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.

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Anatomic Plantar Plate Repair

  1. 1. Anatomic Plantar Plate Repair Using the Weil Metatarsal Osteotomy Approach<br /><ul><li>Presenter: Wenjay Sung, DPM
  2. 2. Authors: Lowell Weil, Jr., DPM, Lowell Scott Weil, Sr., DPM, and Kelly Malinoski, DPM.</li></li></ul><li>Disclosures<br />WS - nothing to disclose<br />LWJ - consultant for Arthrex, Inc, Wright Medical Technologies, and MMI.<br />LSW - consultant and receives royalties for Cropper Medical (BioSkin Products), Wright Medical, Tornier Orthopedics<br />KM - nothing to disclose<br />
  3. 3. Overview<br />Purpose<br />Methods<br />Statistical Analysis<br />Results<br />Discussion<br />Conclusions<br />
  4. 4. Purpose<br />The purpose of this study was to report the results of a technique for anatomic plantar plate repair utilizing a Weil metatarsal osteotomy approach. <br />
  5. 5. Purpose<br />RETROSPECTIVE CASE SERIES<br />EBM Level of evidence: IV (therapeutic)<br />
  6. 6. Purpose<br />background<br />The principle stabilizer of the MTP joint <br />Integrity is essential to stabilize the proximal phalanx of the lesser toes.<br />Its attrition often results in metatarsalgia, plantar swelling, hammertoe deformity, and lesser toe subluxation1-4. <br />
  7. 7. Purpose<br />Background<br />We believe that plantar plate attrition is most commonly due to an elongated or sub-located metatarsal3,5. <br />
  8. 8. Purpose<br />background<br />Several techniques have been introduced to repair and correct the deformity, but most rely on atraditional plantar approach1-3.<br />
  9. 9. Purpose<br />background<br />We present our experience with a technique8 that anatomically repairs the plantar plate ligament tear through a Weil metatarsal osteotomy<br />
  10. 10. Methods<br />We retrospectivelyidentifiedconsecutive adult patients who were treated by the senior author (LWJ) and diagnosed with 2nd MTP instability<br />January 2007 toAugust 2009<br />Twenty-one patients were initially treated with nonsurgical care<br />Shoe modifications, custom orthotics, NSAIDs<br />Thirteen patients (15 feet) had unresolved MTP instability and pain after 3 months<br />
  11. 11. Methods<br />Pre-op and post-op<br />Post-op only<br />Visual analog pain scale<br />American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal (AOFAS LMI) clinical rating scale6<br />Satisfaction<br />
  12. 12. Statistical Analysis<br />A paired student t-test was used to determine significance with p < 0.01.<br />
  13. 13. Procedure<br />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<br />
  14. 14. Results<br />Demographics<br />There were 13 patients (15feet) that underwent anatomic plantar plate repair.<br />Ten were female and three were male with an average age of 57 years (range from 50 to 69). <br />The average post-operative follow-up was 22.5 months (range from 13.0 to 32.0). <br />
  15. 15. Results<br />AVERAge VAS<br />significance<br />Pre-operative scores <br />7.3 (SD = 1.6; 95%CI = 6.4 to 8.1) <br />Post-operative scores <br />1.7 (SD = 1.8; 95%CI = 0.7 to 2.7). <br />This was significantly different (P < 0.01). <br />
  16. 16. Results<br />Average AOFAS LMIS<br />Satisfaction<br />85.7 (SD = 13.1; 95%CI = 79.1 to 91.5) out of 100<br />Ten of 13 patients (77%) reported either “satisfied” or “very satisfied” with outcome<br />Twelve of 15 feet (80%) were reported as “satisfied” or “very satisfied” with outcome<br />
  17. 17. Results<br />Complications<br />Revision surgeries<br />Three reported cases of painful hardware<br />One case of continued painful metatarsalgia.<br />There were NO cases of floating toes, wound dehiscence, non-union, mal-union<br />One case elected for surgery to remove painful hardware<br />There were NO cases of re-repair of plantar plate<br />
  18. 18. Results<br />
  19. 19. Discussion<br />
  20. 20. Discussion<br />Repairing 2nd MTP joint instability and plantar plate injury are NOT novel ideas.<br />Several authors have described procedures with excellent reported results9-13.<br />
  21. 21. Discussion<br />Gregg et al14 described a similar technique utilizing a Weil metatarsal osteotomy for all MTP joints.<br />Included plantar plate repairs to all toes (21 patients, 35 toes). <br />“AOFAS Score” was 88.9<br />Three floating toes (8.6%)<br />Infections occurred in four feet (17%)<br />
  22. 22. Discussion<br />Gregg et al14<br />Floating toes<br />Too much shortening<br />All (100%) patients pre-operatively had intra-articular cortisone injections<br />
  23. 23. Discussion<br />Senior author (LWJ) technique: <br />Release plantar attachments<br />Visualize and grasp proximally<br />Never shorten more than 1-2 mm<br />Specialized instrumentation<br />
  24. 24. Discussion<br />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.<br />
  25. 25. Discussion<br />Strength<br />Weakness<br />Single surgeon<br />2nd MTP joint<br />Three clinical outcome measurements<br />No comparative analysis <br />No control<br />Assessor bias<br />
  26. 26. Conclusions<br />This technique enhances visualization of the plantar plate and eases the repair<br />decreasing the chance of plantar tissue trauma as compared to a plantar approach. <br />Demonstrates favorable results with regards to patient pain and clinical outcome scores.<br />
  27. 27. References<br />Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. OrthopClin North Am. 1989;20:535-551.<br />Blitz NM, Ford LA, Christensen JC. Second metatarsophalangeal joint arthrography: a cadaveric correlation study. J Foot Ankle Surg. 2004;43:231-240.<br />Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-444.<br />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.<br />Coughlin MJ. Crossover second toe deformity. Foot Ankle. 1987;8:29-39.<br />Kitaoka HB et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 15:349–353, 1994.<br />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. <br />Weil Jr L, Sung W, Weil Sr LS, et al. Tech Foot Ankl Surg. 2011, 10(1):33-39.<br />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.<br />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.<br />Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. 1987;10:83-89.<br />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.<br />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.<br />Gregg et al. Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability. Foot Ankle Surg. 2007; 13 (116-121).<br />
  28. 28. Thank You<br />

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