Pain or discomfort in the great toe joint is a common occurrence amongst people seeking podiatric treatment. There are numerous reasons why people may experience pain or discomfort in this region. Pain in this area may be due to a restriction of motion, a condition referred to as hallux limitus or rigidus. This condition can lead to jamming of the joint and potential degenerative joint disease or arthritis. Ironically, this will lead to even further stiffening of the joint and pain with walking. Bunions or hallux abductovalgus deformities can also cause pain in the great toe joint. After years of this abnormal alignment of the joint arthritic changes can occur causing even more pain. Prior injury to the joint can lead to the development of traumatic arthritis. This is another potential cause of pain in the great toe joint. Patients with diabetes may develop an altogether different problem related to this lack of motion. In the presence of peripheral neuropathy (lack of painful sensation), these patients can develop skin breakdown and ulceration.
As you can see there are numerous causes for a painful joint. There are also numerous options, conservative and surgical, to treat these conditions. A Keller Arthroplasty is a surgical procedure designed to eliminate pain and discomfort in this joint. It is typically reserved for cases of severe arthritis, previous failed surgeries, diabetic ulcerations or certain types of bunion deformities.
Indications For Surgery
As with all surgical procedures there are certain criteria that are followed in choosing one procedure over another for any individual patient. In the case of the Keller arthroplasty, it is most commonly reserved for patients over the age of 55 with limited athletic activity. These patients are best able to tolerate the alteration in toe function created by this procedure. There should also be a moderate to severe amount of pain on movement of the joint, either passively or with walking that is not relieved by shoe gear, orthotics or other non-surgical means. X-rays are helpful to evaluate the condition of the bone and joint. These may show joint space narrowing, bone spurs or joint deterioration. As with any surgery, it is important that the patient have a clear understanding of all available options. They should also be aware of what to expect after surgery.
The Surgical Procedure
The procedure itself is fairly straightforward. An incision is made over the great toe joint. Once the joint is exposed, a small portion of bone is removed from the base of the proximal phalanx. This allows for an increase in motion in the joint and a reduction in pain. The defect created by the removal of the bone will fill in with soft tissue, creating a “false joint”. Some surgeons may choose to place a pin across the joint to maintain the position of the toe and to allow for scarring. The pin is usually left in place for 3-4 weeks. The soft tissue structures are then re-attached and the wound is closed. The patient is then placed in a surgical shoe. Casting is not necessary and limited ambulation is usually allowed following this procedure.
What to Expect after Surgery
The postoperative recuperation usually involves use of the surgical shoe for 2-3 weeks. Limited ambulation may be allowed. If a pin was inserted, this is usually removed after 3-4 weeks. Because the pin exits out the tip of the great toe, it can usually be removed in the office. It does not require a second surgical procedure. Once the pin is removed, the patient can get the foot wet, increase their weightbearing activities, begin range of motion exercises and gradually advance to sneakers. Most people can return to their usual shoe gear and activity at 6 weeks.
The most common postoperative concerns are prolonged swelling. It is not unusual for some degree of swelling to persist beyond 3 months. This will typically resolve on its own. Occasionally, the use of a compression sock will expedite resolution of the swelling. Also, an orthotic device may be helpful to allow for more efficient transfer of weight during ambulation and more even distribution of weightbearing forces. All in all, when the preoperative criteria are met, this procedure can provide a significant degree of relief from a painful great toe joint.