CAN WE IMPROVE UPON THE KELLER?
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| by Jay Lieberman, DPM, FACFAS |
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Ask ten foot and ankle surgeons how they perform the Keller bunionectomy and you will get ten different answers. Some will tell you that you must routinely pin the Keller to maintain transverse plane correction and allow fibrosis to develop in the space between the proximal phalanx and the head of the first metatarsal. Others insist that you must lengthen the long extensor to lessen the lateral pull on the toe.
Another thought was to interpose the joint capsule in the hope that it would help to prevent anklyosis, but on occasion one would see an hourglass shaped toe. Still others believe in the “Silver Dollar Keller” in which a very small sliver of the proximal phalanx is removed. It was believed that this preserved the function of the short flexor; however, it did not address the internal cubic content of the arthritic joint. In an attempt to address the loss of propulsion, one researcher proposed suturing the flexor apparatus to the plantar stump of the proximal phalanx. However, this resulted in a short lever arm and no significant improvement in propulsion
Any way you look at it, the standard Keller procedure leaves you with a floppy toe, the risk of bony anklyosis, lesser metatarsalgia and in some instances, a hallux malleus.
In my humble opinion, the use of spacers is the answer. The hemi implant has been used successfully for many years in hallux limitus corrections. Even in advanced hallux limitus, the hemi implant has been successful, particularly when used in conjunction with a decompression osteotomy.
Follow the procedure as it progresses: (click on the images below for a larger view).
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Prior to the “silicone panic” I routinely did my Kellers with silastic hemi implants or total joint implants. The concern over bony anklyosis was averted. The retrograde force onto the first metatarsal is maintained and the patient is less apt to develop lesser metatarsalgia. Wright medical hemi implants are perfect for patients with hallux limitus. The angled hemi implant is the ideal spacer for patients requiring a Keller procedure because it addresses the modified articular set angle. The Keller is a salvage procedure. The goals are very different than the osteotomy procedures for hallux abductovalgus. The well informed patient will have a more satisfactory result with state of the art spacers/hemi implants.
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