Current Concepts In Plantar Plate Repair

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

How Patients Have Fared Following The Procedure

Our early results of this procedure were published in Foot and Ankle Specialist in 2011.17 Postoperative visual analogue scale pain scores decreased from 7.3 + 1.6 to 1.7 + 1.8. Eighty-five percent of patients reported improved function and 77 percent of patients were satisfied or very satisfied with the outcome of the procedure. For this group of patients, there were two complications: painful hardware and continued metatarsalgia. There were no incidences of dehiscence, malunion, non-union or recurrent MPJ subluxation or dislocation.

   Since the time of that study’s publication, we have performed many more procedures, all with similar and significant reduction in pain level postoperatively. There have been a few patients who have sustained significantly painful post-op stiffness that has resolved after a joint manipulation with the patient under anesthesia. Further results will be available with longer follow-up of this larger cohort of patients.

In Conclusion

Through our research, we conclude that the incidence of plantar plate pathology is far more prevalent than commonly appreciated. In a randomized group of 20 cadavers, 80 percent of specimens had plantar plate tears.12 Anytime we see a painful metatarsalgia with plantar swelling at the MPJ, we suspect a plantar plate tear.

   An appropriate clinical exam and radiographs can help detect plantar plate problems. Magnetic resonance imaging and ultrasound can help accurately define the presence and location of plantar plate deficits.

   Previously, surgeons would have to choose whether to realign the metatarsal position or repair the plantar plate. Both procedures provide successful outcomes but have limitations as neither addresses the entire pathology involved. The dorsal approach for anatomic plantar plate repair provides a combined alternative to fully correct the complex nature of both a plantar plate repair and metatarsal deformity. The dorsal approach of this procedure allows the surgeon appreciation of both severe and subtler plantar plate injuries that may not be clearly evident from a plantar approach. This approach also allows for metatarsal realignment and prevention of a plantar scar.

   We believe that with further attention and research, we can better understand, diagnose and treat plantar plate problems to provide surgeons and patients alike with the most optimal results.

   Dr. Weil is the President and Fellowship Director of the Weil Foot, Ankle and Orthopedic Institute. He also serves as the Editor of Foot and Ankle Specialist. Dr. Weil is a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Klein is the Reconstructive Foot and Ankle Surgical Fellow at the Weil Foot, Ankle and Orthopedic Institute.

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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