The Foot and Ankle Online Journal 6 (2): 2
Sometimes the success of orthopedic and podiatric surgery may be compromised by inadequate bone repair. In recent years, new tools have been used to improve bone healing by accelerating the rate of bone formation and maturation of the matrix. For instance, there is currently great interest in the use of platelet gel to repair bone defects and accelerate the bone healing process. We report the case of a patient with recurrent hallux valgus following Keller resection arthroplasty for whom the problem was resolved with the use of an autologous cancellous bone graft enriched with platelet-rich plasma as a salvage procedure to enhance arthrodesis. The use of bone graft enriched with platelet-rich plasma (PRP) is a technology in the field of foot surgery should be investigated further.
Key words: Bone graft, Platelet- rich plasma, Keller arthroplasty, Salvage surgery
Accepted: January, 2013
Published: February, 2013
Address correspondence to: Antonio Córdoba-Fernández, Departamento de Podología, Universidad de Sevilla, Edificio Docente de Fisioterapia y Podología, Calle Avicena s/n 41009- Sevilla, Spain.
1Titular Professor. Departamento de Podología, Sevilla, Universidad de Sevilla, Edificio Docente de Fisioterapia y Podología, Calle Avicena s/n 41009- Sevilla, Spain. (034) 954486539 firstname.lastname@example.org
2Assistant Professor. Departamento de Podología, Sevilla, Universidad de Sevilla, Edificio Docente de Fisioterapia y Podología, Calle Avicena s/n 41009- Sevilla, Spain. (034) 954486539 email@example.com
The Keller-Brandes excision arthroplasty technique has been used for decades for the treatment of symptomatic hallux valgus and hallux rigidus. It is even today still sometimes considered a valid procedure for the management of painful adult hallux valgus associated with arthritis of the metatarsophalangeal joint.[1,2] However, the technique often causes the patient dissatisfaction because it fails to maintain the proper alignment and biomechanical functionality of the hallux.
The most common complications associated with the procedure that have been reported in the literature include recurrence of the deformity, transfer metatarsalgia, excessive shortening of the toe, and “cock up” deformity.[3-6] In most cases, the recurrence of the deformity is the result of poor correction of the inter-metatarsal angle after the procedure. Although the technique is out-dated today, it is still relatively common to find patients who have complications after undergoing a Keller arthroplasty. Salvage of the failed procedure by metatarsophalangeal joint arthrodesis (MTPJ-A) of the hallux is a complex surgical problem, especially if it results in shortening of the hallux.
The use of bone graft enriched with platelet-rich plasma (PRP) is a relatively novel technology in the field of podiatric and orthopedic surgery. It is used to enhance bone formation and reduce the risk of delayed consolidation or non-union. The positive impact of PRP on bone healing is attributed to the angiogenic, proliferative, and differentiating effect on osteoblasts of the growth factors and tissue adhesion molecules it contains. The results of numerous studies that have used PRP associated with autologous or heterologous bone grafts show promise for achieving the regeneration of long bones and for the treatment of bone defects. Investigators have shown that PRP and its growth factors and cytokines enhance mesenchymal stem cell proliferation.[8,9]
A 61 year-old woman presented with painful hallux valgus of the left foot. According to her surgical history, in 1989 she had had an operation to correct hallux valgus of both feet by the Keller technique. In 1996, she had a revision on the left foot by means of re-excision arthroplasty and soft tissue reconstruction due of recurrence of the deformity. Our radiographic examination showed severe joint destruction in both feet with the result of asymptomatic hallux rigidus of the right foot, and hallux valgus of the left foot without significant shortening of the great toe. In both feet, there was broadening and flattening of the second and third metatarsal heads secondary to Freiberg’s disease. (Fig. 1)
Surgery was planned for the left foot, consisting in MTPJ-A of the hallux. The procedure consisted of excision of the base of the proximal phalanx of the second toe, and metatarsal remodeling of the second metatarsal head with stabilization of the joint by means of a Kirschner wire. A cancellous bone graft was extracted from the base of the phalanx, second metatarsal head and first metatarsal head (bunion). This was triturated and mixed with 5 ml of PRP which was subsequently activated with 10% calcium chloride in accordance with the PRGF System® protocol (Biotechnology Institute, Vitoria, Spain). (Fig. 2)
Figure 1 Preoperative radiograph shows destruction of the first metatarsophalangeal joint in both feet. Recurrence of hallux valgus with hallux shortening of the left hallux can be observed.
Figure 2 Autologous bone graft triturated and mixed with activated PRP.
A flat osteotomy was performed on the first metatarsal head, and decortication and revascularization at the base of the hallux’s proximal phalanx, with interposition of the graft that had been obtained, and stabilization by means of a 1.5 mm Kirschner wire (Fig. 3). Following surgery, the foot was immobilized in a short leg cast and the patient allowed walk aided by crutches. Progress postoperatively was normal until the fourth week with the onset of inflammation affecting the hallux accompanied by pain and increased local temperature compatible with an infectious process.
Figure 3 Immediate postoperative radiograph of the left foot show interposition of the bone graft with stabilization by Kirschner wire.
This forced the premature withdrawal of the Kirchner wire, and the initiation of antibiotic therapy for three weeks until remission of the clinical signs of infection. The foot remained immobilized in a short leg cast for 4 weeks.
After removal of the cast, the patient was placed in a reverse camber shoe for 4 weeks that elevates and protects the forefoot and allowed full weight bearing assisted by a crutch. Follow-up examinations with radiological control were conducted at 4, 8, 12, and 24 weeks, and one year postoperatively. The 12-week radiological examination showed the presence of lytic lesions at the level of the interphalangeal joint consistent with sequelae of osteoarthritic sepsis. (Fig. 4)
Figure 4 Twelve week anterior posterior radiograph demonstrating the resorption of graft with partial consolidation. Lytic lesions at the level of the interphalangeal joint by septic osteoarthritis can be observed.
Despite the early removal of the fixation, no delay was observed in consolidation of the bone in the zone of the graft. Instead there was steady progression to full fusion. (Fig. 5)
Numerous salvage techniques have been described to resolve complications associated with the Keller-Brandes arthroplasty. These include arthrodesis, re-excision and reconstruction of soft tissue, and placement of hemi-implants or total implants.[6,11] The existing evidence shows that MTPJ-A of the hallux is a good option for the restoration of the biomechanical integrity of the first ray after a Keller arthroplasty.
Figure 5 One year postoperatively radiograph. Complete fusion and satisfactory alignment of the hallux has been attained.
A prospective study with long-term monitoring carried out sequentially on 28 feet which underwent an MTPJ-A following a failed Keller-Brandes arthroplasty found the procedure to be safe and effective, and to result in functional improvement with high patient satisfaction .
However, the technique is sometimes difficult to perform as a result of the resection arthroplasty drastically altering the anatomical configuration of the joint, producing a significant shortening of the hallux with the risk of non-union. In many cases, this circumstance requires the use of an autologous bicortical iliac crest graft combined with rigid fixation elements (low profile plates with cortical screws), thus increasing the technical difficulty of the procedure and its associated risk, as well as donor site morbidity.[12-16]
Although there are no conclusive data on the non-fusion rate following MTPJ-A as a salvage procedure after a failed Keller, according to the literature data, even with stable fixation systems the risk of non-fusion in patients who have undergone a hallux MTPJ-A with interposition of a bone graft as a salvage procedure is in the range 10%–24% compared to only 5%–8% in patients who have undergone the technique as the primary procedure.[15-17] Some of these studies advise against re-fusion after a failed hallux MTPJ-A except for removal of the osteosynthesis material.
New therapies have been used to increase the effectiveness of autologous grafts in bone regeneration for the treatment of bone defects, delayed consolidation, and non-fusion. Some studies have reported satisfactory results associated with the use of PRP for the treatment of bone defects. In the realm of orthopedic surgery, PRP has been used to improve osseous healing in fusion, fracture repair, and limb-lengthening procedures, and to accelerate soft-tissue healing in acute and chronic tendinous injuries.[19-21] Similarly, good results have been reported with the use of PRP to treat recalcitrant nonunions of the lower limbs and in the treatment of post-traumatic spinal fusions.[22-24] PRP has also been successfully employed in association with bone substitutes that have osteoconductive and osteoinductive properties to accelerate the healing process after tibial osteotomy in both animals and humans.[25,26] Although recent studies seem to demonstrate the superiority of other preparations such as recombinant bone morphogenetic protein (rhBMP) associated with bone graft, the recombinant production technique usually involves higher costs than the systems for obtaining autologous PRP.
In the present case, the association of PRP with autologous bone graft led to complete fusion in a bone of poor quality and without rigid fixation elements. Despite the early withdrawal of the Kirschner wire due to the appearance of infection in the interphalangeal joint of the hallux, there was no delay in consolidation, and complete radiological fusion was observed at 24 weeks.
Although the use of a graft obtained from the patient’s own foot has already been reported in the literature as a salvage procedure following a failed Keller, to the best of our knowledge, the present case is the first to use an autologous graft taken from the foot in association with a platelet gel as the salvage procedure.
According to the literature, the use in the technique of non-rigid osteosynthesis material such as Kirschner wires or Steinmann pins in association with the ankle brace surgical shoe is effective, even with immediate loading, and as in the present case, has the advantage of its easy removal in case of complication.[12,29] Nonetheless, it has to be borne in mind that the use of intramedullary fixation elements can lead to increased risk of infection, ankylosis of the hallux’s interphalangeal joint or breakage of the osteosynthesis material in patients who do not adequately comply with postoperative recommendations.
We consider that MTPJ-A with interposition of PRP-enriched autologous bone graft may be a useful alternative for the salvage of failures following Keller arthroplasty when there is no excessive shortening of the hallux. In particular, it can avoid the risks associated with the use of autologous bicortical bone graft and complex osteosynthesis material, with a concomitant reduction in donor site morbidity, better cosmetic results, and reduction in the costs associated with the use of complex osteosynthesis material. We consider that use of bone graft enriched with platelet-rich plasma (PRP) is a relatively novel technology in the field of foot surgery should be investigated further.
1. Putti AB, Pande S, Adam RF, Abboud RJ. Keller’s arthroplasty in adults with hallux valgus and hallux rigidus. Foot Ankle Surg 2012 18: 34-38. [PubMed]
2. Schneider W, Kadnar G, Kranzl A, Knahr K. Long-Term Results Following Keller Resection Arthroplasty for Hallux Rigidus. Foot Ankle Int 2011 32: 933-939. [PubMed]
3. Leonhardt K. Results of Keller-Brandes method of hallux valgus surgery. Beitr Orthop Traumatol.1990 37: 510-517. [PubMed]
4. Schneider W, Knahr K. Keller procedure and chevron osteotomy in hallux valgus: five-year results of different surgical philosophies in comparable collectives. Foot Ankle Int 2002 23: 321-329. [PubMed]
5. Axt M, Wildner M, Reichelt A. Late results of the Keller–Brandes operation for hallux valgus. Arch Orthop Trauma Surg 1993 112: 226-229. [PubMed]
6. Machacek F, Easley M, Gruber F, Ritschl P, Trnka HJ. Salvage of a failed Keller resection arthroplasty. JBJS 2004 86: 1131-1138. [PubMed]
7. Marx RE, Carlson ER, Schimmele SR. Platelet rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radio Endod 1998 85: 638-646. [PubMed]
8. Vogel JP, Szalay K, Geiger F, Kramer M, Richter W, Kasten P. Platelet-rich plasma improves expansion of human mesenchymal stem cells and retains differentiation capacity and in vivo bone formation in calcium phosphate. Platelets 2006 17: 462- 469. [PubMed]
9. Kocaoemer A, Kern S, Klueter H, Bieback K. Human AB-serum as well as thrombin activated platelet-rich-plasma are suitable alternatives to fetal calf serum for the expansion of mesenchymal stem cells. Stem Cells 2007 25: 1270-1278. [PubMed]
10. Anitua E. The use of plasma-rich growth factors (PRGF) in oral surgery. Pract Proced Aesthet Dent 2001 13: 487-493. [PubMed]
11. Simpson-White R, Joseph G, Khan M. Prosthetic replacement arthroplasty as a salvage operation for failed procedures of the first metatarsophalangeal joint: A small series and literature review. The Foot 2007 17: 174-177. [Website]
12. Coughlin MJ, Mann RA. Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure. JBJS 1987 69: 68-75. [PubMed]
13. Georgousis H, Patsalis T, Bertram R. Salvage of the failed Keller-Brandes operation by metatarsophalangeal fusion. Foot Ankle Surg 1996 2: 3-11. [Website]
14. Vienne P, Sukthankar A, Favre P, Werner CML, Baumer A, Zingg PO. Metatarsophalangeal joint arthrodesis after failed Keller-Brandes procedure. Foot Ankle Int. 2006 27:824-901. [PubMed]
15. Myerson MS, Schon LC, McGuigan FX, Oznur A. Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000 21: 297-306. [PubMed]
16. Bennet GL, Kay DB, Sabatta J. First metatarsophalangeal joint arthrodesis: an evaluation of hardware failure. Foot Ankle Int 2005 26: 593-596. [PubMed]
17. Roukis TS. Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. J Foot Ankle Surg 2011 50: 710-713. [PubMed]
18. Hope M, Savva N, Whitehouse S, Elliot R, Saxby TS. Is it necessary to re-fuse a non-union of a hallux metatarsophalangeal joint arthrodesis? Foot Ankle Int 2010 31: 662-669. [PubMed]
19. Dallari D, Savarino L, Stagni C, Cenni E, Cenacchi A, Fornasari PM, Albisinni U, Rimondi E, Baldini N, Giunti A. Enhanced tibial osteotomy healing with use of bone grafts supplemented with platelet gel or platelet gel and bone marrow stromal cells. JBJS 2007 A89: 2413-2420. [PubMed]
20. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med 2009 37: 2259-2272. [PubMed]
21. Kitoh H, Kitakoji T, Tsuchiya H, Katoh M, Ishiguro N. Transplantation of culture expanded bone marrow cells and platelet rich plasma in distraction osteogenesis of the long bones. Bone 2007 40: 522-528. [PubMed]
22. Chiang CC, Su CY, Huang CK, Chen WM, Chen TH, Tzeng YH. Early experience and results of bone graft enriched with autologous platelet gel for recalcitrant. J Trauma 2007 63: 655-661. [PubMed]
23. Hartmann EK, Heintel T , Morrison RH ,Weckbach A. Influence of platelet-rich plasma on the anterior fusion in spinal injuries: a qualitative and quantitative analysis using computer tomography. Arch Orthop Trauma Surg 2010 130: 909-914. [PubMed]
24. Sanchez M, Anitua E, Cugat R, et al. Nonunions treated with autologous preparation rich in growth factors. J Orthop Trauma. 2009 23: 52-59. [PubMed]
25. Dallari D, Savarino L, Stagni C, Cenni E, Cenacchi A, Fornasari PM, Albisinni U, Rimondi E, Baldini N, Giunti A. Enhanced tibial osteotomy healing with use of bone grafts supplemented with platelet gel or platelet gel and bone marrow stromal cells. JBJS 2007 A89: 2413-2420. [PubMed]
26. Kanthan SR, Kavitha G, Addi S, Choon DS, Kamarul T. Platelet-rich plasma (PRP) enhances bone healing in non-united critical-sized defects: a preliminary study involving rabbit models. Injury 2011 42: 782-789. [PubMed]
27. Calori GM, Tagliabue L, Gala L, D’Imporzano M, Peretti G, Albisetti W. Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone nonunions: a prospective randomized clinical study on 120 patients. Injury 2008 39: 1391-1402. [PubMed]
28. Patel S, Mistry RS, Dodd LE, Shaikh N, Palmer SH. Second toe proximal phalanx interposition bone graft to correct a failed Keller’s arthroplasty. A new technique. Foot Ankle Surg 2009 15: 149-151. [PubMed]
29. Mah CD, Banks AS. Immediate weight bearing following first metatarsophalangeal joint fusion with Kirschner wire fixation. J Foot Ankle Surg 2009 48: 3-8. [PubMed]