Questions And Answers On The Suture And Button Technique For Plantar Plate Stabilization

Molly Judge DPM FACFAS

I recently presented the suture and button technique as a preliminary report of my personal experience with second metatarsophalangeal joint (MPJ) instability and predislocation syndrome (see ). This method has been developed for those patients who have failed conservative efforts to stabilize the digit and accommodate the forefoot. This procedure is unique and is not published in the literature to date.

I want to make it infinitely clear that I am not suggesting others pursue this technique at this point. I do not have follow-up beyond eight months post-op. To date, I have performed this technique on three patients and seven digits. The thought and development of this technique comes from mentoring that I have received over the years and the thought process that is fundamental to this technique is not my own.1

I recently presented this technique at the 11th Annual Scientific Seminar of the North West Ohio Academy of Podiatric Medicine in Sandusky, Ohio. I fielded a number of questions regarding the technique and I present those to you as another point of reference for understanding this concept.

Q: Why do you choose this technique over arthrodesis of the digit? Doesn't that force the hammertoe into the proper alignment and eliminate the forefoot pain?

A: The patients on whom I perform this procedure do not have a hammertoe per se. What I am treating is predislocation syndrome, which is associated with plantar plate dysfunction in association with weakness of the long flexor tendon, second dorsal interossei and the first lumbricale of the affected digit. This combination of structural and functional abnormalities results in destabilization at the level of the plantar plate, elevation at the MPJ and transverse plane luxation (often medially), most commonly seen in the second digit.

Hammertoe, in contrast, is associated with overpowering by the flexor digitorum longus, which prompts retrograde buckling at the MPJ level and often high angulation flexion at the proximal interphalangeal joint (PIPJ) level. The apex of deformity for the hammertoe is at the PIPJ and in longstanding cases affects the MPJ secondarily. Predislocation is associated with an apex of deformity at the MPJ and, secondarily, subtle and flexible contracture occurs within the distal digit.

Q: Doesn't pinning the MPJ freeze the MPJ in place and stabilize the toe?

A: Pinning across the MPJ is a procedure that I had previously used to stabilize the toe after a sequential reduction and internal fixation. I have learned over time that running a pin, often 1.25 mm in diameter, through the metatarsal head produces articular damage that may or may not cause degenerative change within the MPJ.

When this does occur, collapse of the metatarsal head and the risk of symptomatic osteoarthritis or even avascular necrosis is possible. That aside, after three to four weeks when the K-wires are typically removed, patients may have a difficult time returning to more normal weightbearing function due to stiffness at this level. The resulting imbalance and overloading at this joint level often cause a transfer of weight to the lesser metatarsals, and may prompt fatigue fracture or painful intramedullary edema in those regions.

Sherman and colleagues published an article on the Keller procedure in which they demonstrated the ill effect of pinning across the hallux interphalangeal joint, showing degenerative and long-lasting change in this region.2 Two of their most significant findings in these cases were the stiffness and degenerative changes documented at this level one year after surgery. They related concern about the long-term impact this would have.

On that note, it would seem that pinning across the MPJ is an invasive technique that causes at minimum (depending on the technique) a singular osteochondral defect that may not be necessary to achieve digital stabilization.

The more important consideration is determining what condition one is treating. This will determine what it will take to reduce deformity and restore balance across the MPJ. Where is the apex of deformity? What structures are involved? Where is the target of tenderness?

In summary, if the answers to these questions fit with instability at the MPJ level, then decompressing the joint and stabilizing the plantar plate will be required. This, in my opinion, does not require pinning across the MPJ.

Q: How exactly are you stabilizing the plate with the suture and button technique?

A: I do not suggest that others perform this procedure. I present this preliminary information as a basis for discussion and debate. To date, I have performed this procedure in only a few patients in whom I have stabilized seven digits. The associated structural and functional considerations in each of these cases are unique and I will discuss them in detail at a later date.

The technique has been refined and now includes simply using straight Keith needles and 3-0 Vicryl suture. Run the suture over the anatomic neck of the metatarsal and the proximal metaphyseal-diaphyseal junction of the proximal phalanx. Run the suture along the medial and lateral aspects of the metatarsal head and phalangeal base, and then run the suture out the plantar fat pad. Then these free suture ends are secured through a sterile button and secure the button with a strand of multiple hand ties. Finally, it is important to interpose drain sponges between the button and the skin.

The buttons remain intact until they either fall off or are removed in four to six weeks. The patient is allowed to heel weight bear in an OrthoWedge shoe immediately after surgery. Return to full weightbearing is determined by consolidation of the associated second metatarsal osteotomy.

In Summary

To date, in my own experience, I have achieved the goals of re-establishing position and alignment of the second MPJ. Elimination of forefoot pain and subjective satisfaction has been excellent in this very short-term follow-up.

Patients have been appreciative of the fact that this procedure does not require external pins and the risk of infection associated with those devices is obviously eliminated. The surgeon’s satisfaction with the procedure comes as much from the patient's return to function and overall well-being as it does the radiographic findings.

Thank you to all of the readers who have been pondering this discussion and given it careful consideration. I invite your questions or concerns, and am happy to entertain further discussion and debate.


1. Personal communications with Luke Cicchinelli, DPM, and the late Gerard V. Yu, DPM, the originator of the term predislocation syndrome

2. Sherman KP, Douglas DL, Benson MK. Keller’s arthroplasty: is distraction useful? A prospective trial. J Bone Joint Surg Br. 1984; 66(5):765-9.


Is this procedure used in conjunction with a Weil type lesser met osteotomy?

Do the sutures exit through the same plantar skin holes or separately on each side of the joint?

Essentially you aren't truly repairing the plantar plate, so this seems more like a temporary digital stabilizing technique. Once the button is removed, what prevents the digit from gradually migrating dorsally again?

Dr. Levin,

I appreciate your reading the blog and taking the time to consider the technique. You are correct in that the procedure I described was not a repair of the plantar plate. The cases that I have used this in to date have not shown a frank tear or rupture of the plantar plate to be repaired. If there is an obvious tear or rupture of the plantar plate, yes, that is suggested. What these cases did have in common was imbalance about the lesser MTPJ region which was addressed by shortening the metatarsal and stabilizing the plantar plate beneath the metatarsal head using the suture button technique. This technique stabilizes the MTPJ much the same as would be achieved using the traditional K-wire across the MTPJ and into the proximal metatarsal technique. The suture button technique eliminates the use of external k-wires and eliminates the postoperative stiffness often secondary to the digital dissection and arthrodesis.

When subluxation of the lesser MTPJs occurs, the destabilizing effect may be due to chronic traction and attenuation, partial tear or rupture of the plantar plate, loss of the medial or lateral collatoral ligaments, defects within the capsule, intrinsic muscle weakness (1st lumbricale, 2nd dorsal interossei ) and extrinsic muscle weakness ( FDL), which may each be contributory in isolation or in combination.

In short, there are a number of factors that lead to the destabilization of the lesser MTPJ. So a direct repair is not always required but stabilization while the area scars is essential to postoperative success. I have encouraged my patients that they will be required to use the metatarsal sling pad device as a long-term method to prevent recurrence of this deformity and they express a good understanding of this concept pre-operatively. The orthotic devices are not a substitute for a metatarsal sling pad and that is an important concept. Thank you for your query and I hope this helps with understanding the intent of this article.

Best regards,


Yes, I perform a 2nd metatarsal osteotomy & prior to fixation of that, you can easily visualize the plantar plate as it is fixed in its soft tissue bed beneath the metatarsal head identical to how the sesamoid apparatus appears beneath the first metatarsal head. Using the suture, you run each pass through the plantar plate corresponding to the four areas of bone that you are harnessing with the suture; the medial and lateral metatarsal neck as well as the medial and lateral phalangeal base. The suture is run out through the small, fibrous pea-sized labrum, the plantar plate, stabilizing the plate beneath the MTPJ. This provides stabilization without the osteochondral damage caused by the more traditional approach where a k-wire is run across the joint.

The more traditional approach involves arthrodesis and running a k-wire through the MTPJ and into the proximal metatarsal shaft. This updated suture and button technique avoids a lot of the dissection in the digital compartment and eliminates the need for joint destruction at the PIPJ level. In total, avoiding extensive digital dissection and osteochondral damage seems to reduce postoperative edema and stiffness allowing for a more smooth transition to full weightbearing.

Once again, I would like to emphasize that my experience with this technique is preliminary and while the early postoperative outcomes at 8.5 months have been rewarding, long-term outcome data is not yet available. I will certainly post long-term results as that information becomes available. To date, the longest follow up I have is 8.5 months and the clinical picture looks very good. These three patients are considering the same procedure for their contralateral digits. Although one patient feels that since they are walking more normally, the opposite forefoot is not as painful. Continued use of metatarsal sling pads in this patient may be the only long-term intervention required. Remember that an Orthofix device is supplemental therapy and is NOT A SUBSTITUTE for the metatarsal sling pad device.

Thank you for your interest and I am happy to address any further questions that you may have concerning this technique.

Best regards,

Molly S. Judge, DPM

Add new comment