Dorsal Anatomic Plantar Plate Repair

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  • 1. Dorsal Anatomic Plantar Plate Repair (DAPPR)
    • Presenter:Wenjay Sung, DPM
    • 2. Lowell Weil, Jr., DPM, MBA
    • 3. Lowell Scott Weil, Sr., DPM
  • Disclosures
    Full disclosure can be found in the Final AOFAS Program Book and the AAOS website for all authors.
    I have no potential conflicts with this presentation.
    LWJ is a consultant for Arthrex Inc.
  • 4. DAPPR
    We report the results of our case series of dorsal anatomic plantar plate repair in conjunction with a Weil osteotomy approach.
    EBM Level of evidence: IV, therapeutic, retrospective case series
  • 5. DAPPR
    Background
    Attrition often results in metatarsalgia, plantar swelling, hammertoe deformity and lesser toe subluxation1-4.
    The plantar plate ligament is the principle stabilizer of the MTP joint
    It is firmly attached to the base of the proximal phalanx and more loosely attached to the metatarsal neck15,16.
    The integrity is essential to stabilize the proximal phalanx of the lesser toes.
  • 6. Methods
    We retrospectively identified consecutive adult patients who were diagnosed with 2nd MTP instability from January 2007 to December 2009 and treated with dorsal anatomic plantar plate repair
    29 patients (32 cases)
    Post-operative follow-up of >12 months
  • 7. Methods
    Assessment
    Visual analog scale (VAS)
    AOFAS LMI clinical rating scale6
    Statistical Analysis
    A paired student t-test was used to determine significance with p < 0.01.
  • 8. Procedure
    Weil L, Jr., Sung W, Weil LS, and Glover JS. Correction of Second MTP Joint instability using a Weil Osteotomy and Dorsal approach Plantar Plate Repair. Tech Foot Ankle Surg. 10(1):33-39, March 2011
    Video at www.youtube.com/weil4feet
  • 9. Procedure
    Dorsal incision
    Incision between EDB & EDL tendons
    McGlamry elevator was used to free soft tissue attachments plantar to the metatarsal head
  • 10. Procedure
  • 11. Procedure
  • 12.
  • 13. Procedure
    Capital fragment was retrograded
    Temporarily fixated
    Application of metatarsophalangeal joint distractor
    Mobilized plantar plate distally
  • 14. Procedure
  • 15. Procedure
  • 16.
  • 17. Procedure
    Plantar plate grasped proximally (#0 fiberwire)
    Mattress stitch
    Created two crossing bone tunnels in proximal phalanx
    Passed ends of mattress stitch through bone tunnels
    Tied suture ends with toe in plantarflexion
  • 18. Procedure
  • 19. Procedure
    Capital fragment was aligned to anatomic contour
    Fixated with 2.5mm headless screw
  • 20. Post-Operative
    Allowed immediate, guarded weight bearing in surgical shoe
    After one week, bandages were removed
    Placed into athletic shoe
    Physical therapy
    Maintain therapeutic splintage
  • 21. Results
    Demographics
    29 patients/32 second MTP joints
    Average age 56.4 years (35 – 71)
    Average follow-up 22.6 M (12 – 40)
    Average number of concurrent procedures was 2.2 per case.
    Bunionectomy
    Hammertoe correction
    Lesser metatarsal osteotomy
  • 22. Results
    Average VAS
    Pre-operative
    7.3
    SD = 1.7; 95%CI = 6.7 to 7.9
    Post-operative
    1.5
    SD = 1.8; 95%CI = 0.8 to 2.2
    This was significantly different (P < 0.01).
    Average AOFAS LMIS
    Post-operative AOFAS LMIS
    87.3 out of 100
    SD = 10.8; 95%CI = 83.3 to 91.3
  • 23. Results
    Plantar Plate Tears
    Completely torn transversely (greater than 50% tear)
    Partially torn transversely at the distal proximal phalanx attachment (less than 50% tear)
    Partially torn longitudinally (“button-holed”) at the weight-bearing point of the metatarsal head.
  • 24. Results
    Complications
    Seven cases reported peri-operative complications
    Painful 2nd MTP stiffness (3)
    Painful hardware (3)
    Painful scar (1)
    There were NO cases of floating toes
    There were no cases of wound dehiscence, nonunion, malunion, floating toes, avascular necrosis, or recurrence of MTP subluxation
    Revision surgeries
    Three (9%) with painful 2nd MTP stiffness underwent manipulation under sedation
    Three (9%) had painful hardware removal
    One (3%) had painful scar revision
    Revisional interventions were performed at an average of 17 months post-surgical reconstruction
  • 25. Discussion
    Various techniques have been proposed to repair a torn plantar plate1,2,10,14,17
    Only one other technique described a dorsal approach to repairing plantar plate14
    Average AOFAS score 88.9 post-operatively in 23 patients (35 plantar plates)
    Two painful hardware
    One transfer lesion
    Three floating toes
  • 26. Discussion
    Cooper et al (2011)
    Dorsal exposure of the 2nd MTP joint in 8 specimens using MTP joint distractor
    Found that the Weil metatarsal osteotomy allowed greatest visualization
  • 27. Discussion
    Our series
    AOFAS LMIS - 87.3
    Significant reduction in pain
    NO floating toes
    Specialized Instrumentation
    <2mm Shortening
    McGlamry elevator
    NOT for visualization but for access
    Able to grasp healthy proximal plantar plate
  • 28. Discussion
    The authors opine that plantar plate injuries may be subtle and undiagnosed by foot and ankle surgeons treating intractable metatarsalgia especially those associated with hammertoe deformity and sub-metatarsal head swelling.
  • 29. Conclusions
    DAPPR
    Enhances visualization and ease in repair while decreasing the chance of plantar tissue trauma as compared to a plantar approach.
    Other advantages include immediate guarded weight bearing of patients postoperatively.
    Demonstrates favorable results with regards to patient pain and clinical outcome scores.
  • 30. Thank You
  • 31. References
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    Weil Jr L, Sung W, Weil Sr LS, et al. Tech Foot Ankl Surg. 2011, 10(1):33-39.
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    Johnston, RB, 3rd; Smith, J; Daniels, T: The plantar plate of the lesser toes: An anatomical study in human cadavers. Foot Ankle Int. 15(5):276–82, 1994.
    Ford, LA; Collins, KB; Christensen, JC: Stabilization of the subluxed second metatarsophalangeal joint: Flexor tendon transfer versus primary repairoftheplantarplate.JFootAnkleSurg.37(3):217 – 22,1998