DEFINITION

The plantar plate is a fibrocartilaginous structure that provides metatarsophalangeal (MTP) joint stability.15

The progressive instability of the MTP joint can result from different patterns of plantar plate tears.12 Each type of plantar plate tear has a particular treatment and different postoperative results.12

 

 

ANATOMY

 

The lesser MTP joint is statically stabilized by the plantar plate, the main collateral ligaments, and the accessory collateral ligaments (FIG 1). The plantar plate provides the major stabilizing force in dorsal/plantar direction.11,15

 

This fibrocartilaginous structure originates on the metaphysis of the metatarsal head via a thin synovial attachment. The strongest insertion is at the base of the proximal phalanx through its two bundles that derives directly from the two major bands of the plantar fascia. Between these two bundles, a small V-shaped synovial

recess can be found.1,15

 

The length of the plantar plate ranges from 16 to 23 mm and the width ranges from 8 to 13 mm.9 The borders are thicker than the central region, and it is mainly composed by type 1 collagen (75%) and type 2 collagen (21%) fibers. The collagen fibers of the plantar plate runs in a longitudinal direction, with oblique bundles

interspersed at regular intervals.4,5

 

The plantar plate serves as an attachment for important structures, including the distal fibers of the plantar fascia, collateral ligaments, transverse metatarsal ligaments, interosseous tendons, and the fibrous sheath of

the flexor tendons.14

 

 

 

FIG 1 • Stabilizers of the lesser MTP joints: (1) proper collateral ligament, (2) accessory collateral ligament, (3) plantar plate, (4) fibrous flexor tendons sheath, (5) plantar fascia insertion to the plantar plate, (6) flexor tendons, (7) dorsal interosseus tendon, (8) plantar interosseus tendon, (9) lumbrical tendon, and (10) deep transversal intermetatarsal ligament.

 

 

The tendon of the lumbrical muscle runs plantar and medial to the plantar plate just beneath the deep transverse intermetatarsal ligament (DTIL). The interossei tendons are dorsal to the DTIL and run adjacent to the plantar plate; the plantar interossei are medially located, whereas the dorsal interossei are laterally

situated.1

 

PATHOGENESIS

 

 

Lesser MTP instability can occur after acute trauma or secondarily to a chronic inflammation of the joint. Synovitis, lesser metatarsal overload, or inflammatory arthropathy can lead to this chronic inflammation.

 

Overloading of the lesser MTP joint can result from a long metatarsal, disruption of the metatarsal parabola, hypermobility of the first ray, hallux valgus, flatfeet, or genetic predisposition.

 

The use of high-heeled shoes is believed to cause repetitive hyperextension forces on the lesser MTP joints, which in time may lead to attenuation or rupture of the plantar plate, followed by subluxation or dislocation of the toe.

 

NATURAL HISTORY

 

Lesser MTP joint instability with plantar plate tear occur more frequently in women aged older than 40 years and often in association with hallux valgus.

 

The clinical symptoms of the patients can be minimal in the early stages and incapacitating with chronic disease.

 

 

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FIG 2 • Widening of the left second web space after the “inflammatory” phase of the MTP plantar plate lesion.

A. Comparison of both feet. B. Detail of the left forefoot.

 

 

Observation of clinical signs and physical examination findings provide a specific diagnosis.

 

The use of local anesthetic injections help to differentiate from other pathologies.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

 

Pain under the affected metatarsal head is the most prevalent and significant complaint. Initial observation reveals swelling or thickening of the MTP joint with no other deformities.

 

When the first inflammation subsides, the affected toe lightly deviates from its natural axis, creating a wider interdigital space in comparison with the other foot (FIG 2).

 

As the disease progresses, dorsal, dorsomedial, or dorsolateral deviation of the toe occurs, followed by the loose of contact of the toe with the ground and a loss of power of the toe (digital purchase); a flexible or fixed hammertoe may develop with time and, at the end, the classic “crossover toe” can be found.

 

 

 

FIG 3 • Hamilton-Thompson MTP “drawer” test: G0 = stable joint, G1 = light instability (<50% subluxable), G2

= moderate instability (>50% subluxable), G3 = gross instability (dislocatable joint), and G4 = dislocated joint.

 

 

Objective physical findings include swelling, malalignment of the toe, positive drawer test, loss of digital purchase, and dysfunction in the normal biomechanics of toe motion.6

 

The MTP joint drawer test (also known as Hamilton-Thompson test) is the first objective sign of MTP joint instability (FIG 3). The involved toe should be plantarflexed 20 degrees during the MTP joint drawer test. Comparison with the normal foot is mandatory to value the physical findings. The stability of the joint is rated as follows:

 

 

G0 = stable joint

 

G1 = light instability (<50% subluxable)

 

G2 = moderate instability (>50% subluxable)

 

 

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FIG 4 • Podoscopic images showing the ground touch signal. A. Normal appearance. B. Patient with complains on the second and third toes, loosening of the ground touch ability of both toes.

 

 

 

G3 = gross instability (displaceable joint) G4 = dislocated joint

 

Ground touch signal is the ability of the toe to keep its pulp pressed in a normal fashion to the ground while standing. It is better evaluated in the podoscope or in a podography. With the progressive deviation of the toe, this ground touch ability disappears (FIG 4).

 

Digital purchase is the ability of the toe to pressure the ground. The toe purchase depends on the stability of the MTP joint. It can be evaluated with the Bouche and Heit2 “paper pullout test.”

 

A thin strip of paper is placed under the affected toe pulp. The examiner attempts to pull the paper strip out while the patient resists with toe pressure against the ground.

 

Table 1 Clinical Staging System for the Metatarsophalangeal Joint Instability

 

 

Results are positive when there is no toe purchase present, reduced when the purchase is present but not powerful enough to resist the paper strip to being pulled out, and negative when the toe is able to prevent the paper strip to being pulled out.

 

Grade

Alignment

Physical Examination

0

MTP joint aligned

Pain but no deformity

MTP plantar pain, thickening and swelling, reduced toe

purchase, negative MTP drawer test

1

Widening of the web MTP plantar pain, swelling of MTP joint, loss of toe purchase,

space mild positive MTP drawer test (<50% subluxable)

Mild medial deviation of the toe

2

Moderate MTP

malalignment

Medial, lateral, dorsal, or dorsomedial deformity Hyperextension of the toe

MTP plantar pain, reduced swelling, no toe purchase,

moderate positive MTP drawer test (>50% subluxable)

3

Severe MTP

malalignment

Dorsal or dorsomedial deformity

Overlap of the toes Flexible hammer toe

Joint and toe pain, little swelling, no toe purchase, very positive

MTP drawer test (dislocatable joint), flexible hammer toe

4

Dorsomedial or dorsal

dislocation

Severe deformity with joint dislocation

Fixed hammer toe

Joint and toe pain, little or no swelling, no toe purchase,

dislocated MTP joint, fixed hammer toe (crossover toe)

From Coughlin MJ, Baumfeld DS, Nery C. Second MTP joint instability: grading of the deformity and

description of surgical repair of capsular insufficiency. Phys Sportsmed 2011;39:132-141.

 

 

Intractable plantar keratosis beneath the metatarsal head is another common finding.

 

A comprehensive review of MTP joint instability reported that a high percentage of patients presents a hammertoe deformity, hallux valgus, hallux rigidus, and hallux varus.17

 

The clinical staging system for lesser metatarsal instability grades the evolution of the deformity in five stages

—0 to 4 (Table 1).

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

The diagnosis of lesser MTP joint instability is most often based on the history and physical examination.18

 

Standing anteroposterior (AP), lateral, and oblique radiographs are necessary to evaluate the MTP joint and exclude osseous pathology (FIG 5A,B). AP and lateral radiographs can demonstrate the magnitude of the MTP joint angular deformity, joint incongruity, the presence of MTP joint arthritis, and determining the

metatarsal parabola.10

 

In a normal AP radiograph, the normal articular cartilage has clear space of 2 to 3 mm. As hyperextension of

the MTP joint progresses, the clear space disappears and the base of the proximal phalanx subluxates dorsally over the metatarsal head. With frank dislocation, the base of the proximal phalanx can lie dorsally over the metatarsal head.

 

Ultrasonography is a very good method to identify the MTP plantar plate tears. As always, the accuracy and specificity of this diagnostic tool depends on the experience of the examiner and this could be an obstacle to its use.

 

Magnetic resonance imaging (MRI) is the more expensive alternative but is essential to some differential diagnosis and to confirm the initial stages of the pathology (FIG 5C,D). The sensitivity of MRI is up to 87%, and this finding can be upgraded with the use of intra-articular contrast or an MRI combined with sonographic

evaluation.8

 

 

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FIG 5 • A,B. AP plain radiographs of the left forefoot of two patients with different stages of plantar plate lesions. A. An initial lesion with a light medial deviation of the second toe. The asymmetric articular space is noted by the arrow. B. A late lesion with severe dislocation of the second MTP joint and a crossover toe deformity. Note the overlap of the images of the base of the proximal phalanx and the second metatarsal head (arrow). C,D. Coronal and sagittal MRIs, respectively, of a patient with second MTP plantar plate lesion (arrows).

 

 

Although MRI may aid in the diagnosing and grading of MTP plantar plate pathology, it is paramount the previous knowledge of each type of plantar plate tear to improve description and correlation between the images and the anatomy.13

 

DIFFERENTIAL DIAGNOSIS

 

MTP joint synovitis

Morton interdigital neuroma Mechanical metatarsalgia Freiberg infraction Degenerative arthritis

Systemic arthritis localized at the lesser MTP joint Stress fracture of the metatarsal neck Intermetatarsal bursitis

Synovial cyst formation

 

 

NONOPERATIVE MANAGEMENT

 

Nonsurgical treatment of lesser MTP joint instability is generally unsuccessful. It may eliminate the symptoms but do not achieve correction or realignment of the toe.3,6

 

Conservative management can include nonsteroidal antiinflammatory drugs (NSAIDs), orthotics, tapping, and physical therapy.3,16

 

The objective of taping is to hold the toe into a neutral position, provide external stability, and help to decrease the inflammation. Prolonged taping does not correct the digital deformity and may lead to chronic edema.

 

The use of NSAIDs can decrease discomfort from inflammation at a symptomatic lesser MTP joint.

 

Orthotics can relieve metatarsal head pressure and alleviate plantar discomfort by redistributing the body weight on the plantar surface of the foot. A rigid rocker bottom sole may help to improve the gait and relieve dorsiflexion stress to the forefoot.

 

Physical therapy can decrease inflammation, improve forefoot load with stretching of the posterior muscular chain, and reduce local edema.

 

SURGICAL MANAGEMENT

 

After the history, clinical, and radiologic evaluation, each involved digit is classified according to the clinical staging system (see Table 1).

 

Each type of plantar plate tear has a particular treatment. The anatomic grading system is a classification that addresses plantar plate dysfunction and matches the clinical staging system. This anatomic grading helps the surgical planning and management of plantar plate ruptures (FIG 6).

 

The surgery indication is failure of conservative treatment in a patient who has appropriate vascular status and no comorbidities that contraindicate surgery.

 

Preoperative Planning

 

The surgery can be done under regional block anesthesia and lower thigh tourniquet.

 

The examination under anesthesia allows for better evaluation of the MTP joint drawer test.

 

In our routine, we start the surgical procedure with an MTP arthroscopy that has two distinct objectives:

 

 

The first is to confirm our clinical assessment of the plantar plate tears

 

 

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FIG 6 • Schematic representation of a right second MTP joint with the anatomic grading system of plantar plate lesions.

 

 

The second is to remove the intra-articular hypertrophic and inflamed synovial tissue and the fringes of fibrous tissue from the torn plantar plate tears. With the help of microshaving instruments (2 mm), one can regularize both the free border of the plantar plate created by the lesion and the plantar rim of the proximal phalanx where the plantar plate will be reattached.

 

In our treatment algorithm, the grades 0 and 1 plantar plate lesions were treated through the radiofrequency shrinkage of the attenuated or partially torn tissue followed by a Weil metatarsal osteotomy, whereas the grade 4 lesions was treated through the combination of a Weil metatarsal osteotomy and the flexor digitorum longus (FDL) tendon transfer technique. These techniques will not be discussed in this chapter.

 

Positioning

 

The patient is placed supine on the operating table. The surgeon starts the procedure facing the dorsal aspect of the forefoot, whereas its first assistant faces the sole of the foot. In some steps of the procedure, they will change their positions to make feasible the surgical maneuvers.

 

 

 

 

FIG 7 • Arthroscopic dorsal (medial and lateral) portals for the second (A), third (B), and fourth (C) MTP joints.

Approach

 

Two dorsal arthroscopic portals are used to perform the lesser MTP joints: the dorsomedial and dorsolateral portals.

 

 

Both are placed at or slightly distal to the MTP articular joint line, medially, and laterally 4 to 5 mm equidistant from the extensor digitorum longus (EDL) tendon (FIG 7).

 

To perform the open repair of the lesser MTP plantar plate through the dorsal approach, we can use:

 

 

A dorsal longitudinal incision centered over the MTP joint (especially when the arthroscopic step of the procedure is not performed)

 

An S-shaped dorsal incision that encompasses the arthroscopic portals (FIG 8)

 

 

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FIG 8 • A. S-shaped dorsal incision encompassing the arthroscopic portals made over the involved digit. B. Long S-shaped dorsal incision encompassing all the arthroscopic portals when more than one MTP joint are involved.

 

TECHNIQUES

• Exposure

The incision is deepened in the space between the EDL and extensor digitorum brevis, taking care not to jeopardize the vascular supply to the metatarsal head.

Both extensor digitorum tendons are retracted medially or Z elongated, depending on the amount of deformity and tendon retraction.

A dorsal longitudinal MTP capsulotomy is performed followed by a partial collateral ligament release of the proximal phalanx.

With the help of a McGlamry elevator, the proximal attachments of the plantar plate and all inflammatory adhesions are released without compromising the vascular supply to the plantar plate or metatarsal head, permitting the adequate positioning of these structures at the end of the repair.

 

• Weil Metatarsal Osteotomy

   

  A Weil distal metatarsal osteotomy is performed using a sagittal saw.

   

  The saw cut is made parallel to the plantar aspect of the foot, starting at a point 2 to 3 mm below the top of the metatarsal articular surface.

   

  In the presence of a plantar keratosis beneath the metatarsal head, a small slice of bone is removed to achieve a subtle elevation of the metatarsal head (TECH FIG 1A).

   

   

   

  TECH FIG 1 • A. Performing the distal Weil osteotomy. B. The capital fragment is pushed proximally as far as possible. (continued)

   

   

  The capital fragment is pushed proximally as far as possible (8 to 10 mm) and held in this position temporarily with a small vertical Kirschner wire (K-wire) (TECH FIG 1B).

   

  It is recommended to resect 2 or 3 mm of the distal metaphyseal flare to improve the plantar plate visualization (TECH FIG 1C).

   

  Longitudinal traction to the toe helps to distract the joint, creating space to the next steps of the procedure.

   

   

  97

   

   

   

  TECH FIG 1 • (continued) C. Resection of the distal margin of the proximal fragment, 2 to 3 mm.

• Preparing the Plantar Plate and the Phalanx

   

  The plantar plate is then inspected and the type of lesion is confirmed.

   

  If some portion of the plantar plate remains connected to the inferior border of the proximal phalanx, it is cut carefully with a small scalpel avoiding lesions to the FDL tendon.

   

  It is important to release the distal margin of the plantar plate from any soft tissue adhesions especially at the plantar surface, creating space for the instruments and the sutures.

   

  The MTP plantar plate is 2.0 to 2.5 mm thick in its anterior border, and care must be taken not to delaminate the plantar plate during the intent to free the margins of the lesion.

   

  Any residual tissue is excised from the plantar margin of the proximal phalanx with a small rongeur or curette, creating a roughened surface for optimal attachment of the plantar plate.

   

  If a longitudinal tear of the plantar plate is detected (grade 3 T- or 7-shaped lesion), it can be repaired through interrupted nonabsorbable 3.0 sutures placed with the help of a small needle holder (TECH FIG 2).

   

   

   

  TECH FIG 2 • Suturing a longitudinal tear of the plantar plate.

• Suture Passing through the Plantar Plate

   

  An elegant and efficient suturing technique for the lesser MTP plantar plate lesions was developed by Michael J. Coughlin, MD and Arthrex (Naples, FL).

   

  They designed a joint distractor that helps to visualize and handle the small structures of the MTP joint including the plantar plate and a mechanical suture passer (MiniScorpion, Arthrex) that can easily and safely place horizontal mattress sutures in the free distal border of the plantar plate in a matter of

  seconds.6

   

  For the treatment of the longitudinal plantar plate tears, they developed a micropigtail suture passer (Mini SutureLasso, Arthrex) that aids with the multiple longitudinal sutures placement.

   

  We developed an alternative surgical technique that has been affectionately called as the ugly technique.

   

  With this technique, before starting to pass the main sutures to the anterior border of the plantar plate, we have to construct a “snakehead” NINJA instrument with a 1.0-mm K-wire (TECH FIG 3A).

   

  The head of the NINJA instrument is positioned under the anterior border of the plantar plate, in its lateral or medial half, taking care to avoid injuries to the flexor tendons. To pass the suture into a healthy tissue, it is important to reach the plantar plate as proximal as possible (TECH FIG 3B,C).

   

  A straight handheld suture passer (SutureLasso, Arthrex) or an 18-gauge needle is passed from dorsal to plantar through the plantar plate, into the snakehead of the NINJA instrument, and through the soft tissue of the sole until it exteriorizes at the plantar face of the foot (TECH FIG 3D-F).

   

  A flexible wire loop is introduced into the needle or suture passer from dorsal to plantar. A folded 2.0 nonabsorbable suture (FiberWire, Arthrex) is passed through the wire loop and pulled up through the plantar plate (TECH FIG 3G,H).

   

  98

   

   

   

  TECH FIG 3 • A. The snakehead NINJA instrument is made by bending a 1.0-mm K-wire with a delicate pair of pliers or a strong surgical needle holder: head (a = 3 mm; b = 5 mm), neck (c = 10 mm), step 1 (first step angle = 45 degrees), bridge (d = 15 mm); step 2 (second step angle = 45 degrees), stem (e = 20 mm), handle (f = 15 mm; g = 20 mm). B. Positioning of the NINJA head under the plantar plate. C. The NINJA head must be positioned as proximal as possible. D. An 18-gauge needle is passed through the plantar plate and the snakehead of the NINJA instrument. E,F. Two different instruments are used to pass the sutures through the plantar plate—an 18-gauge needle (E) and a straight SutureLasso (Arthrex)

  (F). G. A flexible wire loop is introduced into the needle and a folded suture is passed through the wire

  loop. H. The needle is pulled up through the plantar plate. I. The loop of the suture involves the handle of the NINJA instrument. J. A lace is created and the NINJA instrument is pulled out. K. The suture firmly locks into the distal margin of the plantar plate.

   

   

  99

   

  The loop of the suture involves the handle of the NINJA instrument while the free suture tails are firmly kept in the plantar face of the foot by the assistant.

   

  With this maneuver, a lace will be created while the NINJA instrument is pulled out of the surgical field at the same time that the suture tails are released by the assistant (TECH FIG 3I,J).

   

   

  Pulled tight, the suture firmly locks in to the distal margin of the plantar plate (TECH FIG 3K). The same sequence is repeated for the other half of the plantar plate.

   

  At the end, we have two sutures firmly passed through the remaining healthy tissue from the MTP plantar plate.

• Passing Sutures through the Base of the Proximal Phalanx

   

  With use of a 1.5-mm K-wire or a drill bit, two vertical drill holes are made medially and laterally in the base of the proximal phalanx from the dorsal cortex to the plantar rim of the proximal phalanx, matching the sutures placed over the plantar plate (TECH FIG 4A,B).

   

   

   

  TECH FIG 4 • Making bone holes at the base of the proximal phalanx and passing the sutures through them. A. The medial bone hole. B. The lateral bone hole. C. A wire loop is passed through the bone hole.

  D. The suture is introduced into the wire loop. E. Pulling the wire loop out, the suture passes through the bone hole. The procedure is repeated for the other suture and bone hole.

   

   

   

  The same flexible wire loop used in the previous steps is passed from dorsal to plantar through the holes of the phalanx base and then used to catch and pull the sutures through the dorsal side (TECH FIG 4C-E).

   

• Fixing the Weil Osteotomy and Finishing

  00

   

  The Weil osteotomy is fixed in the desired position with one small snap-off self-tapping vertical screw.

   

  The metatarsal shortening is determined in the preoperative planning to achieve a regular metatarsal parabola. Normally, only 2 or 3 mm of metatarsal shortening is required.

   

  Once the Weil osteotomy is fixed, the sutures are tied over the bone bridge at the proximal phalanx, attaching the plantar plate at the base of the phalanx while the toe is held in 20 degrees of plantar flexion

  (TECH FIG 5A).

   

  Lateral soft tissue reefing is performed to repair any lateral collateral ligamentous insufficiency and transverse plane deformities.

   

   

   

  TECH FIG 5 • A. Gross aspect of the MTP joint just before the finalization of the dorsal knots. B,C.

  Dressing with the operated toes held in 20 degrees of plantar flexion.

   

   

  The articular capsule is closed and the EDL tendon is sutured in the appropriate length if elongation was performed.

   

  At this moment, it is important to release the tourniquet and to proceed to a careful hemostasis of the dorsal region of the MTP joints.

   

  Substantial bleeding can result from the small dorsal vessels, and the hematoma formed can compromise the skin coverage of the region with potential skin and soft tissue necrosis with dehiscence of the surgical incision.

   

  After routine wound closure, a postoperative compression dressing is applied with the affected toes held in 20 degrees of plantar flexion (TECH FIG 5B,C).

• Plantar Plate Repair Additional Case

   

  TECH FIGS 6 and 7 show plantar plate repairs undertaken according to the description used in this chapter.

   

   

   

  TECH FIG 6 • A. The exposition of a grade 3 7-type second MTP joint plantar plate lesion. B. The Weil osteotomy starts at a point 2 mm below the dorsal border of the articular surface. C. The metatarsal head is retracted proximally. (continued)

   

   

  01

   

   

   

  TECH FIG 6 • (continued) D. The metatarsal head is temporarily fixed with a K-wire. E. Resection of the distal border of the proximal fragment—2 to 3 mm. F,G. A McGlamry elevator is introduced under the metatarsal head to free all adhesions to the plantar plate. H,I. The snakehead NINJA instrument is introduced under the plantar plate. J. The suture passer is introduced through the plantar plate and the snakehead of the NINJA instrument. K. A flexible wire loop appears at the plantar aspect of the foot. L. A folded 2.0 suture is passed through the wire loop. M,N. The suture passer is pulled up. O-Q. The loop involves the handle of the NINJA instrument. R. At the end, a firm suture locks in the margin of the plantar plate.

   

   

  02

   

   

   

  TECH FIG 7 • A. With a drill bit, two bone holes are made at the base of the proximal phalanx. B-E. The sutures are passed through the bone holes with the help of the flexible wire loop. F. The Weil osteotomy is fixed in the desired position. G. The sutures are tied, bringing the plantar plate to the base of the proximal phalanx. H,I. Final aspect of the corrected toe. Note the plantar flexion of the MTP joint resulting from the reinsertion of the plantar plate at the base of the proximal phalanx.

   

   

  PEARLS AND PITFALLS
  		Diagnosis

  • “Think plantar plate lesion” is the first step to diagnose correctly.

  • Intimacy with the regional anatomy is paramount to understand and propose the right treatment regimen.

  • Acute pain under the affected metatarsal head, widening of the web space, and the positive MTP drawer test are the most important and reliable findings in MTP joint

  instability.

  • The clinical staging system and its correlation with the anatomic grading system for the MTP plantar plate lesions proved to be very important in the treatment decision-making process.

 

Skin incision

• The S-shaped dorsal incision can be elongated to expose two or three MTP joints at the same time.

   

  EDL

  tendon

• Depending on the amount of the toe deformity, consider elongating the EDL tendon.

 

Weil osteotomy

• Try to keep the osteotomy as parallel as possible with the sole, avoiding the descending of the metatarsal head.

• Take off a thin slice of bone if you pretend to elevate the metatarsal head and reduce its overloading.

• Beware of metatarsal shortenings greater than 3 mm.

   

  Plantar plate repair

  • Remove all fibrous tissue from the free border of the plantar plate lesion.

  • Be sure to free the plantar plate from its adhesions to the plantar fat pad before passing the sutures.

  • Be sure to pass the sutures in a healthy tissue.

  • Be sure to identify and suture any longitudinal tear of the plantar plate.

     

    Preparing the phalanx

• Be extremely careful when orienting the K-wire or the drill bit to make the bone holes at the base of the proximal phalanx.

• Leave, at least, 1 mm of bone between the articular cartilage and the bone hole.

• Take care not to jeopardize the metatarsal head while doing the phalangeal bone holes.

   

  Fixing the Weil osteotomy

• Beware of rotational deviation of the metatarsal head while fixing the osteotomy. Use two screws if you feel it is necessary.

• Be gentle while bending the screwdriver of the powered machine at the end of the screw insertion. You can cause a bone fracture at this moment.

   

  Tie the sutures

  • Keep the toe in a 20-degree plantar flexion at the MTP joint while fixing the sutures over the proximal phalanx.

  • Be sure that the MTP joint is stable and aligned at the end of this step.

  • If not, complete the procedure by reefing the collateral ligaments and the articular capsule.

  • Suture the tendons at the appropriate length.

     

    Before closing

  • Caution with the hemostasis before closing the wound.

 

Dressing ▪ Keep the affected toes in 20 degrees of plantar flexion for 6 weeks after the surgery.

 

 

 

 

 

POSTOPERATIVE CARE

03

 

The operated toe is held in 20 degrees of plantar flexion to provide adequate healing of the repaired plantar plate during the first 6 weeks.

 

The patient is allowed to ambulate in a postoperative shoe for 6 weeks with no weight bearing on the forefoot (FIG 9).

 

After 6 weeks, dressings are discontinued and comfortable shoes are permitted.

 

An exercise program to condition the extrinsic and intrinsic muscles of the lesser toes is then initiated.

 

 

 

 

FIG 9 • Postoperative dressing and postoperative shoe. A. Tapping the operated toes in 20 degrees of plantar flexion. B. Frontal view of the same patient at the same moment. C. At the end of the tapping procedure. D. The Barouk postoperative shoe with a reduced forefoot platform to permit the toes to be held in plantar flexion.

OUTCOMES

The objective of plantar plate repair is to restore the stability of the MTP joint and preserve the joint function and motion.

Surgical repair of the plantar plate thought dorsal approach has a reported success rates of 68% to 93%.7,12,17

With the combination of plantar plate repair and a Weil metatarsal osteotomy, over 63% of the patients have the ability to perform digital purchase.12

Regarding the stability, some authors found that 68% of the patients were completely stable after this treatment (grade 0 of the stability classification) and 32% had an unstable MTP joint grade 1 or mild

instability with no clinical implications.12

 

 

COMPLICATIONS

Recurrence of symptoms: This may be due to incorrect diagnosis, incomplete repair of the plantar plate, or true incorrect alignment of the metatarsal parabola.

Painful prominent hardware can occur after fixation of the Weil osteotomy.17 Dorsal hematoma formation and healing skin problem

Scaring and retraction of the surgical incisions Persisting edema (long lasting)

Elevated and insufficient toes

 

 

REFERENCES

1. Armen K. Sarrafian's Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 3. Philadelphia: Lippincott Williams & Wilkins, 2011.

    

    

2. Bouche RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg 2008;47:125-137.

    

    

3. Coughlin MJ, Baumfeld DS, Nery C. Second MTP joint instability: grading of the deformity and description of surgical repair of capsular insufficiency. Phys Sportsmed 2011;39:132-141.

    

    

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