Keller’s arthroplasty is a well-established surgical procedure used to treat painful conditions affecting the big toe joint, particularly hallux valgus (bunion deformity) and hallux rigidus (stiffness and arthritis of the big toe joint). Named after Captain William Keller, who first described it in the early 1900s, this procedure remains an important option for relieving pain and restoring comfort in patients who struggle with joint motion or deformity.
How Common It Is and Who Gets It? (Epidemiology)
Keller’s arthroplasty is most often performed in older adults, typically over age 60, who experience pain and stiffness in the first metatarsophalangeal (MTP) joint. It is particularly beneficial for patients with low physical demands or limited activity levels who wish to relieve pain and improve shoe comfort. The procedure is less commonly used in younger or highly active individuals because it may reduce toe strength and alter foot mechanics.
Why It Happens – Causes (Etiology and Pathophysiology)
Hallux valgus occurs when the big toe drifts toward the second toe, forming a bunion on the inside of the foot. This causes pain, swelling, and difficulty wearing shoes. Hallux rigidus, by contrast, is caused by arthritis in the MTP joint, leading to cartilage loss, stiffness, and bone spur formation. These conditions develop from a combination of genetic, mechanical, and degenerative factors. Keller’s arthroplasty helps by removing part of the base of the big toe bone (proximal phalanx), reducing pressure and allowing smoother motion in the joint.
How the Body Part Normally Works? (Relevant Anatomy)
The first MTP joint is formed by the head of the first metatarsal bone and the base of the proximal phalanx of the big toe. It enables bending of the toe during walking, especially in the push-off phase. When arthritis or deformity affects this joint, the toe can become painful, swollen, and stiff, limiting mobility. By removing the arthritic portion of the joint, Keller’s arthroplasty relieves pressure and restores alignment, improving comfort and function.
What You Might Feel – Symptoms (Clinical Presentation)
Patients with hallux valgus or hallux rigidus often experience pain and stiffness at the base of the big toe, swelling over the bunion, and difficulty wearing shoes. The big toe may drift inward or lose motion, and walking may become painful. Some patients also notice redness or thickened skin over the joint due to irritation from shoes.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is made through physical examination and X-rays. The surgeon evaluates the range of motion in the big toe, identifies the degree of deformity, and checks for tenderness or swelling. X-rays reveal the extent of joint arthritis, the size of any bone spurs, and changes in the alignment of the first metatarsal and proximal phalanx.
Classification
Hallux valgus and hallux rigidus are graded by severity based on joint space narrowing, angular deviation, and mobility. Keller’s arthroplasty is most appropriate for moderate to severe arthritis with mild to moderate deformity, especially when joint preservation is no longer feasible but full fusion is not desired.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that may resemble hallux valgus or rigidus include gout, sesamoiditis (inflammation beneath the first metatarsal), bunionette deformity, and capsulitis of the second MTP joint. Imaging helps differentiate between these causes.
Treatment Options
Non-Surgical Care
Early treatment includes footwear modifications, padding over the bunion, anti-inflammatory medications, orthotics, and activity modification. Stiff-soled shoes or rocker-bottom soles reduce joint motion and pain. Steroid injections may help temporarily.
Surgical Care
Keller’s arthroplasty (CPT 28292) is performed when conservative treatments fail. The procedure involves removing a small portion of the base of the big toe’s proximal phalanx to eliminate the painful contact between the bones and reduce deformity.
Step-by-step:
- A small incision is made over the inner side of the big toe joint.
- The medial eminence (bunion) is removed.
- A section of the proximal phalanx is excised to decompress the joint and relieve pain.
- Soft tissues are balanced to restore toe alignment and mobility.
- The incision is closed, and the foot is dressed and supported in a postoperative shoe.
Unlike fusion procedures, Keller’s arthroplasty preserves some movement in the toe, providing a balance between pain relief and flexibility.
Recovery and What to Expect After Treatment
After surgery, patients wear a postoperative shoe for four to six weeks. Limited weight-bearing is allowed during this time. Stitches are removed after about two weeks. Gradual range-of-motion exercises begin once healing is stable. Most patients can return to comfortable walking and normal shoes within six to eight weeks.
Possible Risks or Side Effects (Complications)
Complications may include infection, excessive shortening of the toe, cock-up deformity (toe elevation), or pain under the ball of the foot (transfer metatarsalgia). Some patients may notice a mild loss of toe strength or stiffness. These risks are minimized with careful surgical technique and postoperative management.
Long-Term Outlook (Prognosis)
Keller’s arthroplasty offers excellent pain relief and improved function for the majority of patients. Studies show that over 75–85% of patients report good to excellent results. While motion is not fully restored, most patients regain comfortable mobility for daily activities. The procedure is particularly effective for older, less active individuals who value pain relief and shoe comfort over complete joint motion.
Out-of-Pocket Cost
Medicare
CPT Code 28292 – Keller’s Arthroplasty (Correction of Hallux Valgus with or without Sesamoidectomy): $159.49
Medicare Part B covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover that remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and reduce patient responsibility.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans often cover any remaining balance, including coinsurance or small deductibles, which usually range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your Keller’s arthroplasty is required due to a work-related injury or progressive deformity aggravated by occupational strain, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and postoperative care. You will not have any out-of-pocket costs, as the employer’s insurance carrier pays for all approved treatments directly.
No-Fault Insurance
If your foot deformity or big toe pain requiring Keller’s arthroplasty is related to an automobile accident, No-Fault Insurance will typically cover the total cost of the procedure and recovery. The only possible out-of-pocket cost may be a small deductible or co-payment depending on your insurance policy.
Example
Patricia Long had chronic pain and stiffness in her big toe joint due to advanced hallux valgus deformity. She underwent Keller’s arthroplasty (CPT 28292) with an estimated Medicare out-of-pocket cost of $159.49. Because Patricia had supplemental coverage through AARP Medigap, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
Q. What is Keller’s Arthroplasty?
A. Keller’s Arthroplasty is a surgical procedure used to treat hallux valgus (bunion) and hallux rigidus (arthritis in the big toe joint) by removing part of the first toe’s proximal phalanx and excising the medial eminence of the first metatarsal to alleviate pain and preserve toe function.
Q. What is the goal of Keller’s Arthroplasty?
A. The goal is to relieve pain and preserve as much function as possible in the big toe, especially in older patients or those with lower physical demands.
Q. How is Keller’s Arthroplasty performed?
A. The surgery is performed through a dorsal medial incision, where portions of the bone and soft tissue are carefully removed. The procedure does not require extensive joint fusion, helping maintain some motion in the toe.
Q. What are the typical outcomes of Keller’s Arthroplasty?
A. The procedure generally results in pain relief and improved ability to wear regular footwear. However, complications such as metatarsalgia or the toe becoming “cocked up” can occur in some cases.
Q. Who is an ideal candidate for Keller’s Arthroplasty?
A. It is most suitable for older, less active patients with hallux valgus or hallux rigidus who prioritize pain relief and maintaining some toe movement rather than joint restoration.
Q. What are the risks and complications of Keller’s Arthroplasty?
A. Risks include metatarsalgia (pain under the ball of the foot), a cocked-up toe, and cosmetic dissatisfaction due to the toe becoming shorter than the second toe.
Q. How does Keller’s Arthroplasty compare with other surgeries like joint fusion?
A. While joint fusion provides permanent pain relief, it eliminates toe movement. Keller’s Arthroplasty preserves some motion, making it preferable for less active patients who prioritize pain relief.
Q. What are the success rates of Keller’s Arthroplasty?
A. Studies show that approximately 87% of patients report good to excellent outcomes, with significant pain relief and improved foot function.
Q. What role does age play in the success of Keller’s Arthroplasty?
A. Older patients generally do better with Keller’s procedure due to their focus on pain relief and reduced need for joint movement. Younger patients may experience more complications and may be better suited for more invasive procedures like joint fusion.
Q. Is cosmetic outcome a concern after Keller’s Arthroplasty?
A. Yes, some patients, especially women, may be dissatisfied with the appearance of their foot post-surgery, particularly if the big toe becomes noticeably shorter than the second toe.
Q. How long does it take to recover from Keller’s Arthroplasty?
A. Recovery typically takes about 6 to 8 weeks, with patients being able to walk with a special shoe during this period. Full recovery may take several months for complete healing.
Q. Will I be able to walk immediately after Keller’s Arthroplasty?
A. Patients are usually allowed to walk with a special surgical shoe or boot immediately after surgery, but weight-bearing is limited initially to ensure proper healing.
Q. Is physical therapy required after Keller’s Arthroplasty?
A. Physical therapy is not typically required, but patients may be advised to perform simple exercises to regain motion and strength in the toe as part of the recovery process.
Q. Can I return to normal activities after Keller’s Arthroplasty?
A. Most patients can return to normal daily activities after the recovery period, but high-impact activities and sports should be avoided until fully healed.
Q. Are there alternatives to Keller’s Arthroplasty?
A. Yes, alternatives include bunionectomy, joint fusion, or even joint replacement, depending on the severity of the condition and the patient’s age and activity level.
Summary and Takeaway
Keller’s arthroplasty is a reliable and time-tested procedure for relieving pain in patients with hallux valgus or hallux rigidus. It removes arthritic bone while maintaining limited motion, offering pain relief and improved shoe comfort. The procedure is best suited for older patients or those with moderate activity levels. With proper patient selection and careful surgical technique, outcomes are excellent, and complications are rare.
Clinical Insight & Recent Findings
A recent study compared long-term outcomes of Keller’s arthroplasty, arthrodesis, and cheilectomy in patients treated for hallux rigidus over 22 years ago. Using gait and dynamic pressure (pedobarographic) analysis, researchers found no significant differences among the three surgeries in walking speed, foot pressure distribution, or patient-reported outcomes.
Participants across all groups showed results similar to healthy individuals, suggesting that each technique—when chosen appropriately for the stage of arthritis—can provide lasting pain relief and functional stability. Interestingly, even Keller’s arthroplasty, once thought to create an unstable big toe, showed comparable long-term performance to the more rigid arthrodesis and the motion-preserving cheilectomy.
The study highlights that careful patient selection and proper staging of disease are key, as all three surgeries can yield favorable results decades later. (“Study on long-term gait and foot pressure outcomes after Keller’s arthroplasty – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Keller’s arthroplasty is performed by an orthopedic foot and ankle surgeon or a podiatric surgeon experienced in reconstructive forefoot surgery. The surgical team includes an anesthesiologist, surgical nurse, and physical therapist.
When to See a Specialist?
You should see a foot specialist if you have persistent big toe pain, stiffness, or deformity that interferes with walking or footwear despite conservative treatment.
When to Go to the Emergency Room?
Seek emergency care if you experience excessive swelling, severe pain, redness, drainage, or fever after surgery, as these may signal infection or complications.
What Recovery Really Looks Like?
Recovery involves limited weight-bearing in a special shoe for several weeks, followed by gradual walking and motion exercises. Swelling improves steadily, and most patients achieve pain-free walking by eight weeks.
What Happens If You Ignore It?
Without treatment, hallux valgus and hallux rigidus can worsen, leading to increased pain, stiffness, and deformity. Over time, this may limit mobility and cause secondary problems such as calluses and transfer pain in other toes.
How to Prevent It?
Wearing supportive footwear, avoiding tight shoes or high heels, and maintaining a healthy weight can help prevent worsening of deformities. Early treatment of bunions and arthritis can reduce the need for surgery later.
Nutrition and Bone or Joint Health
A balanced diet rich in calcium, vitamin D, and protein promotes healing after surgery. Avoid smoking and excessive alcohol intake, as they can slow recovery and increase complication risk.
Activity and Lifestyle Modifications
After recovery, patients should continue wearing comfortable shoes with wide toe boxes and supportive soles. Low-impact activities such as walking or swimming are encouraged to maintain joint health and prevent recurrence of pain.
Dr. Mo Athar
