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Plantar plate partial tear, is surgery required?

Discussion in 'Foot Surgery' started by Mark2, Aug 1, 2006.

  1. Mark2

    Mark2 Member


    Members do not see these Ads. Sign Up.
    Just after some advice.
    I have a partial tear in the plantar plate of my 3rd MTPJ. I have had an MRI to confirm this. I am unsure whether surgey is required. Do any of the surgeons out there have any advice.
    Regards, Mark.
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Trial 6-8 weeks of taping and splinting the toe in slight flexion at the MTPJ level (yes, its a pain in the neck). Add an orthosis with MT dome to elevate the head and accentuate plantar flexion at the MTPJ.

    If you already at Stage 3 (subluxation) I would still try this, you have nothing to lose.

    If this fails, you should consider a delayed primary repair of the rupture through linear plantar incision using 2/0 or 3/0 non-absorbable (eg Ethibond). Make sure the repair is done with the toe slightly overcorrected and the MTPJ slightly flexed as they always stretch out over time. These are certainly a lot easier if there is no transverse plane (Sullivan's sign) drift.

    Hope this helps,

    LL
     
  4. Mark2

    Mark2 Member

    Thank you LL for your reply,
    It has been 2 months since the injury occurred and the early signs showed the transverse deviation of the 3rd toe, and that has improved slightly. I have been wearing orthoses with a lateral wedge to offload the 3rd MTPJ, as I found a met dome uncomfortable when toeing off. I have a very cavoid foot type which doesn't help matters.
    Thanks again for your reply LL.
    Mark.
     
  5. Mark and LL:

    I liked LL's response. I might add that icing the plantar MTPJ area 20 minutes twice daily helps greatly with the edema and pain. I make orthoses for plantar plate tears with the following modifications:

    -anterior edges 5 mm thick
    -longer than normal orthosis plate at affected metatarsal head
    -hard or soft met pads proximal to affected metatarsal head
    -3-4 mm accommodations of the affected metatarsal head with a forefoot extensions

    If patient's are very symptomatic, then casting or bracing may be indicated. I have yet to do a primary plantar plate repair but have done quite a few flexor transfers which work well also for this problem. However, most patients respond well to icing, taping, avoiding barefoot and foot orthoses.

    I would be interested in LL's postsurgical protocol for the plantar incision that results from a plantar plate repair....3 weeks nonweightbearing? Do you use any subcutaneous absorbable suture? Do you make the incision in the intermetatarsal area or directly under the metatarsal head?
     
  6. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Kevin

    In our program we do quite a few delayed primary repairs where there has been ongoing instability and pain that has not settled with splinting, activity modification and orthoses.

    Typically a linear incision over the MTPJ is done plantarly, and dissection is carried through to the flexors, which are retracted to visualise the plantar plate/capsule.

    Tears are typically seen to be transverse or linear, across the bottom of the capsule.

    The margins can then be easily remodelled and sutured to encourage plantarflexion at the MTP joint. Our experience is that a flexor transfer will augment this, but repair of the capsule is the priority.

    Closure is in layers, and often the flexor sheath is tagged to the capsule.

    Deep non-absorbable retention sutures are combined with superficial non-absorbable closure + steristrips. Strict non-weight-beairng for about 2-3 weeks using a post op shoe and felt accomodation to offload the joint should weight go through it during transfers.

    Incision line is typically imperceivable after 3-6 months, but strict non-WB is the key in the first few weeks.

    Cheers,

    LL
     
  7. LCG

    LCG Active Member

    Alternatively, you could trial a 1st ray cut-out which will essentially achieve simalar results to the met dome LL eluded to. Matt Dilnot wrote a paper a couple of years ago which is available on his web site but dont have the address, maybe someone else will be able to post the relevent link for you.
     
  8. Mark2

    Mark2 Member

    Thank you all for your replies.

    I did read the article by Matt Dilnot and Thomas Michaud and was very informative. Infact that was how I came to diagnose myself, then MRI confirmed it.

    The surgery sounds fascinating, just not in my foot!
    I am able to walk with orthoses and sneakers no problems.
    Do I allow it to heal itself or after 2 months since injury occurred, will it continue to improve to the point where sporting activities can be resumed?
    Mark.
     
  9. LCG

    LCG Active Member

    From my experience I have found very few platar plate tears respond well to conservative management. Especially if you intend to return to sporting activities.
    The surgical protocol outlined by LL is much more effective than the traditional orthopedic approach. The last partial tear I consulted underwent a weil osteotomy with IP fusion. Very poor post operative outcome.
     
  10. Contrary to LCG's experience, most of the mild plantar plate tears I see in recreational athletes respond well to conservative management. However, if their activities are compromised by a larger tear and hammertoe deformity/mpj symptoms, then certainly surgery would be recommended.
     
  11. Mark2

    Mark2 Member

    Thanks again for your replies.
    I had a podiatric surgeon consultation a few days ago. It was recommended that I continue strapping the joint for the next month. The pain has significantly reduced, since initial tear I was unable to weight bare. After understanding the anatomy and the avascular nature, healing will be long but eventually get back to sporting activities.
    Thanks again everyone for your opinoins.
    Mark.
     
  12. drsarbes

    drsarbes Well-Known Member

    LL
    In your repair of the plantar plate post I see no mention of the osseous structures.
    Do you routinely NOT perform a second metatarsal osteotomy?
    Mainly do to the return of the deformity, in time, when I had only done a soft tissue repair, I now almost always perform a shortening osteotomy of the metatarsal, one can also angulate the articular surface if needed.
    I'm wondering if you have long term (+5 years) success with the soft tissue repair. If so, I'd be interested in age and life style of these long term successes.
    Thanks
    Steve
     
  13. robcox

    robcox Active Member

    Hi

    has anyone got an electronic copy of this article by Matt Dilnot and Thomas Michaud on plantar plate rupture?

    Also- how would one go about strapping for this condition?

    Regards

    Rob
     
  14. Griff

    Griff Moderator

    Kevin, LL, LCG and all

    Going slightly away from the threads original question, (but still on topic);

    Before any diagnostic imaging has been performed to confirm the diagnosis is there anything during the clinical assessment which would particularly guide your thoughts toward a plantar plate tear?

    Many thanks in advance
     
  15. Ian:

    Here are the clinical hallmarks of plantar plate tears. Some, but not necessarily all, of these clinical findings may be present in significant plantar plate tears:

    1. Plantar tenderness from base of proximal phalanx to 1.0 cm proximal to proximal phalanx base may be present.

    2. Plantar and/or dorsal mpj edema may be present.

    3. Plantar loading of metatarsal head during non-weightbearing exam may not produce plantarflexion of proximal phalanx down to level of transverse plane.

    4. Modified Lachman's test may be positive (i.e. base of proximal phalanx will sublux more than 2 mm relative to the metatarsal head with about 5 pounds, i.e. about 20 N, of dorsally-directed pushing force from examiner on plantar base of proximal phalanx).

    5. Standing exam may demonstrate dorsiflexion deformity of metatarsophalangeal joint (MPJ).

    6. Standing exam may demonstrate dorsal subluxation of proximal phalanx base relative to metatarsal head.

    7. Standing exam may demonstrate decreased digital purchase force when compared to contralateral unaffected corresponding digit.

    Hope this helps.
     
  16. robcox

    robcox Active Member

    Kevin:

    Could subluxation & deviation of the affected digits also observed at the MTPJ joints, in some patients, due to a reduction in transverse plane stability (especially if the transverse ligament is involved)?

    Regards,

    Rob
     
  17. ghammo

    ghammo Welcome New Poster

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