Plantar Plate Repair Using a Direct Plantar Approach: An Outcomes Analysis

Lesser Metatarsophalangeal Joint Instability: Open Surgery Treatment Alternatives

Lesser metatarsophalangeal joint plantar plate degeneration and tear typically presents as an attritional pattern of capsuloligamentous deficiency in middle-aged patients or sports-related chronic injuries. Knowledge of the anatomy, pathophysiological basis, common patterns, grading and classification of these injuries, and indications for surgery will aid imaging interpretation in the preoperative setting. The acuity and extent of injury, tissue quality, and functional requirements of the patient influence clinical decision-making with respect to surgical management. This article provides an overview of the open surgical treatment alternatives and the most used techniques to solve instability of the metatarsophalangeal joints.

Lesser Metatarsophalangeal Joint Instability: Minimally Invasive Surgery Treatment Alternatives

Lesser metatarsophalangeal (MTP) joints instability is usually produced by the rupture of the plantar plate. The treatment algorithm may change in patients with advanced stages of the plantar plate rupture, and surgical treatment is proposed to avoid MTP dislocation. Palliative surgery with minimally invasive surgery (MIS) can offer a less aggressive approach and enable excellent clinical correction and a good function. The authors proposed an algorithm for MIS treatment of MTP instability based on a combination of different osseous and/or soft tissues surgical procedures that the authors will combine differently depending on the evolution degree.

Is It Necessary to Repair the Plantar Plate in the Management of Metatarsophalangeal Joint Instability?

Lesser metatarsophalangeal joint (MTPJ) instability is a common cause of metatarsalgia and is associated with plantar plate pathology. The instability is often due to chronic attenuation and attritional changes of the plantar plate and collateral ligaments, leading to eventual rupture. The plantar plate and collateral ligaments serve as the primary stabilizers of the MTPJ, and rupture or attenuation of these ligaments leads to instability. Surgical intervention is often necessary for plantar plate tears, with various approaches and techniques available.

Surgical Treatment of Metatarsalgia and Severe Instability of Lesser Metatarsophalangeal Joints

The main object of this prospective cohort study was to compare surgical treatment options for primary metatarsalgia and the severe instability of lesser metatarsophalangeal joints. The outcomes of triple Weil osteotomy combined with direct plantar plate repair and triple Weil osteotomy, performed with proximal interphalangeal joint arthrodesis, are analyzed and compared. One hundred thirteen patients (117 feet) were enrolled in the study. They were split into 2 groups. In the first group, undergoing Weil osteotomy, combined with the plantar plate repair, good results, including complete pain reduction, elimination of hyperkeratosis, and American Orthopedic Foot and Ankle Society Score improvement, were achieved in 84.7% of the cases. The second group, where the combination of Weil osteotomy and proximal interphalangeal joint K-wire arthrodesis was used, demonstrated good results in 52.4% of the cases. Weil osteotomy, combined with the plantar plate repair, achieves better results in comparison to osteotomy, performed with the interphalangeal joint arthrodesis.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications

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.

Operative Management: Plantar Plate

The plantar plate is a vital structure for maintaining lesser metatarsophalangeal joint (MPJ) stability. Its primary role is to provide static stabilization of the MPJs, working in conjunction with the long and short flexor and extensor tendons. When insufficiency or attenuation of the plantar plate occurs, a sagittal plane deformity will slowly develop, eventually leading to a "crossover toe" transverse plane deformity. Coughlin coined this descriptive term to describe the later stages of deformity, most commonly affecting the second MPJ. Shortly after, Yu and Judge elaborated on this condition describing it as "predislocation syndrome," an inflammatory condition affecting the plantar plate causing pain and instability, which could progress to subluxation at the MPJ.

Plantar Plate Repair for Metatarsophalangeal Joint Instability of the Lesser Toes

The plantar plate is a known stabilizer of the lesser toe metatarsophalangeal (MTP) joint. MTP instability is a known common cause of metatarsalgia, most commonly in the second toe. In the last decade, clinical staging and anatomic grading mechanisms have been published to guide the surgeons on the treatment of MTP instability; this has also led to an understanding of how plantar plate tears relate to MTP joint instability. Direct surgical repair of the plantar plate has been described, short-term outcomes have been published, and the results are not perfect, but promising with respect to patient satisfaction and pain relief.

A versatile method for dorsal-approach plantar plate repair using standard operative instruments

Background

The plantar plate is an important static stabilizer of the lesser metatarsophalangeal joints, and disruptions of the plantar plate can lead to significant instability and lesser toe deformities. In recent years, direct plantar plate repair has been proposed. Although direct repair via a dorsal approach is attractive, a torn plantar plate is small and difficult to access using regular instruments in a restricted operative field.

Methods

In this report, a unique method for plantar plate repairs was used to repair various configurations of plantar plate tears with standard operative instruments that are available in most operating rooms.

Results

Using this method, 10 patients underwent plantar plate repairs, and the mean follow-up period was 24 (range, 14–38) months. The mean visual analog scale score for pain preoperatively was 4.1 (range, 0–6) and decreased to 0.6 (range, 0–3) at last follow-up. Postoperatively, the mean visual analog scale score for satisfaction was 9.6 (range, 8–10) and the mean American Orthopedic Foot and Ankle Society forefoot score was 88.8 (range, 75–100).

Conclusions

Our study proposes an inexpensive and versatile method for plantar plate repair via a dorsal approach that uses standard operative instruments.

Trial registration

ClinicalTrials.gov, NCT04949685. July 2, 2021 - Retrospectively registered,

Level of clinical evidence

4

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04951-w.

Treatment of Lesser Metatarsophalangeal Joint Instability With Plantar Plate Repair: A Systematic Review and Meta-Analysis

Recognition of metatarsophalangeal joint plantar plate injuries has improved over time as the condition has become more widely understood and identified. With the diagnosis of a plantar plate injury as a subset of metatarsalgia becoming more common place, there are multiple surgical options that have been utilized to address the condition. Direct repair of the plantar plate has emerged as the treatment of choice for foot surgeons with a tendency to favor a direct dorsal approach for the repair. We performed a systematic review and meta-analysis using preferred reporting items for systematic reviews and meta-analysis guidelines, to determine the magnitude of change that can be expected in visual analog scale pain and American Orthopedic Foot and Ankle Society scores postoperatively. A total of 12 studies involving 537 plantar plate tears were included who underwent direct repair of the plantar plate through either a dorsal (10 articles) or plantar approach (2 articles). Summary estimates were calculated which revealed improvement in visual analog scale pain (pooled mean change of -5.01 [95%CI -5.36, -4.66] pre-to postoperative) and improvement in American Orthopedic Foot and Ankle Society scores (pooled postoperative mean improvement 40.44 [95%CI 37.90, 42.97]) of patients within the included studies. Random effects models were used for summary estimates. I² statistic was used to assess for heterogeneity. We concluded there is a predictable level of improvement in pain and function in patients undergoing a direct dorsal approach plantar plate repair with follow-up out to 2 years.

Comparison of Combination Weil Metatarsal Osteotomy and Direct Plantar Plate Repair Versus Weil Metatarsal Osteotomy Alone for Forefoot Metatarsalgia

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.

One-Year Outcome Study of Anatomic Reconstruction of Lesser Metatarsophalangeal Joints

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.

Outcomes Study of an Innovative Method of Direct Repair of Metatarsophalangeal Joint Instability With an Angiocatheter Needle

Plantar plate tears are a common cause of forefoot pain and digital deformity. Repair of the plantar plate has been described from both a dorsal and plantar approach, each with its own benefits and drawbacks. Many of the approaches use costly devices. Our innovative repair method uses low-cost materials available in most operating room settings. We undertook a retrospective case series study to evaluate outcomes in patients who had undergone plantar plate repair with our method of repair. A review was performed to identify patients with plantar plate disruptions treated with this approach by a single surgeon. Clinical position and patient satisfaction of the involved joints were evaluated. Six patients (9 joints) underwent plantar plate repair using this innovative method and were evaluated at a median follow-up time of 19 (range 19 to 39) months. The mean visual analog scale pain score at final follow up was 0.8 ± 2.0. The median sagittal plane position of the toe was 2 mm (range 0 to 6) from the plantar skin of the digit to the ground. Five of the 6 patients (83%) stated that they would have the procedure again. We were able to obtain satisfactory outcomes with good alignment by repairing the plantar plate with this innovative method. Our data suggest that the described method of plantar plate repair can be used as an effective way to treat metatarsal phalangeal joint instability.

Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40 Years of Development in Forefoot Surgery

BACKGROUND

Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability.

MATERIALS AND METHODS

A review of the literature was conducted using the PubMed search engine, with key terms including, "mallet toe," "hammertoe," "neuroma," "metatarsophalangeal joint instability," "plantar plate," and "forefoot surgery." Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years.

CONCLUSIONS

There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems.

LEVEL OF EVIDENCE

Level V, meta-synthesis.

An Innovative Method for Plantar Plate Repair: Technique Guide and Case Report

Disruption of the plantar plate is a common cause of forefoot pain, metatarsalgia, and metatarsophalangeal joint malalignment. Although surgical repair of the plantar plate has improved, there has been no consensus on the clinical superiority of any single technique, or combination of techniques, described in the literature to date. In this publication, we report a case of plantar plate injury treated with an innovative new technique with 20-month follow-up.

Lesser Metatarsophalangeal Joint Pathology Addressed With Arthrodesis: A Case Series

Lesser metatarsophalangeal joint pathology is a common condition facing the foot and ankle surgeon, often beginning as a mild subluxation of the toe and progressing to a full dislocation of the metatarsophalangeal joint. In severe or recalcitrant deformities, traditional conservative and surgical methods can fail to resolve the issue. We report on 4 patients with 5 severely dislocated lesser metatarsophalangeal joints with varied etiologies and comorbidities who underwent arthrodesis of these joints using screw and plate fixation. All patients achieved radiographic and clinical signs of union at an average of 16.4 weeks.

Patient-Perceived Recovery and Outcomes After Silastic Implant Arthroplasty

In some chronic musculoskeletal conditions, patients with persistent pain and disability have still achieved recovery through behavioral adaptations (readjustment) or cognitive coping (redefinition). Although the pendulum shift from physician-reported clinical indicators to patient-reported outcomes measures (PROMs) has recently focused on quantifying residual pain and disability to determine recovery (resolution), whether patients are capable of coping with any ongoing deficits and achieving other forms of recovery has not been considered. We performed a retrospective case series to assess patient-perceived recovery and outcomes after silastic implant arthroplasty for hallux rigidus. From July 2006 to July 2016, 28 patients at a single institution were enrolled. PROMs were prospectively obtained and compared between patients considering themselves recovered without or with residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure rates were recorded. Overall, 50.0% perceived themselves as recovered-resolved, 43% as recovered-not resolved, and 7% as not recovered. The mean modified Foot Function Index was 17.26, the verbal analog scale for pain score was 2.03, and implant survivorship 100% at a median of 67 (interquartile range 28.4 to 103.5) months. Although only 50% of patients reported complete symptom resolution, satisfaction was high, and most perceived themselves as recovered, suggesting recovery in hallux rigidus might not always be predicated by the complete resolution of all symptomatology. Although PROMs relying on pain inference and functional disability will continue to be utilized with increasing frequency, foot and ankle surgeons should be cognizant of their inherent limitations in assessing other forms of recovery.

Lesser Metatarsophalangeal Joint Instability: Advancements in Plantar Plate Reconstruction

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.