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Abstract

Background:

Surgery is often needed for resistant plantar diabetic foot ulcers (DFUs) of the big toe. For noninfected ulcers, 2 types of surgery are available: the Keller and the hallux interphalangeal joint arthroplasty (HIPJ-A) procedures. Yet, no evidence synthesis on the outcomes of these procedures has been conducted; thus, this systematic review is an attempt to fill this gap.

Methods:

Only studies reporting the results of Keller (or its variants) and HIPJ-A (or its variants) procedures for noncomplicated ulcers (Texas 1A/2A, or Wagner I/II) were included. Ulcers located beneath the metatarsal head were excluded. Ultimately, 11 studies were selected for inclusion and were analyzed. The primary outcome was defined as the ulcer healing frequency. The secondary outcomes were mean healing time, ulcer recurrence frequency, ulcer transfer frequency, postoperative infection rate, and revision surgery rate.

Results:

The overall (combined techniques) weighted healing rate was 94% with a mean healing time of 3.1 ± 0.4 weeks. The ulcer recurrence frequency was 6%, the ulcer transfer frequency 4.5%, the postoperative infection rate 18%, and the revision surgery rate 3.8%. No significant differences were found between both techniques. When compared to standard of care, the odds ratio of ulcer healing frequency was 27.1 (95% CI 1.442-508.174, P = .01) in favor of the Keller arthroplasty with a faster healing time (P = .02).

Conclusion:

Both surgical offloading procedures are highly effective in treating chronic noncomplicated DFU of the plantar aspect of the hallux along with low complication frequencies. There is a need to fine-tune the indication in relation to the location of the plantar wound with future comparative controlled research studies with far more patients than we could include in this meta-analysis.

Keywords

diabetic foot ulcer hallux Keller arthroplasty hallux interphalangeal joint arthroplasty surgery meta-analysis

Introduction

The occurrence of diabetic foot ulcers (DFUs) in patients having long-term diabetes is considered as a pivotal event. The complications of the foot wounds could be severe, imposing great morbidity, mortality, and health care cost.^3,19 Although the standard treatment of acute DFU is based on debridement and local topical care, surgery is warranted for those resistant to this standard of care. In fact, a standard of care based on the combination of local wound care and offloading cast has been reported to be an effective method for noncomplicated diabetic foot wounds but with recurrence rates as high as 60%.¹⁶ The surgical treatment is usually divided into 2 categories based on the severity of infection: conservative surgery and amputation. There have been many published systematic reviews and meta-analyses demonstrating the efficacy of conservative surgery.^24
-26,28,29 Depending on the location of DFU and on infection presence, one type of conservative surgery among many could be suggested. The forefoot is considered as the main location for DFU, with the hallucal wounds being the most frequent DFUs.⁴ One meta-analysis studied the effect of resection arthroplasty of resistant hallucal DFU with good to excellent results on nearly all outcomes.²³ However, the included studies were heterogeneous, including infected and noninfected wounds, and grouping altogether the Keller arthroplasty, the hallux interphalangeal joint arthroplasty (HIPJ-A), and the complete resection arthroplasty where both sides of the metatarsophalangeal joint (MTPJ) are resected.²³

Description of the Studied Procedures

Because this systematic review is focused on noncomplicated and noninfected hallucal ulcers, the MTPJ resection arthroplasty is not included for analysis. The 2 procedures that are used for chronic resistant noncomplicated hallucal ulcers are the Keller and HIPJ-A techniques.²³ The Keller consists of resecting the distal part of the metatarsal head to alleviate pressure over wounds near the metatarsophalangeal joint. The HIPJ-A applies a similar principle for ulcers around the interphalangeal joint by resecting the head of the first phalanx.

Objective of the Study

Because new studies have been published, a systematic review based on homogenous studies analyzing resection arthroplasty for noninfected hallucal DFU is needed. Therefore, the aim of this systematic review was to conduct an evidence synthesis and subgroup analysis on the comparative efficacy of Keller and HIPJ-A procedures for the treatment of noncomplicated DFU of the big toe.

Methods

Search Strategy

Electronic databases were searched including PubMed, Web of Science, and Embase. To increase the location accuracy of those relevant studies, broad terms were combined: [(hallux OR “big toe” OR hallucal) AND diabetic AND (ulcer OR wound) AND (Keller OR arthroplasty OR resection OR excision)]. The search was conducted since inception and terminated on December 31, 2023. No limitation on language was imposed.

Study Inclusion Criteria

Only studies reporting the results of resection arthroplasty type procedure in the hallux were accepted: Keller (or its variants) and HIPJ-A (or its variants). Those reporting the results of the total resection arthroplasty of the MTPJ was excluded. Studies reporting outcomes following soft tissue surgeries such as plantar fascia release were also excluded. Only studies reporting the outcome of these procedures used to treat noncomplicated plantar ulcers of the big toe are accepted. Noncomplicated ulcers were defined as Texas 1A/2A, or Wagner I/II. Ulcer location on the plantar aspect of the big toe was also set as a selection criterion; those beneath the metatarsal head were excluded.

Screening and Selection of Studies

Two reviewers independently screened the initial results of the electronic search strategy. After duplicate removal, titles and abstracts were checked. Full manuscripts were obtained for those studies that were considered candidates for inclusion. Reference checking of those studies was conducted. Disagreement on eligibility was resolved by consensus.

Study Outcomes

The unit of analysis was the ulcer, not the patient. The primary outcome was defined as the ulcer healing frequency. The secondary outcomes were mean healing time, ulcer recurrence frequency, ulcer transfer frequency, postoperative infection rate, and revision surgery rate. Recurrent ulcers were ulcers that developed postoperatively at the same site of the original ulcer. Transfer ulcers were those occurring beneath any other lateral toes. Postoperative infection included wound infection, wound dehiscence, delayed healing, and osteomyelitis. Revision surgeries encompassed debridement, bone excision, incision and drainage, and amputation. Outcomes were reported separately in 2 groups depending on study design: case series and case-control outcomes.

Data Collection

Data were extracted and recorded on a pre-prepared Excel sheet. A data extraction sheet was prepared to summarize all relevant details of the studies. The extracted data was double checked and agreed on by 2 reviewers. Patient data, ulcer type and/or classification, ulcer duration, diabetes duration, HbA_1c level, surgery type, and the follow-up period were tabulated for reporting.

Quality Appraisal

Study quality was assessed to detect potential sources by using 2 checklists from The Joanna Briggs Institute (JBI) critical appraisal tools: one for the case control studies⁸ and the other for case series studies.¹⁴

Data Reporting

Most of the selected studies are case series, and a few others were case-control studies. Therefore, we attempted to follow the guidelines of 2 relevant checklists while conducting this review: the Meta-analysis of Observational Studies in Epidemiology (MOOSE)²¹ and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).¹³

Data Analysis

Statistical analysis was conducted using StatsDirect (Cambridge, UK). Proportion meta-analysis (MA) was used to look for weighted frequencies of outcomes in case series studies. Effect size MA was used to look for significant differences between groups of comparison in case-control studies. The Student t test was used to look for significant difference between mean values. The z proportion test of 2 independent groups was used to compare frequencies between or within the 2 treatment groups. Heterogeneity was assessed by the inconsistency test (I²). The random effects estimate was selected for reporting the I² statistic when the value exceeded 50%. A P value of less than .05 was considered as significant.

Results

Search Result

The search strategy yielded 38 hit records, where 3 duplicates were removed. Title and abstract checking reduced the number of eligible studies to 10, and their full manuscripts were retrieved. All 10 studies met the inclusion criteria. Reference checking revealed 1 additional study: a case series reported as a book chapter. Reasons for exclusion of the 28 studies were as follows: 25 studies reported on neuropathic plantar ulcers and 3 studies were reviews. In total, 11 studies were selected for inclusion.^{1,2,5
-7,10
-12,15,18,22} Figure 1 shows the flow diagram of the search result.

Figure 1.

PRISMA flow diagram.

Study and Patient Characteristics

The included 11 studies comprised 7 in the Keller group^{1,2,5,7,11,15,22} and 4 in the HIPJ-A group.^6,10,12,18 In the Keller group, the selected studies comprised 5 case series and 2 case-control studies. In the HIPJ-A group, there were 3 case series and 1 retrospective comparative study. The pooled sample included 296 patients with a mean age of 58.6 ± 8.2 years, totaling 332 procedures. The Keller group comprised 203 patients with 230 procedures, whereas the HIPJ-A group included 93 patients with 102 procedures. The mean follow-up periods were 19.4 ± 13.5 months and 21.3 ± 2 months (P = .8) for the Keller and HIPJ-A groups, respectively. Two studies in each group reported the use of K-wires. Basic demographic data and related information of individual studies for each technique are detailed in Tables 1 and 2.

Table 1.

Characteristics of Keller Procedure Studies.

Studies	Study Design		No. of Patients (RA/SC)	No. of Procedures	Mean Age, y,Mean ± SD	Diabetes Duration, y	Ulcer Duration, wk	Ulcer Stage	HbA_1c	Fixation Type	Follow-up Period, mo
Downs and Jacobs,⁵ 1982^a	Case series		6	6	NR	NR	NR	NR	NR	None	>24
Lin et al,¹¹ 2000	Retrospective comparative
		Keller	14	14	51	NR	7.8	Wagner I	NR	Wire MTPJ	6.5
		SC	15	15	48		11.1	Wagner I	NR	–	6.5
Armstrong et al,¹ 2003	Retrospective comparative
		Keller	21	21	70.5 ± 7.6	14.1 ± 3.4	15.6 ± 6.4	Texas 1A/2A	7.9 ± 1.4	None	6
		SC	20	20						–	6
Berner et al,² 2005	Case series		11	13	66 ± 8.75	Min 0.5		Wagner I/II	NR	Wire MTPJ	>12
Tamir et al,²² 2015	Case series		20	28	59 ± 13	10.7 ± 5.4	21.6 ± 12.4	Wagner I/II	9.7 ± 2.4	None	28 ± 10
Frykberg and Banks,⁷ 2021	Case series		13	13	NR	NR	NR	Wagner I/II	NR	None	42
Periasamy et al,¹⁵ 2023	Case series		118	135	53.2 ± 12	8.9 ± 6.5	NR	Wagner I/II	6.4 ± 1.3	None	30 ± 14

Abbreviations: MTPJ, metatarsophalangeal joint; NR, not reported; RA, resection arthroplasty; SC, standard care,

Split-thickness skin graft on the ulcer.

Table 2.

Characteristics of HIPJ Arthroplasty Studies.

Studies	Study Design		No. of Patients (IP-RA)	No. of Procedures	Mean Age	Diabetes Duration, y	Ulcer Duration	Ulcer Stage	HbA_1c	Fixation Type	Follow-up Period, mo
Rosenblum et al,¹⁸ 1994	Case series		39	45	Adults	NR	NR	Wagner I/II	NR	None	23.6
Martin and Blitch,¹² 1997	Case series		23	25	Adults	NR	NR	Mostly Wagner I	NR	Wire IPJ (when no infection)	NR
Lew et al.,¹⁰ 2015	Retrospective comparative
		HIPJ-A	13	13	13.0	NR	>6 wk	NR	Mostly Wagner I	Wire IPJ (few)	19.5 ± 11.6
		SC	13	13	54.8 ± 12.3		>6 wk	NR	Mostly Wagner I	–	19.5 ± 11.6
Ehredt et al,⁶ 2023	Case series		5	6	66.5 ± 12.5	NR	NR	Wagner I/II	7.8 ± 3.6	None	20.8 ± 3.1

Abbreviations: HIPJ-A, hallucal interphalangeal joint arthroplasty; IP, interphalangeal; IPJ, interphalangeal joint; NR, not reported; RA, resection arthroplasty; SC, standard care.

Study Quality Result

The mean JBI score for case series studies was 7.2, out of a maximum of 10, and the mean JBI for case-control studies was 9, out of a maximum of 10. Details are provided in Supplementary Tables S1 and S2.

Outcome Results

The outcome results of individual studies are summarized in Tables 3 and 4. Comparative meta-analytical outcomes of both procedures are shown in Supplemental Table S3.

Table 3.

Outcomes of Keller Studies.

Studies		Ulcer Healing frequency,n/n (%)	Healing Time, wk, Mean ± SD	Ulcer Recurrence Frequency,n (%)	Transfer Ulcer Frequency,n (%)	Infection/Wound Complication,n (%)	Revision Surgery,n (%)
Downs and Jacobs,⁵ 1982		6/6 (100)	NR	0	0	1 (16.7) delayed healing (dorsal wound)	0
Lin et al,¹¹ 2000
	Keller	14/14 (100)	3	0	0	0	0
	SC	15/15 (100)	6.7	0	0	0	0
Armstrong et al,¹ 2003
	Keller	RA: (21/21) 100	3.5 ± 1.4	1 (4.8)	0	8 (38.1) infection	1 (4.8) amputation
	SC	13/21 (65)	9.5 ± 2.4	7 (35)	0	8 (40) infection	2 (10) amputation
Berner et al,² 2005		13/13 (100)	NR	0	5 (1 with major infection)	3 (23) surgical wound infection: 2 major, 1 minor	3 (23) incision and drainage
Tamir et al,²² 2015		24/28 (85.7)	3.1 ± 1.7	4	1 (tip of second toe)	6 (21.4): 4 wound dehiscence, 1 arthritis, 1 osteomyelitis	1 (3.6) resection of first metatarsal head due to osteomyelitis
Frykberg and Banks,⁷ 2021		13/13 (100)	3.2	0	0	9 (69.2): infection or wound dehiscence at the incision site; all healed]	0
Periasamy et al,¹⁵ 2023		131/135 (95)	3.5 ± 1.2	6 (4.4)	11 (8)	0 infection/wound healing	1 (MTPJ arthrolysis)

Abbreviations: MTPJ, metatarsophalangeal joint; NR, not reported; RA, resection arthroplasty; SC, standard care.

Table 4.

Outcomes of HIPJ-A Studies.

Studies		Mean Healing Rate,n/n (%)	Healing Time, wk,Mean ± SD	Ulcer Recurrence Rate,Mean or n (%)	Transfer Ulcers,Mean	Infection/Wound Complication	Revision Surgery
Rosenblum et al,¹⁸ 1994		41/45 (91)	NR	4	0	4 wound dehiscence	0
Martin and Blitch,¹² 1997		23/25 (92)	<4	0	0	2 deep infection	2 Debridement with bone excision
Lew et al,¹⁰ 2015
	HIPJ-A	13/13 (100)	3.5	1 (7.7)	2	2 wound dehiscence1 infection	0
	SC	8/13 (61.5)	9	7 (53.9)	0	5 deep infection	5 amputation
Ehredt et al,⁶ 2023		6/6 (100)	2.2 ± 1.0	0	0	0	0

Abbreviations: HIPJ-A, hallucal interphalangeal joint arthroplasty; NR, not reported; SC, standard care.

Case series results

No significance was found between outcome frequencies of the 2 groups when using the z-proportion test. Although analysis showed a trend for higher healing rate following Keller procedure, the ulcer transfer rate, complications, and revision surgery rates tended to be lower following HIPJ-A surgery. Overall and subgroup results are showed in detail in Supplementary Table S3.

Periasamy et al¹⁵ reported other complications relevant to Keller procedure such as a cocked up toe deformity (5.2%) and relative hallux shortening observed by the patient (25.2%). Frykberg and Banks⁷ reported a mean shortening of the hallux of 7.3 ± 3.5 mm. The same authors recorded a satisfaction rate of 94% following Keller arthroplasty among this elderly population.⁷

Case-control results

Two retrospective studies reported comparative outcomes between Keller arthroplasty and standard of care. The standard of care was based on topical dressing and offloading cast. The weighted OR of ulcer healing frequency outcome was 27.1 (95% CI 1.442-508.174, P = .01) in favor of the Keller arthroplasty. The Student t test showed faster healing time with Keller (P = .02). The weighed OR for ulcer recurrence was 0.1 (95% CI 0.011-0.905, P = .04). No differences were found for the remaining outcomes.

One study reported comparative outcomes between HIPJ-A and standard of care. The independent proportion test yielded significance for HIPJ-A procedure for the following outcomes: ulcer healing (P = .02), time to heal (P = .03), and ulcer recurrence (P = .03). Although amputation was not encountered in the HIPJ-A procedure, this outcome was observed in 5 of 13 (38.46%) patients (P = .06).

Outcomes based on K-wires

Based on the use of K-wires, no difference was found in both groups for the healing frequency, ulcer recurrence, and complications outcomes. In the Keller group, ulcer transfer and revision surgery frequencies were significantly higher when using K-wires (P = .02 and P = .003, respectively).

Discussion

Main Findings

Both techniques demonstrated excellent results in terms of healing frequency with very acceptable rates of complications. The Keller procedure tended to yield a higher frequency of complications such as ulcer transfer, postoperative infection, and revision surgery. The findings indicated that both techniques are excellent surgical off-loading procedures to treat chronic noninfected nonischemic DFU of the hallux.

Interpretation and limitations

It is customary that the Keller procedure is to be indicated when the ulcer is located at the base of the toe whereas the HIPJ-A would be more suitable when the wound is closer to the interphalangeal joint. Although the commonsense rationale to choose one procedure over the other is based on the location of the plantar ulcer, such indication has not been stated explicitly in most of the selected studies. In addition, in case of an ulcer located halfway between the IPJ and the MTPJ, our review could not offer an answer on which surgery type would be better. Therefore, prospective trials where surgery type indication is based on clear ulcer location are warranted.

Traditionally, Keller arthroplasty has been indicated as a treatment for hallux valgus and hallux rigidus, particularly when associated with degenerative joint disease in the older population.^9,17,20 It is believed that the increased MTPJ dorsiflexion can result in healing of the plantar wound. However, because of some complications following the Keller procedure,⁷ mainly transfer metatarsalgia, floppy hallux, shortened length, and cocked up deformity, the recent recommended variation of the procedure is to remove the very distal base rather than the third or half of the proximal aspect of the metatarsal.^7,22 The variable cut levels reported in the included studies could be a limitation and might impact the outcome results. Although future controlled studies could better inform the impact of the cut level on the results, we believe that the current trend of removing bone as minimal as possible is a sound practice that could lessen many complications related to hallux shortening.

The description of the HIPJ-A technique as stated in the included studies was less heterogeneous. Besides the early report of Rosenblum et al¹⁸ in which the distal half of the proximal phalanx was removed, all 3 other more recent studies recorded the resection of just the head of the proximal phalanx.^6,10,12 Ehredt et al⁶ used a burr to resect the phalangeal head whereas the others used an oscillating saw. Therefore, the technical variable is unlikely to have a significant impact on our studied outcomes.

The use of a K-wire to stabilize the MTPJ following Keller arthroplasty or the IPJ after the HIPJ-A procedure also varied between studies. Two of the 6 studies (33.3%) in the Keller group fixed the MTPJ.^2,11 Two of 4 (50%) in the HIPJ-A group nonsystematically fixed the IPJ.^10,12 In the Keller group, the significant difference in revision surgery outcome was due to the 3 surgical wound infection necessitating a revision surgery for surgical drainage in Berner et al’s² study. In the HIPJ-A group, wound healing differed but with relatively similar infection and wound complication frequency. Subsequently, although the impact of such immobilization on DFU healing would be unknown, postoperative infection might be associated with the use of K-wires.

When compared to standard of care, the Keller procedure seems to yield better results, in particular, for ulcer healing frequency, healing time, and ulcer recurrence outcomes. Although these findings were drawn from only 2 retrospective comparative studies, the rates found in these studies and in the included case series were considerably better than those reported in the literature following standard of care.¹⁶

Although the ulcer stage was similar in all studies, diabetes duration and in particular ulcer duration were not often reported. Ulcer duration could be associated with subclinical infection and, thus, this variable could have induced bias in relation to our outcome results.²⁷ Similarly, HbA_1c level as a confounder was rarely recorded. Studies where relevant data to ulcer healing are taken into account are needed.

Implications for Practice and Research

Although both techniques seem to yield excellent results in terms of healing, this review highlight a common, but nonsystematic, trend to use the Keller procedure for DFUs closer to the MTPJ and HIPJ-A for those closer to the IPJ. When performing a Keller arthroplasty, a minimal resection of the base could reduce length-related complications. A minimal invasive approach was described in 1 HIPJ-A study only⁶; we believe there is opportunity to better explore the feasibility and efficacy of such an approach for both techniques in the future. Surgery seems to be more promising when compared to standard of care but possibly with higher frequency of ulcer transfer. Comparative trials searching for better fine-tuning of indications with far more patients included are needed. Immobilization following the arthroplasty does not seem to be necessary, with possibly less favorable outcomes. Therefore, controlled studies are desirable to evaluate the immobilization confounder. Other variables that could affect ulcer healing such as ulcer size and chronicity and preoperative glycemic control should be accounted for in future research.

Conclusions

Both surgical offloading procedures, the Keller arthroplasty and the HIPJ-A, are highly effective in treating chronic noncomplicated DFUs of the plantar aspect of the hallux. The excellent healing and low complication frequencies would make these procedures the treatment of choice. There is a need to fine-tune the indication in relation to the location of the plantar wound with future large-scale comparative controlled research studies.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114241300139 – Supplemental material for Keller and Interphalangeal Joint Resection Arthroplasties for Chronic Noncomplicated Diabetic Ulcers of the Hallux: A Systematic Review and Meta-analysis

Supplemental material, sj-pdf-1-fao-10.1177_24730114241300139 for Keller and Interphalangeal Joint Resection Arthroplasties for Chronic Noncomplicated Diabetic Ulcers of the Hallux: A Systematic Review and Meta-analysis by Kaissar Yammine, Joseph Mouawad, Mohammad Omar Honeine and Chahine Assi in Foot & Ankle Orthopaedics

Footnotes

Appendix

Supplementary Table S3.

Meta-analytical Results.

Outcomes	Combined Procedures	Keller	HIPJ-A^a	P Value
Mean healing frequency	94% (95% CI 0.903-0.970, I² = 0%)	96.2% (95% CI 0.931-0.984, I² = 5.7%)	92.3% (95% CI 0.860-0.968, I² = 0%)	.1
Mean healing time, wk	3.1 ± 0.4	3.3 ± 0.2	2.9 ± 0.6	.3
Ulcer recurrence frequency	6% (95% CI 0.030-0.097, I² = 0%)	5.2% (95% CI 0.027-0.084, I² = 0%)	6% (95% CI 0.021-0.118, I² = 16.4%)	.5
Ulcer transfer frequency	4.5% (95% CI 0.010-0.103, I² = 56%)	6.3% (95% CI 0.017-0.134, I² = 57%)	2% (95% CI 0.001-0.059, I² = 47.6%)	.07
Postoperative infection rate	18% (95% CI 0.084-0.305, I² = 73.4%)	17.7% (95% CI 0.028-0.415, I² = 91%)	11% (95% CI 0.054-0.182, I² = 0%)	.4
Revision surgery rate	3.8% (95% CI 0.014-0.072, I² = 25%)	6% (95% CI 0.021-0.114, I² = 12.3%)	2.5% (95% CI 0.003-0.066, I² = 21.5%)	.8

Abbreviation: HIPJ-A, hallucal interphalangeal joint arthroplasty.

In favor of HIPJ-A procedure.

Ethical Approval

Ethical approval was not sought for the present study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Kaissar Yammine

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Supplementary Material

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