05/04/2013    Don Peacock, DPM

Post-Keller Complication (Gregory Caringi, DPM)

Unfortunately, this case is a result of an
inappropriate procedure performed on a 54-year-
old patient. Keller procedures should be used
with caution and have a significant history of
complications. In Keller’s original paper, he
discussed that he also performed a extensor
hallucis longus lengthening. This is overlooked
by some surgeons. Kellers are intended for use in
the elderly.

Two of the most significant deformities resulting
from Keller procedures are lack of toe purchase
or diminished plantarflexory function of the
hallux mostly due to sacrificing the intrinsic
insertion. In my opinion, a Keller bunionectomy
is almost always a bad call. You can perform a
medial approach modified silver dollar Keller,
leaving the intrinsic intact with good results in
correcting a degenerative joint disease of the
first metatarsal phalangeal joint.

However, even with this modification, I recommend
it only in the elderly. In this case, there is
1/3 or more resection of the base of the hallux
and the intrinsics have been compromised. This
leads to inadequate hallux weight-bearing and
propulsion. You certainly do not want to
compromise the second metatarsal head by
performing a metatarsal head resection. That will
lead to transfer pain under the third metatarsal.

This is a case where you’re stuck with Catch-22
options. The best procedures would be to fuse the
first metatarsal phalangeal joint and correct
the second toe by performing and Isham lateral
wedge minimally invasive hammertoe procedure.
This would realign the plantarflexors of the
second metatarsal.

The cyst is present because there is excessive
pressure in the second metatarsal and plantar
plate rupture causing 2nd DJD, etc. This is also
be evident in the cortical structures of the
second metatarsal. The cortical bone is obviously
thickening suggesting that excessive pressure is
being place on the second metatarsal. The fusion
should alleviate some of the second metatarsal
pressure.

I would also correct gastrocnemius equinus
deformity if present and it most likely is.
Unfortunately, this patient would of been better
served if her original surgery would have been a
decompression of osteotomy of the 1st met or
hallux or both.

Decompression is often times very effective for
stage I and stage II degenerate joint disease of
the first metatarsal phalangeal joint. It can
even be relatively effective for stage III
degenerate joint disease.

Don Peacock, DPM, Whiteville, NC,
peacockdpm@gmail.com

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