This leaflet aims to answer your questions about having surgery for a Cheilectomy procedure under the care of Mr Rajiv Limaye. It explains the benefits, risks and alternatives, as well as what you can expect when you come to hospital.
What a Cheilectomy?
Based on your medical complaint, the clinical examination of your toe and the imaging, a diagnosis has been made of wear and tear arthritis (osteoarthritis) of your big toe. It may be due to previous trauma or can just happen because of the congenital shape of your foot bones. It is a common condition. In mild or moderate cases, a large amount of the pain can be coming from the new bone that has grown on the top of the joint. It stretches the nerves, tendons and can catch on the shoe or when the toe bends. Cleaning out these bumps is a Cheilectomy. It does not cure the underlying arthritis but can ease the pain in the majority of patients and can improve the range of motion.
Why should I have Cheilectomy surgery?
The intial treatment in non surgical management such as using wide and soft shoes or cus inserts in your shoe to cushion the toes. Sometimes an injection helps the symptoms. If these measures all fail, then you may wish to consider surgery.
The operation aims to help improve the pain you get as the big toe bends up during walking and activity. Some swelling will remain in the forefoot and toes for up to six months after surgery.In addition to improving pain, some improvement in movement of the big toe is also a goal but not always possible due to the arthritis. This is why moving the big toe immediately after surgery is vital to ensure the best return of movement possible.
Because the joint is still arthritic, final outcome depends on whether there is further development of this arthritis.
What are the risks?
In general, the risks of any operation relate to the anesthesia and the surgical procedure itself. In most cases you will have a general anesthetic. You will be able to discuss this with the anesthetist and they will identify the best method for your individual case.
The main surgical risks are listed below:
- Infection - approximately 2% risk in our unit
- Blood clots (thrombosis) – You will be put on Low molecular weight Heparin prophylaxis to reduce the risk of blood clots in calf, thigh or rarely in lungs.
- Numbness - can occur over the outer border of the foot, and usually improves over time
- Pain and swelling-This can occur after any foot and ankle surgery. You have to keep the limb elevated for 48 hours to avoid Swelling: Your foot will swell after the operation as part of the response to surgery and the healing process. This will reduce gradually but it may take more than six months for the swelling to go down completely. It is important to elevate your foot in the early stages.
- Persistent or recurrent pain: A proportion of patients (10 - 20%) experience persistent pain after surgery, or their symptoms may recur. Further surgery may be necessary. A Cheilectomy is a tidy up procedure, the underlying arthritis is still there, and we are doing it to make the already damaged joint less painful. In a small proportion of patients, the pain can persist despite cleaning the bumps.
Are there any alternatives?
Simple non-surgical measures, as detailed above, can be tried before undergoing surgery.
How can I prepare for Cheilectomy surgery?
You should make arrangements to be collected from the hospital. Someone should stay with you overnight if you have a general anesthetic and your operation is a day case. You will need some time off work after the surgery. This will be at least 1-3 weeks but maybe longer if you have a manual job. Mr Limaye will discuss this with you. We advise you speak to your employer before surgery to make plans.
Giving my consent (permission):
Mr Limaye needs to ask your permission to perform the cheilectomy surgery. You will be asked to sign a consent form that says you have agreed to the treatment and that you understand the benefits, risks and alternatives. If there is anything you don’t understand or you need more time to think about it, please tell him or the staff caring for you.
Remember, it is your decision. You can change your mind at any time, even if you have signed the consent form. Let staff know immediately if you change your mind. Your wishes will be respected at all times. If you would like to read our consent policy, please tell a member of staff.
Will I feel any pain?
There will be some pain after the surgery. While you are asleep local anesthetic may be injected into your foot to reduce the pain after the operation even if you go to sleep for the surgery. You will be given medicines to take home to control the pain. The nurse will go through the medicines with you, including how often and when to take them. There will be a combination of strong and weak pain killers.
It is essential that you maintain an adequate level of pain relief after your surgery so make sure that you regularly take your prescribed painkillers. However, the tablets are not compulsory and if you have little pain you may not need to take them.
If your pain does not settle, you can either be reviewed in your scheduled outpatient appointment or you should seek further advice and management from your GP.
The Day of the Surgery:
Mr Limaye will see you before and after your operation. The anesthetist will also see you before your operation on the ward or in theatre, any queries about the anesthesia are best discussed with him/her directly on the day.
Waiting for your operation:
Please note that you may not be the first patient on the operating list and therefore have a variable amount of time during which you will be waiting to go to theatre; how long will depend in your place on the list. If you are the last patient to be scheduled for surgery, it may be up to three or four hours; you should therefore come prepared for a wait. Some reading material is provided by the day case unit but we appreciate a wait of several hours can be tedious; as such you may wish to bring a book, some work or other material to keep yourself occupied.
After your operation, prior to discharge:
Your foot will be heavily bandaged to protect it and reduce the swelling. The gauze bandage which is applied in theatre in a sterile environment will stay on for 2 weeks. There will be no plaster cast. The physiotherapist will issue you with crutches and a special surgical sandal to wear. If you already have either of these, please bring them with you. The crutches are not essential, but as the foot is sore when weight bearing you may find it helpful to use them.
The hospital may bill for any incidentals such as the crutches, surgical shoe, shower cap and any medications.
You will be given medications to take home to control the pain. These will be a combination of strong and weak painkillers. A nurse will go through the medications with you, confirming how often and when to take them.
When you feel comfortable and ready you will be allowed to go home. You should have made arrangements to be picked up from the hospital and have someone staying with you at least overnight if you are a day case.
As a day case patient, you can normally go home about 3-5 hours following surgery. As an overnight patient, you will be discharged around 10 am the next day.
What happens after Cheilectomy surgery?
The day of your surgery:
The surgery will be through a cut on the top of the big toe. When you have recovered from the anesthetic, normally you can get up and walk freely in a special sandal that will help protect the operation site. Your foot and ankle will be securely bandaged to protect it and to reduce the swelling. The gauze bandage which is applied in the operating theatre will stay on for two weeks. There will not be a plaster cast. You must keep your foot elevated. Most patients can go home on the same day as the surgery.
What do I need to do after I go home?
This is a general guide only. Patients will progress and recover from their surgery at different rates. If your surgeon Mr Limaye gives you different advice, then you should follow that.
First two weeks:
The local anesthetic in the joint will start to wear off, so you will need to start taking painkillers.You have to keep your foot elevated and try to mobilise your toe. The pain usually reduces in a weeks time . You can walk short distances to start with and gradually improve your walking distance by 2 weeks to 3 weeks. At the end of two weeks in your pain is tolerable and you feel safe to walk you can retyrn back to office duties. If your job involves lot of walking and standing you may have to delay return to work depending on nature of your work.
You will be seen approximately two weeks (10 – 17 days) after your operation in the outpatient clinic. This appointment will be made for you by Mr Limaye’s secretaries. At this time the wounds will be checked, and any stitches removed. He will advise you at this appointment regarding your return to work.
You will first see the team nurse and then Mr Limaye. At this appointment, the bulky dressings and stitches are removed. Steri-strips, which are paper dressings may be applied. You will leave with the same surgical shoe on or a loose trainer if you have one.
2 – 6 Weeks:
You can start driving after two weeks. The Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. You should contact your doctor or the DVLA and your insurance company if you are concerned about this.
You should remove all the remaining wound dressings at home, by soaking the dressings off in the shower. You should apply skin emollients such around the healing wound. Once the wound is completely healed, you should apply the moisturizer over the wound as well.
You may go swimming if the wound is dry and healed.
At this stage, your foot will still be swollen. Do not expect to fit into your normal shoes. You may start wearing a pair of wider, looser fitting shoes. A good option includes trainers, with loosened laces.
Low impact exercise, such as exercise bike, cross trainer can be started. You may now drive a manual vehicle in addition to an automatic. However, motor insurance companies vary in their policies please check with your insurer first.
It may take 6 weeks to return to your normal sporting activity level. You can start gentle exercises and activities earlier and gradually increase your activity level with time. You should speak to Mr Limaye about this if you are uncertain
6- 12 weeks after surgery:
Your mobility will continue to improve. You can usually return to work after six weeks. Low impact exercise, such as walking, can be started after 6 weeks.
For short haul flights you will be able to fly after 2 ½ weeks. For long haul it is 6 weeks. We do make exception if your home is abroad.
When you return to work, travelling outside of the rush hour is a good way of easing back into your commute. The first few days back at work, you may feel slightly miserable as you are not able to keep the foot up as easily in the office.
3 - 6 months after surgery:
Your foot may continue to be swollen for up to 6 months following this surgery.
What should I do if I have a problem?
If you experience any of the following symptoms, please contact Mr Singh, the ward or your GP:
- Increasing pain
- Increasing redness, swelling or oozing around the wound site
- fever (temperature higher than 38°C).
- suspect you have DVT (deep vein thrombosis) - symptoms include pain and/or burning in the back of your lower leg. You may also feel unwell and have a temperature
If, at any time in your post-operative recovery, there is any sign whatsoever of infection, either suspected by you or diagnosed by your GP, please contact your consultant’s secretary at the hospital.