Metatarsophalangeal Joint Arthrodesis after Failed Keller-Brandes Procedure

Abstract

Background:

Keller-Brandes resection arthroplasty for correction of symptomatic hallux valgus deformity can obtain early good results, but late complications, such as recurrence of the deformity and instability of the first ray, have been described. Arthrodesis of the first metatarsophalangeal, (MTP) joint can be done as a salvage procedure. The aim of this prospective study was to evaluate the clinical outcome of the arthrodesis and its effect on the biomechanics of the first ray.

Methods:

Between October, 1999, and December, 2002, arthrodesis of the MTP joint was done after a failed Keller-Brandes procedure in 28 feet of 26 consecutive patients. Twenty patients (22 feet) with a minimum of 24 months followup were available for clinical and radiographic assessment. Pedobarographic measurements were obtained at latest followup in 16 patients (17 feet).

Results:

Sixteen feet (72%) were pain-free and six feet (28%) had mild, occasional pain. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score increased from a preoperative 44 (range 29 to 67) points to 85 (range 73 to 90) points at longest clinical followup (average 34 months, range 23 to 48, p < 0.001). The average hallux valgus angle was corrected from 24.0 (range 7 to 47) degrees preoperatively to 16.0 (range 0 to 40) degrees postoperatively (p < 0.001). Two feet had pseudoarthroses. Biomechanically, the MTP joint arthrodesis could not fully restore the function of the hallux but produced a significant improvement, allowing a more physiologic loading pattern under the hallux and the metatarsal heads.

Conclusions:

First MTP joint arthrodesis after a failed Keller-Brandes procedure is a technically safe and reliable technique. It resulted in a marked reduction of pain and gain of function that produced high patient satisfaction.

Keywords

Failed Keller-Brandes Procedure Metatarsophalangeal Arthrodesis Outcomes

INTRODUCTION

Among the numerous operative treatments of symptomatic hallux valgus deformities,^{1,6,9,11,16,17,21,29,36,40,41,48,50} resection arthroplasty as described by Keller and Brandes^1,18,19 has been used since its introduction in the beginning of the last century. Although good early results were described, late complications have included recurrence of the hallux valgus deformity, secondary decompensation of the forefoot leading to pain over the first metatarsophalangeal (MTP) joint, and overloading of the rest of the metatarsal bones because of instability of the first ray. Cock-up deformities and flail toes also have been reported.^23,37,46 Conservative treatment of these complications often fails so that operative intervention is needed.^26,47 One treatment option³⁹ is an arthrodesis^{12,13,24,28,33,49} of the MTP joint to restore the biomechanical integrity of the first ray. However, MTP joint arthrodesis is difficult because the Keller-Brandes resection dramatically alters the anatomic configuration of the joint and shortens the hallux. An autograft often is needed, causing additional donor site morbidity. Interpositional arthrodesis of the joint has been described as a salvage procedure,³² but we found no prospective study evaluating the outcome of this procedure.

The aim of this study was to evaluate the clinical, radiographic, and pedobarographic outcomes of arthrodesis of the MTP joint after failed a Keller-Brandes arthroplasty.

MATERIAL AND METHODS

Between October, 1999, and December, 2002, arthrodesis of the first MTP joint was done after failed Keller-Brandes procedures in 28 feet of 26 consecutive patients. The Keller- Brandes procedure was considered to have failed when a patient had the typical painful sequelae of the resection arthroplasty, such as hallux valgus recurrence, cock-up toe deformity, or instability of the MTP joint. Surgery was indicated when conservative treatment (custom-made shoe) failed to stabilize the MTP joint or relieve the pain sufficiently. All arthrodeses were done by the senior author (PV). At the time of followup one patient had died, one could not be reexamined because of poor medical condition, and four patients refused further examination because they were asymptomatic. Twenty patients (22 feet; 15 right feet, 7 left feet) were available for followup examination at a minimum of 24 months after surgery.

Operative Technique

The patients were supine and spinal or regional anesthesia was administered. The ipsilateral iliac crest also was draped. A tourniquet was applied. The MTP joint was approached dorsomedially through the preexisting incision, and the joint capsule was incised longitudinally. The first metatarsal head and the base of the first phalanx of the great toe were exposed. The remaining cartilage and the joint capsule were resected. The joint surfaces were prepared to allow stable fusion in a correct position. We did not ream the joint surfaces but drilled them with a 1.5-mm drill to increase the blood supply at the joint surface. If shortening of the first toe was excessive, a tricortical bone graft from the ipsilateral iliac crest was inserted. This was necessary in seven feet. The joint was stabilized with 2.4-mm lag screws. Two crossed screws were used in 19 feet (Figure 1), in one foot two screws were parallel, in one foot only one screw was used, and in one foot one screw and a dorsal plate were used. The prominent medial border of the joint was resected with an oscillating saw to avoid medial discomfort. A medial capsulorraphy was added, and the skin was closed with a continuous suture. A stabilizing bandage was applied. Postoperatively, patients were allowed to ambulate with full weightbearing in a special shoe with a hard sole for 6 weeks. All patients except for one had simultaneous operative corrections of additional disorders of the forefoot or midfoot. Table 1 summarizes the patient demographics.

Clinical Assessment

Clinical assessment included preoperative and postoperative structured interviews and detailed, standardized examinations using the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score.²⁰ Because of the MTP joint arthrodesis, the highest achievable postoperative AOFAS forefoot score was 90 points. In addition, the subjective satisfaction of the patient was measured by using the rating system reported by Coughlin⁵ (Table 2).

Radiographic Assessment

Preoperative and postoperative radiographs were available for all feet. The hallux valgus angle, the first-second intermetatarsal angle, and the relative length of the first ray were defined measured preoperatively and postoperatively on dorsoplantar and lateral full weightbearing plain radiographs of the foot. Length of the first ray was defined with respect to the second MTP joint. A line crossing the second MTP joint and perpendicular to the axis of the second metatarsal was drawn. The shortest distance between this line and a parallel line tangential to the tip of the distal phalanx of the great toe was defined to measure the relative length of the first ray. The healing of the arthrodesis was verified on full weightbearing dorsoplantar and lateral plain radiographs at 6 and 12 weeks postoperatively and at the final followup.

Pedobarographic Measurements

Pedobarographic measurements were done at final follow-up in 17 feet (16 patients). In five feet (four patients) pedobarographic measurements could not be done because of medical reasons (three patients had fear of falling, one patient suffered from spastic hemiparesis, and one patient was unable to walk without crutches due to severe osteoarthritis of the knee).

The EMED-SF4 system (Novel Gmbh, Munich, Germany) was used for the pedobarographic measurements. This device uses 2736 sensors with a resolution of four sensors per cm² and provides a sampling frequency of 50 Hz. The two-step method³ was chosen, and the subjects were asked to walk at a self-selected speed. Three or more measurements have been shown to provide excellent reliability.¹⁴ Five individual plantar pressure measurements were collected and averaged to obtain one mean pressure pattern for each foot. Each forefoot was geometrically divided into eight anatomical regions by the EMED Automask software, using a built- in algorithm. This foot division technique is objective and consistent, which is especially important when dealing with varying foot forms. The eight defined regions are each of the five metatarsal heads, the hallux, the second toe, and the third to fifth toes. For each of these foot areas, the peak pressure was recorded. To compare postoperative pedobarographic measurements, plantar pressure values for normal feet were taken from the work of Bryant et al.³ and from Milani et al.³¹ We did not use preoperative forefoot measurements of our patients, because all patients had pain with barefoot walking from the disturbed first metatarsal joint. We preferred to use the normal values and compare them with our values postoperatively because the patients could walk barefoot and painfree. We could show that peak pressure under the first toe could be established after arthrodesis of the MP-I-joint (our series).

Table 1:

Patient demographics

Pt	Gender	Age	Side	Graft	Screws	Simultaneous procedures
1	Female	57	Right	0	2 cross	Girdlestone-Taylor II-V
2	Male	57	Left	1	1 cross	double arthrodesis, gastrocslide
3	Female	55	Right	1	2 cross	Excision Morton neuroma
4	Female	74	Right	0	2 cross	Chevron-OT
5	Female	69	Right	0	2 cross	Chevron-OT
6	Female	59	Left	1	2 cross	Girdlestone-Taylor II-III
7	Female	58	Right	1	2 cross	Girdlestone-Taylor II-IV, resection tailor's bunion
8	Female	72	Right	0	2 parallel	Girdlestone-Taylor II-IV
9	Female	67	Right	0	2 cross	Gastrocslide
10	Female	84	Right	0	2 cross	Girdlestone-Taylor II-IV
	Female		Left	0	2 cross	Girdlestone-Taylor II
11	Female	73	Left	0	2 cross	Girdlestone-Taylor IV
12	Female	56	Right	0	2 cross	Metatarsal-OT, tenotomy FDL V
13	Female	63	Right	1	1 cross plate	Girdlestone-Taylor II-V
14	Male	80	Right	0	2 cross	0
15	Female	59	Right	0	2 cross	Girdlestone-Taylor II, Resection tailor's bunion
	Female		Left	0	2 cross	Girdlestone-Taylor II, Resection tailor's bunion
16	Female	61	Right	0	2 cross	Girdlestone-Taylor II
17	Male	48	Right	1	2 cross	Osteophyte resection os naviculare
18	Female	56	Left	0	2 cross	Gastrocslide, midfoot arthrodesis
19	Female	53	Left	1	2 cross	Girdlestone-Taylor II
20	Female	61	Right	0	2 cross	Girdlestone-Taylor II-IV, gastrocslide

Table 2:

Scoring system by Coughlin⁵

Rating
Excellent	Without problems, very satisfied, mild or no pain, walks without difficulty
Good	A few problems, satisfied, mild pain, walks without difficulty or with mild difficulty, would still have had surgery
Fair	Moderate pain, limited walking, reservation about success of surgery
Poor	Continued pain, little improvement in walking ability, regrets surgery

Statistical Analysis

A Wilcoxon signed rank test was used for statistical analysis of the preoperative and postoperative AOFAS scores, for the radiographic findings and to detect differences between feet with and without iliac-crest cortical bone graft. A p value of < 0.05 was considered to be significant.

RESULTS

At average followup of 34 (range 24 to 48) months, a significant decrease of pain and marked functional improvement of the forefoot were achieved, as indicated by increased AOFAS scores. Radiographically, correction of the hallux valgus angle was significant. Clinical and radiographic results are summarized in Table 3.

Clinical Findings

The AOFAS forefoot score increased from 44 (range 29 to 67) points preoperatively to 85 (range 73 to 90) points at time of followup (p < 0.001). Nineteen (86%) patients considered their results as excellent, one (5%) as good, and two (9%) as fair. Pain decreased significantly (p < 0.001) from 18 points preoperatively to 37 points postoperatively; 16 feet (72%) were pain-free and six feet (28%) had mild, occasional pain. Two patients had excessive dorsiflexion in their fused MTP joint that caused localized pressure on the tip of the great toe and proximal interphalangeal joint in closed shoes. One patient had a mildlysymptomatic pseudoarthrosis. Another patient had transfer-metatarsalgia related to an insufficient posterior tibial muscle causing instability of the midfoot. A local tenderness over the screws caused mild pain in another patient who did not want screw removal. In one patient no specific reason could be found, but pain decreased after hardware removal.

Table 3:

Clinical and radiographic results

Patient	Followup	AOFAS Preoperative points	AOFAS followup points	Pain followup points	Pain followup points	Satisfaction^***	HV angle preoperative degree	HV angle followup degree	Difference in length mm	Fusion
1	27	52	85	20	40	excellent	17	10	4	Yes
2	28	42	90	20	40	excellent	8	10	14	Yes
3	37	42	90	20	40	excellent	32	8	9	Yes
4	35	42	73	20	30	fair	25	15	−7	Yes
5	47	37	73	20	30	good	27	17	−17	Yes
6	30	42	80	20	30	excellent	23	27	7	Yes^*
7	34	42	90	20	40	excellent	26	25	18	Yes
8	38	42	85	20	40	excellent	47	23	5	Yes
9	29	29	75	0	30	fair	24	24	−5	Yes
10	31	49	90	20	40	excellent	32	29	−10	Yes
	31	49	90	20	40	excellent	32	19	−6	Yes
11	35	47	90	0	40	excellent	20	12	−1	Yes
12	42	37	85	20	40	excellent	7	7	−7	Yes
13	43	52	85	20	40	excellent	17	0	11	Yes
14	28	57	90	20	40	excellent	17	7	−5	Yes
15	33	42	80	20	30	excellent	19	0	−3	No^**
	33	42	90	20	40	excellent	15	13	−2	Yes
16	40	42	85	20	40	excellent	14	18	−1	Yes
17	26	50	90	0	40	excellent	14	12	9	Yes
18	48	42	90	20	40	excellent	40	40	−2	Yes
19	40	67	80	30	30	excellent	42	21	6	Yes
20	23	32	90	20	40	excellent	29	15	3	yes

mean	34	44	85	18	37		24	16	10.5
p		<0.001		<0.001			<0.001

after revision;

asymptomatic;

***

Scoring System by Coughlin⁵;

HV = hallux valgus.

Twenty-one feet (95%) caused no limitations of daily activities while one foot (5%) caused limited recreational activity. Four patients (four feet) required modified footwear, and 18 feet used conventional fashion shoes. All patients were satisfied with the outcome and would undergo the operation again.

There were no intraoperative complications but two immediate postoperative complications (a seroma and a delayed wound healing) occurred at the donor site on the iliac crest. In both, no specific therapy was required after infection was ruled out. Late complications included two pseudoarthroses.

Radiographic Findings

The average hallux valgus angle was corrected from 24.0 (range 7 to 47) degrees preoperatively to 16.0 (range 0 to 40) degrees postoperatively (p < 0.001).

The length of the first ray increased by 10 (5 to 18) mm in the seven patients with iliac crest cortical bone grafts and decreased in those without bone grafts by 4 (range −17 to 5) mm. Arthrodesis did not change the intermetatarsal angle: preoperative, 10.0 + 4 degrees; postoperative, 10.8 + 4 degrees.

Two feet developed pseudoarthroses. One had a successful revision and reached a maximal AOFAS score of 90 points at longest followup. This patient had a lengthening of the first ray with an iliac crest cortical bone graft. The second pseudoarthrosis occurred in one of the patients with simultaneous bilateral procedures. This patient had mild intermittent pain, which had decreased to the preoperative level, and he refused to undergo revision.

There was one implant loosening, without screw breakage that did not affect healing of the arthrodesis. The patient was pain free at followup.

Removal of the hardware was necessary in two patients who complained about painful implant prominence on the medial aspect of the first metatarsal and dorsal region of the hallux. After removal with the use of local anesthesia, both patients were pain-free and totally satisfied with the procedure. Figures 2 shows the radiographic results in a 61-year-old woman 36 months after MTP joint arthrodesis.

Pedobarographic Findings

Peak pressure in the hallux region of the 17 measured feet averaged 175.29 ± 133.74 kPa. The average peak pressures (kPa) in the forefoot from the five trials were: Meta I 561.76 ± 318.71, Meta II 630.29 ± 368.37, Meta III 547.65 ± 342.01, Meta IV 215.88 ± 100.05 and Meta V 168.53 ± 114.25 kPa. Average peak pressures are summarized in Table 4.

DISCUSSION

Relief of pain, restoration of a physiological and stable position of the MTP joint and restoration of the load-bearing function of the great toe are the essential goals of a salvage procedure after failed Keller-Brandes operation. In terms of pain relief and patient satisfaction, our results are comparable to those of previously published series that focused on MTP joint arthrodesis after failed Keller-Brandes procedures.^5,26 To our knowledge, only a few studies have used the AOFAS scoring system to quantify the outcomes^{2,6,8,22,26,34} after MTP joint arthrodesis. The reported AOFAS scores ranged from 53 to 90 points.^{2,6,8,22,26,34} However, only Machacek et al.²⁶ had a subgroup that was comparable to our series. Their patients had an average postoperative AOFAS score of 76 points. In other studies,^{2,6,8,22,26,34} patients had varying etiologies and conditions leading to a first MTP joint arthrodesis. In our series, the AOFAS forefoot score increased significantly (p < 0.001) and averaged 85 points at final followup.

Table 4:

Average peak pressures of all patients for the eight forefoot regions in kPa, and standard deviation

Pedobarographic measurement	Pressure [kPa]	SD
Meta 1	561.76	318.71
Meta 2	630.29	368.37
Meta 3	547.65	342.01
Meta 4	215.88	100.05
Meta 5	168.53	114.25
Hallux	175.29	133.74
2nd toe	109.71	82.61
3rd-5th toe	159.41	101.24

Pain relief, improvement of weightbearing capacity, and gait depend on achieving a solid fusion with physiological alignment. Reported rates of successful primary arthrodesis using various techniques generally range from 79% to 100%.^{2,5,6,8,12,22,25,26,28,34,42} We achieved a stable arthrodesis in 20 (91%) of the 22 feet in our series. The two pseudoarthroses might be related to the fact that one patient had a fusion with interposition of an iliac-crest bone graft and the other had simultaneous bilateral arthrodeses. Use of a tricortical bone graft is known to be associated with an increased risk of pseudoarthroses.^2,34

Coughlin et al.⁵ reported no pseudoarthroses in their series of MTP joint fusions after failed Keller-Brandes operations. The main reason might be the fusion technique that used two 3.7-mm double-ended threaded Steinmann pins, which were retained until radiographic proof of bony healing. However, this technique requires removal of the hardware. In contrast, we use two 2.4-mm screws, depending on the amount and quality of residual bone, as well as the need for an iliac-crest cortical bone graft.

Politi et al.³⁵ stated that the combination of an oblique lag screw and a dorsal plate is the most stable technique for obtaining fusion. However, as important as achieving a stable fusion is the correct position of the arthrodesis, which is difficult with a straight plate.

The recommended hallux valgus angle for arthrodesis ranges from 0 to 30 degrees.^{4,10,13,24,27,34,44,45} In our series, the average postoperative hallux valgus angle was 16 degrees. We believe that the correct angle of hallux abduction should be determined for each patient individually taking both the position of the second toe and the intermetatarsal angle into account.

The position of the hallux in terms of dorsiflexion also is important. The dorsiflexion angle can be defined as either the angle of the hallux relative to the floor^13,28,43 or as being the angle between the first metatarsal and the phalanx.^{4,10,24,27,30} The first method might be the most accurate and easiest to obtain, choosing the inclination angle of the hallux approximately 15 degrees relative to the floor. Furthermore, the ideal position also might be influenced by the patient's preferred type of shoe and heel height.⁴³ In our series, two patients complained of local soreness caused by excessive dorsal extension in the fused MTP joint.

Contrary to other studies^7,25 that reported a decrease in the intermetatarsal angle after arthrodesis, this was unchanged in our series. The pedobarographic results indicate a marked improvement compared to the condition after failed Keller- Brandes operation. A more physiologic loading pattern under the hallux and the metatarsal heads was restored after MTP joint arthrodesis. The peak pressure diagram (Figure 3) shows that in our series the hallux was bearing some-what less than 50% of the peak pressure of a nonpathological foot.^3,15 The load is shifted posteriorly, mainly to the first, but also to the second and third metatarsal heads. The hallux peak pressure after a Keller-Brandes operation³¹ drops to 20% of the normal peak pressure value.^3,15 The MTP joint arthrodesis, therefore, restored some of the natural hallux function after failed Keller-Brandes procedure.

Comparing our data with the plantar pressures after the Keller-Brandes procedure,³¹ it is important to note the medial shift of the peak pressure from the third metatarsal head onto the first. This new load distribution may reduce the risk of developing metatarsalgia. None of our patients developed transfer metatarsalgia related to the fusion. This load shift in a medial direction is likely to be caused by the partial restoration of weightbearing capacity of the fused MTP joint, which is not provided by the Keller-Brandes procedure.

Limitations of this study include the small number of patients. The pedobarographic measurements were available only after arthrodesis and could not be compared to preoperative measurement. The high standard deviations observed in our series might arise from the additional procedures done in most of the feet: MTP joint arthrodesis was done as an isolated procedure in only one foot.

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