Abstract
Background: A number of typical complications have been associated
with Keller resection arthroplasty. Recurrent valgus deformity, cock-up
deformity, and a flail toe may be difficult problems for the treating surgeon
because options for salvage are limited. In this study, we evaluated
arthrodesis of the first metatarsophalangeal joint as a salvage technique
following a failed Keller procedure. In addition, the outcomes of
motion-preserving procedures were reviewed in a separate series.
Methods: Arthrodesis of the first metatarsophalangeal joint was
performed in twenty-eight patients (twenty-nine feet, group A), and either a
repeat Keller procedure or an isolated soft-tissue release was performed in
eighteen patients (twenty-one feet, group B). The patients were evaluated at
least twenty-four months postoperatively, with a personal interview and a
clinical examination with use of a modification of the hallux
metatarsal-interphalangeal scale. Radiographs were also made for the group
treated with the arthrodesis.
Results: In group A, the average duration of follow-up was
thirty-six months and fusion was achieved in twenty-six of the twenty-nine
feet. Satisfaction was excellent or good in twenty-three cases, and the
postoperative score according to the modified hallux
metatarsal-interphalangeal scale averaged 76 points (maximum, 90 points). A
repeat arthrodesis was necessary in five feet because of malposition or
pseudarthrosis. In group B, the average duration of follow-up was seventy-four
months. Satisfaction was excellent or good in only six cases, and the patient
was dissatisfied in eleven cases. The score according to the modified hallux
metatarsal-interphalangeal scale averaged 48 points. Valgus deviation and
cock-up deformity had recurred in the majority of the feet at the time of
follow-up.
Conclusions: Although it is more technically demanding, we recommend
arthrodesis for salvage following a failed Keller procedure since it may be
associated with a higher rate of patient satisfaction and better clinical
results.
Level of Evidence: Therapeutic study, Level III-2
(retrospective cohort study). See Instructions to Authors for a complete
description of levels of evidence.
Resection arthroplasty of the first metatarsophalangeal joint, introduced
by Keller in 19041,
has been utilized to treat both hallux valgus and hallux rigidus. This
procedure offers a number of advantages, including technical simplicity,
satisfactory pain relief, and easy postoperative care. However, the Keller
procedure has been reported to be associated with several common
complications2,3,
including recurrent hallux valgus, transfer metatarsalgia, cock-up deformity,
and a floppy toe when an excessive amount of bone has been resected. When
these complications require salvage surgery, options are limited, and the
literature contains few reports evaluating different salvage techniques.
Arthrodesis of the first metatarsophalangeal joint is an accepted treatment
for severe hallux valgus and hallux rigidus. Its use as a salvage procedure
following failed bunion surgery has been described in several
studies4-8,
but we are aware of only one report addressing arthrodesis for salvage after a
failed Keller
procedure9. In 1987,
Coughlin and Mann9
reported the results of sixteen arthrodeses of the first metatarsophalangeal
joint that had been performed after a Keller procedure had failed in eleven
patients. Fusion was achieved in each patient, and all of the results were
excellent or good. Lateral metatarsalgia was present in twelve feet
preoperatively, and it resolved in all but one after the surgery.
Other procedures that can be potentially used for salvage following a
failed Keller resection arthroplasty include implant arthroplasty and repeat
resection arthroplasty with soft-tissue techniques (i.e., tendon lengthening),
but their clinical effectiveness has not been reported, to our knowledge.
Treatment following a failed Keller procedure has been a controversial
topic at our institution. In the past, joint-motion-preserving techniques were
routinely used as salvage procedures. In the early 1990s, encouraged by the
results of the study by Coughlin and
Mann9, we extended
the indication for arthrodesis of the metatarsophalangeal joint to include a
failed resection arthroplasty, and increasing numbers of arthrodeses were
performed in the following years.
The aim of our study was to review the outcomes of two salvage techniques
used for the treatment of patients with a failed Keller procedure. We present
the results of a series of consecutive arthrodeses of the first
metatarsophalangeal joint and a series of two other, motion-preserving
procedures: (1) z-shaped lengthening of the extensor hallucis longus tendon in
patients with an isolated cock-up deformity and (2) a repeat Keller procedure
with further proximal phalangeal resection in patients with recurrence of
hallux rigidus or valgus deformity.
AKeller procedure was considered to have failed when a patient had the
typical painful sequelae of the resection arthroplasty, such as a valgus
deformity or a cock-up toe. Surgery was indicated when conservative treatment,
primarily with a custom-made shoe insert, did not relieve the pain
sufficiently. Because of the retrospective nature of this study, the
allocation of treatment between the two groups was not randomized; the type of
procedure performed depended on the surgeon's preference and experience. The
decision was not based on a selection criterion such as the severity of the
deformity or any specific contraindication. Nevertheless, a selection bias
cannot be ruled out, and therefore the two groups were not compared
directly.
Arthrodesis (Group A)
Between 1993 and 1999, we performed thirty-three arthrodeses of the first
metatarsophalangeal joint for salvage following a failed Keller operation in
thirty-two patients (Table I).
Twenty-eight patients (twenty-nine feet) were available for follow-up, and
they formed the study group. All patients except two were female. The mean age
at the time of the surgery was sixty-four years (range, forty-nine to
seventy-eight years). The interval between the resection arthroplasty and the
arthrodesis averaged thirteen years (range, two to thirty-eight years). Eight
patients had undergone previous surgery: four had had another bunion procedure
prior to the Keller procedure, and four had had revision surgery after the
resection arthroplasty because of a cock-up toe deformity and recurrent valgus
deformity (a tendon lengthening had been done in three patients and an implant
arthroplasty, in one).
Preoperative diagnoses included painful cock-up toe deformity (twelve
feet), recurrent hallux valgus (ten), persistent hallux rigidus (six), and
hallux varus (one). Transfer metatarsalgia in which callosities under the
metatarsal heads were combined with symptoms was diagnosed in sixteen of the
twenty-nine cases.
Operative Technique
We performed the salvage arthrodesis of the first metatarsophalangeal joint
with use of regional anesthesia (peripheral nerve block), and a tourniquet was
used in fourteen cases in this series. Through a dorsal approach, we performed
a z-lengthening of the extensor hallucis longus tendon, released the
contracted capsule, and débrided the joint. Residual articular
cartilage was removed, and a ball-and-socket or flat-cut configuration was
prepared for arthrodesis. (Between 1993 and 1999, our technique evolved from
flat cuts to the ball-and-socket configuration.) It was our aim to position
the fusion so that the residual proximal phalanx was in 15° of valgus and
20° of dorsiflexion in relation to the first metatarsal, but the position
of the second toe and the inclination of the first metatarsal may have had an
effect on the final position in some cases. In fourteen of the procedures, two
crossed cannulated cancellous screws (3.0 mm in diameter; Synthes, Paoli,
Pennsylvania) were used for fixation. In patients with insufficient bone in
the residual phalanx, we inserted a single screw (three feet), one screw and a
Kirschner wire (nine feet), or two crossed Kirschner wires (two feet). In one
patient, we used a dorsal minifragment plate. Depending on the intraoperative
stability of the fusion and the anticipated compliance by the patient, the
patients either wore a stiff-soled shoe and were allowed weight-bearing to
tolerance on the heel only for an average of seven weeks or had a
below-the-knee walking cast for an average of six weeks, after which they wore
a postoperative shoe for another four weeks.
Additional procedures: Associated subluxation of lesser
metatarsophalangeal joints and hammer toes were treated simultaneously if they
were symptomatic. Additional procedures were performed in eighteen of the
twenty-nine feet. These procedures included a Weil shortening osteotomy of the
lesser metatarsals (nine feet), a Helal osteotomy of the lesser metatarsals
(one), a Hohmann partial phalangeal resection (five), and bunionette
procedures (a condylectomy of the fifth metatarsal head in two feet and a
Hohmann metatarsal osteotomy in one).
Group B
The other group in our study comprised twenty-nine feet (twenty-six
patients) in which we attempted to salvage the failed Keller operation without
doing an arthrodesis of the first metatarsophalangeal joint
(Table I). The procedures were
performed between 1989 and 1997. Twenty-one feet (eighteen patients) were
available for follow-up, four patients could not be located, and four patients
had died. All patients were female; the mean age at the time of surgery was
sixty-two years (range, forty-nine to seventy-four years). The preoperative
diagnoses included hallux valgus (seven feet), hallux rigidus (two), and
cock-up deformity (twelve). Symptomatic callosities under the lesser
metatarsal heads were noted in ten feet before the revision surgery.
Operative Technique
The specific revision procedure in each patient in this group was dictated
by the particular residual deformity. When a patient had an isolated cock-up
toe deformity with contracture of the extensor hallucis longus tendon, we
performed a z-lengthening of the tendon (twelve feet). In the presence of
recurrent valgus deformity or painful limitation of joint motion, we performed
a repeat Keller procedure with further resection of the base of the proximal
phalanx and a medial capsulorrhaphy (nine feet). The extensor hallucis longus
tendon was also lengthened in patients who had, in addition, a cock-up
deformity, and medial sesamoidectomy was performed in one patient with
sesamoiditis. The use of transient Kirschner wire fixation depended on the
surgeon's preference, and it was used in five feet. Patients were permitted to
bear weight as tolerated while wearing a stiff-soled postoperative shoe, for
an average of four to six weeks, before resuming regular shoe wear.
Additional procedures were performed in six of the twenty-one feet. These
procedures included a Helal osteotomy of the lesser metatarsals (two feet) and
a resection of the lesser metatarsal heads (one) in three feet with lateral
metatarsalgia as well as a Hohmann partial phalangeal resection in another
three feet with symptomatic hammer toes.
Follow-up Evaluation
At the time of follow-up, we evaluated patients with use of the American
Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsal-interphalangeal
scale10. This
100-point scale was modified to a maximum score of 90 points for patients who
had undergone arthrodesis, since 10 points of the original scale are assigned
to the range of motion of the first metatarsophalangeal joint
(Table II). Furthermore,
because this outcome tool does not address transfer lesions of the lesser
metatarsals, we noted the presence of transfer metatarsalgia independent of
the AOFAS hallux metatarsal-interphalangeal score. The diagnosis of transfer
metatarsalgia was based on the combination of the patient's report of symptoms
and the presence of callosities under the metatarsal heads.
Special attention was paid to the presence of hallux valgus and cock-up
deformities. Furthermore, patients were asked to rate their satisfaction with
the result of the procedure. The result was considered excellent when the
patient was very satisfied, had no problems related to the foot, and would
have the procedure again without reservation. The result was considered good
when the patient was satisfied despite minor problems and would definitely
undergo the surgery again. The result was defined as fair when the patient had
major problems, only some improvement, and reservations about the success of
the surgery, whereas the result was graded poor when the patient was
dissatisfied and regretted having had the surgery.
Anteroposterior and lateral weight-bearing radiographs were made for the
patients treated with the arthrodesis, to determine whether there was evidence
of metatarsophalangeal joint fusion and to assess proximal phalanx-to-first
metatarsal alignment. Joint fusion was considered to be present when there was
trabecular bone crossing the fusion site, and the angle formed by the
intersection of the diaphyseal axes was measured. In group B, preoperative
weight-bearing radiographs were not available for a number of patients,
especially those who had had an isolated soft-tissue procedure. Therefore, a
radiographic evaluation of this group was not performed.
Group A (Arthrodesis)
Twenty-nine feet (twenty-eight patients) treated with an arthrodesis were
evaluated at the time of follow-up, at a mean of thirty-six months (range,
twenty-four to seventy-six months). The average AOFAS hallux
metatarsal-interphalangeal score was 76 points (range, 50 to 90 points). Since
1995, this score has been assessed routinely at our institution, and the
preoperative score was available for fourteen feet. In this subset of
patients, the average AOFAS hallux metatarsal-interphalangeal score improved
from 42 points (range, 15 to 65 points) preoperatively to 80 points (range, 70
to 90 points) at the time of follow-up. We did not try to determine
preoperative scores retrospectively, as such scores are a poor indicator of
the patient's preoperative
condition11.
The average hallux valgus angle decreased 12.8°, from 27.3° (range,
5.5° to 53.5°) preoperatively to 14.5° (range, 6° to
32.5°) at the time of follow-up. Two cases of preoperative varus deformity
(—2.5° and —37°) were changed to postoperative values of
10.5° and —9.5°, respectively. The one case of postoperative
hallux varus was the result of a nonunion. The average preoperative and
postoperative intermetatarsal angles were 9.9° (range, 2° to
17.5°) and 9.8° (range, 4.5° to 15°), respectively.
Radiographically, dorsal angulation of the hallux (the angle formed by the
longitudinal axes of the first metatarsal and the proximal phalanx) averaged
21° (range, 5° to 42°). The mean first metatarsal inclination was
21° (range, 11° to 31°). Clinically, this translated into an
average proximal phalangeal position that was neutral relative to the
ground.
Assessment of radiographic evidence of preoperative arthrosis of the
interphalangeal joint was limited in feet with severe cock-up toe deformity.
Postoperative radiographs suggested only one case of degenerative changes of
the interphalangeal joint, in an asymptomatic patient.
The outcome of the salvage arthrodesis was considered by the patient to be
excellent for thirteen feet, good for ten, fair for one, and poor for five.
All five feet with a poor result were subsequently treated with a revision
arthrodesis. Fusion of the metatarsophalangeal joint was achieved in
twenty-six of the twenty-nine feet (Figs.
1-A, 1-B, and 1-C). One asymptomatic fibrous nonunion was
observed; the AOFAS score was 85 points, and no additional surgical management
was performed. There were two other, symptomatic nonunions, and they were
treated with a revision arthrodesis. Malunion was the indication for the other
three revision arthrodeses. In these cases, inadequate abduction and/or
dorsiflexion of the proximal phalanx created pain, abnormal hallux
load-bearing, and limitations with regard to shoe wear.
We observed sixteen cases of transfer metatarsalgia preoperatively; at the
time of follow-up, nine cases had resolved, five had improved, and two had
remained unchanged. In ten of the sixteen feet, simultaneous shortening
osteotomies of the lesser metatarsals were performed
(Figs. 2-A and 2-B), and, at
the time of follow-up of these ten feet, the transfer metatarsalgia had
resolved in seven, decreased in two, and remained unchanged in one. There was
a single case of new-onset transfer metatarsalgia following the
arthrodesis.
In addition to the three malunions and three nonunions, other complications
included two superficial wound infections, one deep infection, one complex
regional pain syndrome, and four cases of painful hardware. The superficial
wound infections resolved with local wound care and oral antibiotics. The deep
infection was eradicated with intravenous antibiotics. The complex regional
pain syndrome resolved after one year, and removal of prominent screws
alleviated the symptoms that they had been causing in the four patients.
Group B
Twenty-one feet (eighteen patients) treated with a salvage procedure other
than an arthrodesis were available for follow-up at an average of seventy-four
months (range, twenty-seven to 132 months). The AOFAS hallux
metatarsal-interphalangeal score averaged 51 points (range, 15 to 80 points),
and when the values for metatarsophalangeal joint motion were subtracted (as
they were in group A) the scores averaged 48 points (range, 15 to 75 points).
None of the outcomes were rated by the patient as excellent; six were rated as
good; four, as fair; and eleven, as poor. Problems leading to less favorable
outcomes included cock-up toe deformity (eight feet,
Fig. 3-A) and recurrent valgus
deformity (five feet). Cock-up toe deformity resulted in subjective loss of
push-off strength, transfer metatarsalgia, and shoe-wear limitations. Not all
patients with recurrent hallux valgus were symptomatic; one patient with a
42° hallux valgus angle was asymptomatic when wearing custom shoes. The
other four feet with recurrent hallux valgus subsequently underwent a salvage
arthrodesis.
Transfer metatarsalgia was diagnosed in ten feet preoperatively. At the
time of follow-up, symptomatic callosities were noted in nine feet
(Fig. 3-B), and in five of them
the callosities had developed postoperatively.
There was also one deep infection in this group, which resolved with
intravenous antibiotics.
Failed Keller resection arthroplasty is a difficult problem, both for the
patient and the treating surgeon. Persistent pain, shoe-wear limitations,
instability or stiffness, and transfer metatarsalgia are often recalcitrant to
nonoperative management and more disabling than the original problem that led
to the Keller procedure. Several studies have demonstrated that the extent of
the proximal phalangeal resection dictates functional outcome, and most
authors have recommended removing between one-third and one-half of the
proximal
phalanx2,3,12.
Resection of less than one-third increases the risk of insufficient
decompression of the metatarsophalangeal joint, leading to recurrent hallux
rigidus and reduced joint
mobility2.
Conversely, excessive resection often results in an unstable toe. Detachment
of the flexor hallucis brevis tendon may lead to the development of a cock-up
toe deformity. Decreased stability of the first metatarsophalangeal joint is a
common complication after the Keller procedure. As a consequence,
weight-bearing on the first ray is
impaired12-14,
often resulting in transfer metatarsalgia as excessive loads are placed on the
lesser metatarsal heads. Although modifications of the original method have
been
described15,16,
instability and its consequences still occur.
Salvage procedures consist of either (1) arthrodesis of the first
metatarsophalangeal joint or (2) joint-motion-retaining surgery, which is
confined to correcting the existing deformity. The second approach does not
typically solve the problem of instability, which is the underlying cause for
most of the complications occurring after resection arthroplasty. This
shortcoming was noted with an alarming frequency in our patients in group B.
Moreover, joint-motion-preserving surgery failed to consistently treat
preexisting transfer metatarsalgia.
In contrast, successful arthrodesis of the metatarsophalangeal joint
addresses instability, alignment, and transfer metatarsalgia relatively
effectively, although at the expense of mobility. To our knowledge, the only
study addressing metatarsophalangeal arthrodesis as a salvage procedure
following a failed Keller procedure was the study of eleven patients by
Coughlin and Mann9.
Five of their patients underwent a bilateral procedure, for a total of sixteen
procedures. Fixation was achieved with multiple intramedullary threaded
Steinmann pins, and interposition of an iliac crest graft was performed in
four feet. The results in this small series, after an average duration of
follow-up of twenty-nine months, were exceptional. Satisfaction was excellent
in twelve cases and good in four. We observed good-to-excellent results after
twenty-three of twenty-nine salvage arthrodeses of the first
metatarsophalangeal joint.
Improvement in weight-bearing and gait depends on achieving a solid fusion
in acceptable alignment. In the face of a relatively short first ray, the
potential for persistent transfer lesions exists despite arthrodesis. In such
cases, the surgeon may wish to consider rebalancing the lengths of the first
ray and lesser metatarsals. This can be achieved by means of bone-block
distraction arthrodesis of the first metatarsophalangeal joint or shortening
osteotomies of the lesser metatarsals, as were done in several of our patients
(Figs. 2-A and 2-B). We do not
wish to imply that such forefoot rebalancing procedures are a necessity. Of
primary importance is achieving a successful fusion of the first
metatarsophalangeal joint. Any additional procedures introduce the potential
for new complications, but if they are performed successfully, they may
further reduce the potential for persistent transfer metatarsalgia. In certain
cases, bone-block distraction arthrodesis of the first ray may also be a
useful way to realign the forefoot. Although reports of this technique have
been encouraging, it is technically more difficult than in situ arthrodesis
and is associated with increased nonunion rates, wound complications, and skin
necrosis5-7.
In our series, we were able to successfully perform a revision in situ
arthrodesis in all five feet in which the arthrodesis following the Keller
procedure had failed.
In revision surgery, the amount of residual bone often dictates the method
of fixation. Two crossed cancellous screws were used in fourteen of the feet
in our series. While fusion was achieved in all of those feet, nonunion was
observed in two feet in which fixation had been limited to a single screw.
Nonunion also occurred in one of two feet in which two crossed Kirschner wires
had been used. We therefore emphasize that stabilization should include more
than a single screw.
McKeever stressed that "it is the arthrodesis and its position that
is important and not the method by which it is
produced."17
The recommended hallux valgus angle for
arthrodesis7,11,18-23
has ranged from 0° to 30°; however, in a practical sense, the amount
of abduction of the hallux is limited by the position of the second
toe17,24,25.
In our series, the average hallux valgus angle measured 13.2° at the time
of follow-up, with the vast majority ranging from 5° to 20°.
Subjective results were rated as excellent even by patients with hallux valgus
angles measuring —1° and 32°. In our opinion, the correct amount
of hallux abduction should be determined for the individual patient, with the
position of the second toe and the intermetatarsal angle taken into
account.
The dorsiflexion angle of the hallux can be determined by the angle between
the metatarsal and the
phalanx17-19,21,22
or by the angle of the hallux relative to the
floor20,26,27.
Although setting dorsiflexion of the phalanx relative to the first metatarsal
may be practical in the operating room, we recommend that the degree of
metatarsal inclination as seen on preoperative lateral weight-bearing
radiographs be taken into account. In our series, we revised one salvage
arthrodesis because of intractable pain under the proximal phalanx. In this
patient, the metatarsophalangeal joint was fused in only 12° relative to
the metatarsal, but, when we reviewed preoperative lateral weight-bearing
radiographs, we noted a first metatarsal inclination angle of 31°.
Finally, the position of the fusion site may be influenced by the preferred
type of shoe and height of
heel26.
Salvage of a failed Keller procedure should create a stable, well-aligned
first ray to improve gait and weight-bearing. In our experience, a repeat
Keller procedure and tendon lengthening failed to correct instability and
deformity in most patients. However, it must be stressed again that these poor
results cannot be compared directly with the results of the arthrodeses. The
allocation of treatment to the two groups was not randomized, and a selection
bias cannot be ruled out. We also wish to point out that salvage arthrodesis
following a failed Keller resection arthroplasty is technically demanding, and
failures can be anticipated when stabilization is inadequate or the fusion is
in a poor position. Nevertheless, successful arthrodesis of the first
metatarsophalangeal joint in an anatomic position consistently improved
function and provided acceptable patient satisfaction in our series.
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