Plantar Plate Ligament Augmentation Using the Forefoot InternalBrace™ System Surgical Technique Plantar Plate Ligament Augmentation Using the Forefoot InternalBrace™ System Arthrex is pleased to add the Plantar Plate InternalBrace ligament augmentation technique to our extensive product offering for lesser metatarsophalangeal (MTP) joint instability. This technique can be performed using the Forefoot InternalBrace ligament augmentation repair system and is designed to be used in instances where a direct plantar plate repair may prove difficult (ie, stage IV plantar plate tears or any other complex type of plantar plate tear). It is important to note that this technique can be performed with or without a Weil osteotomy. The plantar plate augmentation technique provides a simple time-zero construct1 to treat plantar plate pathology and restores the normal alignment of the lesser MTP joints. Due to the proximal nature of the 1 hardware at the phalanx, the plantar plate InternalBrace ligament augmentation procedure can be easily With the patient in the supine position, make a dorsal combined with a proximal interphalangeal joint longitudinal incision at the center of the MTP joint. (PIP) fusion. The collateral ligaments should be released at the base of the proximal phalanx. Reference 1. Viens NA, Wijdicks CA, Campbell KJ, Laprade RF, Clanton TO. Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Broström repair techniques with the intact anterior talofibular ligament.Am J Sports Med. 2014;42(2):405-411. doi:10.1177/0363546513510141. 2 Use a McGlamry elevator to release the proximal plantar plate. If the metatarsal is long and contributing to the pathology, a Weil osteotomy can be performed to shorten the overall length of the metatarsal. The cut should be made 1 mm to 2 mm below the dorsal aspect of the articular surface and aimed such that the cut is parallel to the weight-bearing surface of the foot. The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation. 01 I Plantar Plate Internal Brace Ligament Augmentation System Plantar Plate Ligament Augmentation Using the Forefoot InternalBrace™ System 3 Use a K-wire to temporarily fixate the Weil osteotomy in the desired FINAL position. A second K-wire can be placed in the proximal phalanx as a joystick. Resect the plantar plate from the base of the proximal phalanx. 4 Next, insert a bicortical K-wire proximally at the metatarsal, angled towards the joint. Proceed to drill a bicortical tunnel with the 2.5 mm cannulated drill. It is important to leave at least a 5 mm bone bridge between the K-wire for the InternalBrace ligament augmentation procedure and the K-wire for the Weil osteotomy. Plantar Plate Internal Brace Ligament Augmentation System I 02 Plantar Plate Ligament Augmentation Using the Forefoot InternalBrace™ System 5 Insert the straight Micro SutureLasso™ suture passer through the prepared bone tunnel in the metatarsal. Use the sharp tip of the lasso to also puncture through the plantar plate remnant. (Tip: Use forceps to hold tension on the plantar plate to facilitate puncturing through the plantar plate.) At this point, shuttle the lasso wire and retrieve the wire through the dorsal incision. Load a doubled-over LabralTape™ suture into the wire loop and shuttle the suture and wire through the metatarsal tunnel. Note: A McGlamry elevator can be placed plantar to the plantar plate to help facilitate passage of the lasso wire. As an alternative, the Pigtail SutureLasso right and left curves can be used to shuttle the LabralTape suture deep to the plantar plate. Note: make sure the LaberalTape loop in the metatarsal is secured with a hemostat so the loop is not pulled through the bone tunnel while shuttling the sutures. 6a When the plantar plate has been completely mobilized, load the Mini Scorpion™ DX suture passer with SutureTape. Use a pick-up to stabilize the plantar plate as the Mini Scorpion DX suture passer is inserted into the MTP joint and grasp the plantar plate medially or laterally by closing Mini Scorpion DX suture passer using the lever handle on the device. With the suture passer in place, squeeze the instrument with the palm of your hand, advancing the needle and suture through the tissue. The needle will retract when the handle is released. 03 I Plantar Plate Internal Brace Ligament Augmentation System Plantar Plate Ligament Augmentation Using the Forefoot InternalBrace™ System 6b Surgical Pearl: When ready to engage the needle and pass the suture in the plantar plate, rotate your hand 45° to prevent the needle from hitting the metatarsal head. When passed through the plantar plate, the suture locks into the “trap-door” feature of the Mini Scorpion DX suture passer, allowing for easy retrieval and “blind” shots. Retract the Mini Scorpion DX suture passer from the tissue and release the suture. Reload the free end of the SutureTape into the Mini Scorpion DX suture passer and throw a second stitch into the plantar plate 3 mm to 5 mm medial or lateral to the initial stitch placement. As an alternative, the CPR™ Viper can be used in the same manner to pass the SutureTape through the plantar plate. This is a useful tip when space is limited or when a Weil osteotomy will not be performed. 7 8 Remove the joystick K-wire and place the appropriate K-wire bicortically through the proximal phalanx, once again aiming toward the joint. Use the 2.5 mm cannulated bit to drill a bicortical tunnel in the phalanx. Plantar Plate Internal Brace Ligament Augmentation System I 04 Plantar Plate Ligament Augmentation Using the Forefoot InternalBrace™ System 9 Once more, use the straight Micro SutureLasso™ suture passer to shuttle a wire loop from dorsal to plantar, now through the proximal phalanx. Feed the two free limbs of LabralTape™ suture as well as the four free ends of the SutureTape sutures into the wire loop and shuttle the construct through the proximal phalanx. Note: To ease the shuttling process, it may be useful to shuttle the LabralTape suture first, then pass the straight Micro SutureLasso suture passer again and shuttle the SutureTape sutures. 10 Fixate the Weil osteotomy with the QuickFix™ cannulated screw system using one or two 2 mm × 11 mm and 2 mm × 13 mm snap-off screws. Typically, there is only 1 mm to 2 mm of shortening at the osteotomy site. The QuickFix clamp helps prevent rotation of the capital fragment and plantar gapping of the osteotomy. To begin to secure the plantar plate primary repair as well as the InternalBrace™ ligament augmentation procedure, implant the 3 mm × 8 mm PEEK Tenodesis screw into the proximal phalanx, spreading both the LabralTape and SutureTape sutures and putting the screw in between. Note: Make sure the LabralTape loop is secured with a hemostat so the loop is not pulled through the metatarsal tunnel when securing the proximal phalanx screw. 05 I Plantar Plate Internal Brace Ligament Augmentation System Plantar Plate Ligament Augmentation Using the Forefoot InternalBrace™ System 11 12 Prior to implanting the final screw, simulate For final fixation, you may simply cut flush to the bony weightbearing and ensure that the patient has the surface. proper amount of dorsiflexion while also preventing the floating toe phenomenon. Once the adequate tension has been applied, split the LabralTape™ loop to the medial and lateral aspect of the metatarsal and insert the last 3 mm × 8 mm PEEK Tenodesis screw into the metatarsal. Post-op Protocol ■ Weeks 0-2: Post-op shoe or CAM boot to protect incisions. Heel weightbearing. Toes unrestricted. Active motion of toes encouraged. Dressing to remain on until week 2 follow-up. ■ Weeks 2-4: As long as full bone healing is present, advance to weightbearing as tolerated in post-op shoe or CAM boot (heel weightbearing until week 6 if concurrent hallux valgus osteotomies performed); transition to regular footwear as tolerated by week 4. Passive ROM activities for toes, including toe crunches, initiated under physical therapy guidance. Pool therapy to begin if wounds allow. ■ Weeks 4-6: Regular footwear as tolerated. Unrestricted active and passive toe ROM. Low-resistance biking, elliptical, walking. ■ Week 6: Advance activities as tolerated. Plantar Plate Internal Brace Ligament Augmentation System I 06 Ordering Information Forefoot InternalBrace™ System Mini Scorpion DX CPR Instrument Set (AR-8690S) Product Description Item Number Product Description Item Number 3 mm × 8 mm PEEK Tenodesis Screw AR-1530P-CP Mini Scorpion DX AR-8999 LabralTape™ Suture, white/black, 36 in, 1.5 mm, qty. 2 Small Joint Distractor AR-8690SJD #2 FiberTape® Suture, blue #0 TigerWire® Suture w/ Needle, white/green McGlamry Metatarsal Elevator AR-8930M 4-0 FiberLoop® Suture w/ Needle, blue, 12 in QuickFix Clamp AR-8930MC Micro SutureLasso™ Suture Passer, straight w/ wire Small Handle w/ AO Connection AR-2001AOT Oblong Button, 2.6 mm Guidewires, 43 in × 4.75 in, qty. 2 Driver Shaft for QuickFix Screw, 2 mm AR-8930D Drill, cannulated, 2.5 mm QuickFix Screw Cutter, 2 mm AR-8930R Drill, cannulated, 3.0 mm Metatarsal Head Pusher AR-8690P Suture Retrieval Funnels, qty. 2 Mini Scorpion Instrument Case AR-8690C Suture Passing Wire, 8 in If performing a Weil osteotomy, the following QuickFix™ screws