1) One should perform a small dorsal incision for release of the MPJ contracture and a metatarsal osteotomy (if necessary) first.
2) Complete a partial tear in a transverse fashion and resect 2 to 3 mm of redundant plantar plate once you have pinned the toe and MPJ with a wire.
3) Utilize a pants-over-vest primary repair with a non-absorbable suture and a UR-6 needle to allow for easier suture passing.
4) If one encounters a complete tear from the proximal phalanx, consider a small suture anchor in the proximal phalanx for added fixation.
5) Maintain the use of a wire in a plantarflexed position for at least four weeks postoperatively during healing.
6) Careful anatomic dissection and retraction, as well as eversion of skin edges during closure, will help prevent a painful plantar scar.
Correcting The Crossover Toe With Direct Plantar Plate Repair
One should ensure supine positioning of the patient on the operating room table and the use of a well-padded thigh tourniquet. We most frequently utilize a regional popliteal block and general anesthesia. First, make a dorsal incision over the MPJ to address the soft tissue dorsiflexion contracture. Carry dissection down to the level of the MPJ where you can perform a transverse capsulotomy and release of the collateral ligaments. If a concomitant shortening metatarsal osteotomy or hammertoe correction is also indicated, perform that procedure at this time. Following the release of the MPJ from the dorsal incision, place a wire by hand from dorsal to plantar through the MPJ and plantar skin to identify the proper location for the plantar incision.
Proceed to make a curvilinear plantar incision around the wire for the direct visualization of the plantar plate. One can then remove the wire and perform further layered dissection. Using a self-retaining soft tissue retractor is helpful to protect the digital neurovascular bundle and spread the subcutaneous tissue present in this location. After identifying the flexor digitorum longus and brevis tendon sheaths, incise the sheaths parallel to the tendons and retract them medially or laterally.
At this point, the plantar plate is readily identifiable. The plantar plate is a thick fibrocartilaginous structure having attachments at both the proximal phalanx and metatarsal head. Most commonly, one will see a transverse partial plantar plate tear at the level of the insertion into the base of the proximal phalanx. A proposed anatomic grading system can be helpful in classifying the extent of the plantar plate tear.9 If a partial tear or attenuation is visible in the plantar plate, the surgeon must complete the tear in order to perform an adequate end-to-end repair.
To allow for repair of the plantar plate, pin the toe and metatarsal in slight plantarflexion with a 0.062 inch wire. This plantarflexed position will allow the resection of a 2 to 3 mm wedge of redundant plantar plate in order to complete a primary repair. Repair of the plantar plate occurs with a #0 or #2 absorbable suture in a pants-over-vest manner. If we encounter a complete tear, we will perform the repair with a small suture anchor to provide additional stability with the fixation into bone.
Then close the incision in layers with absorbable and non-absorbable sutures with proper skin eversion. Place the extremity in a posterior compression splint and emphasize a non-weightbearing gait for the patient in the first postoperative week. After one week, physicians can allow patients to wear an immobilizing boot with heel-touch weightbearing for an additional three weeks. At four weeks, one typically removes the wire in the office and permits weightbearing in a tennis shoe.
We have found this direct plantar approach repair of plantar plate tears to be our preferred technique. Increased visualization of the anatomic structures and a direct primary repair of the plantar plate allow a dramatic correction of the deformity. Careful dissection and closure have minimized painful plantar scars. Additionally, this repair has also eliminated a floating toe or the recurrence of the deformity postoperatively.
Dr. Peterson is a Fellow at the Orthopedic Foot and Ankle Center in Westerville, Ohio.
Dr. Hyer is a Fellow of the American College of Foot and Ankle Surgeons, and serves on its Board of Directors. He is the Fellowship Director and an attending physician at the Orthopedic Foot and Ankle Center in Westerville, Ohio.