2. Lowell Weil, Jr., DPM, MBA

4. DAPPR We report the results of our case series of dorsal anatomic plantar plate repair in conjunction with a Weil osteotomy approach. EBM Level of evidence: IV, therapeutic, retrospective case series

5. DAPPR Background Attrition often results in metatarsalgia, plantar swelling, hammertoe deformity and lesser toe subluxation1-4. The plantar plate ligament is the principle stabilizer of the MTP joint It is firmly attached to the base of the proximal phalanx and more loosely attached to the metatarsal neck15,16. The integrity is essential to stabilize the proximal phalanx of the lesser toes.

6. Methods We retrospectively identified consecutive adult patients who were diagnosed with 2nd MTP instability from January 2007 to December 2009 and treated with dorsal anatomic plantar plate repair 29 patients (32 cases) Post-operative follow-up of >12 months

7. Methods Assessment Visual analog scale (VAS) AOFAS LMI clinical rating scale6 Statistical Analysis A paired student t-test was used to determine significance with p < 0.01.

8. Procedure Weil L, Jr., Sung W, Weil LS, and Glover JS. Correction of Second MTP Joint instability using a Weil Osteotomy and Dorsal approach Plantar Plate Repair. Tech Foot Ankle Surg. 10(1):33-39, March 2011 Video at www.youtube.com/weil4feet

9. Procedure Dorsal incision Incision between EDB & EDL tendons McGlamry elevator was used to free soft tissue attachments plantar to the metatarsal head

10. Procedure

11. Procedure

13. Procedure Capital fragment was retrograded Temporarily fixated Application of metatarsophalangeal joint distractor Mobilized plantar plate distally

14. Procedure

15. Procedure

17. Procedure Plantar plate grasped proximally (#0 fiberwire) Mattress stitch Created two crossing bone tunnels in proximal phalanx Passed ends of mattress stitch through bone tunnels Tied suture ends with toe in plantarflexion

18. Procedure

19. Procedure Capital fragment was aligned to anatomic contour Fixated with 2.5mm headless screw

20. Post-Operative Allowed immediate, guarded weight bearing in surgical shoe After one week, bandages were removed Placed into athletic shoe Physical therapy Maintain therapeutic splintage

21. Results Demographics 29 patients/32 second MTP joints Average age 56.4 years (35 – 71) Average follow-up 22.6 M (12 – 40) Average number of concurrent procedures was 2.2 per case. Bunionectomy Hammertoe correction Lesser metatarsal osteotomy

22. Results Average VAS Pre-operative 7.3 SD = 1.7; 95%CI = 6.7 to 7.9 Post-operative 1.5 SD = 1.8; 95%CI = 0.8 to 2.2 This was significantly different (P < 0.01). Average AOFAS LMIS Post-operative AOFAS LMIS 87.3 out of 100 SD = 10.8; 95%CI = 83.3 to 91.3

23. Results Plantar Plate Tears Completely torn transversely (greater than 50% tear) Partially torn transversely at the distal proximal phalanx attachment (less than 50% tear) Partially torn longitudinally (“button-holed”) at the weight-bearing point of the metatarsal head.

24. Results Complications Seven cases reported peri-operative complications Painful 2nd MTP stiffness (3) Painful hardware (3) Painful scar (1) There were NO cases of floating toes There were no cases of wound dehiscence, nonunion, malunion, floating toes, avascular necrosis, or recurrence of MTP subluxation Revision surgeries Three (9%) with painful 2nd MTP stiffness underwent manipulation under sedation Three (9%) had painful hardware removal One (3%) had painful scar revision Revisional interventions were performed at an average of 17 months post-surgical reconstruction

25. Discussion Various techniques have been proposed to repair a torn plantar plate1,2,10,14,17 Only one other technique described a dorsal approach to repairing plantar plate14 Average AOFAS score 88.9 post-operatively in 23 patients (35 plantar plates) Two painful hardware One transfer lesion Three floating toes

26. Discussion Cooper et al (2011) Dorsal exposure of the 2nd MTP joint in 8 specimens using MTP joint distractor Found that the Weil metatarsal osteotomy allowed greatest visualization

27. Discussion Our series AOFAS LMIS - 87.3 Significant reduction in pain NO floating toes Specialized Instrumentation <2mm Shortening McGlamry elevator NOT for visualization but for access Able to grasp healthy proximal plantar plate

28. Discussion The authors opine that plantar plate injuries may be subtle and undiagnosed by foot and ankle surgeons treating intractable metatarsalgia especially those associated with hammertoe deformity and sub-metatarsal head swelling.

29. Conclusions DAPPR Enhances visualization and ease in repair while decreasing the chance of plantar tissue trauma as compared to a plantar approach. Other advantages include immediate guarded weight bearing of patients postoperatively. Demonstrates favorable results with regards to patient pain and clinical outcome scores.

30. Thank You

31. References Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. OrthopClin North Am. 1989;20:535-551. Blitz NM, Ford LA, Christensen JC. Second metatarsophalangeal joint arthrography: a cadaveric correlation study. J Foot Ankle Surg. 2004;43:231-240. Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-444. Yu GV, Judge MS, Hudson JR, et al. Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. J Am Podiatr Med Assoc. 2002;92:182-199. Coughlin MJ. Crossover second toe deformity. Foot Ankle. 1987;8:29-39. Kitaoka HB et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 15:349–353, 1994. Ware J et al. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996 Mar; 34(3); 220-33. Weil Jr L, Sung W, Weil Sr LS, et al. Tech Foot Ankl Surg. 2011, 10(1):33-39. Bouche RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorumlongus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008;47:125-137. Blitz NM, Ford LA, Christensen JC. Plantar plate repair of the second metatarsophalangeal joint: technique and tips. J Foot Ankle Surg. 2004;43:266-270. Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. 1987;10:83-89. Haddad SL, Sabbagh RC, Resch S, et al. Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity. Foot Ankle Int. 1999;20:781-788. Powless SH, Elze ME. Metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management. J Foot Ankle Surg. 2001;40:374-389. Gregg et al. Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability. Foot Ankle Surg. 2007; 13 (116-121). Deland, JT; Sung, IH: The medial crosssover toe: A cadaveric dissection.FootAnkleInt.21(5):375 – 8,2000. Johnston, RB, 3rd; Smith, J; Daniels, T: The plantar plate of the lesser toes: An anatomical study in human cadavers. Foot Ankle Int. 15(5):276–82, 1994. Ford, LA; Collins, KB; Christensen, JC: Stabilization of the subluxed second metatarsophalangeal joint: Flexor tendon transfer versus primary repairoftheplantarplate.JFootAnkleSurg.37(3):217 – 22,1998