Current Concepts In Plantar Plate Repair

Author(s): 
Lowell Weil Jr., DPM, FACFAS, and Erin E. Klein, DPM, MS

Do you find yourself in certain cases choosing between metatarsal realignment and plantar plate repair? Given this dilemma, these authors suggest that combining the Weil osteotomy with a dorsal approach to the anatomic plantar plate may be beneficial in addressing both plantar plate tears and metatarsalgia.

With any surgical procedure, there are problems and complications. The most commonly discussed problem associated with the Weil osteotomy is the “floating toe.” Studies had identified the floating toe to occur 15 to 50 percent of the time following a Weil osteotomy.1-3 The floating toe does not touch the floor with neutral weightbearing after undergoing a metatarsal osteotomy.

   Additionally, there is weakness and decreased ability to plantarflex the toe actively. Many have theorized as to the cause of floating toe and have suggested modifications to the procedure in order to prevent its occurrence.4-7 However, most of these changes have not altered the outcome and increased other complications (transfer metatarsalgia, stiffness, edema, etc.) and disability postoperatively.

   For years, we have been trying to find a solution to the problem, whether it is making sure to perform the procedure in the articular surface to prevent plantar translation, performing appropriate dorsal soft tissue release, encouraging early physical therapy (seven days postoperative), and emphasizing plantarflexion strength and night splinting of the toe. Nonetheless, floating toe still occurred, although at rates much lower than cited in the literature. In our most unstable metatarsophalangeal joints (MPJs), we started trying to repair the plantar plate in conjunction with the osteotomy but with limited success due to the difficulty of exposure from the dorsal approach.

   In the fall of 2007, the lead author had given a lecture on the Weil osteotomy at a Podiatry Institute conference in Florida. Immediately following the lecture, Craig Camasta, DPM, gave a lecture on plantar plate pathology and repair. Dr. Camasta was one of the real leaders in discussing the plantar plate and he made a very compelling argument as to the role of the plantar plate in lesser metatarsophalangeal joint problems. Listening to Dr. Camasta’s rationale made the lead author strongly consider the possibility that plantar plate insufficiency may have more to do with the painful metatarsalgia entity and postoperative floating toe problems than previously appreciated. It also made him think that combining the Weil osteotomy with a plantar plate repair would be the best of both worlds.

   Later in the exhibit hall, the lead author came across a company that was showing bone anchor concepts that were the standard of care for arthroscopic rotator cuff repair at the time. The delivery system for repairing the rotator cuff was something with which he was totally unfamiliar but he watched the salesman demonstrate the placement of sutures into tissue in a tight space. At that moment, he realized that he had a way to suture the plantar plate through the same dorsal exposure as the Weil osteotomy.

Comments

In your experience, do you think patients have plantar plate tears because of a long second metatarsal and a functional hallux limitus, or an elevated first ray? If so, do you treat the 1st MTPJ pathology surgically at the same time or just address the 2nd MTPJ?

Some patients I see who have ALL the signs and symptoms of a grade 1-2 plantar plate tear sometimes have negative MRI findings. When they do not respond to conservative treatment, I often have difficulty getting a surgeon to operate on them.

This is different in knees for some reason. Often, the knee surgeon will do exploratory surgery and find the issue and fix it in spite of a lack of MRI findings.

My question is: Do you operate with a lack of MRI findings and if so, do you often find the cause during the operation?

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