Stepping on Toes: Is Cheilectomy Better than Arthrodesis for Mild-to-Moderate Hallux Rigidus?
Many patients with hallux rigidus don’t want to jump immediately to fusion. Cheilectomy offers a joint-preserving alternative.
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Although the traditional treatment for end state hallux rigidus has been fusion, many patients are reticent to turn immediately to arthrodesis. At Cleveland Clinic, our podiatry group has addressed this issue by studying the results of cheilectomy in patients with severe arthritis.
The cheilectomy involves resection of 20 to 30 percent of the dorsal metatarsal head, where there is typically denuded cartilage and osteophyte formation (Figure 1). The procedure has several advantages. First, the surgery provides the patient with an alternative to surgical procedures that can be joint destructive, such as arthrodesis.
A cheilectomy preserves and restores the first metatarsophalangeal joint (MTPJ) range of motion more than an arthroplasty or arthrodesis. Following a cheilectomy, the first MTPJ passive range of motion has been shown to increase between 17 and 46 degrees (Figure 2). The procedure also preserves the length of the first ray and respects the sesamoid apparatus and intrinsic pedal musculature, maintaining the stability of the first metatarsophalangeal joint.
The primary concern with performing a cheilectomy versus an arthrodesis is the recurrence of arthritic degeneration — reformation of the dorsal exostosis and progression of chondrolysis and joint deterioration. This may result in the return of joint pain and functional limitation. Fortunately, the post-procedural cheilectomy joint can easily be converted to an arthrodesis at any time without any issues.
We tested a number of satisfaction variables, including current pain, range of motion, limitations and return to function, among others. The success of the cheilectomy procedure in our study (87.69 percent) is consistent with satisfaction rates in the literature which range from 72 to 97 percent. We found that cheilectomy for hallux rigidus grades 1 through 3 yields favorable satisfaction outcomes after long-term follow up (average 7 years). In the largest cheilectomy study on 93 patients, Coughlin and Shurnas reported that 97 percent of patients had good or excellent results.
In our study, the highest mean satisfaction rates were reported in radiograph stages 2 and 4 of 93.53 percent (n = 17) and 93.75 percent (n = 4), respectively. Coughlin and Shurnas concluded that patients with extensive degeneration of the joint or grade 3 joints involving greater than 50 percent of the articular surface should be treated with an arthrodesis.
Complications with the procedure include transfer metatarsalgia (6 percent), pain or stiffness in the joint (9 percent) (10), and sesmoiditis (25 to 86 percent). However, these complaints are generally temporary and resolve in less than 6 months. A prior study noted a 30 percent recurrence rate of dorsal osteophytes following a cheilectomy. In our study, a subsequent arthrodesis was performed in only two of 60 (3.33 percent) patients.
There were several limitations of our study including its retrospective nature and the number of patients included. We hope these results will help prompt the prospective or randomized control trials that are necessary to further evaluate this procedure.
Nonetheless, the cheilectomy yields favorable, long-term outcomes for hallux rigidus grades 1 through 3. The likelihood that this procedure necessitates a subsequent first MTPJ arthrodesis is low. An aggressive cheilectomy is a valuable procedure for a patient with hallux rigidus and should not be overlooked.
Dr. Nicolosi is a podiatrist in the Department of Orthopaedic Surgery.