Dorsal Anatomic Plantar Plate Repair


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Dorsal Anatomic Plantar Plate Repair

  1. 1. Dorsal Anatomic Plantar Plate Repair (DAPPR)<br /><ul><li>Presenter:Wenjay Sung, DPM
  2. 2. Lowell Weil, Jr., DPM, MBA
  3. 3. Lowell Scott Weil, Sr., DPM</li></li></ul><li>Disclosures<br />Full disclosure can be found in the Final AOFAS Program Book and the AAOS website for all authors.<br />I have no potential conflicts with this presentation.<br />LWJ is a consultant for Arthrex Inc. <br />
  4. 4. DAPPR<br />We report the results of our case series of dorsal anatomic plantar plate repair in conjunction with a Weil osteotomy approach. <br />EBM Level of evidence: IV, therapeutic, retrospective case series<br />
  5. 5. DAPPR<br />Background<br />Attrition often results in metatarsalgia, plantar swelling, hammertoe deformity and lesser toe subluxation1-4. <br />The plantar plate ligament is the principle stabilizer of the MTP joint <br />It is firmly attached to the base of the proximal phalanx and more loosely attached to the metatarsal neck15,16.<br />The integrity is essential to stabilize the proximal phalanx of the lesser toes.<br />
  6. 6. Methods<br />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<br />29 patients (32 cases) <br />Post-operative follow-up of >12 months<br />
  7. 7. Methods<br />Assessment<br />Visual analog scale (VAS)<br />AOFAS LMI clinical rating scale6<br />Statistical Analysis<br />A paired student t-test was used to determine significance with p < 0.01.<br />
  8. 8. Procedure<br />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<br />Video at<br />
  9. 9. Procedure<br />Dorsal incision<br />Incision between EDB & EDL tendons<br />McGlamry elevator was used to free soft tissue attachments plantar to the metatarsal head<br />
  10. 10. Procedure<br />
  11. 11. Procedure<br />
  12. 12.
  13. 13. Procedure<br />Capital fragment was retrograded<br />Temporarily fixated<br />Application of metatarsophalangeal joint distractor<br />Mobilized plantar plate distally<br />
  14. 14. Procedure<br />
  15. 15. Procedure<br />
  16. 16.
  17. 17. Procedure<br />Plantar plate grasped proximally (#0 fiberwire)<br />Mattress stitch<br />Created two crossing bone tunnels in proximal phalanx<br />Passed ends of mattress stitch through bone tunnels<br />Tied suture ends with toe in plantarflexion<br />
  18. 18. Procedure<br />
  19. 19. Procedure<br />Capital fragment was aligned to anatomic contour<br />Fixated with 2.5mm headless screw<br />
  20. 20. Post-Operative<br />Allowed immediate, guarded weight bearing in surgical shoe<br />After one week, bandages were removed<br />Placed into athletic shoe<br />Physical therapy<br />Maintain therapeutic splintage<br />
  21. 21. Results<br />Demographics<br />29 patients/32 second MTP joints<br />Average age 56.4 years (35 – 71)<br />Average follow-up 22.6 M (12 – 40)<br />Average number of concurrent procedures was 2.2 per case.<br />Bunionectomy<br />Hammertoe correction<br />Lesser metatarsal osteotomy<br />
  22. 22. Results<br />Average VAS<br />Pre-operative<br />7.3 <br />SD = 1.7; 95%CI = 6.7 to 7.9 <br />Post-operative<br />1.5 <br />SD = 1.8; 95%CI = 0.8 to 2.2 <br />This was significantly different (P < 0.01). <br />Average AOFAS LMIS<br />Post-operative AOFAS LMIS<br />87.3 out of 100<br />SD = 10.8; 95%CI = 83.3 to 91.3<br />
  23. 23. Results<br />Plantar Plate Tears<br />Completely torn transversely (greater than 50% tear)<br />Partially torn transversely at the distal proximal phalanx attachment (less than 50% tear)<br />Partially torn longitudinally (“button-holed”) at the weight-bearing point of the metatarsal head.<br />
  24. 24. Results<br />Complications<br />Seven cases reported peri-operative complications<br />Painful 2nd MTP stiffness (3)<br />Painful hardware (3) <br />Painful scar (1)<br />There were NO cases of floating toes<br />There were no cases of wound dehiscence, nonunion, malunion, floating toes, avascular necrosis, or recurrence of MTP subluxation<br />Revision surgeries<br />Three (9%) with painful 2nd MTP stiffness underwent manipulation under sedation<br />Three (9%) had painful hardware removal<br />One (3%) had painful scar revision<br />Revisional interventions were performed at an average of 17 months post-surgical reconstruction<br />
  25. 25. Discussion<br />Various techniques have been proposed to repair a torn plantar plate1,2,10,14,17<br />Only one other technique described a dorsal approach to repairing plantar plate14<br />Average AOFAS score 88.9 post-operatively in 23 patients (35 plantar plates)<br />Two painful hardware<br />One transfer lesion<br />Three floating toes<br />
  26. 26. Discussion<br />Cooper et al (2011)<br />Dorsal exposure of the 2nd MTP joint in 8 specimens using MTP joint distractor<br />Found that the Weil metatarsal osteotomy allowed greatest visualization<br />
  27. 27. Discussion<br />Our series <br />AOFAS LMIS - 87.3<br />Significant reduction in pain<br />NO floating toes<br />Specialized Instrumentation<br /><2mm Shortening<br />McGlamry elevator<br />NOT for visualization but for access<br />Able to grasp healthy proximal plantar plate<br />
  28. 28. Discussion<br />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. <br />
  29. 29. Conclusions<br />DAPPR <br />Enhances visualization and ease in repair while decreasing the chance of plantar tissue trauma as compared to a plantar approach. <br />Other advantages include immediate guarded weight bearing of patients postoperatively. <br />Demonstrates favorable results with regards to patient pain and clinical outcome scores.<br />
  30. 30. Thank You<br />
  31. 31. 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 />Deland, JT; Sung, IH: The medial crosssover toe: A cadaveric dissection.FootAnkleInt.21(5):375 – 8,2000.<br />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.<br />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<br />