By Neal Blitz, DPM, FACFAS 

 Medically reviewed by Danielle McNeil, D.P.M

Cheilectomy is the clinical name for big toe bone spur surgery. The procedure is done to remove bony projections that result from hallux rigidus, a condition that can develop due to repetitive foot injuries and arthritis of the big toe joint.

Cheilectomy is considered a joint-sparing treatment because it reduces pain and stiffness while preserving motion of the toe joint.

This article discusses why this surgery is done, its risks and benefits, and what to expect both during the procedure and cheilectomy recovery.

Dr. Neal Blitz

What Is Cheilectomy?

Cheilectomy is an operation of the metatarsophalangeal (MTP) joint, where the big toe bends and attaches to the foot. The procedure involves an incision in the skin and removal of excess bone with the aid of orthopedic tools that cut away the bone spurs. This helps to relieve pain and create space for the toe joint to move.

In addition, something called micro-fracture may be performed. In this, holes are drilled into the bone where the cartilage is missing. This creates extra blood flow and allows a chance for a scar-like tissue or cartilage to form.

Generally, the bone spurs are located on the top of the joint, but those on the sides of the joint can be removed during cheilectomy surgery as well. 

This outpatient foot surgery is performed by an orthopedic surgeon or a podiatrist. It is done under local anesthesia as either an open surgery or as a minimally invasive procedure with a smaller incision.1

Sometimes cheilectomy is done along with another surgery. For instance, advanced hallux rigidus may require treatment with a combination of osteotomy (cutting and reshaping the bone) and cheilectomy.2

Contraindications

This surgery isn't right for everyone. If your foot condition involves more complicated structural issues beyond bone spurs and joint stiffness, it might not improve with a simple cheilectomy.

If you are at risk for healing problems, you could be prone to complications that would make having the surgery ill-advised. For example:

• Vascular insufficiency (inadequate blood flow) in the foot can interfere with healing after surgery and might be a reason to carefully reconsider this procedure.

• Decreased sensation due to peripheral neuropathy can increase your risk of complications by reducing your detection of pain—a common sign of post-operative infection.

Even if none of this applies to you, you may need to delay your surgery if you have an active foot infection or a foot wound.

Potential Risks

Big toe bone spur surgery is generally safe and uncomplicated. However, there are risks to be aware of.

Risks of cheilectomy include:3

• A foot infection

• An infection that spreads to other areas of the body

• Delayed or inadequate healing

• Scarring

• A post-operative callous

• Increased foot pain

These are more likely if your foot is not kept clean during your recovery or if you have severe chronic disease, like uncontrolled diabetes.

Generally, with a minimally invasive procedure, you should expect a smaller scar and faster recovery. However, complications are more common with a minimally invasive procedure than with an open one.1

Purpose of Cheilectomy

A cheilectomy is done to improve severe pain and/or stiffness in your big toe that's associated with bone spurs.

Bone spurs generally develop on top of the big toe joint and sometimes on the sides. This growth can cause pain and may limit movement of your big toe, interfering with the way you walk.3

These bone spurs can develop due to damage, inflammation, or wear and tear of the joint.4

Common predisposing factors associated with bone spurs of the big toe and hallux rigidus include:

• Osteoarthritis is a degenerative condition of the cartilage. Over time, the cartilage erodes, exposing the underlying bone. Protective bone spurs can form over these exposed areas.

• Trauma, such as stubbing or spraining your toe

• Repetitively pounding your foot, such as during sports, which can lead to tiny fractures and inflammation. A condition described as turf toe (a sprained toe) can develop. Eventually, these issues can trigger the growth of bone spurs around the injured toe.

• Genetic factors4

Before Surgery Is Considered

Hallux rigidus, a consequence of arthritis of the big toe, is often preceded by hallux limitus, a milder form of big toe arthritis in which the joint is somewhat stiff, but not as painful or rigid as with hallux rigidus.

Often, before considering cheilectomy, the pain and inflammation of hallux limitus or hallux rigidus are managed by taking over-the-counter pain medications, applying heat alternating with ice, wearing orthotic shoes, and/or getting corticosteroid injections.4

When these measures are not effective, you might discuss surgery for big toe bone spurs with your healthcare provider.

Some foot conditions—like bunions or bone fractures—may look and feel like bone spurs. The difference can be identified with a physical examination of your foot and an X-ray.

How to Prepare for Cheilectomy Surgery

Your healthcare provider will examine your foot and order one or more X-rays to both confirm that you have bone spurs and identify their location for surgical planning.

If you need to have bone spurs in both of your feet removed, you and your practitioner can decide whether that will be done on the same day or if having two separate surgeries is best. The decision may hinge on a number of factors, including anticipated recovery time and even the surgeon's preference.

Location

You will have your foot operation in an operating room or surgical suite. This is an outpatient procedure, and you should expect to go home on the same day as your cheilectomy.

What to Wear

You can wear comfortable clothes and shoes to your appointment. After your surgery, you will need to wear a surgical shoe on your operative foot as you leave to head home.

Food and Drink

You don't need to make any adjustments to what you eat or drink in preparation for this procedure.

Medications

Your healthcare provider might tell you to stop or adjust some of your medications, like blood thinners or anti-inflammatories, for a few days prior to your surgery. If you are not sure about if you should stop a particular medication, be sure to ask.

What to Bring

Bring a form of identification, your health insurance card, and a form of payment if you are paying for your procedure or if you are paying a co-pay.

You might not be able to drive home after having surgery on your foot, so you should arrange for someone to take you home.

Pre-Op Lifestyle Changes

Most people don't need to make any lifestyle changes prior to surgery.

But if you have issues with wound healing due to vascular insufficiency or neuropathy, your healthcare provider might advise that you take special care of your foot so that open wounds on your foot—which can lead to an infection—are fully healed before your surgery.

What to Expect the Day of Your Cheilectomy

When you go to your surgery appointment, you will be asked to sign a consent form and present your identification and health insurance information and/or payment.

Your procedure should take approximately one hour.

Before the Surgery

After you sign in, you will go to a pre-op area, where you will be asked to take off your shoes and socks. You might also need to put on a gown.

You might have your blood pressure and temperature checked. You may also have a pulse oximeter or another monitor placed on your finger to monitor your heart rate and oxygen level.

Your medical team will take you to the operating room or surgical suite.

During the Surgery

Your surgical team will put a drape over your leg, exposing your foot. Your foot will then be cleansed with an antiseptic.

You will then have local anesthesia injected into your skin with a needle. This may pinch or tingle for a few seconds as the needle and anesthetic medication are inserted. The needle will be removed, and your foot may feel numb within a few minutes.

Before starting your surgery, your medical team will confirm that you can't feel pain by pressing on your foot and asking you if it hurts or you notice pressure.

The incision for cheilectomy might be on the top of the big toe joint, though an incision on the side of the joint may be used in some cases. Bone spurs are cut with an orthopedic chisel or a power saw.2

If you are having a minimally invasive procedure, your surgeon will use tiny tools that are inserted through the small incision to cut the bone.1

Your surgeon may place surgical bone wax on raw bone surfaces to thwart bone spurs from reforming.

Then your skin will be closed with sutures and the area will be cleaned and covered with bandages. Your anesthetic medication should wear off within a few hours.

After the Surgery

After your surgery, your medical team will talk with you about pain control and wound care.

You should be able to walk on the day of surgery. You will need to wear a surgical shoe that is recommended by your healthcare provider, typically for several weeks after your procedure.

Cheilectomy Recovery

The cheilectomy recovery period involves resting the foot that was operated on, limiting certain other activities, taking good care of your incision(s), and minimizing pain and swelling.

You will need a follow-up appointment about two weeks after your surgery. Your practitioner will examine your foot and remove your sutures at this appointment.

Physical Activity

You should experience improvement in the range of motion of your big toe joint right after your surgery. It might take a few days for you to adapt to your improved toe and foot mobility.

You should stay off your foot in the days after your cheilectomy. Thereafter, you can walk using special shoes recommended by your healthcare provider. These will have wooden or other hard soles that support your feet and don't squeeze your toes. (These are only necessary during recovery, and your surgeon will let you know when you can go back to wearing your regular shoes.)

You should not run or lift heavy objects that would put extra weight on your foot until it has fully healed and you get approval from your healthcare provider. At that point, you should not have any limitations.

Wound Care

Take care of your wound by keeping it dry and clean. (If your dressing is water-resistant, bathing will not be a concern. If not, ask about how best to wash yourself while you are healing.)

Change dressings as directed by your medical team. Be sure to keep an eye out for signs of impaired healing or infection such as redness, increased swelling, warmth, or oozing blood or pus.

After you recover, you will have a small visible scar in the area of your surgical incision. It may be approximately 5 centimeters (cm) in length if you've had an open procedure, and about 1 cm in length if you've had a minimally invasive procedure.1

Pain Relief and Swelling

You should have resolution of any post-operative foot pain within a few days. Generally, over-the-counter pain relievers like Tylenol (acetaminophen) or Advil (ibuprofen) should provide relief.

You can expect your toe to remain swollen for about six to eight weeks after surgery. The swelling should decrease rather than increase throughout this time. However, it's important that you start moving your toe soon after surgery to prevent scar tissue from making the toe stiff again.4

If your pain is severe, or swelling worsens, talk to your healthcare provider to make sure that you aren't experiencing a complication.

Possible Future Surgeries

A cheilectomy is intended to be a one-time operation for the relief of pain and stiffness caused by hallux rigidus.

However, it is estimated that after cheilectomy, hallux rigidus recurs approximately 30% of the time.5 You and your healthcare provider might discuss a repeat surgery or other treatment options if your symptoms return.

If cheilectomy surgery fails to relieve your symptoms, other treatment options may include fusing the joint bones together (arthrodesis) or joint replacement (arthroplasty).4

Lifestyle Adjustments

Overall, having cheilectomy provides relief of pain and improved range of motion.

If you have a history of foot trauma due to your participation in athletics, you may be prone to recurrent injuries if you continue to participate in the same activities.

Shoe styles you once wore may need changing if they are too narrow. If you continue to participate in athletic activities, talk to your healthcare provider about how to select footwear that might help protect you from further injuries.

Summary

Having cheilectomy surgery to remove bone spurs from the big toe can provide you with lasting pain relief and improved mobility. Generally, this is considered a minor surgery with good recovery and a low risk of complications.

If you are prone to foot problems, be sure to see a foot care provider regularly so any new issues can be detected and taken care of at an early stage.

 Sources

Stevens R, Bursnall M, Chadwick C, et al. Comparison of complication and reoperation rates for minimally invasive versus open cheilectomy of the first metatarsophalangeal joint. Foot Ankle Int. 2020;41(1):31-36. doi:10.1177/1071100719873846

Elliott AJ, Sayres SC, O'malley MJ. Treatment of advanced stages of hallux rigidus with cheilectomy and proximal phalangeal osteotomy: Surgical technique. JBJS Essent Surg Tech. 2014;3(3):e14. doi:10.2106/JBJS.ST.M.00026

Lam A, Chan JJ, Surace MF, Vulcano E. Hallux rigidus: How do I approach it? World J Orthop. 2017;8(5):364-371. doi:10.5312/wjo.v8.i5.364

American Academy of Orthopaedic Surgeons. Stiff big toe (hallux rigidus).

Lee JY, Tay KS, Rikhraj IS. Distal oblique osteotomy versus cheilectomy for moderate-advanced hallux rigidus: A 2-year propensity-score-matched study [published online ahead of print, 2020 Jun 13]. Foot Ankle Surg. 2020;S1268-7731(20)30108-9. doi:10.1016/j.fas.2020.06.001

By Neal Blitz, DPM, FACFAS
 Neal Blitz, DPM, FACFAS, is a board-certified doctor of podiatric medicine and creator of the Bunionplasty procedure.