Cheilectomy

Primary Indications

Absolute Indications

• Coughlin-Shurnas Grade I hallux rigidus: dorsal osteophyte impingement with pain at end-range dorsiflexion, full or near-full passive motion, normal or near-normal plantar articular cartilage
• Coughlin-Shurnas Grade II hallux rigidus: moderate restriction of dorsiflexion (less than 50% of normal), plantar cartilage at least 50% preserved on pre-operative assessment
• Failure of conservative management: minimum 3–6 months of modified footwear (stiff-soled or rocker-bottom shoe), activity modification, anti-inflammatory medication, and orthotic management

Relative Indications

• Isolated dorsal pain with active dorsiflexion impingement in younger, active patients
• Dorsal ganglion or synovitis at first MTP joint refractory to aspiration/injection
• Combined hallux valgus and early hallux rigidus where hallux valgus correction is the primary procedure and cheilectomy is performed adjunctively

Contraindications

• Coughlin-Shurnas Grade III with less than 50% of metatarsal head articular cartilage remaining: arthrodesis is preferred (Coughlin-Shurnas 2003)
• Coughlin-Shurnas Grade IV (stiff painful joint with pain through mid-range motion, severe cartilage loss): arthrodesis is the procedure of choice
• Active infection at or around first MTP joint
• Severe vascular insufficiency limiting wound healing
• Inflammatory arthropathy with active synovitis (relative — treat systemic disease first)
• Unrealistic patient expectations about residual stiffness

Coughlin-Shurnas Classification (2003)

The Coughlin-Shurnas system grades hallux rigidus on dorsiflexion range, radiographic appearance (osteophytes, joint space, sclerosis) and clinical pain pattern. It is the most prognostically validated of the 18+ described systems (Beeson 2008).

Grade 0

• Dorsiflexion 40–60° (10–20% loss versus the contralateral side); no osteophyte; no pain, only stiffness — non-operative management

Grade 1

• Dorsiflexion 30–40° (20–50% loss); dorsal osteophyte, minimal joint space narrowing; mild/occasional pain at terminal dorsiflexion — cheilectomy first-line

Grade 2

• Dorsiflexion 10–30° (50–75% loss); moderate dorsal/lateral/medial osteophytes, mild-moderate joint space narrowing and sclerosis; moderate-severe pain just before terminal range — cheilectomy appropriate

Grade 3

• Dorsiflexion 10–30° but plantarflexion also reduced; severe osteophytes, marked joint space narrowing, subchondral cyst/sclerosis; near-constant pain at extremes of range — cheilectomy only if 50%+ of metatarsal head cartilage remains at surgery, otherwise arthrodesis

Grade 4

• Same radiographic findings as Grade 3 but with definite pain on mid-range passive motion; severe cartilage loss
• Cheilectomy contra-indicated; arthrodesis is the procedure of choice

Evidence Base

Landmark Studies

Coughlin MJ, Shurnas PS (2003) — J Bone Joint Surg Am 85(11):2072–2088 (PMID 14630834)

• Prospective evaluation of one surgeon's practice over 19 years; 110 of 114 patients returned; 80 patients (93 feet) underwent cheilectomy, mean follow-up 9.6 years
• 97% of patients (107/110) had a good or excellent subjective result; 92% of cheilectomies (86/93) were successful for pain relief and function
• Cheilectomy was used with predictable success for Grade 1, Grade 2 and selected Grade 3 disease
• Patients with Grade 4, or Grade 3 with less than 50% of the metatarsal head cartilage remaining at surgery, should undergo arthrodesis
• No association found between hallux rigidus and first-ray hypermobility, functional hallux limitus, or metatarsus primus elevatus

Mann RA, Clanton TO (1988) — J Bone Joint Surg Am 70(3):400–406 (PMID 3126190)

• 25 patients (25 feet), mean follow-up 56 months; pain relief in 22/25, with three failures
• Joint motion improved by an average of 20°, reaching an acceptable range in 23 patients
• No patient required further surgery during follow-up; concluded cheilectomy was superior to arthrodesis, resection arthroplasty or flexible implant arthroplasty for this group
• Historically cited as establishing adequate dorsal resection to relieve impingement

Roukis TS (2010) — J Foot Ankle Surg 49(5):465–470 (PMID 20797588, systematic review)

• 23 studies, 706 isolated cheilectomies; 62 (8.8%) underwent surgical revision, most commonly arthrodesis (n=23)
• Grade-specific revision (6 studies): Grade I 20% (2/10), Grade II 14.8% (8/54), Grade III 9.1% (12/132), Grade IV 55.6% (5/9)
• The very high Grade IV revision rate reinforces that advanced (Grade 4) disease should not be treated with isolated cheilectomy
• Concluded the overall low revision rate supports cheilectomy as a first-line surgical treatment

Moberg E (1979) — Clin Orthop Relat Res (142):55–56 (PMID 498648)

• Original description of the dorsal closing-wedge osteotomy of the proximal phalanx; now combined with cheilectomy in high-demand Grade 2 patients to convert preserved plantarflexion into functional dorsiflexion (MTP-to-IP axis shift)

Failure Rates and Conversion to Arthrodesis

• Overall revision after isolated cheilectomy: 8.8% at mean follow-up over 12 months, most commonly conversion to arthrodesis (Roukis 2010, 706 cheilectomies)
• Revision is concentrated in advanced disease: Grade IV 55.6% versus Grade III 9.1% (Roukis 2010)
• Cheilectomy does not preclude later arthrodesis; salvage arthrodesis outcomes are comparable to primary arthrodesis
• Strongest avoidable predictor of early failure: failure to achieve adequate intra-operative dorsiflexion (target at least 70°) at the index procedure

First MTP Joint Architecture

Metatarsal Head

• Broadly convex articular surface covering dorsal and plantar aspects of the metatarsal head
• Dorsal 30%: Most commonly affected in hallux rigidus with osteophyte formation; this is the target of resection
• Plantar 70%: Usually well preserved in Grade I–II; the functional weight-bearing and toe-off surface — must be protected
• The dorsal-most point of the metatarsal head (apex of the osteophyte) typically migrates proximally with progressive disease, causing impingement with dorsiflexion

Osteophyte Distribution

• Dorsal metatarsal osteophyte: present universally; the primary target
• Dorsal proximal phalangeal osteophyte: present in 70–80% of cases; must also be removed
• Lateral and medial osteophytes: present in advanced disease; remove if causing impingement
• Sesamoid enlargement and periarticular bony proliferation: seen in Grade III–IV

Soft Tissue Relationships — Dorsomedial Approach

Medial branch of the dorsal cutaneous nerve

• Origin: Branch of the superficial peroneal nerve crossing the dorsum of the foot
• Course: Runs along the medial border of the extensor hallucis longus at the level of the first MTP joint; lies superficial to the joint capsule and first dorsal interosseous fascia
• Risk: Crosses directly over the incision zone in the dorsomedial approach

Extensor hallucis longus (EHL)

• Runs centrally over the first MTPJ; its medial expansion blends with the joint capsule
• The dorsomedial capsulotomy is made immediately medial to the EHL tendon
• Must be identified clearly before any capsule incision; retracted laterally during bony work

EHL expansion and dorsal capsule

• The dorsal capsule of the first MTPJ is thin and closely adherent to the EHL expansion
• Z-lengthening or longitudinal capsulotomy incision are both acceptable; longitudinal with flap elevation is preferred for exposure

Joint capsule and collateral ligaments

• Medial and lateral collateral ligaments arise from the metatarsal head and insert on the proximal phalanx base
• Preserve collateral ligament origins to maintain joint stability after cheilectomy
• Excessive lateral dissection risks lateral collateral ligament injury and predisposes to medial drift/hallux valgus

Sesamoid Complex

• Medial (tibial) and lateral (fibular) sesamoids lie in the grooves (crista) on the plantar metatarsal head
• Not directly at risk in standard cheilectomy; however plantar over-resection can disrupt the crista and destabilise the sesamoid mechanism

Blood Supply

• Metatarsal head receives blood supply from the plantar aspect via the plantar digital arteries and dorsal anastomoses
• Subperiosteal dissection must be limited to the dorsal aspect only; excessive plantar elevation risks avascular necrosis of the metatarsal head

Positioning and Preparation

Patient Position: Supine, foot at end of operating table; a small sandbag or bump under the ipsilateral buttock helps with foot rotation to improve medial access

Anaesthesia: General, spinal, or ankle block (posterior tibial, superficial peroneal, deep peroneal, sural, saphenous); ankle block excellent for ambulatory setting

Tourniquet: Ankle tourniquet at 250 mmHg or thigh tourniquet; ankle tourniquet is sufficient and reduces systemic tourniquet complications

Equipment: Standard small-joint set, osteotome (6–10 mm width), oscillating saw (optional), rongeur, small burr (optional for edge smoothing)

Operative Steps

Step 1: Skin Incision — Dorsomedial Approach

Mark incision: Longitudinal incision 5–7 cm centred over the dorsomedial aspect of the first MTP joint; 3 cm proximal to 3 cm distal to the joint line, placed in the internervous plane between the medial dorsal cutaneous nerve medially and the EHL centrally

Technique:

• Incise skin only; deepen carefully with scissors through subcutaneous fat
• Identify and protect the medial branch of the dorsal cutaneous nerve early — it runs just superficial to the capsule in this plane
• Use fine-tipped mosquito clamp to identify the nerve; loop with vessel loop if needed

Exam Pearl: The dorsal medial approach is preferred over a central dorsal approach because it allows medial capsule repair and keeps the EHL retracted laterally with tension on its natural lateral expansion

Step 2: Deep Dissection — Capsulotomy

Identify EHL: Confirm the position of the EHL tendon before any capsule incision; retract laterally with narrow Langenbeck or self-retaining retractor

Capsule incision options:

• Longitudinal: Incise capsule in line with the metatarsal shaft from 2 cm proximal to 2 cm distal to joint line; elevate medial and lateral flaps for exposure — preferred technique
• Z-plasty or T-shaped: Allows formal repair with possible lengthening if capsule tight; used when capsule is contracted

Periosteal elevation: Elevate periosteum off the dorsal metatarsal head circumferentially enough to fully visualise the osteophyte — 270° exposure (dorsal, medial, lateral, but NOT plantar); avoid plantar subperiosteal elevation

Step 3: Exposure and Assessment of Joint

Inspect joint surfaces:

• Confirm intra-operative grade: assess plantar cartilage quality directly (often visible on the metatarsal head with 20–30° plantarflexion)
• Quantify plantar cartilage preservation — if less than 50% then consider abandoning and planning arthrodesis as staged procedure (or convert immediately if pre-operative discussion included this contingency)
• Document loose bodies, synovitis, and osteophyte extent on all aspects of the joint

Decision point: If plantar cartilage is worse than anticipated (less than 50%), discuss with patient pre-operatively that arthrodesis may be required — joint conversion intra-operatively is acceptable if consent obtained

Step 4: Dorsal Osteophyte Resection — THE CRITICAL STEP

Marking the resection plane:

• Place a 6–10 mm osteotome at the dorsal margin of the normal articular cartilage
• Angle the osteotome at 30–45° relative to the metatarsal shaft axis to resect the dorsal 30% of the metatarsal head
• The cut should emerge at or just proximal to the dorsal cortical apex of the osteophyte

Technique options:

• Osteotome technique: Single controlled strike with mallet; bimanual control of osteotome is critical; an assistant can steady the foot
• Oscillating saw: More controlled and reproducible; saw blade angled at 30–45°; copious irrigation to prevent thermal necrosis

Phalangeal osteophyte: Inspect the dorsal base of the proximal phalanx — osteophyte present in 70–80% of patients; resect with rongeur or small osteotome until smooth and non-impinging

Smooth all edges: Use rongeur and burr to smooth all cut bone edges and remove any remaining sharp cortical margins; this prevents post-operative bony irritation and reduces the risk of heterotopic ossification recurrence

Step 5: Intra-operative Dorsiflexion Check — MUST NOT BE OMITTED

Technique:

• Release tourniquet (or release manual compression) if using ankle tourniquet and assess passive dorsiflexion of the hallux at the MTP joint
• Target: at least 70° dorsiflexion from neutral (plantigrade) at the first MTPJ

If target not achieved:

• Re-inspect for residual dorsal impingement (retained osteophyte, sharp cortical ridge, or phalangeal osteophyte)
• Further resect under direct vision
• Do not close until 70° is confirmed

Exam Pearl: Failure to achieve 70° intra-operative dorsiflexion is the strongest predictor of persistent symptoms and early failure — always perform and document this check

Step 6: Loose Body Removal and Joint Irrigation

Inspect thoroughly:

• Decompress joint with small laminar spreader to inspect plantar recess
• Remove all osteocartilaginous loose bodies with small rongeur or grasper
• Copious saline lavage (at least 500 mL) of the joint before closure

Step 7: Capsule and Wound Closure

Capsule closure:

• Close capsule with absorbable sutures (2-0 Vicryl or PDS); avoid over-tight closure which recreates dorsiflexion restriction
• The capsule should appose without tension with the toe in neutral
• If capsule deficient or cannot close, partial capsular repair is acceptable

Subcutaneous layer: Absorbable sutures (3-0 Vicryl); confirm nerve not caught in suture

Skin: Monofilament non-absorbable (3-0 or 4-0 nylon) or absorbable interrupted sutures

Dressing: Non-adherent dressing, soft padding; no plaster required; stiff-soled post-operative shoe applied immediately

Specific Management Pearls

Recognising and Managing Inadequate Resection

• Always test dorsiflexion before closure — this step cannot be skipped
• If dorsiflexion is less than 70°, return to the joint and perform additional resection under direct vision
• Common residual areas: lateral metatarsal head dorsal cortex (missed lateral corner of osteophyte), dorsal phalangeal base osteophyte
• Document intra-operative ROM in operative notes for medicolegal clarity

Conversion to Arthrodesis

• Cheilectomy does not preclude subsequent arthrodesis — salvage fusion outcomes are comparable to primary arthrodesis
• Pre-operative counselling must include the conversion risk (Roukis 2010: 8.8% overall revision after isolated cheilectomy)
• Patients with any of the following should be counselled that arthrodesis may be appropriate as a primary procedure: advanced (Grade 3–4) disease, under 50% metatarsal head cartilage, marked mid-range pain, high physical demands with extensive degenerative change
• Arthrodesis technique: dorsal plate with a separate lag screw across the joint; position at roughly 10–15° dorsiflexion relative to the floor (about 20–25° to the metatarsal shaft), 10–15° valgus, neutral rotation

Immediate Post-operative Phase (0–2 Weeks)

Weight-Bearing and Footwear

• Immediate full weight-bearing in a stiff-soled post-operative shoe is the standard protocol
• The stiff sole prevents dorsiflexion of the MTP joint, protecting the resection site and reducing pain
• Crutches are not routinely required but may be helpful for the first 24–48 hours for comfort
• Elevate foot above heart level for the first 48 hours to reduce swelling

Pain Management

• Simple analgesia: paracetamol + NSAID combination
• Consider regional ankle block with long-acting local anaesthetic (ropivacaine or bupivacaine) for first 12–24 hours
• Avoid NSAIDs if concern about wound healing or renal impairment

Wound Care

• Keep dressing clean and dry for first 10–14 days
• Suture removal at 10–14 days
• Scar massage begins after suture removal once wound fully healed

Intermediate Phase (2–6 Weeks)

Footwear Progression

• Weeks 2–3: Continue stiff-soled shoe; begin gentle active dorsiflexion exercises within comfort
• Weeks 3–6: Transition to normal footwear with a wide, deep toe box; avoid rigid narrow shoes
• Avoid high heels for a minimum of 3 months to protect the resected surface

Physiotherapy and ROM

• From day 1–2: Gentle active and passive dorsiflexion exercises — the aim is to maximise the ROM gained intra-operatively
• Scar mobilisation once wound healed
• Hydrotherapy walking after wound closure (typically from 2–3 weeks)
• Avoid forced passive dorsiflexion stretching in the first 2 weeks to protect capsule repair

Recovery and Return to Activity (6 Weeks to 6 Months)

Expected Outcomes

• Most patients are in comfortable regular footwear by 6 weeks
• Pain relief is typically early (2–6 weeks); ROM improvement continues for 3–6 months
• Return to sport (low-impact): 6–8 weeks
• Return to running and high-impact sport: 3–4 months; expect some permanent reduction in terminal dorsiflexion

Long-term Monitoring

Follow-up Schedule:

• 2 weeks: wound check, suture removal
• 6 weeks: assess ROM, footwear, return to activity
• 3 months: assess pain, function, AOFAS score
• 12 months: final outcome assessment; repeat weight-bearing X-ray if symptoms

Outcome Measurement:

• AOFAS Hallux Score (range 0–100): pre- and post-operative
• Patient-reported outcome: Visual Analogue Scale for pain, patient satisfaction
• Weight-bearing AP and lateral radiographs at 6–12 weeks

Warning Signs Requiring Urgent Review:

• Increasing pain, erythema, wound discharge after day 5 (suggests deep infection)
• Complete loss of dorsiflexion following initial improvement (suggests heterotopic bone or inadequate resection)
• Toe numbness or persistent dysaesthesia suggesting nerve injury