Reassessing Surgical Options For Recalcitrant Hallux Limitus In An Active Population

John F. Grady, DPM, FASPS

   It is so misunderstood that in an article, “Diagnosis and Treatment of First Metatarsophalangeal Joint Disorders, Section 2: Hallux Rigidus,” describing clinical practice guidelines for first metatarsophalangeal joint disorders, the panel shows an algorithm of treatment, which refers to “cheilectomy (including modified Valenti).”5 There is no way this very destructive procedure of a Valenti is any type of a cheilectomy. In fact, it is a modification of a Keller and Mayo procedure. This is a very destructive procedure for Stage 3 and Stage 4 lesions, but it is listed in this article for Stage 1 and Stage 2 lesions.

   I think it has been a long-held myth that a Valenti is nothing more than an aggressive cheilectomy. A Valenti is rather a true joint destructive procedure, which has significant ramifications if surgeons use it for more minor cases of hallux limitus and in cases in which the majority of cartilage is normal.

   I think this is a misconception that can lead to significant misinterpretation of surgical reasoning. These are fairly old practice guidelines that are long outdated in many ways. While acknowledging that some patients with hallux limitus need to go on to arthrodesis and that the implant has the good effects of reasonably eliminating joint pain and occasionally increasing range of motion, implant arthroplasty currently does not have many indications due to the numerous factors of complications with implants.6

   It is stunning to me how many people give implant arthroplasty and arthrodesis as the only methods of treating Stage 4 hallux rigidus. It is disappointing that patients who really need other options do not get a choice.

Rethinking The Progression Of Procedures In The Armamentarium For Recalcitrant Hallux Limitus

When it comes to patients who do not respond to a more aggressive non-implant arthroplasty type of procedure, I actually think the sequence of procedures to consider would be as follows: cheilectomy to a more radical cheilectomy; then a Valenti type of procedure; and, lastly, arthrodesis.

   Additionally, I think the surgeon employs much more risk in performing these non-implant arthroplasties as opposed to arthrodesis as there is still motion. Therefore, with these non-implant arthroplasties, there is still the possibility of joint pain (including rheumatic joint pain), such as pain in the tendons, sesamoids and capsule as well as joint pain emanating from degeneration of the joint as well. Obviously, arthrodesis eliminates this possibility. However, it also makes one generally less able to have agility and be more prone to transfer weight when the foot is in certain positions due to the lack of joint motion.

   To argue the point, my own experience is quite good with more aggressive types of arthroplasties. We had initial studies in which we used the Valenti procedure and showed a similar increase in range of motion to that of the double stem implant arthroplasty.3 We were able to increase motion and change the arthroplasty procedure we do currently. It is now nothing like a Valenti procedure and nothing like a cheilectomy. To call it either would be stretching the extremes of either procedure.

   Toe purchase is obviously a problem in an athletic population as this can diminish stability at the first metatarsophalangeal joint when the patient is jumping or pivoting.

A Descriptive Guide To The Modified Valenti Resection Arthroplasty

One would make a 6.0 cm linear incision over the first metatarsophalangeal joint. Employing sharp dissection, the surgeon should take care not to remove the capsule from the degenerative bone surrounding the first metatarsophalangeal joint.

   Proceed with further dissection to expose the degenerated cartilage and hypertrophic bone. Remove the osteophytes from around the joint. It is important to remove debris that is within the joint as well as eccentric hypertrophic bone.


Dr. Grady,

I have used the Valenti Arthroplasty and Keller Interpositional Arthroplasty with good success for
hallux limitus. I agree with you rethinking our approach to Hallux Limitus.

Emanuel Willis,DPM,FACFAS
Scholl's Class of 1986

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