Plantar Plate Repair via a Direct Plantar Approach: An Outcomes Analysis Mark A. Prissel, DPM, AACFAS; Christopher F. Hyer, DPM, MS, FACFAS; Jacqueline K. Donovan, DPM; Amanda L. Quisno, DPM Orthopedic Foot & Ankle Center | Columbus, OH | 614-895-8747 | www.orthofootankle.com

INTRODUCTION: RESULTS: Plantar plate injury is an underdiagnosed and A Ultimately, 131 patients (144 toes) were included and the Table 1: Unique Patients Table 3: Pre- Post- Demographic Characteristics (n=131) Foot Function Index (FFI) Operative Operative p-value difficult to treat pathology (1-21). Surgical response rate for mailed surveys was 52.8% (76 of 144 nd Female, n (%) 107 (81.7) Scores (n=74) (n=74) management of the dorsally subluxed 2 toes). Clinical outcomes reported a well-aligned toe in Age, mean (SD) 58.6 (10.2) FFI total score, mean (SD) 42.0 (22.6) 21.3 (20.2) <0.001 metatarsophalangeal joint (MTPJ) is challenging, 87.1% of cases, with a recurrence rate of 7.6% (11 of 144) Body mass index, mean (SD) 28.8 (5.2) FFI subscales, mean (SD) with sometimes unpredictable long-term result Side(s), n (%) Pain 51.8 (23.7) 26.4 (25.8) <0.001 and a revision rate of 2.8% (4 of 144). Statistically Right 70 (53.4) Disability 45.0 (27.2) 22.7 (22.8) <0.001 (1,3,4,10,12-21). Direct plantar plate repair significant improvement in overall modified FFI (p<0.001) Left 58 (44.3) Activity limitation 15.5 (18.3) 8.5 (15.1) 0.001 techniques via a plantar approach have been Both 3 (2.3) and subscales scores for pain (p<0.001), disability Number of affected toe(s), n (%) Table 4: Affected Toes described in expert opinion or technique guides, Plantar Plate Repair Satisfaction (n=76) (p<0.001), and activity limitation (p=0. 001) were noted One 118 (90.1) Figure 2: MRI image of a planar plate tear. with few reports of outcomes or clinical result Two 13 (9.9) Current pain level of affected toe, 2.0 (0.0 – 10.0) post-operatively when compared to pre-operative data. The median (range) (3,18-21). More recently, in addition to direct Clinical Characteristics Affected Toes (n=144) B median post-operative VAS pain level reported at the time Affected toe, n (%) Affected toe touches the ground plantar plate repair techniques via plantar of survey completion was 2.0 (range 0.0 – 10.0; mean 2.3; 2nd 128 (88.9) when standing, n (%) DISCUSSION: approach, dorsal techniques have been developed 3rd 16 (11.1) Yes 55 (72.4) SD 2.6). Regarding the subjective patient survey, patients No 21 (27.6) Despite the modified FFI scores, patient secondary to concerns regarding potential painful Pre-operative diagnosis reported 72.4% of affected toes to “touch the ground when Plantar plate tear 55 (38.2) Scar on the bottom of the foot satisfaction questionnaire data reported plantar scars and wound healing complications standing.” There was no difference in patient satisfaction MTP instability 39 (27.1) causes pain, n (%) mixed results. Our modified FFI results Crossover toe 28 (19.4) Yes 24 (31.6) (1,10,12-15). The purpose of this retrospective with the outcome of the procedure for toes that touched the No 52 (68.4) demonstrate this approach provides Figure 1: (A) Anteroposterior MTP dislocation 13 (9.0) review was to determine the outcomes of a Experienced wound healing excellent post-operative pain relief, radiograph of a 2nd plantar plate ground compared to toes that did not touch the ground Hammertoe deformity 7 (4.9) nd rd complication(s) with the incision, improvement of associated disability, and previously described plantar plate repair technique tear, (B) Lateral radiograph of a (χ2(1): 1.73; p=0.188). Patients were more likely to report 2 /3 MTP instability 2 (1.4) Concomitant Weil osteotomy 82 (56.9) n (%) improvement of activity limitations. The (3). chronic dislocated 2nd toe. being dissatisfied with the outcome of the procedure for Yes 7 (9.2) performed, n (%) importance of managing patient toes in which the scar on the bottom of the foot caused No 69 (90.8) METHODS: Table 2: Affected Toes Knowing what the patient knows expectations is acknowledged secondary to A retrospective analysis of patients 18 years of age and older who underwent direct 2nd or pain compared to toes in which the scar on the bottom of Clinical Outcomes (n=144) now about the procedure and Days to final clinical follow-up, median (range) 196.5 (29.0 – 793.0) the discrepancy with patient satisfaction rd the foot caused no pain (76.2% and 26.0%, respectively) recovery, the patient would have 3 plantar plate repair via plantar approach with or without concomitant Weil osteotomy at Toe position on final clinic note, n (%) data and the modified FFI results. Further (χ2(1): 15.42; p<0.001). Returned patient surveys indicated this repair again, n (%) a single foot and ankle specialty practice from December 2010 through April 2014 Good/excellent/well-aligned 121 (87.1)* Yes 42 (55.3) prospective study is warranted comparing identified via chart review, as well as, a prospective patient reported subjective outcomes self-perceived wound healing complications in 7 toes Elevated MTPJ / dorsiflexed toe 9 (6.5)* No 33 (43.4) this technique to alternate dorsal (9.2%, 7 of 76), interestingly contrary to the clinical Transverse malalignment 4 (2.9)* No response 1 (1.3) analysis was performed. Patients who underwent revision plantar plate repair, indirect Plantarflexed toe / Overcorrection 4 (2.9)* Satisfied with the outcome of the approaches for plantar plate repair with and (e.g. dorsal approach) plantar plate repair, underwent other surgical repair of the 2nd documentation review reporting 6 toes (4.2%, 6 of 144) Rigid 1 (0.7)* procedure, n (%) without associated commercially available Complications, n (%) MTPJ (e.g. Girdlestone-Taylor procedure), experienced acute surgical repair of plantar with wound healing complications. For 55.3% (42 of 75) of Extremely satisfied 21 (27.6) suture passing systems. affected toes, the patient reported that knowing what they Wound problems 6 (4.2) Somewhat satisfied 21 (27.6) plate injury, patients younger than 18 years of age at the time of surgery, or patients Recurrence 11 (7.6) Neutral 5 (6.6) without adequate available medical record documentation were excluded. know now about the procedure and recovery, he/she would Revision 4 (2.8) Somewhat dissatisfied 21 (27.6) have this repair again in the future if needed. Extremely dissatisfied 8 (10.5) REFERENCES: 1. Watson TS, Reid DY, Frerichs TL. Dorsal approach for plantar plate repair with Weil osteotomy: operative technique. Foot Ankle Int. 2014 May;35(7):730-739. 12. Sullivan M, Panti JP. The use of McGlamry elevator to assist suture passing in the dorsal technique of plantar plate repair with Weil osteotomy for lesser metatarsal joint instability. Foot Ankle Spec. 2015;8(3):209-11. 2. Sung W, Weil L Jr, Weil LS Sr, et al. Diagnosis of plantar plate injury by magnetic resonance imaging with reference to intraoperative findings. J Foot Ankle Surg. 2012;51(5): 570-574. 13. Doty JF, Coughlin MJ. Metatarsophalangeal joint instability of the lesser toes. J Foot Ankle Surg. 2014;53:440-5. 3. McAlister JE, Hyer CF. The direct plantar plate repair technique. Foot Ankle Spec. 2013 Dec;6(6):446-51. 14. Sung J. Technique using interference fixation repair for plantar plate ligament disruption of lesser metatarsophalangeal joints. J Foot Ankle Surg. 2015;54:508-12. 4. Nery C, Coughlin MJ, Baumfeld D, et al. Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears. Foot Ankle Int. 2014 Sep;35(9):876-85. 15. Sanhudo JAV, Gomes JLE. Pull-out technique for plantar plate repair of the metatarsophalangeal joint. Foot Ankle Clin N Am. 2012;17:417-24. 5. Nery C, Coughlin MJ, Baumfeld D, et al. MRI evaluation of the MTP plantar plates compared with arthroscopic findings: a prospective study. Foot Ankle Int. 2013 Mar;34(3): 315-22. 16. Chalayon, O, Chertman C, Guss AD, Saltzman CL, Nickisch F, Bachus, KN. Role of plantar plate and surgical reconstruction techniques on static stability of lesser metatarsophalangeal joints: a biomechanical study. 6. Klein EE, Weil L Jr, Weil LS Sr, et al. Clinical examination of plantar plate abnormality: a diagnostic perspective. Foot Ankle Int. 2013 Jun;34(6):800-4. Foot Ankle Int. 2013;34(10):1436-42. 7. Klein EE, Weil L Jr, Weil LS Sr, et al. The underlying osseous deformity in plantar plate tears: a radiographic analysis. Foot Ankle Spec. 2013 Apr;6(2):108-18. 17. Ford LA, Collins KB, Christensen JC. Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate. J Foot Ankle Surg. 1998;37(3):217-22. 8. Barouk LS. Weil's metatarsal osteotomy in the treatment of metatarsalgia. Orthopade.1996; 25:338–44. 18. Camasta CA. Plantar plate repair of the second metatarsophalangeal joint. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery Fourth Edition, Volume 1. 2013:pp 187-201. 9. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg Br. 1951; 33:539–42. 19. Blitz NM, Ford LA, Christensen JC. Plantar plate repair of the second metatarsophalangeal joint: technique and tips. J Foot Ankle Surg. 2004;43(4):266-70. 10. Weil L Jr, Sung W, Weil LS Sr, Malinoski K. Anatomic plantar plate repair using the Weil metatarsal osteotomy approach. Foot Ankle Spec. 2011 Jun:4(3):145-50. 20. Powless SH, Elze ME. Metatarsophalangeal joint capsule tears: An analysis by arthrography, a new classification system and surgical management. J Foot Ankle Surg. 2001;40(6):374-89. 11. Highlander P, VonHerbulis E, Gonzalez A, Britt J, Buchman J. Complications of the Weil osteotomy. Foot Ankle Spec. 2011;4(3):165-70. 21. Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. 1987;10(1):83-9.