Is the Keller Bunionectomy Outdated?

By Mark Hofbauer, DPM, and Steven Kravitz, DPM

Yes, Mark Hofbauer, DPM, cites the limited indications of the procedure. He says the first MPJ fusion is a better option for hallux abductovalgus patients as it provides enhanced stability and biomechanical effects. For the past 10 to 15 years, there has been a great debate over whether the Keller bunionectomy has become an outdated procedure. Proponents on both sides have been able to make solid arguments. The Keller bunionectomy began to get a black eye years ago when surgeons stretched the indications for its use. This was due in part because it was an easy, quick procedure to perform. As time has passed, the indications have narrowed significantly, not necessarily to the point of extinction, but at least to the endangered list. When deciding on a procedure for hallux abductus valgus repair, one has to weigh many considerations including joint destruction versus joint preservation, the patient’s activity level and his or her chance for the best long-term results. The reason for failed hallux abductovalgus surgery is almost always poor procedure selection. Having said that, we need to focus on what procedures will provide the best long-term results for the patient. Notice that I did not say “what procedure works best in my hands” or make statements such as “People have been doing Kellers for years” or “All of my patients with Kellers do great.” These types of statements and thought processes only slow the progression of a more scientifically based process toward accurate procedure selection for patients with a hallux abductovalgus deformity. What’s the first question we should ask when evaluating a patient with hallux abductovalgus? Is a joint preservation procedure or joint destructive procedure indicated? The answer in this case is a joint destructive procedure. The second question is: What joint destructive procedure will provide the patient with the most predictable, functional, best long-term result? When answering this question for almost all patients, the answer is first metatarsal phalangeal joint (MPJ) fusion, not a Keller bunionectomy. Understanding The Limitations Of Keller Bunionectomies And The Strengths Of First MPJ Fusions If we take a look at the indications for a Keller bunionectomy, they are limited at best. Essentially, you would use this procedure for an elderly, apropulsive patient with bump pain. Period. How many of these types of patients walk into your office every day? Very few. Many studies have shown that the Keller bunionectomy has withstood the test of time. This may be true to some extent, but how many of these studies have looked at patients five years down the road? Very few. How many of these studies have looked at whether the patient may have done even better with a different procedure? None. Our job is to look at history with a critical eye, expand upon our knowledge base, learn new technologies and strive for the best procedure for the patient. When we look at the articles written over the years concerning first ray stabilization in the rheumatoid arthritis patient, this is where we begin to learn of the Keller bunionectomy’s lack of predictability and lack of stabilizing force as opposed to that which is provided by the first metatarsal phalangeal joint fusion. When examining this subgroup of patients, we see that patients score much higher following first metatarsal phalangeal joint fusion (in comparison to the Keller bunionectomy) with regard to stride length, push-off power, pain relief, cosmeses, lesser metatarsalgia and activity level. This is due in part to the stabilizing effect of the first ray with a fusion versus the instability of the intrinsics about the first metatarsal phalangeal joint created by a Keller bunionectomy. One needs only to review the exhaustive studies of first ray pathology and anatomy, precisely those of Dudley Morton, to understand the importance of stabilizing and balancing the forefoot. Many of you will argue that one can reestablish the intrinsics about the first MPJ following a Keller bunionectomy by suturing the intrinsics to the base of the remaining phalanx. However, the studies show that push-off power is lost after a Keller bunionectomy. It is the same concept as to why lesser digital fusions do better than arthroplasties. Fusions create more stability and convert the soft tissues and intrinsics into stabilizing forces.

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