valgus may cause difficulty in shoe wear. Likewise,
excessive dorsiflexion may cause pressure on the dorsal aspect of the toe,
whereas inadequate dorsiflexion may create pressure on the tip of the toe.Inadequate joint preparation, which may lead to a nonunion or fibrous
union. In the presence of sclerotic bone, meticulous joint preparation
requires reaming and débridement to cancellous bone surfaces to enable
a successful arthrodesis.
Malalignment after the arthrodesis. It is critical to achieve neutral
rotation, adequate dorsiflexion, and adequate valgus. On the other hand, too
little valgus places the interphalangeal joint at risk of degenerative
arthritis while excessive valgus may cause difficulty in shoe wear. Likewise,
excessive dorsiflexion may cause pressure on the dorsal aspect of the toe,
whereas inadequate dorsiflexion may create pressure on the tip of the toe.
Inadequate joint preparation, which may lead to a nonunion or fibrous
union. In the presence of sclerotic bone, meticulous joint preparation
requires reaming and débridement to cancellous bone surfaces to enable
a successful arthrodesis.
AUTHOR UPDATE
The original article reported on a series of patients who had undergone an
arthrodesis with preparation of the metatarsophalangeal joint with a curved
concentric reamer system followed by the application of a straight dorsal
plate that was bent to the appropriate alignment in order to achieve the
desired amounts of valgus and dorsiflexion. The reamers described in that
article are no longer available. A second-generation set of metatarsal head
and phalangeal reamers are now used. They are power driven and cannulated for
a central Kirschner wire, and they shape the corresponding metatarsal and
phalangeal surfaces concentrically. A second change is the means of internal
fixation. A titanium plate is now used. This plate has been shaped into
15° of dorsiflexion and 15° of valgus, which we believe minimizes the
chance of either inadequate or excessive dorsiflexion or valgus when
positioning the hallux.
Postoperative Care
One week following surgery, passive range-of-motion exercises of the
metatarsophalangeal joint are initiated. Patients are encouraged to exercise
this joint hourly. Weekly office visits are scheduled to monitor the range of
motion. Walking is permitted after surgery with full weight-bearing in a
stiff-soled postoperative shoe. Physical therapy may be ordered, depending
upon both the patient's compliance and the success with joint mobilization.
Typically, two to three months following surgery, most swelling subsides and,
at this point, maximal improvement regarding range of motion can be
expected.
Arthrodesis of the first metatarsophalangeal joint is performed with use of
regional anesthesia. The patient is placed on the operating table in the
supine position. An Esmark bandage is used to exsanguinate the extremity and
then is used as a tourniquet. A dorsal longitudinal incision is centered over
the metatarsophalangeal joint. It begins at the middle of the proximal phalanx
and extends 4 to 5 cm proximally. The incision is deepened along the medial
border of the extensor hallucis longus tendon
(Fig. 9) and is then deepened
through the extensor hood and joint capsule. The capsule is preserved for
later repair. On occasion, the extensor hallucis longus tendon must be incised
to obtain adequate exposure; when this is performed, the tendon should be
repaired at the conclusion of the procedure. The joint space is
débrided, loose bodies are removed, and peripheral osteophytes are
resected (Fig. 10). A sagittal
saw is then used to remove the medial eminence. In the presence of a long
first ray, a thin wafer of bone is removed from the distal first metatarsal
articular surface. The proximal phalanx is then plantar flexed, and a 0.062-mm
Kirschner wire is centered on the first metatarsal head articular surface and
driven in a proximal direction. A power-driven small joint reamer is then used
to prepare the metatarsal head surface for arthrodesis. A concave cannulated
metatarsal reamer is used to create a convex metatarsal head surface (Figs.
11-A,
11-B, and
11-C). The Kirschner wire is
then removed, and attention is directed to the proximal phalanx. Another
Kirschner wire is centered on the articular surface of the base of the
proximal phalanx and driven distally to prepare for the cannulated reaming. If
the surface is quite sclerotic, it is perforated with several drill-holes
prior to the reaming (Fig.
12). A convex cannulated phalangeal reamer is used to prepare a
concave cup-shaped surface in the proximal phalanx. This surface matches the
prepared metatarsal head surface (Fig.
13). The Kirschner wire is removed, and any joint debris is
resected. These congruous cancellous joint surfaces are then coapted in the
desired position. Typically, the hallux is placed in neutral rotation, 15°
of valgus, and 20° of dorsiflexion in reference to the axis of the first
metatarsal. After proper alignment is obtained, the arthrodesis site is
temporarily stabilized with a single 0.062-mm Kirschner wire (Figs.
14-A,
14-B,
14-C,
14-D). Next, a six-hole
mini-compression plate is placed on the dorsal surface and is fixed with six
bicortical screws. The plate is placed just lateral to the midaxial line to
maintain 15° of valgus. A dorsal bend of the plate allows better
conformity in order to achieve approximately 15° to 20° of
dorsiflexion of the proximal phalanx in relation to the metatarsal
(Fig. 15). A lag screw is then
directed from distal medial to proximal lateral, crossing the joint surface
and replacing the Kirschner wire (Fig.
16). If incised, the extensor hallucis longus is then repaired.
The closure is identical to that for cheilectomy
(Figs. 17-A, 17-B, and
17-C).
Postoperative Care
Gauze and tape compression dressing is applied at the time of surgery and
is changed every ten days for the next eight to twelve weeks until there is
radiographic evidence of a successful fusion. The patient is allowed to walk
in a stiff-soled postoperative shoe following surgery. Weight-bearing is
allowed on the heel and the lateral aspect of the foot. The first ray is
protected until there is radiographic evidence of fusion.