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ANATOMIC PLANTAR PLATE REPAIR USING THE WEIL METATARSAL

OSTEOTOMY APPROACH

• Presenter: Wenjay Sung, DPM

• Authors: Lowell Weil, Jr., DPM, Lowell Scott Weil, Sr., DPM, and Kelly Malinoski, DPM.

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Disclosures

WS - nothing to disclose LWJ - consultant for Arthrex, Inc, Wright

Medical Technologies, and MMI. LSW - consultant and receives royalties

for Cropper Medical (BioSkin Products), Wright Medical, Tornier Orthopedics

KM - nothing to disclose

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Overview

Purpose Methods Statistical Analysis Results Discussion Conclusions

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Purpose

The purpose of this study was to report the results of a technique for anatomic plantar plate repair utilizing a Weil metatarsal osteotomy approach.

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Purpose

RETROSPECTIVE CASE SERIES EBM Level of evidence: IV (therapeutic)

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Purpose

BACKGROUND

The principle stabilizer of the MTP joint Integrity is essential to

stabilize the proximal phalanx of the lesser toes.

Its attrition often results in metatarsalgia, plantar swelling, hammertoe deformity, and lesser toe subluxation1-4.

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Purpose

BACKGROUND

We believe that plantar plate attrition is most commonly due to an elongated or sub-located metatarsal3,5.

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Purpose

BACKGROUND

Several techniques have been introduced to repair and correct the deformity, but most rely on a traditional plantar approach1-3.

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Purpose

BACKGROUND

We present our experience with a technique8 that anatomically repairs the plantar plate ligament tear through a Weil metatarsal osteotomy

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Methods

We retrospectively identified consecutive adult patients who were treated by the senior author (LWJ) and diagnosed with 2nd MTP instability January 2007 to August 2009 Twenty-one patients were initially treated with

nonsurgical care Shoe modifications, custom orthotics, NSAIDs

Thirteen patients (15 feet) had unresolved MTP instability and pain after 3 months

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Methods

PRE-OP AND POST-OP POST-OP ONLY

Visual analog pain scale

American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal (AOFAS LMI) clinical rating scale6

Satisfaction

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Statistical Analysis

A paired student t-test was used to determine significance with p < 0.01.

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Procedure

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

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Results

DEMOGRAPHICS

There were 13 patients (15 feet) that underwent anatomic plantar plate repair.

Ten were female and three were male with an average age of 57 years (range from 50 to 69).

The average post-operative follow-up was 22.5 months (range from 13.0 to 32.0).

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Results

AVERAGE VAS SIGNIFICANCE

Pre-operative scores 7.3 (SD = 1.6; 95%CI

= 6.4 to 8.1)

Post-operative scores 1.7 (SD = 1.8; 95%CI

= 0.7 to 2.7).

This was significantly different (P < 0.01).

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Results

AVERAGE AOFAS LMIS SATISFACTION

85.7 (SD = 13.1; 95%CI = 79.1 to 91.5) out of 100

Ten of 13 patients (77%) reported either “satisfied” or “very satisfied” with outcome

Twelve of 15 feet (80%) were reported as “satisfied” or “very satisfied” with outcome

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Results

COMPLICATIONS REVISION SURGERIES

Three reported cases of painful hardware

One case of continued painful metatarsalgia.

There were NO cases of floating toes, wound dehiscence, non-union, mal-union

One case elected for surgery to remove painful hardware

There were NO cases of re-repair of plantar plate

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Results

 Table 1 Age VAS AOFAS LMIS

Pre-op Average 57.0 7.3  Post-opAverage 58.9 1.7 85.7

Significance   P < 0.01  

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Discussion

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Discussion

Repairing 2nd MTP joint instability and plantar plate injury are NOT novel ideas.

Several authors have described procedures with excellent reported results9-13.

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Discussion

Gregg et al14 described a similar technique utilizing a Weil metatarsal osteotomy for all MTP joints. Included plantar plate repairs to all toes (21

patients, 35 toes). “AOFAS Score” was 88.9 Three floating toes (8.6%) Infections occurred in four feet (17%)

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Discussion

Gregg et al14

Floating toes Too much

shortening

All (100%) patients pre-operatively had intra-articular cortisone injections

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Discussion

Senior author (LWJ) technique: Release plantar

attachments Visualize and grasp

proximally Never shorten

more than 1-2 mm Specialized

instrumentation

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Discussion

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.

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Discussion

STRENGTH WEAKNESS

Single surgeon 2nd MTP joint Three clinical

outcome measurements

No comparative analysis

No control Assessor bias

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Conclusions

This technique enhances visualization of the plantar plate and eases the repair decreasing the chance of plantar tissue

trauma as compared to a plantar approach.

Demonstrates favorable results with regards to patient pain and clinical outcome scores.

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References1. Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clin North Am.

1989;20:535-551.2. Blitz NM, Ford LA, Christensen JC. Second metatarsophalangeal joint arthrography: a cadaveric

correlation study. J Foot Ankle Surg. 2004;43:231-240.3. Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-444.4. Yu GV, Judge MS, Hudson JR, et al. Predislocation syndrome. Progressive subluxation/dislocation of the

lesser metatarsophalangeal joint. J Am Podiatr Med Assoc. 2002;92:182-199.5. Coughlin MJ. Crossover second toe deformity. Foot Ankle. 1987;8:29-39.6. Kitaoka HB et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot

Ankle Int. 15:349–353, 1994.7. 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. 8. Weil Jr L, Sung W, Weil Sr LS, et al. Tech Foot Ankl Surg. 2011, 10(1):33-39.9. Bouche RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon

transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008;47:125-137.

10. 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.

11. Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. 1987;10:83-89.

12. 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.

13. 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.

14. Gregg et al. Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability. Foot Ankle Surg. 2007; 13 (116-121).

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