An Alternative Approach To Plantar Plate Derangement

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Here one can see an open arthroscopic synovectomy and primary repair of the plantar plate of the second MPJ.
This photo is a post-debridement view of degenerative tissue.
In this post-synovectomy view, one can see an exposed degenerative plantar plate of the first MPJ.
In this photo, one can see debridement of the plantar plate.
The affected plantar plate usually requires nine to 12 microablations.
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Author(s): 
By Kerry Zang, DPM

Pertinent Pointers On Conservative Care

     Conservative care would consist of a combination of functional orthotic control and antiinflammatory medications. The clinician should be careful to avoid steroid injections into the area as this would increase the risk of rupture of the already weakened degenerative plantar capsulopathy. One can utilize compounded, nonsteroidal, non-systemic antiinflammatory medication. I use a compound made from ketoprofen (10%), ibuprofen (10%), piroxicam (2%) and cyclobenaprine (2%), three different antiinflammatory medications with a muscle relaxant. The benefit of this compound is its lack of cross-reactivity with other systemic medications the patient may be taking as it is utilized locally. In rare occasions, the patient may develop a rash and should discontinue its use immediately.

     One may also strap the involved digits together and hold them in plantarflexed position for a few weeks to help in offloading the plantar plate. These efforts generally take approximately three to six weeks to demonstrate any degree of success. If conservative efforts are unsuccessful, consider surgical intervention. In place of the traditional surgery, one might offer patients the option of the microdebridement procedure.

Comparing Microdebridement To Conventional Surgical Treatment

     Conventional surgical treatment of plantar plate derangement with synovitis most commonly consists of dissecting the plantar plate/capsule and realigning soft tissue dorsally. One would usually perform this procedure in conjunction with repair of the digital deformity. More recently, alternative surgical repair consists of decompressing the metatarsophalangeal joint complex with a shortening osteotomy of the metatarsal. Although both types of surgery are generally successful clinically, postoperative recovery can take several months.

     Plantar plate derangement is a capsulopathy but the condition appears to demonstrate a similar pattern of painful hypovascular tissue degeneration as the overuse injuries of tendinosis and fasciosis. During the past few years, surgeons have successfully used plasma-mediated, radiofrequency-based (Coblation®, ArthroCare) microdebridement to treat symptomatic chronic tendinosis.2 The objective of this microdebridement approach is to promote a low-grade inflammatory response in treated tissue. This stimulates neovascularization, which initiates a biochemical profile associated with the healing process in degenerated tissue and the formation of new blood vessels.3-7 Some are currently using plasma-mediated, radiofrequency-based microdebridement to treat refractory symptoms associated with tendinosis in the shoulder and elbow.2,8

     In my clinical experience utilizing this technique over the past three years, I have found it is excellent in treating Achilles tendinosis and intractable plantar fasciosis. Since plantar plate derangement shows evidence of having similar characteristics to the pathologies of tendinosis and fasciosis, this radiofrequency-based procedure could provide an excellent alternative to surgical dissection of the capsule for treating this capsulopathy. The microdebridement procedure may offer substantial benefits over conventional surgery, including quicker recovery and less risk of postoperative complications.

Step-By-Step Pearls For The Procedure

     Accordingly, we recently undertook a study to evaluate the technical ease of using this approach to treat patients with plantar plate derangement, metatarsalgia and synovitis of the second metatarsophalangeal joint complex, and to assess early postoperative clinical findings.

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