Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears

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.

Plantar Pressure Distribution Before and After Surgery for Lesser Metatarsophalangeal Joint Dislocation With Hallux Valgus

Hallux valgus surgery and open reduction of the lesser metatarsophalangeal joints with metatarsal shortening osteotomy help treat severe hallux valgus concomitant with the lesser metatarsophalangeal joint dislocation; however, pre- and postoperative plantar pressure distribution and its effect on the foot remain unclear. The pre- and postoperative groups comprised 16 patients with moderate-to-severe symptomatic hallux valgus with lesser metatarsophalangeal joint dislocation. All feet underwent open reduction and collateral ligament reconstruction of the second metatarsophalangeal joint and proximal metatarsal shortening osteotomy under the second metatarsal with proximal osteotomy of the first metatarsal. Twenty healthy participants (20 feet) were included in the control group. The plantar pressure distribution was determined by measuring the peak pressure, maximum force, contact area, and force-time integral for 12 regions. Under the second toe, all measurements in the preoperative group were significantly lower than those of the control group. The peak pressure, maximum force, and contact area of the postoperative group were significantly greater than those of the preoperative group. However, no differences were observed between the postoperative and control groups. Under the second metatarsal head, the peak pressure of the preoperative group was significantly higher than that of the control group. The peak pressure of the postoperative group was significantly lower than that of the preoperative group and showed no differences from the control group. Open reduction and collateral ligament reconstruction of the lesser metatarsophalangeal joints and proximal metatarsal shortening osteotomy with proximal osteotomy of the first metatarsal in hallux valgus with lesser metatarsophalangeal joints dislocation cases may improve operative outcomes, including favorable foot function.

Republication of "Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults: Operative Technique"

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.

Claw Toe With Dislocated Second Metatarsophalangeal Joint: Treated by Plantar Plate Tenodesis and Release of Collateral Ligaments

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.

Anatomy: Plantar Plate

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.

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.

Degenerative injuries of the metatarsophalangeal plantar plate on magnetic resonance imaging: a new perspective

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.

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.

Transverse laxity of the forefoot

BACKGROUND

Splay of the forefoot reflects the loss of tension in the soft tissues and indicates failure of the biomechanics of the tie-bar system. By identifying and quantifying the soft tissue structures involved in the destruction of forefoot stability we could increase the understanding of forefoot pathologies.

METHODS

We investigated the transverse forefoot laxity on healthy feet, feet with forefoot pathology and cadaveric feet undergoing sequential dissection.

RESULTS

Statistical difference in transverse laxity was seen between healthy feet (n = 160) and feet with symptomatic forefoot pathology requiring surgery (n = 29). Presence of lesser ray pathology is associated with increased transverse laxity. For the dissected cadaveric feet (n = 9) sequential sectioning the plantar plate causes a progressive evolution of transverse laxity. The repair of plantar plates greatly improves transverse stability.

CONCLUSIONS

Forefoot pathology causes increased transverse laxity. In case of a major transverse laxity of the forefoot a plantar plate lesion should be suspected.

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.

Flexor tenodesis procedure in the treatment of lesser toe deformities

In this technical report study, we describe the use of a flexor tenodesis procedure in the treatment of lesser toe deformities (LTD). Using a specific implant, both the flexor digitorum longus and brevis tendons are attached to the plantar aspect of the proximal phalanx, allowing dynamic correction of flexible deformities of metatarsophalangeal and interphalangeal joints. Good clinical results and absence of complications were observed in a series of 3 patients, with considerable correction of the LTD, and absence of substantial residual floating toe or metatarsophalangeal joint stiffness. LEVEL OF EVIDENCE: V - Technical Report/Case Report/Expert Opinion.

Dislocations of the second and third metatarsophalangeal joints after local steroid injection in patients with refractory metatarsalgia: A case report

Local steroid injections are frequently administered to patients with refractory metatarsalgia. No reports have described dislocation of the second and third metatarsophalangeal joints after local steroid injections. A 46-year-old woman had suffered from metatarsalgia and received multiple local steroid injections for over 2 years. The second and third metatarsophalangeal joints revealed dorsal dislocations on the lateral radiograph. Therefore, collateral ligament reconstruction of the metatarsophalangeal joints was performed. Intraoperative findings suggested that the rupture of the plantar plate may have caused dorsal dislocation of both joints. Thus, unnecessary multiple steroid injections around the lesser metatarsophalangeal joint should be avoided.

Ultrasound findings of plantar plate tears of the lesser metatarsophalangeal joints

Lesser metatarsophalangeal (MTP) joint plantar plate tears are a common and increasingly recognised cause of metatarsalgia, MTP joint instability and forefoot deformity. Increased interest in early accurate diagnosis of plantar plate tears follows recent surgical innovations allowing direct plantar plate repair. The purpose of this review is to describe the ultrasound features of normal lesser MTP joint plantar plates and to characterise and illustrate the direct and indirect ultrasound findings of plantar plate tears. Lesser MTP joint plantar plate tears are most commonly located at the 2nd MTP joint, involving the lateral distal plantar plate insertion with variable propagation medially and proximally. The most common ultrasound appearance of a plantar plate tear is a discrete partial or full thickness hypoechoic defect in the plate substance. Flattening and attenuation or non-visualisation of the plantar plate represent more extensive tears. Dynamic imaging with toe dorsiflexion improves visualisation of tears and augments MTP joint subluxation. A common indirect finding is pericapsular fibrosis along the MTP joint capsule adjacent to a plantar plate tear, which requires differentiation from Morton's neuroma, and key distinguishing features at ultrasound are described. Other indirect findings include the cartilage interface sign, flexor tendon subluxation onto the metatarsal head or medial to the midline, flexor tenosynovitis, proximal phalangeal enthesophytes or avulsion and MTP joint synovitis. Ultrasound offers several advantages over MR imaging but requires a meticulous ultrasound examination, and optimisation of scanning technique is described.

Correction of Severe Crossover Toe Deformity By Plantar Plate Tenodesis, Arthroscopic Release of Lumbrical and Plication of Lateral Capsuloligamentous Complex

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.

Presence of Neovascularization in Torn Plantar Plates of the Lesser Metatarsophalangeal Joints

BACKGROUND

Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears, yet it remains unknown whether the plantar plate has the biological capacity to heal these repairs. Therefore, a better understanding of the plantar plate vasculature in response to injury may provide further insight into the potential for healing after anatomic plantar plate repair. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano-computed tomographic (CT) imaging methods.

METHODS

Seven fresh-frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging, the second through fourth toe metatarsophalangeal joints of 7 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and 11 toes remained. The plantar plate microvasculature for these 11 toes was analyzed, and calculation of vascular density along the plantar plate was performed. Using analysis of variance (ANOVA), this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal. A power analysis was performed, determining that 11 experimental toes and 35 control toes would be adequate to provide 80% power with an alpha of 0.05.

RESULTS

Significantly greater vascular density (vascular volume/tissue volume) was found along the entire length of the plantar plate for the torn plantar plates compared to intact plantar plates (ANOVA, P < .001). For the first quartile of length (proximal to distal), the vascular density for the torn plantar plates was 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it was 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it was 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile was 0.600 (SD 0.183) vs 0.319 (SD 0.082).

CONCLUSION

Torn plantar plates showed increased vascular density throughout the length of the plantar plate with an increase in density most notable in the region at or just proximal to the attachment to the proximal phalanx. Our analysis revealed that torn plantar plates exhibit neovascularization around the site of a plantar plate tear that does not exist in normal plantar plates.

CLINICAL RELEVANCE

The clinical significance of the increased vascularity of torn plantar plates is unknown at this time. However, the increase in vasculature may suggest that the plantar plate is a structure that is attempting to heal.

Correction of Crossover Toe Deformity by Plantar Plate Tenodesis and Arthroscopic Release of Lumbrical

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.

[Reconstruction of the plantar plate of the metatarsophalangeal joint using a dorsal transarticular approach]

OBJECTIVE

Reconstruction of the plantar plate to stabilize a dislocated or instable lesser metatarsophalangeal joint using a dorsal approach in combination with a Weil osteotomy.

INDICATIONS

Dislocated or instable lesser metatarsophalangeal joint with rupture of the plantar plate.

CONTRAINDICATIONS

Infection, circulatory disorders, symptomatic degenerative arthritis lesser metatarsophalangeal joint.

SURGICAL TECHNIQUE

Weil osteotomy using a dorsal approach. Temporary dislocation of the metatarsal head as proximal as possible. Inspection of the plantar plate. Assessment and classification of type and extent of the rupture. Suturing of the plantar plate to the plantar bases of the proximal phalanx. Fixation of the Weil osteotomy with correction of the metatarsal alignment.

POSTOPERATIVE MANAGEMENT

Weight bearing in a postoperative shoe as tolerated. X‑ray control 6 weeks postoperative. Full weight bearing in a conventional shoe after bony consolidation.

RESULTS

A total of 23 surgical reconstructions of the plantar plate (complete plantar plate repair) between 12/2012 and 10/2014 were performed. The mean follow-up was 18.6 (12-30) months. Five secondary dislocations were observed: one deep postoperative infection, one early dislocation of unknown cause, one secondary dislocation caused by severe hallux valgus recurrence, one massive foreign body reaction to the non-resorbable sutures, and one late secondary dislocation occurred between 6 weeks and 1 year postoperative. Normal function of the reconstructed joint was achieved in 13 of the 23 reconstructions (57%). A reduced toe purchase was observed in 3 reconstructions (13%). A floating-toe resulted after 7 reconstructions (30%).

Distal Metatarsal Segmental Shortening for the Treatment of Chronic Metatarsophalangeal Dislocation of Lesser Toes

BACKGROUND

This retrospective study aimed to describe the techniques and results of distal metatarsal segmental shortening (DMSS) for the treatment of chronic irreducible metatarsophalangeal (MTP) dislocation of lesser toes.

METHODS

We retrospectively reviewed patients who underwent DMSS for chronic dislocation of MTP joints of lesser toes between January 2010 and December 2017 with follow-up of at least 24 months. Demographic data, radiographic measurements, functional outcomes, and complications were analyzed. Furthermore, the results of patients with short segment of shortening (group I, <10 mm) were compared to those with long segment of shortening (group II, ≥10 mm). A total of 43 MTP joints of 30 patients with an average age of 70.4 years were included.

RESULTS

Union was observed in 42 metatarsals (97.7%). Mean American Orthopaedic Foot & Ankle Society scale scores improved significantly from 42.2 (range, 15-65) preoperatively to 79.1 (range, 52-90) (P < .001). Mean visual analog scale pain score improved significantly from 5.0 (range, 1-9) preoperatively to 1.8 (range, 0-6) (P < .001). Complications included 1 nonunion, 1 osteonecrosis, 3 metatarsal angulation, 4 recurrent instability, 4 symptomatic osteoarthritis, 3 transfer metatarsalgia, and 1 floating toe. Group I included 23 MTP joints and group II included 20 MTP joints. There was no significant difference in clinical outcomes and complications between the 2 groups.

CONCLUSION

DMSS was a reliable procedure for the treatment of chronic irreducible dislocated MTP joint of lesser toes. It provided satisfactory surgical outcomes and a low rate of postoperative complications, regardless of length of metatarsal shortening.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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.

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.

Lesser Metatarsophalangeal Instability: Diagnosis and Conservative Management of a Common Cause of Metatarsalgia

CONTEXT

Lesser metatarsophalangeal (MTP) instability is a common condition that can become debilitating and require surgery.

EVIDENCE ACQUISITION

An extensive literature review was performed through MEDLINE and Google Scholar for publications relating to the etiology, diagnosis, and treatment of lesser MTP instability using the keywords metatarsophalangeal instability, athlete, forefoot pain, and metatarsalgia from database inception to 2019.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Lesser MTP instability is a common condition, especially in the active and aging populations. It is frequently misdiagnosed, causing delays in treatment that allow for progressive pain and deformity, which prevents an active lifestyle. Fortunately, MTP instability can be diagnosed easily with the drawer test. Magnetic resonance imaging is helpful when still in doubt. Conservative treatment entails joint immobilization and gradual return to play with taping and offloading metatarsal pads.

CONCLUSION

Lesser MTP instability is a common diagnosis. Its early detection and conservative treatment can help the patient regain their previous level of activity and avoid surgery.

The use of polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric study

BACKGROUND

The use of synthetic polyvinyl alcohol hydrogel (PVAH) implants for treatment of lesser toe metatarsophalangeal joint (MTPJ) arthritis is promising and currently limited by the size of implants available. The primary objective of this cadaveric study was to investigate the maximum drilling size and largest PVAH implant dimension that could be safely introduced while still preserving an intact bone rim of the lesser metatarsal heads.

METHODS

Height and width of all lesser metatarsals were measured on CT and during anatomic dissection. Sequential reaming of the second to fourth metatarsals was performed. Maximum reaming size, largest implant inserted, and failure of the metatarsal head were recorded. Metatarsal head sizes were compared and a multiple regression analysis evaluated measurements that influenced maximum drilling and implant size.

RESULTS

CT and anatomical measurements demonstrated significant correlation (ICC range, 0.-0.85). Mean values for height and width of the metatarsal heads were respectively: second (14.9 mm and 9.9 mm), third (14.8 mm and 8.8 mm), fourth (14.0 mm and 8.7 mm) and fifth (12.3 mm and 9.3 mm). All the second, third and fourth metatarsal heads could be safely drilled up to 7.5 mm, preserving an intact bone rim. At 80% of the time, the heads could be safely drilled up to 8.0 mm. Height of the metatarsal heads was the only factor to significantly influence the size of maximum reaming and implant introduced. In respectively 20%, 40% and 50% of the second, third, and fourth metatarsal heads, neither 8 mm nor 10 mm PVAH implants could be used.

CONCLUSIONS

Our cadaveric study found that the even though the majority of the lesser metatarsal heads could be safely drilled up to 8 mm, the smallest PVAH implant size currently available in most countries (8 mm) could be inserted in most of the second, but only in about half of the third and fourth metatarsal heads. The remaining bone rim around inserted implants was considerably thin, usually measuring less than 1 mm. In order to optimize the use PVAH in lesser metatarsal heads, smaller implant options are needed.

Metatarsalgia: Assessment Algorithm and Decision Making

Historically, metatarsalgia was approached as a forefoot condition, most often associated with hallux valgus. Consequently, surgical treatments were limited to that anatomic zone, disregarding more proximal structures. In order to assess this entity properly, it is necessary to consider anatomic and biomechanical factors, as well as general and local conditions of the affected patients. A thorough understanding of the multiple potential causal factors is essential to ensure selection of the optimal treatment.

Microvasculature of the Plantar Plate Using Nano-Computed Tomography

BACKGROUND:

Lesser toe plantar plate attenuation or disruption is being increasingly implicated in a variety of common clinical conditions. A multitude of surgical techniques and devices have been recently developed to facilitate surgical repair of the plantar plate. However, the microvascular anatomy, and therefore the healing potential in large part, has not been defined. We investigated the microvasculature of the plantar plate by employing a novel technique involving microvascular perfusion and nano-computed tomography (nano-CT) imaging.

METHODS:

Twelve human adult cadaveric lower extremities were amputated distal to the knee. The anterior and posterior tibial arteries were perfused with a barium solution. The soft tissues of each foot were then counterstained with phosphomolybdic acid (PMA). The second through fourth toe metatarsophalangeal (MTP) joints of 12 feet were imaged with nano-CT at 14-micron resolution. Images were then reconstructed for analysis of the plantar plate microvasculature and calculation of the vascular density along the length of the plantar plate.

RESULTS:

A microvascular network extends from the surrounding soft tissues at the attachments of the plantar plate on both the metatarsal and proximal phalanx. The midsubstance of the plantar plate appears to be relatively hypovascular. Analysis of the vascular density along the length of the plantar plate demonstrated a consistent trend with increased vascular density at approximately the proximal 29% and distal 22% of the plantar plate.

CONCLUSION:

There is a vascular network extending from the surrounding soft tissues into the proximal and distal attachments of the plantar plate.

CLINICAL RELEVANCE:

The hypovascular midportion of the plantar plate may play an important role in the underlying pathoanatomy and pathophysiology of this area. These findings may have significant clinical implications for the reparative potential of this region and the surgical procedures currently described to accomplish anatomic plantar plate repair.

Technique and Tips for Multiplanar Correction of Plantar Plate Repairs in Lesser Metatarsophalangeal Joints

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.

Plantar Plate Injury and Angular Toe Deformity

Lesser toe plantar plate injuries at the metatarsophalangeal (MTP) joint are a common source of metatarsalgia. The second MTP joint is the most commonly affected digit. The fibrocartilaginous plantar plate is the most important static stabilizer of the MTP joint; high loading with weight bearing can lead to attritional plantar plate injuries. Chronic pain with weight bearing is the common presentation of lesser toe instability. Untreated plantar plate instability can lead to hammer toe and mallet toe deformities. Combined Weil osteotomy and plantar plate repair yields favorable pain relief and angular deformity correction for patients who fail conservative treatment.

A Systematic Review of Plantar Plate Repair in the Management of Lesser Metatarsophalangeal Joint Instability

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.

Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults

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.

Biomechanical Evaluation of Suture Configurations in Lesser Toe Plantar Plate Repairs

BACKGROUND

Lesser toe metatarsal-phalangeal (MTP) joint instability can be a major source of pain and dysfunction. Instability occurs when there is incompetence of the plantar plate and/or collateral ligaments. Newer operative treatments focus on performing anatomic repairs of the plantar plate. The goal of this study was to compare the biomechanical properties of 3 suture configurations that may be used for plantar plate repairs.

METHODS

Biomechanical analysis of 27 lesser toe plantar plates from fresh frozen human cadavers was completed. The plantar plate was detached from the proximal phalanx, and suture was placed in the distal plantar plate in a horizontal mattress, luggage-tag, or Mason-Allen suture configuration. Cyclic loading followed by load-to-failure testing was performed.

RESULTS

There was a significant difference in peak load-to-failure force between constructs (mattress: 115.53 ± 15.95 N; luggage-tag 102.42 ± 19.33 N; Mason-Allen: 89.96 ± 15.78 N; P = .015). Post hoc analysis demonstrated that the mattress configuration had significantly higher load-to-failure force compared with the Mason-Allen configuration ( P = .004). There were no significant differences between the mattress and the luggage-tag configurations or the luggage-tag and the Mason-Allen configurations. There were no differences in construct stiffness, axial displacement at the time of failure, or number of cycles required to produce 2 mm of displacement.

CONCLUSION

The mattress configuration demonstrated better peak load-to-failure force compared with the Mason-Allen configuration but was not statistically different from the luggage-tag configuration. Although not significant, the mattress configuration trended toward higher load-to-failure force compared with the luggage-tag.

CLINICAL RELEVANCE

The horizontal mattress stitch may be the biomechanically superior configuration in plantar plate repairs.

Association Between Second Metatarsal Length and Forefoot Loading Under the Second Metatarsophalangeal Joint

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.

Lesser Metatarsophalangeal Joint Instability: Treatment with Tendon Transfers

Complex digital deformities and metatarsophalangeal joint instability encompass a wide range of pathology, and we must identify the different degrees of ligamentous disruption. It is important to address a combination of procedures to treat gross deformities of the lesser toes. Surgical treatment should be individualized and requires a sequential process for adequate reduction and deformity correction. There is no gold standard procedure for every deformity. Although residual stiffness can result from tendon transfer, overall patient satisfaction levels remain high when it is performed under the proper indications and concomitantly with other procedures to gain full correction of these challenging deformities.

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.

Managing Complications of Lesser Toe and Metatarsophalangeal Joint Surgery

The anatomy of the lesser toes is highly complicated and not yet well understood. The high propensity of the metatarsophalangeal joint to develop hyperextension deformity should be recognized. Surgeons should provide each patient with a realistic expectation for lesser toe reconstructive procedures. A successful surgical result requires a well-planned procedure, accurate execution using proper techniques, and meticulous postoperative care. When complications occur, surgeons should identify culprits so that proper treatment strategies can be successfully executed. This article discusses a wide array of tactics to manage common complications in lesser toe surgery.

Nonoperative Treatment of a Lesser Toe Plantar Plate Tear with Serial MRI Follow-up: A Case Report

With the current data concentrating on different operative treatment options for plantar plate tears, few data can be found on possible nonoperative treatment strategies for this entity and the specifics of such treatment. In the present case report, the successful nonoperative treatment of a patient with a rupture of the plantar plate in a lesser toe metatarsophalangeal joint is presented. The patient was followed up using repeat clinical examinations and high-resolution magnetic resonance imaging scans for 1 year after the imitation of therapy to provide information on the different stages of the healing process.

Association of Abnormal Metatarsal Parabola With Second Metatarsophalangeal Joint Plantar Plate Pathology

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.

Modified double plantar plate tenodesis

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.

Plantar Plate Repair for Lesser Metatarsophalangeal Joint Instability

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.

Metatarsalgia

The causes of metatarsalgia are classified as primary, secondary, and iatrogenic. Anatomical and biomechanical considerations separate "static" from "propulsive" forms of metatarsalgia. The physical examination should be combined with an assessment of weight-bearing radiographs and, if needed, of ultrasound or magnetic resonance imaging scans. The first-line treatment is conservative (stretching exercises, footwear modification, insoles, and lesion debridement). Soft-tissue surgical procedures (gastrocnemius muscle recession, tendon transfer, and plantar plate repair) should also be considered. Among the various types of metatarsal osteotomy, the Weil procedure is reliable. Percutaneous methods are being developed but require evaluation. A treatment algorithm can be developed based on whether the hallux is normal or abnormal. Metatarsalgia due to inflammatory disease requires a specific treatment strategy.

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

Direct plantar plate repair using a plantar approach has been described previously, but with few reports of the outcomes or clinical results. The purpose of the present study was to determine the outcomes of this technique. We performed a retrospective analysis of patients who had undergone direct plantar plate repair with or without concomitant Weil osteotomy and a prospective patient-reported subjective outcomes analysis. Ultimately, 131 patients (144 toes) were included, and the response rate for the mailed surveys was 53.5% (77 of 144 toes). The clinical outcomes reported a well-aligned toe in 87.1% of cases, with a recurrence rate of 7.6% (11 of 144) and a revision rate of 2.8% (4 of 144). Statistically significant improvement in the overall modified Foot Function Index (p < .001) and subscale scores for pain (p < .001), disability (p < .001), and activity limitation (p = .001) were noted postoperatively compared with the preoperative data. The median postoperative visual analog pain scale level reported at survey completion was 2.0 (range 0.0 to 10.0; mean ± standard deviation 2.3 ± 2.6). Despite the modified Foot Function Index scores, the patient satisfaction questionnaire data reported mixed results. Our modified Foot Function Index results demonstrated that this approach provides excellent postoperative pain relief, improvement of associated disability, and improvement in activity limitations. The importance of managing patient expectations is acknowledged secondary to the discrepancy with the patient satisfaction data and the modified Foot Function Index results. Further prospective study is warranted to compare this technique with alternate dorsal approaches for plantar plate repair with and without associated commercially available suture passing systems.

Correction of Crossover Toe Deformity by Arthroscopically Assisted Plantar Plate Tenodesis

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.

Anatomic Repair of Plantar Plate With Flexor Tendon Sheath Reinforcement: Case Series

Plantar plate pathology has gained considerable attention in recent time, and with this increased awareness multiple treatments have been proposed. There have been no comparison studies between these treatments. The authors feel a direct approach for anatomic repair allows for plantar plate repair and tightening to desired tension, without any plantar prominences or potentially irritating hardware. In addition if the plantar plate is found to be attenuated or there is a lack of residual tissue, the described imbrication utilizing the flexor digitorum longus sheath, which is not possible with hardware or newest instrumentation, allows for a robust repair. The presented case series provides results from consecutive patients treated with proposed concurrent plantar and dorsal incisions, providing proof of concept and viability of novel technique.

LEVELS OF EVIDENCE

Level V: Case series.

Percutaneous Surgery for Metatarsalgia and the Lesser Toes

The traditional open surgical options for the treatment of metatarsalgia and lesser toe deformities are limited and often result in unintentional stiffness. The use of percutaneous techniques for the treatment of metatarsalgia and lesser toe deformities allows a more versatile and tailor-made approach to the individual deformities. As with all percutaneous techniques, it is vital the surgeon engage in cadaveric training from surgeons experienced in these techniques before introducing them into his/her clinical practice.

Evaluation of lesser metatarsophalangeal joint plantar plate tears with contrast-enhanced and fat-suppressed MRI

OBJECTIVE

To present findings of plantar plate (PP) lesions from MRI with administration of gadolinium and to differentiate PP lesions from others causes of metatarsalgia.

MATERIALS AND METHODS

Two musculoskeletal radiologists reviewed 249 contrast-enhanced forefoot MRI scans from patients with metatarsalgia between June 2012 and June 2013. Evaluations focused on hyper-vascularized/fibrous tissue and other findings associated with PP tears.

RESULTS

Fifty-nine patients had PP tears, 59 % were female. Most of these patients, 48/59 (81.4 %), had a single metatarsophalangeal (MTP) PP lesion in one foot, although 7/59 patients had one lesion in each foot, 3/59 (5.1 %) had two in one foot, and 1/59 (1.7 %) had three lesions in one foot. The second MTP joint was the most common location for PP tears (n = 56), followed by the third (n = 12) and fourth (n = 3) MTP joints. Lateral (n = 33) and full thickness (n = 28) PP lesions were the most frequent, and central (n = 3) and lateral/central (n = 7) tears were less prevalent. Fifty (70.5 %) PP lesions showed pericapsular fibrosis in pre-contrast sequences, and 21 (29.5 %) were visible only after administration of gadolinium. All PP lesions had collateral ligament involvement. Others findings included interosseous tendon lesions (n = 29), interosseous tendon rupture (n = 29), synovitis (n = 49), flexor tenosynovitis (n = 28), crossover toe (n = 2), hammertoe (n = 1), intermetatarsal space (IS) neuromas (n = 11), and third IS neuromas (n = 12).

CONCLUSION

PP tears are a common cause of metatarsalgia, accounting for more than 20 % of cases in our sample. A substantial portion of the lesions (29.5 %) became visible only after the administration of gadolinium.

Plantar plate radiofrequency and Weil osteotomy for subtle metatarsophalangeal joint instablity

Background

To the present day, literature has only discussed how to treat extensive plantar plate and collateral ligament lesions, with gross joint subluxation and obvious clinical instability. The treatment options for early stages of the disease with minor injuries and subtle instabilities have not been described. The main purpose of this prospective study is to evaluate the efficacy of the combination of the arthroscopic radiofrequency shrinkage and distal Weil osteotomy in the treatment of subtle metatarsophalangeal joint instability.

Method

Prospective data (clinical, radiological, and arthroscopic findings) of 19 patients, with a total of 35 slightly unstable joints, was collected. The physical examination defined the hypothesis for plantar plate lesions (grades 0 and 1), which was confirmed during the diagnostic step of the arthroscopic procedure.

Results

Among our patients, 73 % were females and 63 % reported wearing high heels. The average age was 59 years and post-operative follow-up was 20 months. In the initial sample frame, 62 % of joints showed spread-out toes with increased interdigital spacing. The mean American Orthopedic Foot and Ankle Society score rose from 53 points pre-operatively to 92 points post-operatively and a visual-analog pain scale average value of eight points pre-operatively decreased to zero post-operatively. During the pre-operative evaluation, none of the patients had stable joints and over 97 % were classified as having grade 1 instability (<50 % subluxation). After treatment, 83 % of the joints became stable (degree of instability 0) and over 97 % were congruent. All studied parameters showed statistically significant improvements in the post-operative period (p < 0.001) showing the efficiency of the treatment in pain relief, while restoring the joint stability and congruity.

Conclusion

Arthroscopic radiofrequency shrinkage in combination with distal Weil osteotomy promotes functional improvement, pain relief, and restores the joint stability in the plantar plate lesion grades 0 and 1.