Hallux rigidus surgery: cheilectomy, fusion and joint replacement

When surgery is considered

For background on the condition, see hallux rigidus. Non-surgical care, such as stiffer-soled shoes, orthotics, anti-inflammatory medicine and injections, is tried first, though about half of people treated that way go on to have surgery within a year or two.^[4,8] Surgery is considered when pain limits walking, work or exercise despite those measures. The choice depends on the stage of the arthritis, your age and activity, and your goals.^[2]

The main types of operation

• Cheilectomy. The bone spurs on top of the joint are removed so the toe can bend upward without pinching. It preserves the joint, can be done through a small incision, and is used for milder to moderate arthritis. Some surgeons add a bone cut (osteotomy) to reduce pressure on the joint.^[6,2]
• Arthrodesis (fusion). The joint surfaces are prepared and the big toe bone is joined to the metatarsal with screws or a plate. The joint no longer moves, but the aim is a stable, pain-free toe that can push off.^[2,7]
• Interpositional arthroplasty. The joint surfaces are reshaped and a spacer of soft tissue, or another interposition material, is placed between them, preserving some motion.^[2,9]
• Implant arthroplasty. The joint is replaced with an implant, either of the toe bone alone (hemiarthroplasty) or of both sides of the joint.^[3,10]

For fusion in other joints, see foot and ankle joint fusion and replacement. If the toe also drifts sideways, see bunions.

What do the results show?

• Overall evidence. A review of 135 studies graded the evidence for fusion as fair (grade B) and that for cheilectomy, osteotomy, implants and interpositional operations as poor (grade C). There were no properly powered comparisons that would show which procedure is best overall.^[1]
• Cheilectomy. A systematic review of 23 studies (706 cheilectomies) found that 8.8% needed surgery again, most often a conversion to fusion. The author concluded that the low rate of revision supports cheilectomy as a first-line surgical option.^[5]
• Fusion. A review of modern fixation techniques for fusion reported a union rate of 95.7% with a mean healing time of about 12 weeks and a complication rate of 5.8%.^[7] A review of return to sport after fusion found that most people (67% to 88%, depending on the activity) said their sport was about the same as before, and fewer reported that it had become harder.^[11]
• Fusion versus replacement. A meta-analysis of seven comparison studies found no significant difference between implant arthroplasty and fusion in function scores, satisfaction, reoperations or complications, but pain scores were lower after fusion.^[10] A systematic review of 33 studies found that fusion was better than total joint replacement for improving function and reducing pain.^[3]
• Interpositional arthroplasty. A systematic review of 16 studies found that scores and motion improved significantly, but that the evidence is limited.^[9]

Recovery

Recovery depends on the operation. Recovery after a cheilectomy is generally quicker than after a fusion, because no bone has to heal together, and work on toe motion usually starts early. After a fusion, you protect the toe in a stiff shoe or boot while the bone heals, which takes about 12 weeks on average, and you may be limited in weight-bearing at first.^[7] Return to sport takes longer than a return to walking. In a review of return to sport after fusion, the one study that reported timing found a return after about 12 weeks on average.^[11] Your surgeon will give you a timetable. See recovery after foot and ankle surgery and preparing for foot and ankle surgery.

Risks

Risks include infection, wound-healing problems, stiffness, ongoing pain, nerve irritation, a fusion that doesn’t heal (nonunion), a toe positioned at an angle that causes discomfort, implant problems, arthritis progressing in nearby joints, the need for another operation, and the general risks of surgery, including blood clots.^[7,5,3]

Questions to ask before deciding

• What stage is my arthritis, and how does that affect the choice between cheilectomy, fusion and a spacer?
• If I choose cheilectomy, what is the chance I will need another operation?
• If I choose fusion, how will it change how I walk, exercise and choose shoes?
• When can I put weight on the foot, drive, and return to work and sport?

When to seek care