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Anatomic Plantar Plate Repair
 

Anatomic Plantar Plate Repair

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This is my retrospective study on our anatomic plantar plate repair technique utilizing a Weil metatarsal osteotomy.

This is my retrospective study on our anatomic plantar plate repair technique utilizing a Weil metatarsal osteotomy.

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    Anatomic Plantar Plate Repair Anatomic Plantar Plate Repair Presentation Transcript

    • Anatomic Plantar Plate Repair Using the Weil Metatarsal Osteotomy Approach
      • Presenter: Wenjay Sung, DPM
      • Authors: Lowell Weil, Jr., DPM, Lowell Scott Weil, Sr., DPM, and Kelly Malinoski, DPM.
    • Disclosures
      WS - nothing to disclose
      LWJ - consultant for Arthrex, Inc, Wright Medical Technologies, and MMI.
      LSW - consultant and receives royalties for Cropper Medical (BioSkin Products), Wright Medical, Tornier Orthopedics
      KM - nothing to disclose
    • Overview
      Purpose
      Methods
      Statistical Analysis
      Results
      Discussion
      Conclusions
    • Purpose
      The purpose of this study was to report the results of a technique for anatomic plantar plate repair utilizing a Weil metatarsal osteotomy approach.
    • Purpose
      RETROSPECTIVE CASE SERIES
      EBM Level of evidence: IV (therapeutic)
    • Purpose
      background
      The principle stabilizer of the MTP joint
      Integrity is essential to stabilize the proximal phalanx of the lesser toes.
      Its attrition often results in metatarsalgia, plantar swelling, hammertoe deformity, and lesser toe subluxation1-4.
    • Purpose
      Background
      We believe that plantar plate attrition is most commonly due to an elongated or sub-located metatarsal3,5.
    • Purpose
      background
      Several techniques have been introduced to repair and correct the deformity, but most rely on atraditional plantar approach1-3.
    • Purpose
      background
      We present our experience with a technique8 that anatomically repairs the plantar plate ligament tear through a Weil metatarsal osteotomy
    • Methods
      We retrospectivelyidentifiedconsecutive adult patients who were treated by the senior author (LWJ) and diagnosed with 2nd MTP instability
      January 2007 toAugust 2009
      Twenty-one patients were initially treated with nonsurgical care
      Shoe modifications, custom orthotics, NSAIDs
      Thirteen patients (15 feet) had unresolved MTP instability and pain after 3 months
    • Methods
      Pre-op and post-op
      Post-op only
      Visual analog pain scale
      American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal (AOFAS LMI) clinical rating scale6
      Satisfaction
    • Statistical Analysis
      A paired student t-test was used to determine significance with p < 0.01.
    • Procedure
      Weil L, Sung W, Weil LS, and Glover JS. Correction of Second MTP Joint instability using a Weil Osteotomy and Dorsal approach Plantar Plate Repair. Techniques in Foot & Ankle Surgery.2011, 10(1):33-39
    • Results
      Demographics
      There were 13 patients (15feet) that underwent anatomic plantar plate repair.
      Ten were female and three were male with an average age of 57 years (range from 50 to 69).
      The average post-operative follow-up was 22.5 months (range from 13.0 to 32.0).
    • Results
      AVERAge VAS
      significance
      Pre-operative scores
      7.3 (SD = 1.6; 95%CI = 6.4 to 8.1)
      Post-operative scores
      1.7 (SD = 1.8; 95%CI = 0.7 to 2.7).
      This was significantly different (P < 0.01).
    • Results
      Average AOFAS LMIS
      Satisfaction
      85.7 (SD = 13.1; 95%CI = 79.1 to 91.5) out of 100
      Ten of 13 patients (77%) reported either “satisfied” or “very satisfied” with outcome
      Twelve of 15 feet (80%) were reported as “satisfied” or “very satisfied” with outcome
    • Results
      Complications
      Revision surgeries
      Three reported cases of painful hardware
      One case of continued painful metatarsalgia.
      There were NO cases of floating toes, wound dehiscence, non-union, mal-union
      One case elected for surgery to remove painful hardware
      There were NO cases of re-repair of plantar plate
    • Results
    • Discussion
    • Discussion
      Repairing 2nd MTP joint instability and plantar plate injury are NOT novel ideas.
      Several authors have described procedures with excellent reported results9-13.
    • Discussion
      Gregg et al14 described a similar technique utilizing a Weil metatarsal osteotomy for all MTP joints.
      Included plantar plate repairs to all toes (21 patients, 35 toes).
      “AOFAS Score” was 88.9
      Three floating toes (8.6%)
      Infections occurred in four feet (17%)
    • Discussion
      Gregg et al14
      Floating toes
      Too much shortening
      All (100%) patients pre-operatively had intra-articular cortisone injections
    • Discussion
      Senior author (LWJ) technique:
      Release plantar attachments
      Visualize and grasp proximally
      Never shorten more than 1-2 mm
      Specialized instrumentation
    • Discussion
      We opine that plantar plate injuries may be subtle and undiagnosed by foot and ankle surgeons who are treating intractable metatarsalgia especially those associated with hammertoe deformity and sub-metatarsal head swelling.
    • Discussion
      Strength
      Weakness
      Single surgeon
      2nd MTP joint
      Three clinical outcome measurements
      No comparative analysis
      No control
      Assessor bias
    • Conclusions
      This technique enhances visualization of the plantar plate and eases the repair
      decreasing the chance of plantar tissue trauma as compared to a plantar approach.
      Demonstrates favorable results with regards to patient pain and clinical outcome scores.
    • References
      Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. OrthopClin North Am. 1989;20:535-551.
      Blitz NM, Ford LA, Christensen JC. Second metatarsophalangeal joint arthrography: a cadaveric correlation study. J Foot Ankle Surg. 2004;43:231-240.
      Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-444.
      Yu GV, Judge MS, Hudson JR, et al. Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. J Am Podiatr Med Assoc. 2002;92:182-199.
      Coughlin MJ. Crossover second toe deformity. Foot Ankle. 1987;8:29-39.
      Kitaoka HB et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 15:349–353, 1994.
      Ware J et al. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996 Mar; 34(3); 220-33.
      Weil Jr L, Sung W, Weil Sr LS, et al. Tech Foot Ankl Surg. 2011, 10(1):33-39.
      Bouche RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorumlongus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008;47:125-137.
      Blitz NM, Ford LA, Christensen JC. Plantar plate repair of the second metatarsophalangeal joint: technique and tips. J Foot Ankle Surg. 2004;43:266-270.
      Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. 1987;10:83-89.
      Haddad SL, Sabbagh RC, Resch S, et al. Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity. Foot Ankle Int. 1999;20:781-788.
      Powless SH, Elze ME. Metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management. J Foot Ankle Surg. 2001;40:374-389.
      Gregg et al. Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability. Foot Ankle Surg. 2007; 13 (116-121).
    • Thank You