Current Concepts In Plantar Plate Repair

Start Page: 62
72
Author(s): 
Lowell Weil Jr., DPM, FACFAS, and Erin E. Klein, DPM, MS

   If the plantar plate has pathology, one must carefully dissect the entirety of the plantar plate off the base of the proximal phalanx. The flexor tendons run in close plantar (deep) proximity to the plantar plate at this level and one must take care not to cut them. After resecting the plantar plate off the phalanx, carry dissection proximally to create a full thickness flap of the plantar plate for advancement. A Freer elevator may be helpful to maintain a consistent level of tissue during this dissection.

   After completely mobilizing the plantar plate, utilize a Mini-Scorpion device from the Complete Plantar Plate Repair System (Arthrex) to create a wide three-stitch mattress. Remove the distraction device and place a right angle towel clamp around the sides of the proximal phalanx. Perform manual distraction/plantarflexion to expose the base of the proximal phalanx. Remove any soft tissue attachments on the plantar surface of the proximal phalanx base. Using a small curette, roughen the plantar bony surface to facilitate plantar plate reattachment.

   Create crossed bone tunnels in the proximal phalanx from distal dorsal medial to proximal plantar lateral. Create a second tunnel by drilling from distal dorsal lateral to proximal plantar medial. Then pass the sutures attached to the plantar plate from plantar to dorsal through the bone tunnels in the phalanx.

   Proceed to remove the temporary fixation for the metatarsal head and pull the metatarsal head to its desired length. It is rare to shorten more than 3 mm. After achieving accurate alignment, fixate the osteotomy with one or two Snap-Off screws.

   Plantarflex the phalanx to approximately 15 to 20 degrees. Then pull the sutures tightly to advance the plantar plate into the base of the proximal phalanx. Tie the sutures dorsally to secure the plantar plate position. The toe will appear plantarflexed. Then reapproximate deep tissue and skin, and apply a bulky compressive bandage to hold the second toe in plantarflexion. This bandage should remain in place for seven to 10 days with guarded partial weightbearing in a surgical shoe.

   After removing the bandages, instruct the patient to return to a supportive athletic shoe with guarded weightbearing. The patient receives a night brace to reduce swelling. This brace (AFTR DC brace with osteotomy strap, BioSkin) will serve as a night splint to hold the toe in plantarflexion. This night splinting technique helps prevent dorsal contracture and scar tissue formation that can lead to limited postoperative plantarflexion.

   Aggressive physical therapy begins at seven to 10 days postoperatively with particular emphasis on plantarflexion strength. Passive and active range of motion of the short and long flexor tendons — often under the direction of a physical therapist — two to three times a week is often included in the postoperative regimen.

   Patients are able to return to normal shoe gear six to eight weeks postoperatively and begin aggressive weightbearing activities.

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Michele Kurlanskisays: April 5, 2012 at 12:20 pm

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?

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Dr. Victor J Runcosays: January 20, 2013 at 8:39 am

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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