Current Insights On Treating Second MPJ Dysfunction
In cases in which the second metatarsal is long or plantarflexed, and associated with chronic, well localized forefoot pain, then decompression of the MPJ should be the primary procedure. Repairing the primary stabilizing structure of the MPJ (the plantar plate) becomes a mandatory adjunct. If in fact we have the process backwards, we should be decompressing the MPJ as our first maneuver in the stepwise approach to MPJ dysfunction. This may make the routine practice of arthroplasty/arthrodesis nearly obsolete.
Jolly and colleagues popularized the repair of the plantar plate and the procedure has received much attention in the literature ever since.5 Numerous authors have suggested variations in approach to this repair.6 Surgeons generally employ the technique in conjunction with a second metatarsal osteotomy. Weil Sr. and Weil Jr. provided a detailed review of their approach to MPJ pathology.7 They supported the repair of the plantar plate after completing successful shortening of the second metatarsal.
While I was intrigued by the device the authors described for securing suture in repairing the plantar plate, it became apparent that this technique was not a simple one.7 The space available for the repair of the plantar plate is scant and even the most slender of fingers will be challenged by performing the required maneuvers. I have since developed a modified approach to stabilizing the plantar plate and have found it quite rewarding in the few patients in whom I have selected to use it.
Before going into the details of this technique, I submit to you that most patients I evaluate and treat for MPJ pain and dysfunction recover from their symptoms and impairment very well with the benefit of digital stabilization and accommodative padding of the joint. I believe conservative methods can slow if not halt progressive lesser MPJ dysfunction. The key is in early identification of the condition and proper patient education.
Step-By-Step Pointers On Using The Suture And Button Technique
It bears mentioning that I prefer to avoid plantar approach incisions to this dissection as I think the hazards of that outweigh the benefit in the ease of exposure of the plantar plate.
Make a dorsolinear incision. Start over the distal aspect of the second metatarsal and extend it onto the digit beyond the proximal phalanx base. Identify and isolate the second MPJ. One can subsequently perform a dorsolinear capsulotomy to expose the metatarsal head and proximal phalanx, and the chondral surface of the metatarsal head. Then begin a frontal plane osteotomy at the distal aspect of the dorsum of the anatomic neck of the metatarsal, and make a cut proximal and plantar, creating a long plantar wing.
Translocate the metatarsal head proximally to achieve joint decompression. The metatarsal head will shift independently given the fact that its previously elongated condition loaded the metatarsal head and elevated the physiologic pressure there. The prevailing thinking is this intraarticular pressure causes the joint inflammation and chronic wear and tear that ultimately disrupts joint function, leading to symptoms. Surgical experience in osteotomizing a long second metatarsal demonstrates this phenomenon and underlines the importance of shortening the second metatarsal bone when attempting to correct MPJ dysfunction.
With the metatarsal head disarticulated, it is easiest to evaluate the plantar plate from this dorsal approach. In my limited experience with this procedure, the plate itself is not usually deviated in a direction commensurate with the subluxation of the digit. Homologous to the relationship between the first metatarsal head and the sesamoid apparatus, it is the metatarsal head that seems to be shifted out of position.8 Once one has decompressed the joint, the realignment of the metatarsal osteotomy restores the anatomic relationship between the plantar plate and the metatarsal head.