dorsal anatomic plantar plate repair
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Dorsal Anatomic Plantar Plate Repair (DAPPR)
• Presenter: Wenjay Sung, DPM• Lowell Weil, Jr., DPM, MBA • Lowell Scott Weil, Sr., DPM
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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.
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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
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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.
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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
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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.
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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
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Procedure
Dorsal incision
Incision between EDB & EDL tendons
McGlamry elevator was used to free soft tissue attachments plantar to the metatarsal head
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Procedure
Capital fragment was retrograded
Temporarily fixated
Application of metatarsophalangeal joint distractor
Mobilized plantar plate distally
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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
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Procedure
Capital fragment was aligned to anatomic contour
Fixated with 2.5mm headless screw
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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
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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
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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
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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.
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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
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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
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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
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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
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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.
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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.
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Foot Ankle Int. 15(5):276–82, 1994.17. Ford, LA; Collins, KB; Christensen, JC: Stabilization of the subluxed second metatarsophalangeal joint: Flexor tendon
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