dorsal anatomic plantar plate repair
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Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Dorsal Anatomic Plantar Plate Repair (DAPPR)
• Presenter: Wenjay Sung, DPM• Lowell Weil, Jr., DPM, MBA • Lowell Scott Weil, Sr., DPM
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Disclosures
Full disclosure can be found in the Final AOFAS Program Book and the AAOS website for all authors.
I have no potential conflicts with this presentation.
LWJ is a consultant for Arthrex Inc.
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
DAPPR
We report the results of our case series of dorsal anatomic plantar plate repair in conjunction with a Weil osteotomy approach.
EBM Level of evidence: IV, therapeutic, RETROSPECTIVE CASE SERIES
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
DAPPRBackground
Attrition often results in metatarsalgia, plantar swelling, hammertoe deformity and lesser toe subluxation1-4.
The plantar plate ligament is the principle stabilizer of the MTP joint It is firmly attached to the
base of the proximal phalanx and more loosely attached to the metatarsal neck15,16.
The integrity is essential to stabilize the proximal phalanx of the lesser toes.
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Methods
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 29 patients (32 cases) Post-operative follow-up
of >12 months
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
MethodsAssessment
Visual analog scale (VAS)
AOFAS LMI clinical rating scale6
Statistical Analysis
A paired student t-test was used to determine significance with p < 0.01.
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Procedure
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
Video at www.youtube.com/weil4feet
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Procedure
Dorsal incision
Incision between EDB & EDL tendons
McGlamry elevator was used to free soft tissue attachments plantar to the metatarsal head
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Procedure
Capital fragment was retrograded
Temporarily fixated
Application of metatarsophalangeal joint distractor
Mobilized plantar plate distally
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Procedure
Plantar plate grasped proximally (#0 fiberwire)
Mattress stitch
Created two crossing bone tunnels in proximal phalanx
Passed ends of mattress stitch through bone tunnels
Tied suture ends with toe in plantarflexion
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Procedure
Capital fragment was aligned to anatomic contour
Fixated with 2.5mm headless screw
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Post-Operative
Allowed immediate, guarded weight bearing in surgical shoe
After one week, bandages were removed
Placed into athletic shoe
Physical therapy
Maintain therapeutic splintage
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
ResultsDemographics
29 patients/32 second MTP joints
Average age 56.4 years (35 – 71)
Average follow-up 22.6 M (12 – 40)
Average number of concurrent procedures was 2.2 per case. Bunionectomy Hammertoe correction Lesser metatarsal
osteotomy
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
ResultsAverage VAS
Pre-operative 7.3 SD = 1.7; 95%CI = 6.7 to
7.9
Post-operative 1.5 SD = 1.8; 95%CI = 0.8 to
2.2
This was significantly different (P < 0.01).
Average AOFAS LMIS
Post-operative AOFAS LMIS 87.3 out of 100 SD = 10.8; 95%CI = 83.3
to 91.3
Twitter: @jaysung#foot2011
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ResultsPlantar Plate Tears
Completely torn transversely (greater than 50% tear)
Partially torn transversely at the distal proximal phalanx attachment (less than 50% tear)
Partially torn longitudinally (“button-holed”) at the weight-bearing point of the metatarsal head.
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
ResultsComplications
Seven cases reported peri-operative complications Painful 2nd MTP stiffness (3) Painful hardware (3) Painful scar (1)
There were NO cases of floating toes
There were no cases of wound dehiscence, nonunion, malunion, floating toes, avascular necrosis, or recurrence of MTP subluxation
Revision surgeries
Three (9%) with painful 2nd MTP stiffness underwent manipulation under sedation
Three (9%) had painful hardware removal
One (3%) had painful scar revision
Revisional interventions were performed at an average of 17 months post-surgical reconstruction
Twitter: @jaysung#foot2011
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Discussion
Various techniques have been proposed to repair a torn plantar plate1,2,10,14,17
Only one other technique described a dorsal approach to repairing plantar plate14
Average AOFAS score 88.9 post-operatively in 23 patients (35 plantar plates)
Two painful hardware One transfer lesion Three floating toes
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Discussion
Cooper et al (2011) Dorsal exposure of the 2nd
MTP joint in 8 specimens using MTP joint distractor Found that the Weil
metatarsal osteotomy allowed greatest visualization
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Discussion
Our series AOFAS LMIS - 87.3 Significant reduction in
pain
NO floating toes Specialized
Instrumentation <2mm Shortening McGlamry elevator
NOT for visualization but for access
Able to grasp healthy proximal plantar plate
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Discussion 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.
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
Conclusions
DAPPR Enhances visualization and
ease in repair while decreasing the chance of plantar tissue trauma as compared to a plantar approach. Other advantages include
immediate guarded weight bearing of patients postoperatively.
Demonstrates favorable results with regards to patient pain and clinical outcome scores.
Twitter: @jaysung#foot2011
www.weil4feet.comlwj@weil4feet.com
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).15. Deland, JT; Sung, IH: The medial crosssover toe: A cadaveric dissection.FootAnkleInt.21(5):375 – 8,2000.16. 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, 1994.17. 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
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