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Sahr ME, Grünebaum A, Positano RC, Nwawka OK, Chervenak FA, Positano RG. Common foot and ankle disorders in pregnancy: the role of diagnostic ultrasound. J Perinat Med 2024; 52:674-687. [PMID: 39213647 DOI: 10.1515/jpm-2024-0276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 09/04/2024]
Abstract
Foot and ankle disorders are common during pregnancy, driven by significant physiological changes including weight distribution, hormonal fluctuations, and fluid balance. These changes often result in conditions such as varicose veins, thrombophlebitis, deep vein thrombosis (DVT), edema, overpronation, ankle sprains, metatarsalgia, stress fractures, ligament tears, synovitis, tendon tears, tenosynovitis, paratenonitis, plantar fasciitis, and Morton's neuroma. This paper emphasizes the diagnostic utility of ultrasound for these conditions, given its safety, non-invasiveness, and real-time imaging capabilities without ionizing radiation. Ultrasound is particularly effective for diagnosing venous disorders like varicose veins and thrombophlebitis, leveraging Doppler ultrasound to assess vein structure and function. It is also instrumental in identifying DVT, detecting vein dilation, reflux, and thrombosis. For conditions such as edema, ultrasound helps differentiate physiological from pathological causes, ensuring accurate diagnosis and management. In cases of musculoskeletal issues like overpronation, ankle sprains, ligament tears, and tendon pathologies, ultrasound provides detailed images of soft tissues, allowing for precise diagnosis and effective treatment planning. It is equally useful for detecting metatarsalgia, plantar fasciitis, and Morton's neuroma, offering insights into soft tissue abnormalities and guiding therapeutic interventions. Ultrasound's role extends to diagnosing foreign bodies in the foot and ankle, where it demonstrates high sensitivity and specificity. The accessibility and cost-effectiveness of ultrasound make it an invaluable tool in various healthcare settings, ensuring timely and accurate diagnosis and management of foot and ankle disorders during pregnancy, ultimately enhancing patient outcomes and quality of life.
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Affiliation(s)
- Meghan E Sahr
- Radiology & Imaging, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021
| | - Amos Grünebaum
- Zucker School of Medicine, Northwell, 2000 Marcus Ave., Suite 300, New Hyde Park, 11042-1069, NY, USA
| | - Rock C Positano
- Non-Surgical Foot and Ankle Center, Hospital for Special Surgery, New York, USA
| | - Ogonna K Nwawka
- Radiology & Imaging, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021
| | - Frank A Chervenak
- Zucker School of Medicine, Northwell, 2000 Marcus Ave., Suite 300, New Hyde Park, 11042-1069, NY, USA
| | - Rock G Positano
- Non-Surgical Foot and Ankle Center, Hospital for Special Surgery, New York, USA
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2
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Jaffe DE, Brodsky JW. Republication of "Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults: Operative Technique". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231193402. [PMID: 37566696 PMCID: PMC10408342 DOI: 10.1177/24730114231193402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient's ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.
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Affiliation(s)
- David E Jaffe
- OrthoArizona, Arizona Bone and Joint Specialists, Scottsdale, AZ, USA
| | - James W Brodsky
- Baylor University Medical Center, Orthopaedic Surgery, Dallas, TX, USA
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3
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Connors JC, Zulauf EE, Manji AA. Novel Extramedullary Fixation Device for Hammertoe Correction: A Retrospective Review of 100 patients. J Foot Ankle Surg 2023:S1067-2516(23)00038-8. [PMID: 36997364 DOI: 10.1053/j.jfas.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/07/2023] [Accepted: 02/15/2023] [Indexed: 04/01/2023]
Abstract
Classically, one of the more common treatment options for rigid hammertoe correction consists of end-to-end arthrodesis stabilized by temporary Kirschner wire (K-wire) fixation maintained until osseous consolidation or complication necessitating premature removal. However, single K-wire fixation allows for axial rotation which results in loss of compression at the arthrodesis site. To counteract this, intramedullary implants were designed to provide fusion site stability in all planes negating extra-skeletal extension of the wire. Nevertheless, manual pressfit implants arguably offer less reliable positioning of the fusion site in a true end to end orientation due to variation in intramedullary stem placement compared to direct visualization with dorsal plating. Larger diameter implants create an osseous void at the bony interface reducing the potential of true bony union. Hammertoe implant failure poses a unique and challenging salvage scenario which can ultimately end in amputation. Extramedullary fixation is uniquely designed to merge both benefits of K-wires and intramedullary implants while eliminating inadequacies of each. A total of 100 patients who underwent 150 rigid hammertoe corrections with an extramedullary implant were retrospectively reviewed. The mean postoperative follow-up was 12.6 months (range 12-18 months). Overall, 94 of 100 patients (94%) achieved radiographic union, defined by 2 or more bridged cortices at the arthrodesis site without signs of hardware breakage or signs of lucency across one or more fusion sites at a mean 8.8 weeks (range 7-10 weeks). This study demonstrated excellent results in regards to postoperative arthrodesis when utilizing an extramedullary implant for hammertoe deformity correction. This device minimizes osseous deficit by extramedullary application, all while augmenting intramedullary K-wire fixation.
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Affiliation(s)
- James C Connors
- Associate Professor, Division of Foot and Ankle Surgery, Kent State University College of Podiatric Medicine, Independence, OH.
| | - Emily E Zulauf
- Fellow, Alexander Orthopedic Associates, St. Petersburg, FL
| | - Ali A Manji
- Podiatric Surgery Resident, Mercy Regional Medical Center, Lorain, OH
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Leung YT, Lui TH. Claw Toe With Dislocated Second Metatarsophalangeal Joint: Treated by Plantar Plate Tenodesis and Release of Collateral Ligaments. Arthrosc Tech 2022; 11:e1695-e1702. [PMID: 36311323 PMCID: PMC9596388 DOI: 10.1016/j.eats.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/07/2022] [Indexed: 02/03/2023] Open
Abstract
Claw toe deformity of the second toe is a common forefoot deformity faced by foot and ankle surgeons. Frequently, it develops as the result of plantar plate insufficiency and subsequent metatarsophalangeal (MTP) joint instability. As the disease deteriorates, the MTP joint can be dislocated. Reduction of the MTP joint without metatarsal osteotomy seems to be a logical approach unless there is excessively long second metatarsal. However, adequate periarticular soft-tissue release including the dorsal capsule, collateral ligaments and extensor tendon is needed to reduce the intra-articular pressure and minimize the risk of joint degeneration. The purpose of this Technical Note is to describe the details of plantar plate tenodesis and release of collateral ligaments for correction of claw second toe associated with dislocation of the metatarsophalangeal joint.
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Affiliation(s)
| | - Tun Hing Lui
- Address correspondence to Dr. Tun Hing Lui, M.B.B.S. (H.K.), F.R.C.S. (Edin.), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Rd., Sheung Shui, NT, Hong Kong SAR, China.
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5
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Sharpe BD, Ebaugh MP, Philbin TM, Prissel MA, Hyer CF, Berlet GC, Goss DA. Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications. Foot Ankle Spec 2022:19386400221118500. [PMID: 36004609 DOI: 10.1177/19386400221118500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. METHODS This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). RESULTS Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. CONCLUSION To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. LEVEL OF EVIDENCE IV Retrospective Case Series. CATEGORY Lesser Toes.
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Affiliation(s)
- B Dale Sharpe
- University of Virginia Health Systems, Charlottesville, Virginia
| | - M Pierce Ebaugh
- Department of Orthopedics, Jewett Orthopedic Institute at Orlando Health, Orlando, Florida
| | | | | | | | | | - David A Goss
- Associates in Orthopedics and Sports Medicine, Dalton, Georgia
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6
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Malani K, Ravine M, Schneider HP. Nonoperative Treatment of Plantar Plate Tears. Clin Podiatr Med Surg 2022; 39:451-459. [PMID: 35717062 DOI: 10.1016/j.cpm.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The plantar plate is a critical structure involved in stabilizing the metatarsophalangeal joint. Its disruption can not only be painful for the patient but also may lead to subsequent structural deformities. There are several conservative treatment modalities available to help mitigate symptoms including splinting, offloading, and intraarticular injections. That being said, once the pathology progresses to advanced stages, these treatments are not efficacious. Reported success with conservative treatment modalities is limited to case studies and series with a low level of clinical evidence. As such, this represents an area where further investigation is needed to evaluate the true efficacy of conservative treatment and to allow for development of a more standardized approach.
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Affiliation(s)
- Karan Malani
- Cambridge Health Alliance, 1493 Cambridge Street, Department of Surgery, Cambridge, MA 02139, USA
| | - Madison Ravine
- Cambridge Health Alliance, 1493 Cambridge Street, Department of Surgery, Cambridge, MA 02139, USA
| | - Harry P Schneider
- Cambridge Health Alliance, 1493 Cambridge Street, Department of Surgery, Cambridge, MA 02139, USA.
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Abstract
The lesser metatarsophalangeal joint plantar plate and calcaneonavicular (spring) ligament are highly specialized soft tissue structures within the foot, consisting partly of fibrocartilage and capable of withstanding high compressive and tensile loads. Preoperative advanced imaging, in the form of point-of-care ultrasound and MRI, has become indispensable for surgeons hoping to confirm, quantify, and better localize injuries to these structures before surgery. This article describes the technical considerations of ultrasound and MRI and provides examples of the normal and abnormal appearances of these structures. The pros and cons of each imaging modality are also discussed.
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Affiliation(s)
- Adam E Fleischer
- Weil Foot & Ankle Institute, 3000 N, Halsted Suite 700, Chicago, IL 60657, USA; Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA.
| | - Rachel H Albright
- Stamford Health Medical Group, 800 Boston Post Road, Suite 302, Darien, CT 06820, USA
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8
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Hatch DJ. Anatomy: Plantar Plate. Clin Podiatr Med Surg 2022; 39:411-419. [PMID: 35717059 DOI: 10.1016/j.cpm.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The fibrocartilaginous component of the plantar plate offers stability at the metatarsophalangeal joint. In conjunction with the attachments of the deep transverse metatarsal ligaments and collateral ligaments, the plantar plate complex resists tensile forces anchored by the plantar fascia and compression forces under the metatarsal heads.
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Affiliation(s)
- Daniel J Hatch
- Director of Surgery, North Colorado Podiatric Medical Surgical Residency, 1931 65th Avenue, Suite A, Greeley, CO 80634, USA.
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9
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Mann TS, Nery CADS, Baumfeld D, Fernandes EDÁ. Degenerative injuries of the metatarsophalangeal plantar plate on magnetic resonance imaging: a new perspective. EINSTEIN-SAO PAULO 2022; 20:eAO6543. [PMID: 35476080 PMCID: PMC9000981 DOI: 10.31744/einstein_journal/2022ao6543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/22/2021] [Indexed: 11/12/2022] Open
Abstract
Objective The magnetic resonance imaging diagnostic criteria for a complete tear of metatarsophalangeal plantar plate are well-established. However, more subtle abnormalities can also occur and be a source of pain. The objective of this study is to determine the prevalence of degenerative plantar plate injuries in patients with metatarsalgia who underwent forefoot magnetic resonance imaging and describe the main abnormalities found. The hypothesis is that mild capsular fibrosis will have high sensitivity but low specificity for plantar plate degenerative injuries. Methods A retrospective cross-sectional study was conducted with 85 patients (105 feet) with metatarsalgia who underwent forefoot magnetic resonance imaging using a specific protocol to study metatarsophalangeal plantar plate. The experiment observer classified second toe plantar plate as normal, complete rupture or degenerative lesion and described the main magnetic resonance imaging findings. Results A normal plantar plate was observed in 75 (71.4%) of the 105 feet assessed, in 25 (24%) feet there were degenerative plantar lesions, and in 5 (4.6%) feet there were complete ruptures. Degenerative injury of the plantar plate was best identified in coronal short axis intermediate-weighted images, with high sensitivity (92%). Pericapsular fibrosis below the intermetatarsal ligament was identified in 96% of cases, with high sensitivity (96%) for diagnosis of degenerative plantar plate injury. Conclusion Degenerative lesions of the metatarsophalangeal plantar plate were more prevalent than complete ruptures and were best viewed in coronal short axis intermediate-weighted sequences. Pericapsular fibrosis below the intermetatarsal ligament was the indirect finding most strongly associated with degenerative plantar plate injury.
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10
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Diagnostic Accuracy of Magnetic Resonance Imaging (MRI) Versus Dynamic Ultrasound for Plantar Plate Injuries: A Systematic Review and Meta-Analysis. Eur J Radiol 2022; 152:110315. [DOI: 10.1016/j.ejrad.2022.110315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/14/2022] [Accepted: 04/06/2022] [Indexed: 11/18/2022]
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11
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Son HM, Chai JW, Kim YH, Kim DH, Kim HJ, Seo J, Lee SM. A problem-based approach in musculoskeletal ultrasonography: central metatarsalgia. Ultrasonography 2021; 41:225-242. [PMID: 34879474 PMCID: PMC8942737 DOI: 10.14366/usg.21193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/25/2021] [Indexed: 11/23/2022] Open
Abstract
Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of metatarsalgia. The superficial location of structures in the foot, dynamic capability of US, and the ability to perform direct real-time evaluations of the pain site are also strong advantages of US as a modality for examining the foot. Moreover, knowing the possible pain sources to investigate when a patient has a specific site of pain will enhance the diagnostic quality of US, and will help radiologists to perform US efficiently and effectively. The purpose of this article is to review the common etiologies of metatarsalgia including Morton’s neuroma, plantar plate injury, synovitis, tenosynovitis, bursitis, and metatarsal fractures, and to discuss their US features.
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Affiliation(s)
- Hye Min Son
- Department of Radiology, Yeungnam University College of Medicine, Daegu, Korea
| | - Jee Won Chai
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Hee Kim
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hyun Kim
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Jin Kim
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jiwoon Seo
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Moon Lee
- Daegyeong Imaging and Healthcare Center, Daegu, Korea
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12
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Lui TH, Chan YLC. Correction of Severe Crossover Toe Deformity By Plantar Plate Tenodesis, Arthroscopic Release of Lumbrical and Plication of Lateral Capsuloligamentous Complex. Arthrosc Tech 2021; 10:e1921-e1927. [PMID: 34401234 PMCID: PMC8355197 DOI: 10.1016/j.eats.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/16/2021] [Indexed: 02/03/2023] Open
Abstract
Plantar plate deficiency is the major cause of instability of the metatarsophalangeal joint, and plantar plate tenodesis can provide dynamic stabilization of the plantar plate. In case of crossover toe deformity, incorporation of arthroscopic release of the medial capsuloligamentous complex and the lumbrical tendon can eliminate the medial deforming force. However, in case of severe deformity, the lateral capsuloligamentous complex is attenuated. The purpose of this Technical Note is to incorporate the technique of arthroscopic plication of the lateral capsuloligamentous complex into the technique of plantar plate tenodesis and arthroscopic release of the medial capsuloligamentous complex and the lumbrical tendon.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong,Address correspondence to Tun Hing Lui, M.B.B.S. (HK), F.R.C.S. (Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.
| | - Yi Lok Charis Chan
- Department of Orthopaedics and Traumatology, United Christian Hospital, Hong Kong, China
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13
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Lui TH, Ng CK. Correction of Crossover Toe Deformity by Plantar Plate Tenodesis and Arthroscopic Release of Lumbrical. Arthrosc Tech 2021; 10:e1621-e1626. [PMID: 34258213 PMCID: PMC8252812 DOI: 10.1016/j.eats.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 02/03/2023] Open
Abstract
Plantar plate deficiency is the major cause of instability of the metatarsophalangeal joint. As the joint subluxates dorsally, the lumbrical is tethered on the medial side of the joint by the deep metatarsal ligament and becomes a deforming force for the development of crossover toe deformity. Release of the lumbrical is needed to achieve adequate medial soft-tissue release. Plantar plate tenodesis has been described to correct the deformity by suturing the plantar plate to the extensor digitorum longus tendon. The purpose of this Technical Note is to incorporate the technique of arthroscopic release of the lumbrical tendon into the technique of plantar plate tenodesis.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, Hong Kong
- Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.
| | - Chun Kiu Ng
- Department of Orthopaedics and Traumatology, Yan Chai Hospital, Tsuen Wan, Hong Kong
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14
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Fleischer AE, Klein EE, Bowen M, McConn TP, Sorensen MD, Weil L. Comparison of Combination Weil Metatarsal Osteotomy and Direct Plantar Plate Repair Versus Weil Metatarsal Osteotomy Alone for Forefoot Metatarsalgia. J Foot Ankle Surg 2021; 59:303-306. [PMID: 32130995 DOI: 10.1053/j.jfas.2019.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/20/2019] [Accepted: 08/25/2019] [Indexed: 02/03/2023]
Abstract
Although many surgeons believe that shortening osteotomies are appropriate in patients with metatarsalgia and long second metatarsals, there remains ambiguity regarding when to repair the injured plantar plate and when to leave it alone. We prospectively assessed consecutive adult subjects who underwent an isolated second Weil metatarsal osteotomy (WMO) or a WMO plus plantar plate repair (WMO + PPR) for sub-second metatarsophalangeal joint pain during a 3.5-year period at our practice. Eighty-six patients (86 feet: 21 WMO only and 65 WMO + PPR) with a mean age of 61 ± 11 years were followed for 1 year. Patients were assessed via use of the Foot and Ankle Outcome Score and radiographic parabola/alignment of the operative digit preoperatively and postoperatively. Patients in the WMO + PPR group demonstrated significant improvements preoperatively to postoperatively in 4 of the 5 FAOS subscales (Pain, Other Symptoms, Sport and Recreation Function, and Ankle- and Foot-Related Quality of Life [QoL], all p < .05) and had higher QoL and Pain subscale scores at 1 year compared with those in the WMO-only group (QoL: 68.6 ± 26.7 versus 49.7 ± 28.5, respectively [p = .01]; Pain: 83.2 ± 14.5 versus 73.6 ± 19.9, respectively [p = .04]). The WMO + PPR group tended to have higher-grade tears on intraoperative inspection (median 3, range 0 to 4) compared with those in the WMO group (median 1, range 0 to 3). There were otherwise no group differences in preoperative or postoperative radiographic parabola, alignment of the second toe, or complication rates. Our findings suggest that when a shortening osteotomy is performed, imbricating/repairing and advancing the plantar plate may be valuable regardless of injury grade in the plate.
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Affiliation(s)
- Adam E Fleischer
- Director of Research, Weil Foot and Ankle Institute, Mount Prospect, IL; Associate Professor, Dr. William M. Scholl College of Podiatric Medicine, North Chicago, IL.
| | - Erin E Klein
- Associate Director of Research, Weil Foot and Ankle Institute, Mount Prospect, IL
| | - Michael Bowen
- Surgeon, Fredericksburg Orthopedics Associates, Fredericksburg, VA
| | - Timothy P McConn
- Immediate Past Fellow, Weil Foot/Ankle & Orthopedic Institute, Advanced Surgical Fellowship, Mount Prospect, IL
| | - Matthew D Sorensen
- Fellowship Director, Weil Foot/Ankle & Orthopedic Institute, Advanced Surgical Fellowship, Mount Prospect, IL
| | - Lowell Weil
- CEO, Weil Foot and Ankle Institute, Mount Prospect, IL
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15
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Hendrick SE, Kannegieter E. SmartToe, ToeGrip and buried k-wire versus percutaneous k-wire fixation for 2nd PIPJ arthrodesis: A comprehensive review of outcomes. Foot (Edinb) 2020; 45:101692. [PMID: 33181397 DOI: 10.1016/j.foot.2020.101692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 03/09/2020] [Accepted: 05/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Proximal interphalangeal joint arthrodesis is a reliable and repeatable method of surgical correction for the semi-rigid and rigid hammer toe deformity. In recent years the authors have noted a significant increase in the use of novel intramedullary devices in place of the traditional percutaneous Kirschner wires (k-wire). This paper set out to critically review three methods of internal fixation; ToeGrip implant, SmartToe implant and buried k-wire technique in comparison to the traditional method of percutaneous k-wire fixation during arthrodesis of the proximal interphalangeal joints (PIPJ) of the toes. The objectives were to review osseous fusion rates, infection, hardware complications, patient satisfaction, and the comparative cost of each modality. RESULTS In total 3878 outcomes were reviewed consisting of 3255 percutaneous k-wires, 347 SmartToe implants, 218 ToeGrip implants, and 58 buried k-wires. Overall Infection rates where low; SmartToe infection rates ranged between 1.2% and 5%, percutaneous k-wire fixation 0.3%-7% buried k-wire 3.3%. The SmartToe Implant had the highest hardware failure rate up to 20.7%, the lowest hardware failure occurred in percutaneous k-wire studies at 0.1%-4.3%, no evidence of hardware failure was associated in both ToeGrip and buried k-wire techniques. Percutaneous k-wire migration ranged between 4.4%-5.5% and 3.8%-10% for the SmartToe implant, all significantly lower than buried k-wire migration of 33%. The SmartToe implant demonstrated the highest mean osseous union rate 87.2%, 83% in ToeGrip studies, similar results between the buried k-wire and percutaneous k-wire studies 72% and 73% respectively. Individual unit costs for k-wires £0.37, ToeGrip implant £236.94 and SmartToe implants £331, demonstrating a 640 and 894 fold increase in cost when using implants in comparison to k-wires. Patient satisfaction was poorly reported. CONCLUSIONS Percutaneous k-wire fixation remains a reliable and cost effective method of stabilisation during hammertoe correction in comparison to newer more costly implantable devices. LEVEL OF EVIDENCE IV - critical literature review.
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Affiliation(s)
- Scott E Hendrick
- Podiatric Surgery Departments; Braintree Community Hospital, Essex CM7 2AL, United Kingdom; Mexborough Montagu Hospital, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, S64 0AZ, United Kingdom; Ilkeston Hospital, Derbyshire Community Health Service, NHS Foundation Trust, Heanor Road, DE7 8LN, United Kingdom.
| | - Ewan Kannegieter
- Podiatric Surgery Departments; Braintree Community Hospital, Essex CM7 2AL, United Kingdom
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Cook JJ, Cook EA, Hansen DD, Matthews M, Karthas T, Collier B, McKenna B, Manning E. One-Year Outcome Study of Anatomic Reconstruction of Lesser Metatarsophalangeal Joints. Foot Ankle Spec 2020; 13:286-296. [PMID: 31185739 DOI: 10.1177/1938640019846974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Lesser metatarsophalangeal joint (MTPJ) and plantar plate pathologies are commonly seen forefoot conditions. Traditional rebalancing techniques are commonly used but can have concerning adverse effects. The purpose of this study was to analyze the 1-year outcomes of a new technique consisting of anatomic repair of the plantar plate and collateral ligaments involving lesser MTPJs. Methodology: A retrospective cohort study of 50 consecutive patients treated with anatomic plantar plate and collateral ligament reconstruction were evaluated for lesser MTPJ imbalances between 2013 and 2016. The primary outcome was postoperative digital stability defined as a normal dorsal drawer test and normal paper pull-out test. Secondary outcomes included pre- and postoperative visual analogue scale pain measurements, MTPJ radiographic alignment, and ACFAS Forefoot module scores. Results: All patients had digital instability prior to the surgical intervention. Final follow-up revealed that 92% of patients showed improved digital stability, P = .0005. Multivariate regression found statistically significant improvement in pain reduction via the visual analogue scale of 51.2 mm (P < .0001) and ACFAS Forefoot module scores improved to 92 (P < .0001). The 45 joints with preoperative abnormal transverse plane deformity, had either complete (n = 29) or partial (n = 16) radiographic MTPJ correction. Conclusion: These results suggest that anatomic repair of lesser MTPJ improved digital stability, pain, function and radiographic alignment with greater than one year of follow-up.Levels of Evidence: Level IV: Retrospective cohort study.
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Affiliation(s)
- Jeremy J Cook
- Harvard Medical School, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Emily A Cook
- Harvard Medical School, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, Massachusetts
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17
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McCartan BL, Juels CA, Shih JA. Technique and Tips for Multiplanar Correction of Plantar Plate Repairs in Lesser Metatarsophalangeal Joints. J Am Podiatr Med Assoc 2019; 109:80-86. [PMID: 30964313 DOI: 10.7547/17-086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Plantar plate repairs are challenging procedures because of the small anatomy of the plantar plate. This can make them daunting, time-consuming procedures to perform. Advances in technology, such as interference screws and small suture passers, have created improved technique possibilities to decrease difficulty, correct multiple planes of deformity, create stronger constructs, and improve patient results. The plantar plate repair technique presented in this article includes a dorsal approach with a metatarsal osteotomy, a knotless repair that provides a strong construct to allow patients to protectively bear weight immediately, and can reduce operative time by presenting tips to quickly navigate the procedure. The presented technique allows for detailed correction of all three planes of deformity, maximizing patient results.
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Affiliation(s)
- Brant L. McCartan
- Wheaton Franciscan Healthcare–St. Joseph Hospital, Whitefish Bay, WI
| | | | - Jonathan A. Shih
- Wheaton Franciscan Healthcare–St. Joseph Hospital, Whitefish Bay, WI
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18
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Bergeron MC, Ferland J, Malay DS, Lewis SE, Burkmar JA, Giovinco NA. Use of Metatarsophalangeal Joint Dorsal Subluxation in the Diagnosis of Plantar Plate Rupture. J Foot Ankle Surg 2019; 58:27-33. [PMID: 30448184 DOI: 10.1053/j.jfas.2018.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Indexed: 02/03/2023]
Abstract
A dorsal drawer exam, also known as a modified Lachman's test, is a common clinical test for plantar plate insufficiency. This disorder presents as a dislocated metatarsophalangeal joint. The aim of this cadaveric case study was to quantify the degree of the plantar plate pathology necessary to correlate with a positive Lachman's test. The second metatarsophalangeal joint was tested on 18 cadaveric lower extremities. Limbs with previous digital surgery or with an obvious digital deformity were excluded from this study. A plantar linear incision over the plantar aspect of the second metatarsophalangeal joint was performed, and the flexor tendons were retracted to expose the plantar plate. After evaluating the plantar plate's integrity and measuring its width, a Lachman's test was then performed under fluoroscopy. The plantar plate was subsequently severed in a serial manner in 2-mm increments. A modified Lachman's test was performed with the different levels of rupture to assess the degree of dislocation. We found that a tear as small as 2 mm, detected in 12 (66.7%) of 18 specimens, produced gross instability in the second metatarsophalangeal joint. We also showed that a simulated plantar plate tear ≥4 mm but <6 mm resulted in joint subluxation (positive modified Lachman's test) with a sensitivity of 90.3%. This study reinforces the finding that a modified Lachman's test is a clinical exam that demonstrates high sensitivity in diagnosing plantar plate insufficiency.
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Affiliation(s)
- Marie-Christine Bergeron
- Faculty, Department of Surgery, New York College of Podiatric Medicine, New York, NY; Faculty, The Podiatry Institute, Decatur, GA.
| | - Julie Ferland
- Faculty, The Podiatry Institute, Decatur, GA; Staff Surgeon, Kosciusko Community Hospital, Warsaw, IN
| | - D Scot Malay
- Faculty, The Podiatry Institute, Decatur, GA; Staff Surgeon and Director of Podiatric Research, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Sara E Lewis
- Faculty, The Podiatry Institute, Decatur, GA; Staff Surgeon and Director of Podiatric Research, Penn Presbyterian Medical Center, Philadelphia, PA; Fellow, The Southeast Permanente Medical Group, Atlanta, GA
| | | | - Nicholas A Giovinco
- Faculty, The Podiatry Institute, Decatur, GA; Resident, Dekalb Medical Center Podiatry Residency, Decatur, GA; Staff Surgeon, Piedmont Clinics Physician, Newnan, GA
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19
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Cook JJ, Johnson LJ, Cook EA. Anatomic Reconstruction Versus Traditional Rebalancing in Lesser Metatarsophalangeal Joint Reconstruction. J Foot Ankle Surg 2018; 57:509-513. [PMID: 29685561 DOI: 10.1053/j.jfas.2017.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Indexed: 02/03/2023]
Abstract
Traditional rebalancing techniques, such as capsulotomies and capsulorrhaphies, are commonly performed during complex hammertoe and lesser metatarsal osteotomy procedures involving metatarsophalangeal joint (MTPJ) contractures; however, floating toes, digital instability, and malalignment are concerns. We critically analyzed the outcomes after anatomic reconstruction of the plantar plate and collateral ligaments compared with those after traditional rebalancing techniques. A case-control study was conducted of 54 patients who had undergone surgical correction of lesser MTPJ imbalances due to complex hammertoe deformities (power 80%, type I error = 0.05). Cases were defined as consecutive patients treated with anatomic plantar plate and collateral ligament reconstruction. Controls had undergone traditional lesser MTPJ rebalancing and were matched to cases by age, gender, follow-up duration (minimum 12 months), and concomitant procedures of the same lesser ray. Multivariate logistic regression demonstrated that patients treated with anatomic reconstruction had greater digital stability (negative dorsal drawer and negative paper pull-out test findings) at final follow-up examination compared with the controls. American College of Foot and Ankle Surgeons (ACFAS) forefoot module scores were greater in the anatomic group in all domains (p ≤ .05). Controls had greater postoperative radiographic MTPJ angles than the cases, with no differences detected between the 2 groups in visual analog scale scores or proximal interphalangeal joint angles. The importance of restoration of the plantar plate and collateral ligament integrity as a digital stabilizer is generally accepted but has not been well studied. We found that anatomic reconstruction yielded greater digital stability, greater ACFAS Forefoot module scores, and better radiographic MTPJ alignment than controls. Additional studies are warranted to assess the long-term viability of anatomic lesser MTPJ reconstruction.
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Affiliation(s)
- Jeremy J Cook
- Clinical Instructor in Surgery, Harvard Medical School, Boston, MA; Director of Research and Quality Assurance, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA
| | - Lindsay J Johnson
- Clinical Instructor in Surgery, Harvard Medical School, Boston, MA; Chief, Division of Podiatric Surgery, Department of Surgery, Harvard Vanguard Medical Associates, an Affiliate of Atrius Health, Braintree, MA; Assistant Director of Resident Training, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA
| | - Emily A Cook
- Clinical Instructor in Surgery, Harvard Medical School, Boston, MA; Director of Resident Training, Division of Podiatric Surgery, Department of Surgery, Mount Auburn Hospital, Cambridge, MA.
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20
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Elmajee M, Shen Z, A'Court J, Pillai A. A Systematic Review of Plantar Plate Repair in the Management of Lesser Metatarsophalangeal Joint Instability. J Foot Ankle Surg 2018; 56:1244-1248. [PMID: 28893531 DOI: 10.1053/j.jfas.2017.05.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Indexed: 02/03/2023]
Abstract
The plantar plate is a major structure that maintains metatarsophalangeal joint (MTPJ) stability and has only recently gained attention. Anatomic plantar plate repair can directly address the pathologic entity, rather than relying on indirect reduction of the MTPJ instability by osteotomy or tendon transfer techniques. The present report aimed to determine the effectiveness of plantar plate repair for the treatment of patients with lesser MTPJ instability. Different databases were searched using the guidelines in the Cochrane Handbook and recommendations from the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. Six case series, describing 162 patients who had undergone plantar plate repair in conjunction with either Weil osteotomy or flexor digitorum longus transfer, were retrieved. Favorable outcomes were described in each of the studies included in the present systematic review. However, these results should be interpreted with caution because of the methodologic limitations and biases inherent in the included studies. More rigorous clinical investigations are required to fully understand the effectiveness of plantar plate repair for the management of lesser MTPJ instability.
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Affiliation(s)
- Mohammed Elmajee
- Senior Registrar, The Royal Oldham Hospital, Oldham, Manchester, United Kingdom.
| | - Zhiyu Shen
- Senior House Officer, Salford Royal Hospital, Manchester, United Kingdom
| | - Jamie A'Court
- Senior Registrar, The Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Anand Pillai
- Consultant Foot and Ankle and Adult Reconstruction Surgeon, University Hospitals South Manchester, Manchester, United Kingdom
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21
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Jaffe DE, Brodsky JW. Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418782488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient’s ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.
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Affiliation(s)
- David E. Jaffe
- OrthoArizona, Arizona Bone and Joint Specialists, Scottsdale, AZ, USA
| | - James W. Brodsky
- Baylor University Medical Center, Orthopaedic Surgery, Dallas, TX, USA
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22
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Fleischer AE, Hshieh S, Crews RT, Waverly BJ, Jones JM, Klein EE, Weil L, Weil LS. Association Between Second Metatarsal Length and Forefoot Loading Under the Second Metatarsophalangeal Joint. Foot Ankle Int 2018; 39:560-567. [PMID: 29374967 DOI: 10.1177/1071100717753829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Metatarsal length is believed to play a role in plantar plate dysfunction, although the mechanism through which progressive injury occurs is still uncertain. We aimed to clarify whether length of the second metatarsal was associated with increased plantar pressure measurements in the forefoot while walking. METHODS Weightbearing radiographs and corresponding pedobarographic data from 100 patients in our practice walking without a limp were retrospectively reviewed. Radiographs were assessed for several anatomic relationships, including metatarsal length, by a single rater. Pearson correlation analyses and multiple linear regression models were used to determine whether metatarsal length was associated with forefoot loading parameters. RESULTS The relative length of the second to first metatarsal was positively associated with the ratio of peak pressure beneath the respective metatarsophalangeal joints ( r = 0.243, P = .015). The relative length of the second to third metatarsal was positively associated with the ratios of peak pressure ( r = 0.292, P = .003), pressure-time integral ( r = 0.249, P = .013), and force-time integral ( r = 0.221, P = .028) beneath the respective metatarsophalangeal joints. Although the variability in loading predicted by the various regression analyses was not large (4%-14%), the relative length of the second metatarsal (to the first and to the third) was maintained in each of the multiple regression models and remained the strongest predictor (highest standardized β-coefficient) in each of the models. CONCLUSIONS Patients with longer second metatarsals exhibited relatively higher loads beneath the second metatarsophalangeal joint during barefoot walking. These findings provide a mechanism through which elongated second metatarsals may contribute to plantar plate injuries. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Adam E Fleischer
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA.,2 Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Shenche Hshieh
- 3 Rhode Island Hospital/Brown University, Providence, RI, USA
| | - Ryan T Crews
- 4 Center for Lower Extremity Ambulatory Research at Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | | | - Jacob M Jones
- 2 Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Erin E Klein
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
| | - Lowell Weil
- 1 Weil Foot and Ankle Institute, Des Plaines, IL, USA
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23
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Frey-Ollivier S, Catena F, Hélix-Giordanino M, Piclet-Legré B. Treatment of Flexible Lesser Toe Deformities. Foot Ankle Clin 2018; 23:69-90. [PMID: 29362035 DOI: 10.1016/j.fcl.2017.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Lesser toe deformities are among the most common complaints presented to foot and ankle specialists. These deformities present in variable ways, which makes surgical decision making complex. For every type of deformity, there could be a combination of soft tissues and bony procedures, chosen according to the surgeon's preferences. This article first describes modern classification of lesser toe deformities, and then presents the different treatments and procedures available for those flexible deformities. In addition, this article proposes an algorithm based on clinical/radiological evaluation and step-by-step surgical decision making.
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Affiliation(s)
| | - Fernanda Catena
- Orthopaedics and Sports Medecine Department, Hospital Nove de Julho, Sao Paulo, France
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24
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Hsu RY, Barg A, Nickisch F. Lesser Metatarsophalangeal Joint Instability: Advancements in Plantar Plate Reconstruction. Foot Ankle Clin 2018; 23:127-143. [PMID: 29362028 DOI: 10.1016/j.fcl.2017.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The plantar plate and associated collateral ligaments are the main stabilizers of each of the lesser metatarsophalangeal joints. Although clinical examination and plain radiographs are usually sufficient to establish the diagnosis of a plantar plate tear, MRI or fluoroscopic arthrograms may help in specific cases. Recent results with a dorsal approach to plantar plate repair are promising with respect to pain relief and patient satisfaction.
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Affiliation(s)
- Raymond Y Hsu
- Department of Orthopedics, The University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA.
| | - Alexej Barg
- Department of Orthopedics, The University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Florian Nickisch
- Department of Orthopedics, The University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
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25
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Yassin M, Garti A, Heller E, Robinson D. Hammertoe Correction With K-Wire Fixation Compared With Percutaneous Correction. Foot Ankle Spec 2017; 10:421-427. [PMID: 27909213 DOI: 10.1177/1938640016681069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Kirschner wire (K-wire) fixation for correction of hammertoe deformity is the gold standard for hammertoe surgery fixation, the current study compares it to percutaneous surgery with 3M Coban dressings. METHODS All hammertoe corrections performed were retrospectively reviewed. For the K-wire fixation group: resection arthroplasty of the proximal interphalangeal joint was performed and fixed with a K-wire. The percutaneous technique used involved percutaneous diaphyseal osteotomy of the middle and proximal phalanges combined with tendon release. The toes are then wrapped in 3M Coban dressing for 3 weeks. Follow-up duration, preoperative diagnosis, pin duration, concomitant procedures, visual analogue scale (VAS) pain, recurrence rates, and complications were reviewed and analyzed. A total of 352 patients (87 percutaneous/265 open), in whom 675 hammertoes (221 percutaneous/454 open) were corrected. There were 55.9% females, with an average age of 52.8 years, followed for 6 months. The percutaneous group had more diabetics and multiple toes surgery. RESULTS Complications of the open surgery group included 5.5% pin migrations, 4.5% infections, and 8 (3%) had impaired wound healing. There were 6.2% recurrent deformities and 2.6% toes were revised. Malalignment was noted in 3.3% toes. Vascular compromise occurred in 0.5%, with 0.25% amputated. Complications of the percutaneous surgery group included 18.4% cases of impaired healing and 2.3% infection. Deep tissue dehiscence occurred in 4.5% of open surgery patients. VAS score decreased in both groups with a more pronounced decline in the percutanteous group (2 ± 2.1 vs 0.5 ± 1.6). The per toe infection rate of patients undergoing open hammertoe correction was 5.3% was significantly higher than with the percutaneous correction group, which was 2.2%. CONCLUSIONS K-wire fixation and percutaneous surgery have similar abnormal healing rates, alignment and patient satisfaction but the latter technique has fewer infections. LEVELS OF EVIDENCE Level III: Prospective case series with noncontamporenous cohorts.
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Affiliation(s)
- Mustafa Yassin
- Department of Orthopaedic Surgery, Sackler School of Medicine, Tel Aviv University, Petah Tikwa, Israel (MY, AG, EH).,Orthopedic Research Unit and Foot and Ankle Service, Hasharon Hospital, Rabin Medical Center, Petah Tikwa, Israel (DR)
| | - Avraham Garti
- Department of Orthopaedic Surgery, Sackler School of Medicine, Tel Aviv University, Petah Tikwa, Israel (MY, AG, EH).,Orthopedic Research Unit and Foot and Ankle Service, Hasharon Hospital, Rabin Medical Center, Petah Tikwa, Israel (DR)
| | - Eyal Heller
- Department of Orthopaedic Surgery, Sackler School of Medicine, Tel Aviv University, Petah Tikwa, Israel (MY, AG, EH).,Orthopedic Research Unit and Foot and Ankle Service, Hasharon Hospital, Rabin Medical Center, Petah Tikwa, Israel (DR)
| | - Dror Robinson
- Department of Orthopaedic Surgery, Sackler School of Medicine, Tel Aviv University, Petah Tikwa, Israel (MY, AG, EH).,Orthopedic Research Unit and Foot and Ankle Service, Hasharon Hospital, Rabin Medical Center, Petah Tikwa, Israel (DR)
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26
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Stone M, Eyler W, Rhodenizer J, van Holsbeeck M. Accuracy of Sonography in Plantar Plate Tears in Cadavers. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1355-1361. [PMID: 28398696 DOI: 10.7863/ultra.16.06067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 09/21/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Sonography is often used in the evaluation of forefoot disorders, and its use has been suggested in the diagnosis of plantar plate tears. This study aimed to assess the accuracy of sonography in the diagnosis of plantar plate tears of the lesser digits using gross dissection as the reference standard. METHODS The second through fifth digits of 6 cadavers were examined with sonography to evaluate for plantar plate tears. The examination was performed by a single musculoskeletal radiologist in longitudinal and short axes, and plates were graded as torn or intact. The digits were then dissected by a single podiatrist blinded to the prior sonographic results to assess the integrity of the plates. RESULTS Ten plantar plates were graded as torn by sonography, all occurring in the distal plate near the phalangeal insertion. Seven of these plates were identified as torn on direct inspection. Fourteen plantar plates were found to be intact on sonography, 12 of which were intact on gross inspection. Overall, the accuracy, sensitivity, and specificity of sonography were 79.2%, 77.8%, and 80.0%, respectively. No correlation was seen between the accuracy of sonography and plate size, using plate number as a surrogate marker for plate size (P = .822). CONCLUSIONS Sonography is an appropriate modality in the setting of suspected plantar plate tears, with acceptable accuracy, sensitivity, and specificity. No decline in accuracy was seen with smaller plates. Thus, sonography may be especially useful when small anatomy or technical factors make magnetic resonance imaging challenging to perform and interpret.
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Affiliation(s)
- Michael Stone
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - William Eyler
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Joshua Rhodenizer
- Department of Podiatry, St John Hospital and Medical Center, Detroit, Michigan, USA
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27
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Fleischer AE, Klein EE, Ahmad M, Shah S, Catena F, Weil LS, Weil L. Association of Abnormal Metatarsal Parabola With Second Metatarsophalangeal Joint Plantar Plate Pathology. Foot Ankle Int 2017; 38:289-297. [PMID: 27881742 DOI: 10.1177/1071100716674671] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Plantar plate pathology is common, yet it is unclear whether, and to what extent, the length of the second metatarsal contributes to this problem. METHODS We conducted a retrospective case-control (1:2) study to examine radiographic risk factors for plantar plate tears. One hundred patients (age 55.7 ± 12.3 years) with plantar plate injuries and 200 healthy controls (age 56.3 ± 11.3 years) were included. Cases were defined as patients with nonacute, isolated, plantar plate pathology of the second metatarsophalangeal joint confirmed by intraoperative inspection at a single foot and ankle specialty practice from June 1, 2007, to January 31, 2014. Patients presenting for pain outside of the forefoot served as the control group. Controls were matched on age (±2 years), gender, and year of presentation. Weight-bearing foot x-rays were assessed for several predetermined angular relationships by a single rater. Conditional logistic regression was used to identify risk factors for plantar plate injury. RESULTS A long second metatarsal, defined as a metatarsal protrusion index less than -4 mm, was the only significant risk factor for plantar plate pathology in both the univariate and multivariable analyses (multivariate odds ratio 2.5 [95% confidence interval 1.8 to 3.3], P = .002). CONCLUSION We found that a long second metatarsal was a risk factor for developing second metatarsophalangeal joint plantar plate tears. This knowledge may aid foot and ankle surgeons when contemplating the need for second metatarsal shortening osteotomies (eg, Weil osteotomy) during plantar plate surgery and when deciding on the amount of shortening for second metatarsal osteotomies. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
| | - Erin E Klein
- 1 Weil Foot & Ankle Institute, Des Plaines, IL, USA
| | - Maheen Ahmad
- 2 Center for Lower Extremity Ambulatory Research, North Chicago, IL, USA
| | - Shivang Shah
- 2 Center for Lower Extremity Ambulatory Research, North Chicago, IL, USA
| | - Fernanda Catena
- 3 UNIFESP-Escola Paulista de Medicina, São Paulo, SP, Brazil
| | | | - Lowell Weil
- 1 Weil Foot & Ankle Institute, Des Plaines, IL, USA
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28
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Lui TH, LiYeung LL. Modified double plantar plate tenodesis. Foot Ankle Surg 2017; 23:62-67. [PMID: 28159046 DOI: 10.1016/j.fas.2016.05.313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 02/25/2016] [Accepted: 05/03/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Metatarsophalangeal joint instability of the lesser toe can cause acquired toe deformity. Plantar plate deficiency is the major pathology. Plantar plate repair can stabilize the joint but may result in iatrogenic transverse plane toe deformity in correction of claw toe deformity. Limited toe extension can be resulted after correction of crossover toe deformity by plantar plate tenodesis and extensor digitorum brevis transfer. A modification of the technique is proposed. MATERIALS AND METHODS The clinical outcomes of 10 patients with the modified procedure performed were assessed. RESULTS The correction was full in all toes with no recurrence. CONCLUSION The modified technique can stabilize the metatarsophalangeal joint and correct lesser toe deformity without the need of tendon transfer, osteotomy or sophisticated instrumentation.
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Affiliation(s)
- T H Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong Special Administrative Region.
| | - L L LiYeung
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong Special Administrative Region.
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Flint WW, Macias DM, Jastifer JR, Doty JF, Hirose CB, Coughlin MJ. Plantar Plate Repair for Lesser Metatarsophalangeal Joint Instability. Foot Ankle Int 2017; 38:234-242. [PMID: 27852647 DOI: 10.1177/1071100716679110] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lesser metatarsophalangeal (MTP) joint instability is a common cause of forefoot pain. Advances in operative technique and instrumentation have made it possible to anatomically treat plantar plate tears through a dorsal approach. Our goal was to evaluate the subjective, functional, and radiographic outcomes of plantar plate repair (PPR) from a dorsal approach. METHODS A prospective case series was performed evaluating the results of PPR in 97 feet with 138 plantar plate tears. Patients underwent PPR from a dorsal approach with a Weil osteotomy. We followed patients at regular intervals for 12 months and collected data preoperatively and postoperatively with respect to visual analog scale (VAS) scores, MTP range of motion (ROM), paper pull-out test, American Orthopaedic Foot & Ankle Society (AOFAS) scores, satisfaction, and radiographic measures. RESULTS Eighty percent of patients scored "good" to "excellent" satisfaction scores at 12 months. The mean VAS pain score preoperatively was 5.4/10, and postoperatively was 1.5/10. The mean AOFAS scores increased from 49 to 81 points following surgery. The mean MTP ROM preoperatively was 43 degrees and postoperatively 31 degrees. Forty-two percent of toes passed the paper pull out test prior to surgery and 54% at 12 months. Mean metatarsal shortening was 2.4/3.1/1.2 mm for the second, third, and fourth metatarsals, respectively. The mean MTP joint angles preoperatively were 2/4.9/-1.3 degrees and postoperatively were 7.4/9.6/0.2 degrees, respectively, for the second, third, and fourth MTP joints. CONCLUSION We found that the plantar plate could be repaired through a dorsal approach with reliable outcomes. PPR was a viable option to anatomically restore the ligamentous support in the unstable lesser MTP joint. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Wesley W Flint
- 1 Orthopaedic Institute of Henderson, Henderson, NV, USA
| | | | | | - Jesse F Doty
- 4 University of Tennessee Erlanger Foot and Ankle Institute, Chattanooga, TN, USA
| | - Christopher B Hirose
- 5 Coughlin Foot and Ankle Clinic, Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Michael J Coughlin
- 5 Coughlin Foot and Ankle Clinic, Saint Alphonsus Regional Medical Center, Boise, ID, USA
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30
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Nery C, Baumfeld D, Umans H, Yamada AF. MR Imaging of the Plantar Plate. Magn Reson Imaging Clin N Am 2017; 25:127-144. [DOI: 10.1016/j.mric.2016.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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31
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Lui TH. Correction of Crossover Toe Deformity by Arthroscopically Assisted Plantar Plate Tenodesis. Arthrosc Tech 2016; 5:e1273-e1279. [PMID: 28149725 PMCID: PMC5263059 DOI: 10.1016/j.eats.2016.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/20/2016] [Indexed: 02/03/2023] Open
Abstract
Plantar plate deficiency is the major pathology causing metatarsophalangeal joint instability. As the joint subluxates dorsally, the lumbrical is tethered at the medial side of the joint by the deep metatarsal ligament and becomes a deforming force for the development of crossover toe deformity. Plantar plate repair or reconstruction is a logical surgical treatment option. This can be performed through a dorsal or plantar approach. The purpose of this technical note is to report a minimally invasive technique of crossover toe deformity correction by suturing the plantar plate to the extensor tendon. It is indicated for symptomatic crossover toe deformity that is not responsive to nonsurgical treatment. It is contraindicated if the metatarsophalangeal joint is degenerated, destructed, or dislocated, or there is interdigital neuroma at the sides of the deformed toe, or the deformity is caused by bony deformities of the metatarsal head or the proximal phalanx.
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Affiliation(s)
- Tun Hing Lui
- Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.Department of Orthopaedics and TraumatologyNorth District Hospital9 Po Kin RoadSheung Shui, NTHong Kong SARChina
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Fernandes EDA, Mann TS, Puchnick A, Tertulino FDF, Cannato CT, Nery C, Fernandes ADRC. Can ultrasound of plantar plate have normal appearance with a positive drawer test? Eur J Radiol 2014; 84:443-449. [PMID: 25547326 DOI: 10.1016/j.ejrad.2014.11.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 11/28/2014] [Accepted: 11/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The aims of this study were (1) to evaluate the reliability of ultrasound (US) examination in the identification and measurement of the metatarsophalangeal plantar plate (MTP-PP) in asymptomatic subjects and (2) to establish the correlation of US findings with those of physical examination and magnetic resonance imaging (MRI), once it is an important tool in the evaluation of the instability syndrome of the second and third rays. MATERIALS AND METHODS US examinations of the second and third MTP-PPs were performed in eight asymptomatic volunteers, totaling 32 MTP joints, by three examiners with different levels of experience in musculoskeletal US. Plantar plate dimensions, integrity and echogenicity, the presence of ruptures, and confidence level in terms of structure identification were determined using conventional US. Vascular flow was assessed using power Doppler. US data were correlated with data from physical examination and MRI. RESULTS MTP-PPs were ultrasonographically identified in 100% of cases, always showing homogeneous hyperechoic features and no detectable vascular flow on power Doppler, with 100% certainty in identification for all examiners. There was excellent US inter-observer agreement for longitudinal measures of second and third toe MTP-PPs and for transverse measures of the second toe MTP-PP. The MTP drawer test was positive for grade 1 MTP instability in 34.4% of joints with normal US results. Transverse MTP-PP measures were significantly higher in individuals with positive MTP drawer test. US measures and characteristics of MPT-PPs were positively correlated with those of MRI. CONCLUSIONS US is efficient in identifying and measuring MPT-PPs and may complement physical examination. A grade 1 positive MTP drawer test may be found in asymptomatic individuals with normal MPT-PPs, as assessed by imaging.
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Affiliation(s)
- Eloy de Avila Fernandes
- Affiliated Professor, Department of Diagnostic Imaging, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, Brazil
| | - Tania Szejnfeld Mann
- Medical Assistant of Medicine and Surgery of the Foot and Ankle Group, Department of Orthopedics and Traumatology, EPM-Unifesp, São Paulo, Brazil
| | - Andrea Puchnick
- Professor and Coordinator of Educational and Research Support, Department of Diagnostic Imaging, EPM-Unifesp, São Paulo, Brazil.
| | | | | | - Caio Nery
- Associate Professor, Department of Orthopedics and Traumatology, EPM-Unifesp, São Paulo, Brazil
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