Thursday 5 May 2016

The Cheilectomy......!!!

Hi there, I decided to write this blog for my benefit, to be able to look back on, but also to give an insight into what to expect should you the reader need to undergo the same surgery as myself. I do have one or two friends who are troubled by the same problem, and this could be an option for them some time in the future.

So this is from my point of view, a patients point of view, my personal experience, not from a doctors clinical medical website with cold facts and procedures, this is how it really is.

Hallux rigidus is the medical term, but my case isn't the classic. It is arthritis in the metatarsophalangeal joint (won't be spelling that one again) or MTP joint, but I can still bend the toe down and up to a point quite freely, but I get a sharp intense pain if the toe bends too far upwards.
The joint also developed a lump of bone over the top of the joint, a sure sign of the condition.

This sharp intense pain built up slowly in 2014. The joint had felt sore from time to time before this period, but never felt a problem even while hiking up to 15 miles, which I was doing in past years.
But towards the end of the summer 2014 I started getting isolated periods of more intense pain, which climaxed at a weekend meet up with fellow walkers in Glencoe, Scotland in October 2014.
This was when it really caught my attention and became clear it was starting to be a real problem,
and having just climbed one of the classic mountain routes, I could now hardly walk to the pub that evening for that vital end of walk pint.
It was during this mile or so walk (hobble) back, I knew if this didn't get sorted my hiking days were done, not to mention many everyday activities that were starting to be affected, such as gardening and as I'm on my feet all day at work, it would effect my job long term too.

On my return from Scotland, I thought rest would be the answer, so I rested the joint as much as possible and used Ibuleve, and other gels to try and bring down the inflammation. After weeks of rest, the inflammation did calm down, and I resumed my usual routines of working and hill walking only for it to inflame and become painful again.

I went to my GP in early December 2014, and after being tested for gout which came back clear, I was given an x-ray. I was then referred to an Orthopaedic clinic in January 2015 where I saw a Podiatrist.
In early March 2015 I had a steroid injection into the MTP joint and 2 weeks rest followed.

It has to be said that although the steroid took a few weeks to really kick in, it did help to block the pain of walking, and I did think at this point I was sorted as I resumed hiking during the summer months.
But the pain would slowly return late summer, and would feel more intense after each walk, which peaked after a hike in the Lake District in November 2015. The joint was so painful, I could hardly remove my boot after the walk, and left me limping for a week again.
It was at this point, if I'm honest, if I didn't opt for surgery, I could cope with the mild pain caused by walking in every day life. But if I was to return to a love and passion of mine, to climb mountains, then surgery was the only option going forward.

In December 2015 I managed to get a GP's referral for Orthopaedic department at my local hospital. After another round of x-rays in mid February 2016 my surgeon decided a Cheilectomy or a Fusion may be necessary, but he wasn't able to decide which type of operation I would have until he opened up the joint. The operation should have been set for April 2016, but due to the junior doctors strike. It was delayed until the 5th May 2016.

With just three weeks away from my operation. I felt nervous and excited at the same time.
Excited, because this joint had been giving me trouble for sometime, and knowing once the operation is done, I knew then, I was on the road to recovery (I expect a painful road though) opening up the door to return to outdoor adventures once again. or at least that's my hope.



Pre op photo, taken in Autumn 2015, it clearly shows the lump of bone over the MTP joint.


In the final week building up to the operation, I was hospitalised due to a condition I have which is called Crohn's Disease. I swear if I was a horse I would've been shot by now.
Anyway, a two day stay in hospital was needed to recover from this, and put the toe operation in doubt at one point, however I was given the okay to proceed.

Just 24 hours to go, my bag was now packed with dressing gown and slippers, as requested by the hospital along with my letter, I also took a magazine which I never read, and as we were asked to leave valuables at home, I didn't take my mobile into hospital which was a mistake.
One last foot scrub, to clear hard skin off my feet and cut the toe nails, just so they looked half decent.
I've never been proud of my feet, and I will be looking after them a bit more in the future, once I've got through this.
I was "nil by mouth" from midnight, although I chose to have my last meal at 6pm the night before the operation with only water up until 6am as I was a morning day case.

Day 1 Thursday 5th May

 5.30am the alarm sounded, and after a quick shower, my wife and I joined the queue of work commuting traffic on our route to the hospital, arriving just before 7am the time stated in my appointment letter.
Once checked in at reception, I waited patiently with about twenty nervous people, but it wasn't long before my name was called out (second) by a nurse. I would then give my wife a little kiss before she went off to work, as visitors weren't allowed to stay on the ward during the day,
I was called through to a ward of six beds, by a nurse allocated to my care and would care for me during the day.
She told me, I was first on the list, so I guessed I would take longest to recover after surgery, how right I was.


The view down to the toilet door on the left

Once changed into a gown and dressing gown, there was some final paperwork to complete by the nurse, leaving a sick note on top of the file for the surgeon to sign, I then met a physiotherapist at my bed, who measured me up for crutches and a support shoe, before showing me how to walk and negotiate stairs with crutches.



A view of the support shoe AFTER the operation












Back at the ward bed, the anaesthetist arrived, to discuss the anaesthetic, and after discussing the pro's and cons of a general anaesthetic, in the end, I opted for the safer option of an epidural from the waist down with sedation.
The next visitor to my bed was the surgeon, a different one than the one I'd seen through the process. He talked to me about the joint, and if he was 50/50 which way to go regarding a fusion, I felt to go with a Cheilectomy. the lesser op of the two. He then drew an arrow on my right shin bone, signed the sick note for two months and said politely, "see you later" It would be 6 weeks before I saw him again.

About 9am I was taken down to the recovery room on foot by a nice young chap, where I was to wait along side a grey haired lady who I chatted to for a while to help calm both our nerves,
Twenty minutes later I was asked to walk into a cold prep room next to the theatre, I felt more nervous than I had at any point now, as I got on the bed shivering from the cold, I was plugged into the ECG monitor, blood pressure monitor, and a cannula was then inserted into my hand by the friendly theatre staff, one of whom was telling me about his "three peak challenge" walk he'd done after finding out I liked hill walking (all to put you at ease of course) then swinging my legs to the side of the bed as asked, preparation for the epidural injection began, which went into my lower spine, and was quite painless.
I was given a local anaesthetic injection first, while I slouched over a pillow and held there for the correct position, then I felt a warm blanket over part of my back, followed by some spine locating fingers and a small scratch was felt, and that was the epidural done......easy.
With legs swung back onto the bed, I lay waiting for the numbness to take effect, and it was only when I couldn't feel my feet or lower legs with a cold can of sprayed liquid the anaesthetist team used to test when I was ready for sedation, I was then sedated using the cannula at about 9.40am,
Then I really don't remember anything else after that point until I came round after the operation.

I awoke back on the ward with an oxygen mask on as a standard procedure, it felt just like waking from a deep sleep, I didn't feel sick or was in any kind of foot pain, it was about 11.30am now
The anaesthetist was at my bed side, and explained all went well, although my epidural was topped up during the operation as my foot twitched (I was totally unaware of this) so this would delay the wearing off effect of the epidural, which wears off from the feet first.
I was eager to know what I had done in theatre and after months of wondering what I faced, he told me, they had done a Chielectomy. rather than the fusion, as there was about 20% of the joint damaged which I must say was a bit of a relief as I still had the joint/movement, and recovery would be quicker.

I was soon offered a piece of toast and a mug of tea, which I made short work of, but it wasn't long before I could feel my bladder filling to the full mark, and dully asked for a pee bottle.
But it soon became apparent I couldn't feel my backside or any other bits in that area let alone try to operate the muscles within, and with a now painful bladder, I was catheterised very quickly and the sense of relief was just bliss as I filled not one but two bottles with 1.4 litres of pee, the nurses were impressed!!! and said "no wonder you were feeling the pain"
It was now just a waiting game, as I saw my fellow patients go home one by one, I wouldn't be allowed home until I was able to pee unaided, walking to the toilet.

While I was waiting, my phone arrived in an envelope, it turned out my wife had rung to see how I was, and as the information was vague, she asked if she could drop my phone off at the ward.
Patients were arriving for afternoon surgery now and all I could do was keep drinking water.

By the time I was ready for the loo again, the afternoon day cases were recovering, and my caring nurse for the day finished her shift and said good bye as I made my first walk on my crutches across the ward to the toilet, and after five minutes of trying, I failed to do anything and a frustrating return to my bed was made.
Half an hour later, I decided to try again and this time it was a success. with a relived smile on my face, I was given the green light to get ready to go home.


The support shoe, which is designed to allow for some weight on the back of the foot without too much pressure on the front toes.

While my cannula was being removed I rang my wife to ask her to pick me up and quickly changed out of the gown, and into the clothes I'd arrived in minus one sock and shoe.


I was given a bag containing pain killers and some leaflets, but nothing about after care of a Cheilectomy as the ward had none, they asked me to Google it at home.
I was to keep the foot elevated as much as possible, keep dry and the bandages must stay on until my follow up appointment, in the outpatients department in 12 days time.

Once my wife had arrived at the main hospital entrance, I was pushed there in a wheelchair, crutches in hand and a very uncool looking shoe on,
The porter handed over my bag to my wife, helped me into the car, before driving away just after 4pm. probably three or four hours later than planned.




I was still waiting for the pain to kick in at home about 5pm but it never came, I was told there was some slow release pain killers used in the operation, and although I could feel my foot in general, my small toes were still numb.
I do remember thinking whether the bandages were too tight, but they were fine. and the Codeine and Paracetamol was enough to help me sleep that first night.

Day 2 and 3 Fri/Sat

After an early night, I woke about 4.30am and couldn't sleep after that, I had some very mild pain in the foot but found Codeine and Paracetamol was enough to keep any pain away, I also picked up my wife's cold. (thanks love) I kept my leg elevated 95% of the day, and if outside as it was a warm sunny May weekend, kept it out of the sun but without the support shoe on, and only getting up off the bed or sun lounger to go to the toilet on crutches,

I had a spare pair of crutches, so I kept just one crutch at the top of the stairs or one at the bottom, so I didn't need to carry both crutches while holding the hand rail of the stairs.
It worked very well, and made climbing the stairs easy.

After day 2 I stopped using the Codeine as I felt I didn't need it but also worried about constipation, so started taking "Lactulose"

Day 4 Sunday 8th May

I started with a headache, which is very unusual for me as it's something I don't normally get, so was a little concerned after having surgery, but put it down to my cold.

Today would be my first shower, and as the foot must stay dry, I had a bin liner taped to my leg, covering my foot up to my knee. Helped by my wife, who would set the shower, then I was lowered onto a little foot stool in the shower, where I was steady, and could sit, while washing with the sliding doors shut, this seemed to worked very well.
I can honestly say I had no pain in my foot what's so ever today. just the headache.
Still keeping my foot elevated as much as possible, without the support shoe on, using the shoe only when walking with crutches.

Day 5 Monday 9th May

Still constipated, this was a concern for me with having Crohn's Disease, thankfully after another dose of "Lactulose" things started to move. Still had a headache that would come and go with paracetamol.

Day 6 Tuesday 10th May

At this point I was putting a little more weight down on the foot when the support shoe was on, but only with crutches to control the weight.

The shower today was a disaster, my taped bag leaked, wetting the bandages underneath my foot.
after trying a hair dryer, I ended up using a hot air blower for a couple of hours, and even then it still felt damp. Headache easing today.

Day 7 and 8 Wed/Thur

The first week done and feeling more confident about moving around the house, my headache was gone and as all the family were back in work now, my biggest problem was carrying anything around the house with me as I was still using crutches most of the time but could hop/limp about within a short distance ie in the kitchen to make a brew etc.

To solve the problem of carrying stuff, I used a small rucksack, if I went outside as it was sunny, I'd just fill the rucksack with a bottle of juice, magazine, suncream, mobile etc, then walk on crutches with the rucksack on my back.




Day 9 to 12

I was confident enough with my support shoe on and crutches to go out for a meal at a local restaurant.
As it happens the meal was awful, but did have my first pint in a while, so that was good.

I also ventured from the car with my daughter on a 20 minute stroll with our dog to a local river.

I also stood around the kitchen making snacks or wash up a few dishes and found it quite easy making a brew, but I'd need to drink it where I made it, as I was still using crutches and couldn't carry a hot drink yet

12 days is a long time to keep the same bandages tight and neat on a foot, and after the first week, they started to get loose, I think it was the bed sheets that did it during the sleeping hours, so a roll of elastoplast tape would be handy, just to tape up a couple of loose bits.

Day13 Tuesday 17th May

First post op check up today. The dressing was removed, so my surgeon could have a look.
To my surprise, the incision was made on the side of the foot, plus a couple of cuts on top of the joint. When I've seen photo's of this operation, they have been on top of the foot so I wasn't expecting that.
I was also surprised at how little swelling there was.




A bit bruised and sore


The foot was then dressed with a light surgical bandage 

My instructions were to keep the foot dry and keep the support shoe on while walking, and now use only one crutch (on operated foot side) when walking in this 3rd week. but as I was in the Lake District for a long weekend with family, I decided to keep using the two crutches until after the weekend.


I was to start exercises of the toe, while the leg was horizontal, bending the toe 20 times up, and 20 times down, This was to be  done 3 times a day, until I returned in a months time. 

Week 3

The exercises were going well, although it felt easier lifting the toe upward, the toe felt very tender pushing downward. this was a slight concern, as this movement was okay before the operation.
And it was this movement of pushing down that would give me pain.

It was nice to have a shower without all the bag taping up, now the foot can get wet.

Week 4

When the time came to putting one of my shoes back on the operated foot, it was just too tight.
I ended up buying a cheap pair of wide fitting summer plimsolls, as that side area where the incision was made was still too sore.
But while the weather was hot, I was able to wear sandals. I could now get out walking a little more, just short distances but great to get out with my family and the dog for a walk by the river.



This was a week of over doing it a bit. just doing a few things around the house, cutting the grass, using the toe to control balance, when your weight goes forward, you press down on your toes to counter act the motion. so more than a couple of hours standing meant my foot would swell a bit over the Metatarsal bone, and if I had over done it, I wouldn't see this bone when I lifted the toe upwards.
So while sat I always tried to keep the foot elevated as I had for the last month.

Week 5

I needed a haircut, and it was a 10 minute walk to the barbers. this was the first walk I'd done on my own of any length since before the op. and the foot was coping, I'd even got my old shoes back on, but still got a little swelling.
But this was also the last walk aided by the one support crutch.

I just kept to small 10 minute walks this week

All the scabs from the incision had gone, and I was amazed I hadn't picked them once!!!
losing the scabs made wearing my old shoes more comfortable.

At the end of this week I got behind the wheel of my car again, and felt a real milestone had been reached. I probably could have done this a week earlier, as the accelerator and break pedals were both light. If it had been my left foot operated on, it would have been longer than 5 weeks as my clutch is quite stiff.
Just a note, I did ring my car insurance company up to ask, was there a rule of time on this?
They told me no, when you feel fit to drive safely and are able to break safely, then you're okay to drive.

Week 6

Continued building up walks, putting my walking boots on for the first time, and getting less swelling.

I returned to hospital, and saw the surgeon who carried out the operation. He very quickly got my x-rays up on his screen, I was surprised to find out I'd had an x-ray while I was sedated after the operation.
He was able to tell me where the bone had been removed, and explained why that downward movement of the toe was giving me some pain still.
He also showed me just how far the toe could move upward on the x-ray, which I was pleased about, as this was where my pre-op pain came from.
He then went on to refer me for a physio session, as this would help. "just walk as much as you are able, and elevate when resting, and don't worry too much about swelling, this is normal for a while" he told me.

Week 7

With a target of returning to work after week 8, I now wanted to start walking farther than half an hour strolls.
The upward movement wasn't much of a problem when walking, but still a bit painful pushing the toe down to keep balance.
So I started taking my dog on a set route each morning. A mile and a half to start with, building this up each day.
The afternoon was used to rest and elevate the foot for a couple of hours and this was okay.
I knew once I was back at work I'll be on my feet for 10 hours a day, all week, so I needed to be fairly fit to cope.

Week 8

This would be my final week of recovery before returning to work.

A visit to the physio department in hospital really didn't achieve anything at all, apart from reassuring me, the recovery was going well.
As I went through the various movement tests, it soon became clear my recovery was going to plan and wouldn't need to return again for any physio.

Week 9

I returned to work this week, and didn't feel any real problems walking about all day, I would say my toe joint felt about 85% recovered, but still had some stiffness and felt tender when bending the toe down still.

Four months after the operation, I was ready for a walking weekend and I was back in the
Lake District, climbing and walking 25 miles over the weekend, it was still tender, but the walking didn't make it any worse.


Here I am at the summit of Brae Fell


I would say now, it was only at around the eight month mark, that the toe joint really felt 95% better.
Overall the whole experience was far less painful than I thought it would be, but it was a long road to recovery.
would I go through it all again if needed?................in a heartbeat.

It's January 2017, and in the last few months I have got back into hiking on a regular basis, I don't even think about the joint now while out walking, it's not perfect, but it doesn't hold me back anymore, and once again I'm active.

Thank you for taking the time to read my experience, and from me, a big thank you to the NHS here in the UK and in particular the excellent staff involved in my treatment and care.









3 comments:

  1. Congratulations on your improved health! I note that some studies show that more active patients who start with a Cheilectomy may need to go back at about the 8 year mark for an Arthrodesis procedure. Being a hiker, I am wondering how you are faring and if you are still putting in the miles pain and swelling free? Thanks for your post here and experience sharing.

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  2. Thankyou for sharing your experience! I am 7 days post-op cheilectomy/microfracture, and I have been nervous about returning to work because I am also on my feet all day (for the majority of my 12-hr shifts, on a busy unit in the hospital). My dr gave me 8 weeks off. I also have been very eager to do activities that I haven’t been able to do in a while because of HR, and I wasn’t sure if I’m being too optimistic & setting myself up for disappointment. So far my recovery has been going well. Your story was so encouraging!

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  3. I am 9 days post op and your recovery seems to be like mine. I’m due stitches out in 5 days and wanting to do more! I again work in nursing but also do a lot of driving in the day job. Hoping the pain and movement improves post op. Thank you for sharing your story 💞

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