In a patient with both hallux rigidus (first metatarsophalangeal joint arthritis) and hallux valgus (bunion), should a first MTP joint cheilectomy be performed before a bunionectomy, or vice versa?

The Question is Not Clinically Relevant as Stated

The question "cheilectomy vs bunionectomy" presents a false choice because these procedures address completely different pathologies and are not alternatives to one another.

Understanding the Distinction

Cheilectomy treats hallux rigidus (first MTP joint arthritis with dorsal osteophytes and limited range of motion), while bunionectomy treats hallux valgus (lateral deviation of the great toe with medial eminence prominence). These are distinct conditions requiring different surgical approaches 1, 2.

When Both Conditions Coexist

In the uncommon scenario where a patient has both hallux rigidus AND hallux valgus, the surgical approach depends on which pathology is dominant:

Address the Symptomatic Pathology First

• If hallux rigidus is the primary source of pain and disability (dorsal impingement, limited dorsiflexion, joint line tenderness): Perform cheilectomy first
• If hallux valgus is the primary deformity (medial eminence pain, shoe wear issues, lateral deviation): Address the bunion deformity first

Critical Caveat from the Evidence

One study specifically noted that all dissatisfied patients after interposition arthroplasty had coexistent hallux valgus deformity 3. This suggests that unaddressed hallux valgus compromises outcomes when treating hallux rigidus.

Practical Algorithm When Both Present

1. Determine the dominant pathology through:

   • Pain location (dorsal = rigidus; medial eminence = valgus)
   • Functional limitation (dorsiflexion loss = rigidus; shoe fitting = valgus)
   • Radiographic severity of each condition

2. For mild-to-moderate disease of both: Consider combined procedure addressing both pathologies simultaneously (cheilectomy + bunionectomy) 3

3. For advanced hallux rigidus with any valgus: The bunion deformity must be corrected as part of the surgical plan, as isolated treatment of rigidus will fail

The Real Clinical Decision

The actual surgical decision tree for hallux rigidus alone is:

• Early stage (Grade I-II): Cheilectomy 1, 2
• Advanced stage (Grade III-IV): First MTP arthrodesis remains gold standard 2

Bottom line: These procedures are not interchangeable alternatives. Treat the pathology that is present, or both if both exist.