Keller's arthroplasty at Wessex Hospital

Keller's arthroplasty is an operation on the big toe that removes a small piece of bone from the base of the joint, easing arthritis pain and correcting deformity. Because no bone needs to fuse back together afterwards, recovery tends to be more straightforward than with some other toe surgeries.

What conditions does it treat?

Keller's arthroplasty is used when non-surgical treatments haven't given enough relief from problems affecting the joint at the base of your big toe.

• Hallux rigidus: a swollen, painful joint that's become very difficult to move.
• Hallux limitus: a stiffer, more restricted version of the same joint.
• Hallux valgus, or a bunion: where the big toe pushes against the next toe and a bump forms on the side of the joint, especially where there's significant arthritis too.
• A long-standing sore or ulcer on the sole of the big toe that hasn't healed, often linked to diabetes and reduced sensation in the foot (neuropathy).

What are the benefits of Keller's arthroplasty?

• Pain relief and correction of the toe's alignment.
• Because no internal fixation or bone healing is needed, recovery tends to be more straightforward and quicker than with some alternative toe operations.
• It can help a long-standing plantar ulcer heal: in one study, existing ulcers healed in an average of 22.2 days after surgery, and none of the patients needed an amputation.
• High patient satisfaction: 94% of patients in the same study were satisfied with their results, even allowing for some shortening of the toe.
• In a 22-year comparison for hallux rigidus, Keller's arthroplasty was more successful than cheilectomy (a smaller, bone-shaving operation) at stopping the condition's long-term effects, although joint fusion (arthrodesis) had the best overall outlook of the three.

Are there different approaches?

• A thin wire is sometimes used temporarily to hold the toe in position while it heals; many patients don't need this, and it's usually reserved for more severe deformities.
• For more severe bunions, the surgeon may cut the bone at an angle rather than straight across, to help the toe continue to work well.
• The operation is usually done under local anaesthetic, but sedation or a general anaesthetic can be used instead if that's your preference.

What happens before the operation?

This surgery tends to be considered once non-surgical treatments haven't worked well enough, such as:

• Changing your activity levels
• Painkillers or anti-inflammatory medication
• Supportive or custom footwear and insoles
• A joint injection
• Alternative surgery, such as joint fusion or a bone-cutting procedure (osteotomy).

If you have an open sore on your toe, your surgeon will check beforehand that there's no sign of infection reaching the bone, as this would rule out the operation. Since you'll go home the same day, arrange for a responsible adult to travel home with you and help you through the first night.

What happens during the procedure?

1. You're usually given a local anaesthetic, so you're awake but shouldn't feel pain; sedation or a general anaesthetic can be used instead if you'd prefer.
2. Your surgeon makes a cut along the top of the joint at the base of your big toe.
3. The joint capsule is opened, and the base of the toe bone, along with any bony lumps, is removed.
4. The remaining soft tissue is stitched into place to cushion the gap left behind, sometimes described as a false joint.
5. A temporary wire may be used to hold the toe in position while it settles, though this isn't always needed.
6. The wound is closed with stitches. The whole procedure usually takes about 30 minutes.

What does recovery look like?

On the day

This is a day-case procedure. You'll spend some time in the day surgery unit being monitored, then go home the same day with a responsible adult, who should stay with you for the first night in case you need help getting around.

In the weeks afterwards

• First 2 weeks: pain is usually at its worst now, so keep taking the painkillers you're given, rest with your foot raised, and limit walking to short, essential trips, using crutches if you have them.
• Around 2 weeks: a follow-up appointment removes your stitches and any wire that was used; many people can move into ordinary shoes from around now, though some need longer.
• 2 to 8 weeks: swelling and discomfort gradually ease as you take more weight through the foot in supportive shoes, sometimes alongside physiotherapy.
• 8 to 12 weeks: the foot usually starts to feel more normal, and a return to sport may be possible depending on your progress.
• 6 to 8 months: a final review checks your longer-term result, as improvements in pain, alignment and movement can continue well beyond the early weeks.

What are the risks and complications?

• Pain, bleeding, infection or scarring, as with any operation.
• Ongoing joint pain, or pain in the ball of the foot (metatarsalgia).
• Shortening of the big toe, which can be significant enough that it no longer touches the ground.
• Weakness or misalignment of the toe, or the deformity returning, or the toe drifting the other way (hallux varus).