Surgery for Plantar Plate Tears

NewsBot · Jan 20, 2022

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A versatile method for dorsal-approach plantar plate repair using standard operative instruments
Shun-Min Chang et al
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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.
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NewsBot · Jan 20, 2022

Related Thread:
Others threads on plantar plate problems

NewsBot · Feb 7, 2022

Surgical Imbrication of Plantar Plate to Metatarsal Neck in the Setting of Lesser Toe Metatarsophalangeal Joint Instability
Paul G. Talusan, MD, Eric Colomb, Robert N. Kent, ...
Foot & Ankle Orthopaedics January 20, 2022

Introduction/Purpose:
Persistent metatarsalgia refractory to non-operative therapy with accompanying plantar plate injury represents a common and challenging treatment problem. In previous studies, radiofrequency shrinkage has been used for the treatment of MTP joint instability secondary to low-grade plantar plate lesions.1 In the shoulder, this technique shows histological evidence of modest regenerative capacity but is also associated with several chronic sequelae including capsular stretching, nerve damage, recurrent instability, adhesive capsulitis, and thermally-induced chondrolysis.2-6 The purpose of this observational study was to examine the efficacy of surgical imbrication of the plantar plate to the metatarsal neck as a novel, cost-effective approach to repair Grade 0-1 plantar plate injuries. We sought to characterize patient-reported and radiographic outcomes in patients undergoing this procedure.

Methods:
Patients from a single fellowship-trained orthopaedic surgeon (1/2017 - 12/2020) were screened by electronic medical record review. Inclusion criteria were age >18 years, a pre-operatively measured Patient-Reported Outcomes Measurement Information System (PROMIS) score, a Grade 0 or 1 plantar plate tear discovered at time of surgery, and repair via surgical imbrication to the metatarsal neck. PROMIS Physical Function and Pain Interference scores were obtained from 14 enrolled patients (median age was 55 years; range: 40-69; 12 female) post-operatively at 6-9 weeks, 3 months, 6 months, and 1-2 years.

Basic demographic information and pertinent medical information were also obtained. Three fellowship-trained orthopaedic surgeons independently reviewed radiographs to assess reduction of the metatarsophalangeal joint, and joints were graded as reduced, subluxated, or dislocated. Wilcoxon signed-rank tests compared pre- and post-operative PROMIS scores. Changes in PROMIS scores were compared to numerical and categorical patient characteristics via univariate linear regressions and Mann- Whitney U-tests, respectively.

Results:
Median postoperative times to most recent PROMIS score and radiographs were respectively 13.0 months (95% confidence interval: 10.0-21.4) and 7.6 months (2.9-10.0). Median preoperative and most recent Physical Function scores were 39.5 (35-50) and 52.5 (41-62), respectively (p=0.003), and median Pain Interference scores changed from 61.0 (56-68) to 53.5 (39- 58) (p=0.002) (Fig. 1). Changes in PROMIS scores showed no association with BMI, age, preoperative opioid use, wound complications, concomitant dislocation, fibromyalgia, or mood disorder (p>0.10). Preoperatively, 9 second MTP joints were concentrically reduced, and 5 were subluxated (n=14). At 6 weeks post-operation, 13 joints remained reduced (n=14). At most recent measurement, all (n=10) joints were reduced (4 patients missing data). 9 of 14 patients underwent concomitant correction of hallux valgus at time of surgery.

Conclusion:
Patients with Grade 0-1 plantar plate injuries improved significantly in radiographic parameters and patient reported outcome scores following surgical imbrication of the plantar plate to the metatarsal neck. This procedure represents a novel, alternative approach that is both efficacious and cost-effective. Our work contributes valuable surgical outcomes data to a limited knowledgebase regarding pathophysiology and management for low-grade plantar plate lesions in MTP joint instability. Future work will involve larger, prospective studies to better understand outcomes of and indications for this approach.
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NewsBot · Feb 28, 2022

Treatment of Lesser Metatarsophalangeal Joint Instability with Plantar Plate Repair: A Systematic Review and Meta-Analysis
Jeffrey R.Baker et al
The Journal of Foot and Ankle Surgery; 22 February 2022

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 (PRISMA) guidelines, to determine the magnitude of change that can be expected in visual analog scale (VAS) pain and American Orthopedic Foot and Ankle Society (AOFAS) 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 VAS pain (pooled mean change of -5.01 (95%CI -5.36, -4.66) pre-to postoperative) and improvement in AOFAS 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.
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NewsBot · Jun 23, 2022

Plantar Plate Repair for Metatarsophalangeal Joint Instability of the Lesser Toes
James R Jastifer
Orthop Clin North Am. 2022 Jul;53(3):349-359

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.
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NewsBot · Aug 29, 2022

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications
B Dale Sharpe et al
Foot Ankle Spec. 2022 Aug 25

Background: Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series.

Methods: This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling).

Results: Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery.

Conclusion: To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs.
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NewsBot · Nov 22, 2022

Extensive Lesser Toes Plantar Plate Tears Reconstruction
Marcelo P. Prado, MD, PhD, Daniel Baumfeld, MD, […], and Caio A. Nery, MD
Source

Introduction/Purpose:
The plantar plate is a fibrocartilaginous structure that plays a fundamental role in the sagittal stability of the metatarsophalangeal joint (MTPJ). Traumatic and degenerative lesions affecting the plantar plate have the potential to cause instability, swelling, pain and deformity. Extensive plantar plate tears (grade IV) still challenge surgeons as primary repair is impossible, demanding a reconstructive procedure which, unfortunately, can be associated with high morbidity such as stiffness, persistence of discomfort, vascular compromise to the digit and amputation. The purpose of this work is to describe a new technique that uses a synthetic tape and one absorbable screw to achieve the MTPJ stabilization in plantar plate grade IV tears. We believe that this procedure can achieve better results than other techniques described in the literature.
Methods:
Two bone tunnels are made at the base of the proximal phalanx. Both medial and lateral tunnels are directed in a light oblique fashion from a distal-dorsal entry point to a proximal, justarticular plantar exit. Two new oblique dorsal-plantar bone tunnels - medial and lateral - are made at the distal metaphyseal metatarsal area. A #2 FiberTape is passed through the bone tunnels guided by a Nitinol wire, creating a mesh for the plantar stabilization of the MTPJ. Then both Fiber Tapes limbs are driven, with the help of a nitinol loop, through the plantar orifices of corresponding sides of the metatarsal bone tunnels, exiting in its dorsal aspect. One of the limbs of the tape is passed from dorsal to plantar trough the other metatarsal orifice. Both limbs are tensioned, and the toe should be kept at neutral sagittal position (flexion-extension). Fixation is made with a Biotenodesis screw.
Results:
Only a few patients were submitted to this technique. At one year follow up, none of them presented with complaints or complications.
Conclusion:
The surgical technique described in this article can change the way physicians treat plantar complex plantar plate tears when there is no viable biologic tissue to repair. A lesser complication rate it's also expected. Nonetheless comparative, and biomechanical studies are still needed to confirm our hypothesis.
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NewsBot · Jan 17, 2023

Arthroscopic Repair of Chronic Plantar Plate Tears of the First Metatarsophalangeal Joint: A New Surgical Technique With Patient Outcomes
Elisabeth Ellingsen Husebye, Are Haukåen Stødle
Orthop J Sports Med. 2022 Dec 23;10(12):23259671221137558

Background: Most plantar plate tears of the first metatarsophalangeal joint can be treated successfully by nonoperative means. Primary repair may be indicated to restore continuity of the plantar structures and joint stability. Inadequate or failed nonoperative treatment may cause persistent pain and disability and thereby represent a career-threatening injury to an athlete. The chronic plantar plate tears are difficult both to diagnose and to treat. When surgical treatment is indicated, traditionally a wide plantar or 2 parallel incisions are used. An arthroscopic approach allows for verification and visualization of the injury and, at the same time, repair of the injury.

Purpose: To describe findings of plantar plate tears, present a new arthroscopic procedure for plantar plate tear repair, and present the outcomes after surgery.

Study design: Case series; Level of evidence, 4.

Methods: This was a retrospective study on the first 10 patients treated with the arthroscopic technique. The patients underwent surgery between June 2017 and January 2021. Patient data, clinical symptoms and findings, and operative details were obtained from the patient records. Patients were contacted via email to complete patient-reported outcome measures (Manchester Oxford Foot Questionnaire [MOxFQ] and Numeric Rating Scale [NRS] for pain).

Results: Four female and 6 male patients with a median age of 24 years (range, 12-44 years) were operated on at a median of 20 months (range, 2-38 months) after injury. Of the 10 patients, 8 had a hyperextension injury of the first metatarsophalangeal joint and 7 had a subtle valgus malalignment of the hallux; 8 patients were injured during sport activity. All patients reported plantar pain at pushoff. All but 1 patient returned to the same level of preinjury activity within 6 months. At a median of 29 months (range, 7-49 months) after surgery, the median MOxFQ score was 6 (range, 0-41) and the median NRS pain score was 0.

Conclusion: Arthroscopic plantar plate repair of chronic plantar plate tears resulted in a high rate of return to activity/sport and excellent outcome scores.
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NewsBot · Sep 14, 2023

SURGICAL TREATMENT OF METATARSALGIA AND SEVERE INSTABILITY OF LESSER METATARSOPHALANGEAL JOINTS
Dmitry S. Bobrov, MD, PhD et al
September 13, 2023

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 and thirteen patients (117 feet) were enrolled in the study. They were split into two groups. In the first group, undergoing Weil osteotomy, combined with the plantar plate repair, good results, including complete pain reduction, elimination of hyperkeratosis, AOFAS 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.
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Surgery for Plantar Plate Tears

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Surgery for Plantar Plate Tears

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Plantar plate partial tear, is surgery required?

Arthroscopic Surgery for the Treatment of Chronic Plantar Heel Pain

Patient-reported outcomes following plantar incisions in foot surgery

Surgery Versus Nonsurgical Methods in Treating Neuropathic Plantar Forefoot Ulcers

Surgery for Intractable Plantar Keratosis

shockwave therapy for plantars fasciitis vs surgery?

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