Felix Machacek, Jr., MD1, Mark E. Easley, MD2, Florian Gruber, MD1, Peter Ritschl, MD1 and Hans-Jörg Trnka, MD1
1 Orthopaedic Hospital Gersthof, Wielemansgasse. Vienna. Austria.
2 Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710
Investigation performed at Orthopaedic Hospital Gersthof, Vienna, Austria
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.
J Bone Joint Surg Am 2004 86: 1131-1138.