This is my retrospective study on our anatomic plantar plate repair technique utilizing a Weil metatarsal osteotomy.

3. Overview Purpose Methods Statistical Analysis Results Discussion Conclusions

4. Purpose The purpose of this study was to report the results of a technique for anatomic plantar plate repair utilizing a Weil metatarsal osteotomy approach.

5. Purpose RETROSPECTIVE CASE SERIES EBM Level of evidence: IV (therapeutic)

6. Purpose background The principle stabilizer of the MTP joint Integrity is essential to stabilize the proximal phalanx of the lesser toes. Its attrition often results in metatarsalgia, plantar swelling, hammertoe deformity, and lesser toe subluxation1-4.

7. Purpose Background We believe that plantar plate attrition is most commonly due to an elongated or sub-located metatarsal3,5.

8. Purpose background Several techniques have been introduced to repair and correct the deformity, but most rely on atraditional plantar approach1-3.

9. Purpose background We present our experience with a technique8 that anatomically repairs the plantar plate ligament tear through a Weil metatarsal osteotomy

10. Methods We retrospectivelyidentifiedconsecutive adult patients who were treated by the senior author (LWJ) and diagnosed with 2nd MTP instability January 2007 toAugust 2009 Twenty-one patients were initially treated with nonsurgical care Shoe modifications, custom orthotics, NSAIDs Thirteen patients (15 feet) had unresolved MTP instability and pain after 3 months

11. Methods Pre-op and post-op Post-op only Visual analog pain scale American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal (AOFAS LMI) clinical rating scale6 Satisfaction

12. Statistical Analysis A paired student t-test was used to determine significance with p < 0.01.

13. Procedure Weil L, Sung W, Weil LS, and Glover JS. Correction of Second MTP Joint instability using a Weil Osteotomy and Dorsal approach Plantar Plate Repair. Techniques in Foot & Ankle Surgery.2011, 10(1):33-39

14. Results Demographics There were 13 patients (15feet) that underwent anatomic plantar plate repair. Ten were female and three were male with an average age of 57 years (range from 50 to 69). The average post-operative follow-up was 22.5 months (range from 13.0 to 32.0).

15. Results AVERAge VAS significance Pre-operative scores 7.3 (SD = 1.6; 95%CI = 6.4 to 8.1) Post-operative scores 1.7 (SD = 1.8; 95%CI = 0.7 to 2.7). This was significantly different (P < 0.01).

16. Results Average AOFAS LMIS Satisfaction 85.7 (SD = 13.1; 95%CI = 79.1 to 91.5) out of 100 Ten of 13 patients (77%) reported either “satisfied” or “very satisfied” with outcome Twelve of 15 feet (80%) were reported as “satisfied” or “very satisfied” with outcome

17. Results Complications Revision surgeries Three reported cases of painful hardware One case of continued painful metatarsalgia. There were NO cases of floating toes, wound dehiscence, non-union, mal-union One case elected for surgery to remove painful hardware There were NO cases of re-repair of plantar plate

18. Results

19. Discussion

20. Discussion Repairing 2nd MTP joint instability and plantar plate injury are NOT novel ideas. Several authors have described procedures with excellent reported results9-13.

21. Discussion Gregg et al14 described a similar technique utilizing a Weil metatarsal osteotomy for all MTP joints. Included plantar plate repairs to all toes (21 patients, 35 toes). “AOFAS Score” was 88.9 Three floating toes (8.6%) Infections occurred in four feet (17%)

22. Discussion Gregg et al14 Floating toes Too much shortening All (100%) patients pre-operatively had intra-articular cortisone injections

23. Discussion Senior author (LWJ) technique: Release plantar attachments Visualize and grasp proximally Never shorten more than 1-2 mm Specialized instrumentation

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

25. Discussion Strength Weakness Single surgeon 2nd MTP joint Three clinical outcome measurements No comparative analysis No control Assessor bias

26. Conclusions This technique enhances visualization of the plantar plate and eases the repair decreasing the chance of plantar tissue trauma as compared to a plantar approach. Demonstrates favorable results with regards to patient pain and clinical outcome scores.

27. 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).

28. Thank You