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Why You Should Consider Cheilectomy As A First-Line Treatment For All Stages Of Hallux Rigidus
Emphasizing the joint-sparing nature of the procedure and infrequent complications, these authors discuss the benefits of cheilectomy for hallux rigidus.
Hallux rigidus is defined as progressive lack of motion at the first metatarsophalangeal joint (MPJ) secondary to degenerative arthritic changes to the joint cartilage.1 There are a variety of surgical treatment options for hallux rigidus that have become available to foot and ankle surgeons in the last several decades.
The choice of procedure is based upon the severity of hallux rigidus. In 2003, Coughlin and Shurnas published the most commonly used 0-4 staging system that highlights the progression of this condition.2 Additionally, the choice of procedure is based upon the patient’s age, goals, expectations, job requirements and activity level. Surgical treatment is categorized as being either joint-preserving or joint-destructive. Most foot and ankle surgeons advocate joint-preserving options for early stages of hallux rigidus and joint-destructive options for late stages of hallux rigidus.
Cheilectomy is broadly defined as the removal of loose joint bodies with additional removal of approximately 25 to 33 percent of the first metatarsal head dorsally, and ideally 70 degrees or more dorsiflexion available intraoperatively.2 Surgeons have typically used this procedure for early stages of hallux rigidus with good results. However, based on the recent literature, cheilectomy can be useful as a first-line treatment for all stages of this disease. This is due to its inherent simplicity, low complication rates, preservation of joint motion and ease of revision to arthrodesis in the incidence of failure.
Accordingly, let us take a closer look at the utility of cheilectomy for all stages of hallux rigidus as it has yielded consistently good results with minimal complications.
Why Should You Consider Cheilectomy?
Multiple authors have demonstrated high success rates with the cheilectomy procedure. In a systematic review article looking at 23 studies consisting of a total of 706 cheilectomies, Roukis found an overall success rate of 91.2 percent with a low revision rate of 8.8 percent from cheilectomy to arthrodesis over an average 12-month follow-up period.3 This low complication rate supports the use of cheilectomy as a first-line treatment. In a more recent study, Bussewitz and colleagues in 2013 found an overall 98.5 percent success with a failure rate of 1.5 percent in 189 consecutive patients with grades 1-3 hallux rigidus who had a cheilectomy over an average 3.2-year follow-up.4 In 67 of the cases, surgeons performed adjunct procedures including osteochondral drilling, first metatarsal osteotomy and proximal phalanx osteotomy, highlighting the ability to perform adjunctive procedures with cheilectomies.
Further evidence has shown the benefits of cheilectomy, even in later stages. Easley and coworkers in 1999 reported an overall 87 percent success rate for grades 1-3 hallux rigidus in 52 patients with an average follow-up of 63 months.5 They noted that patients with grade 3 hallux rigidus had results comparable to those with grades 1 and 2 hallux rigidus.5 Cetinkaya and colleagues reported no failures with cheilectomies for 22 moderately active patients with grade 3 hallux rigidus with an average follow-up of 24.8 months.6 Despite the relatively short follow-up period and small sample size, this study reveals no revisions when utilizing the cheilectomy as a first-line procedure for late- stage hallux rigidus.6
In the study with the longest follow-up to date, Coughlin and Shurnas in 2003 found that out of 93 of the 110 patients who had a cheilectomy, only seven (8 percent) had failed in the mean 9.6-year follow-up.2 This 92 percent success rate is comparable to their significantly smaller arthrodesis group in which 32 out of 34 patients (94 percent) had successful fusion during a 6.7-year postoperative follow-up period.2 On clinical evaluation, the total range of motion (ROM) at the time of final follow-up averaged 64 degrees with the average dorsiflexion of the first MPJ improving from 14.5 degrees preoperatively to 38.4 degrees postoperatively. The average American Orthopaedic Foot and Ankle Society (AOFAS) scores increased from 45 preoperatively to 90 postoperatively. Of the seven failed cheilectomies, five feet were originally classified as stage 4 and the patients elected for cheilectomy. These five went on to arthrodesis at a mean of 6.9 years after the cheilectomy. Further evaluation of these patients revealed less than 50 percent of the remaining metatarsal head cartilage at the time of initial surgery, suggesting that primary arthrodesis may be a better treatment option. However, cheilectomy is still a viable initial treatment for stage 4 as it still afforded these patients an average of 6.9 years before arthrodesis was necessary.
A more recent retrospective study in 2015 by Nicolosi and colleagues looked at the long-term results of cheilectomy over a mean follow-up of 7.14 years.7 Out of 58 patients, the average success rate was 87.69 percent with 51 (87.93 percent) reporting no limitation to daily activities. Only two patients (3.3 percent) failed and went on to arthrodesis. At the time of surgery, 49 out of 58 patients were able to be classified radiographically according to Coughlin and Shurnas.2,7 Eight (16.33 percent) patients were grade 1, 17 (34.69 percent) were grade 2, 20 (40.81 percent) were grade 3 and four patients (8.16 percent) were grade 4. The average survey satisfaction score postoperatively after cheilectomy was 82.49 percent, 95.53 percent, 84.8 percent, 93.75 percent for patients with stages 1, 2, 3 and 4 respectively.7 Despite the small sample size of stage 4 patients, these results suggest that with such high success rates over a 7.14-year period, an isolated cheilectomy is worth considering as a first-line surgical treatment for all stages of hallux rigidus.
Why Not Perform Joint Destructive Procedures Initially?
Joint destructive procedures typically address end-stage hallux rigidus with the three most common procedures being joint implant arthroplasty, resection arthroplasty and arthrodesis.8 In their multicenter retrospective study, Kim and colleagues compared the outcomes of all three of these options in 158 patients (105 females, 53 males) over a median postoperative period of 159 weeks.8 Fifty-one patients had arthrodesis, 52 had a hemi-implant and 55 had resectional arthroplasty procedures with no significant difference in age between groups. The results revealed no statistical difference between groups in terms of AOFAS and modified AOFAS scores.8
However, the authors noted the following complications.8 In the arthrodesis group, there was metatarsalgia (9.8 percent), non-union (7.8 percent), malalignment (7.8 percent), hallux interphalangeal joint pain (3.9 percent) and delayed union (2 percent). Surgeons performed three revisions with two fusions using a bone graft and one fusion not requiring a bone graft. The authors reported that the most prevalent complication for arthrodesis was a combined 9.8 percent rate for non-unions and delayed unions, which is consistent with published literature ranging from 2 to 13 percent non-union rates.8
In the hemi-implant group, complications included bony overgrowth into the joint (28.8 percent), radiolucency around the implant (19.2 percent), migration of the implant (15.4 percent), dorsal drift of the hallux (11.5 percent), cystic changes around the implant (7.7 percent), metatarsalgia (7.7 percent), elevation of the first ray (5.8 percent), subsidence of the implant (1.9 percent) and sub-first metatarsal pain (1.9 percent). Surgeons performed two revision surgeries and involved the removal of the implant with resectional arthroplasty in both cases.8
In the resectional arthroplasty group, complications included floating hallux (30.9 percent), metatarsalgia (14.5 percent), sesamoiditis (5.5 percent) and remodeling/regrowth at the head of the first metatarsal (3.6 percent). No revision surgeries occurred in this group.8
The results of these procedures highlight not only the variety of complications that can arise from these joint destructive procedures but also the severity and difficulty of revision surgeries in comparison to the cheilectomy.
In Conclusion
Cheilectomy is a great first-line surgical treatment option for all stages of hallux rigidus. This is due to its inherent simplicity, low complication rates, preservation of joint motion and ease of revision to arthrodesis in the incidence of failure. The literature supports the use of cheilectomy for all stages of hallux rigidus.
Lastly, cheilectomy is an ideal first-line surgical treatment option because it does not "burn any bridges" if revision is required. With any joint preserving procedure, the ultimate goals are to reliably decrease or eliminate pain, and increase or maintain joint motion in both the short and long-term with minimal complications while allowing for easy revision to a joint-destructive procedure in the long term if necessary.1 The cheilectomy consistently achieves these goals and thus deserves consideration as the first-line surgical treatment for all stages of hallux rigidus.
Dr. Hook is in practice at Midland Orthopedic Associates and is affiliated with the residency program at Mercy Hospital and Medical Center in Chicago, IL.
Dr. Wilson is a first-year resident at Mercy Hospital and Medical Center in Chicago, IL.
References
1. Perler AD, Nwosu V, Christie D, Higgins K. End-stage osteoarthritis of the great toe/hallux rigidus. Clin Podiatr Med Surg. 2013; 30(3):351-395.
2. Coughlin MJ, Shurnas PS. Hallux rigidus: grading and long-term results of operative treatment. J Bone Joint Surg. 2003; 85(11):2072-2088.
3. Roukis TS. The need for surgical revision after isolated cheilectomy for hallux rigidus: a systematic review. J Foot Ankle Surg. 2010; 49(5):465-470.
4. Bussewitz BW, Dyment MM, Hyer CF. Intermediate-term results following first metatarsal cheilectomy. Foot Ankle Spec. 2013; 6(3):191-195.
5. Easley ME, Davis WH, Anderson RB. Intermediate to long-term follow-up of medial-approach dorsal cheilectomy for hallux rigidus. Foot Ankle Int. 1999; 20(3):147-152.
6. Cetinkaya E, Yalcinkaya M, Sokucu S, Polat A, Ozkaya U, Parmaksizoglu AS. Cheilectomy as a first-line surgical treatment option yields good functional results in grade III hallux rigidus. J Am Podiatr Med Assoc. 2016; 106(1):22-26.
7. Nicolosi N, Hehemann C, Connors J, Boike A. Long-term follow-up of the cheilectomy for degenerative joint disease of the first metatarsophalangeal joint. J Foot Ankle Surg. 2015; 54(6):1010-1020.
8. Kim PJ, Hatch D, DiDomenico LA, Lee MS, Kaczander B, Count G, Kravette M. A multicenter retrospective review of outcomes for arthrodesis, hemi-metallic joint implant, and resectional arthroplasty in the surgical treatment of end-stage hallux rigidus. J Foot Ankle Surg. 2012; 51(1):50-56.
