- Email: [email protected]
Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability
Foot and Ankle Surgery 13 (2007) 116–121 www.elsevier.com/locate/fas
Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability Julie Gregg a,b,*, Morry Silberstein a, Callum Clark c, Tim Schneider d a
Department of Medical Imaging, Faculty of Medicine, Monash University, Clayton, Vic., Australia b Symbion Health, Vaucluse Hospital, 82 Moreland Road, Brunswick 3056, Vic., Australia c Wexham Park Foot and Ankle Unit, Wexham Park Hospital, UK d Melbourne Orthopaedic Group, Melbourne, Vic., Australia Received 11 July 2006; received in revised form 13 November 2006; accepted 23 January 2007
Abstract This study reviews results of the combined Weil osteotomy and direct plantar plate repair for instability of the lesser metatarsals. Between 6th June 2002 and 4th February 2004, patients with an unstable, or multiple unstable metatarsophalangeal joints, underwent a Weil osteotomy and plantar plate repair operation for degenerative rupture. Thirty-five plantar plate repairs were performed on 23 feet, with or without PIP arthrodesis. Twelve feet also underwent concomitant hallux valgus corrections. The American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal scale was used for outcome rating. Early reports are promising with satisfactory results in most patients. # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Weil; Plantar plate; Metatarsophalangeal; Hammertoe
1. Introduction Instability of the metatarsophalangeal (MTP) joints is a common cause of forefoot pain and deformity. Previous reports suggest that the plantar plate is the stabilising structure for the metatarsophalangeal joint. Plantar plate disruption, acute or chronic, will result in MTP joint instability [1–3]. The plantar plate, a fibrocartilaginous structure, with a relatively loose proximal attachment to the diaphysis of the metatarsal neck, has a firm attachment to the proximal phalanx, resisting hyperextension of the MTP joint [3]. Factors such as hallux valgus deformity, a long second ray or hypermobile joints all overload the lesser metatarsals. This leads to synovitis and eventual stretching and rupture of the plantar plate [4–8]. The surgical management of plantar plate rupture and its sequelae may involve soft tissue, bony * Corresponding author at: Symbion Health, Vaucluse Hospital, 82 Moreland Road, Brunswick 3056, Vic., Australia. Tel.: +61 6 03 93836266; fax: +61 6 03 9384 0235. E-mail address: [email protected] (J. Gregg).
or combined procedures, and may preserve or excise the MTP joint. The correction of extension, subluxation and dislocation deformities of the MTP joint are progressively more challenging. Excision arthroplasty procedures will leave a floppy toe, and so the Weil shortening osteotomy has gained popularity. The main drawback of this procedure is residual extension deformity or ‘‘floating toe’’ [4,9]. The senior author has devised a procedure to reconstruct the plantar plate in conjunction with a Weil osteotomy, and hypothesises that this will result in a lower incidence of floating toe deformity. This study reviews results of the combined Weil osteotomy and direct plantar plate repair for instability of the lesser metatarsals.
2. Methods All patients undergoing plantar plate repair between 6th June 2002 and 4th February 2004 were identified from the senior author’s database. Patients with diabetes, neurological disorders or rheumatoid arthritis were excluded, leaving
1268-7731/$ – see front matter # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2007.01.001
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
only degenerative plantar plate ruptures. Patients were excluded if they were unavailable for post-operative followup. Twenty-one patients (23 feet) with an unstable, or multiple unstable metatarsophalangeal joints, underwent a Weil osteotomy and plantar plate repair operation for degenerative rupture. Before surgery, all patients had been conservatively treated with orthotics, cortisone intraarticular injection or a combination of these. Pre-operative data were obtained retrospectively from review of the notes, and pre-operative radiographs. Clinical follow-up was performed at a mean of 26 months (range, 19– 36 months). Of these, 17 were followed-up clinically and the remainder by telephone by an independent surgeon (CC). Thirty-five plantar plate repairs were performed on the 23 feet, with or without proximal interphalangeal (PIP) arthrodesis (Table 1). Twelve feet also underwent concomitant hallux valgus corrections. There were 19 women and 2 men, with an average age at surgery of 59 years (range, 42–76 years). At follow-up, subjective results were recorded for pain, activity limitations, footwear requirements, toe mobility, and level of satisfaction. Physical examination included the inspection of the forefoot for presence of callus or any deformity of the toes, and performance of the Lachmann test. Range of motion of the MTPJ was assessed and categorised as normal to mild restriction, moderate restriction or severe. The assessment of the operation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) score [10].
117
Follow-up weight-bearing radiographs were obtained in the anteroposterior and lateral projections. The hallux valgus and intermetatarsal angles were measured. Varus/valgus inclination of the proximal phalanx in relation to the metatarsal shaft of the affected toe/s was recorded. The second metatarsal length was evaluated in relation to a line plotted between the distal articular surfaces of the first and third metatarsals, with a positive value denoting excess length.
3. Operative procedure A dorsal incision was made over the related interspace and a longitudinal capsulotomy performed at the affected MTP joint. Extensor digitorum brevis was divided, then a ‘‘Z’’ tenotomy performed on extensor digitorum longus. This was followed by a full collateral release of the MTP joint. Using a microsagittal saw, a small wedge of bone was resected, and then provisionally fixed in a maximally shortened position with a 1.2 mm K-wire. By pulling on the toe, the plantar plate could now be inspected. When a partial or total disinsertion of the plantar plate into the base of the proximal phalanx was found, the plantar rim of the proximal phalanx was freshened. Two drill holes were made, running from the dorsal cortex to the plantar rim of the proximal phalanx, medially and laterally using a 1.6 mm K-wire. A single bite of 1/0 ethibond suture was passed across the plantar plate proximal to the disruption
Table 1 Pre-operative presentation, plantar plates repaired and level of post-operative pain Age
Pain level
Hallux valgus
MT excess length
MTPJ sagittal alignment
MTPJ varus or valgus deviation
Plantar plates repaired
Post-operative pain
60 59 72 72 60 69 76 57 63 47 52 57 62 42 59 47 61 56 52 52 69 53 64
Mild Mild Moderate Moderate Moderate Moderate Moderate Moderate Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe
0 + + + 0 0 0 0 + + 0 + 0 0 0 + 0 + 0 0 0 0 0
+ + + + + + + + 0 + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + + + + + + + + +
0 0 + 0 + 0 0
2 2 2 2 2, 2, 2 2, 2 2, 2, 2 2, 2, 2 2, 2, 2 2 2 2, 2, 2
Mild No pain No pain No pain No pain No pain No pain No pain No pain Mild No pain Moderate No pain No pain Mild No pain No pain No pain No pain No pain No pain Mild No pain
0 + 0 0 0 + 0 0 0 0 0 0 0
3 3 3, 4 3 3 3 3 3 3
3 3
Hallux valgus: present (+), normal alignment (0). Metatarsal excess length: excessive (+), normal (0). MTPJ sagittal alignment: extended (+), normal (0), flexed ( ). MTPJ varus/valgus deviation: varus (+), normal (0), valgus ( ).
118
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
and passed back through the holes in the proximal phalanx (Fig. 1). The Weil osteotomy was then formally fixed in optimal position with a 1.3 mm titanium ‘Twist-off’ screw (DePuy/Johnson & Johnson, Leeds, UK). Finally, the two suture ends were tied over the dorsal phalangeal cortex, thus advancing the plantar plate onto the base of the proximal phalanx. A 1.6 mm K-wire was then passed through the toe, and across the MTP joint, holding the toe in a neutral position. Post-operative care included elevating the foot and inspection of the wound at 7–10 days. For the first 6 weeks, weight-bearing was allowed in a multipurpose medicalsurgical shoe. The K-wire was removed at 4 weeks.
4. Results Patients initially presented with an insidious on-set of pain averaging 32 months (range, 4–96 months). Pain was graded as severe in 15 feet, moderate in 6, and mild in 2 (Table 1). Physical examination revealed a varying degree of swelling over the metatarsophalangeal joint/s. All feet had a degree of extension deformity at the MTP joint/s, and 16 feet had significant callosities. Post-operatively the Lachmann test detected one MTPJ with >50% subluxation, nine toes with mild subluxation and the remainder with no subluxation (out of 35 toes). One foot showed evidence of callus recurrence. Sagittal extension
Fig. 1. Diagrammatic representation of the plantar plate repair. Dorsal (a) and sagittal (b) views. Resection of a small wedge of bone allowed inspection of the plantar plate. Drill holes were positioned medially and laterally through the dorsal cortex of the proximal phalanx. Suture was passed across the plantar plate to the disruption and passed back through the holes. (c) Photograph of the placement of drill holes through the proximal phalanx.
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
119
Table 2 Subjective results (post-operative pain level, activity limitations, joint stiffness, footwear requirements, and satisfaction) Post-operative pain level
Activity limitations
Stiffness
Footwear
Satisfied
No pain (n = 18)
8 None, 9 noticeable, 1 impairs 3 Noticeable, 1 impairs
Moderate pain (n = 1)
1 Intermittent
1 Noticeable
9 3 2 1 1
16 Satisfied, 2 dissatisfied
Mild pain (n = 4)
11 No limitation, 6 occasional, 1 intermittent 2 No limitation, 2 intermittent
was within normal limits for most patients, with mildly increased sagittal extension in two metatarsophalangeal joints, and marked in one joint, starting to overlap the third toe. Eighteen patients were pain-free, four mildly painful and one moderately painful. All patients noted an improvement in their pain. Thirteen patients reported no limitation in their activities, six occasional and four intermittent limitation (Table 2). Furthermore, 12 were wearing normal footwear, 7 were restricted to flat shoes and 4 to extra-wide/deep shoes. Eight patients felt there was no stiffness in their toes, nine occasional stiffness, four noticeable stiffness and two felt their function was impaired by toe stiffness. AOFAS scores were made at each MTPJ undergoing plantar plate repair, and the mean post-operative AOFAS score was 88.9 (range, 63–100). Feet with associated hallux valgus correction had a mean AOFAS score of 86.9 versus 90.8 without. At telephone follow-up, patients were asked whether they were generally satisfied or dissatisfied with the surgery. Seventeen reported that they were satisfied and six were dissatisfied with their surgery. The length of the second metatarsal pre-operatively was determined to be high in 96% of the feet (n = 22). Sixteen pre-
Normal, 6 sensible/flat, wide Normal, 1 sensible/flat, wide Normal
1 Satisfied, 3 dissatisfied 1 Dissatisfied
operative and 18 post-operative radiographs were available for review (Fig. 2). The mean pre-operative hallux valgus angle was 218 (range, 58 to 358), post-operatively the hallux valgus angle was 128 (range, 58 to 298). The intermetatarsal angle pre-operatively was 108 (range, 5–188) and post-operatively 68 (range, 0–138). The mean pre-operative inclination of lesser metatarsals was 108 valgus (range, 168 varus to 428 valgus). Post-operative inclination of the lesser metatarsals was 108 valgus (range, 58 varus to 258 valgus). Pre-operatively, varus deviation of a lesser metatarsal was present in four feet and valgus deviation in three. Post-operatively, no varus or valgus deviation was present. Pre-operatively, metatarsophalangeal joint rotation was present in two of the feet; post-operatively, rotation was reported in one foot. Post-operative infection occurred in four feet which were successfully treated with oral antibiotics and local care. In two feet the screws were irritating the adjacent extensor tendon and were removed. There were no complications related to K-wires. Periarticular swelling was experienced in three feet and was successfully treated with articular steroid injections. Three patients complained that their toes did not grip the floor, one complained of night cramps in the toe, and one transfer lesion to the adjacent toe.
Fig. 2. Fifty-two-year-old female presenting with severe pain (a) pre-operative radiograph which demonstrates moderate rotation and valgus displacement of the second and third phalanges. (b) Post-operative radiograph with corrected alignment and plantar plate repairs of the second and third MTPJs.
120
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
5. Discussion Acute trauma or chronic microtrauma can cause disruption of the plantar plate [11]. It is often associated with use of high-heeled shoes but may also occur in athletes. Thompson and Hamilton [8] suggested the presence of a short first ray and long second ray predisposed patients to metatarsophalangeal joint instability. Coughlin [12] has also reported that a long second metatarsal increases the amount of weight carried through ambulation, increasing the stress on the second plantar plate. Although metatarsophalangeal joint instability may be associated with hallux valgus, Coughlin reported that it may also be present without any hallux deviation. Sixty-one percent (n = 14) of our patients had either previous hallux valgus deformity surgery or underwent hallux correction at the same time as repair to the lesser metatarsal instability. Ninety-six percent of our patients had a long second/third metatarsal. Proponents of this type of surgery often state that the second and third metatarsals act as a pair, and that they should be shortened together. It is the feeling of the senior author that this is not strictly the case and that it is preferable to leave the third if it is not specifically indicated. The decision to operate on the second or the second and third MTPJ was based on the presence of clinical symptoms at that joint and the relative length of the second to the third. Patients who demonstrated well localized second MTPJ pain combined with an excessively long metatarsal and radiological evidence of overload with metatarsal shaft hypertrophy or an isolated hyperextension deformity only had the second MTPJ operated upon. It was seen to be important to maintain reasonably normal relative metatarsal lengths. Previous literature describes either tendon transfers or a primary plantar repair [3,11–18]. We present a new or previously undocumented technique in the repair of the plantar plate. By performing bony decompression in combination with plantar plate repair and addressing other concurrent foot deformities such as hallux valgus and hammertoe, we have attempted to correct biomechanics. The mechanisms at play with the correction of these deformities are complex. The plantar plate attaches distally to the base of the proximal phalanx. It forms part of the articulation for the metatarsal head when weight bearing and is involved in positioning of the MTPJ by providing a static restraint as well as a coupling to the more proximal plantar fascia and contributions by the short flexors. Proximal to this the plantar fascia is attached to the metatarsal. The plantar fascia limits flattening of the longitudinal arch and depresses the metatarsal head. By displacing the MTPJ proximally, the ‘‘windlass’’ for that toe will slacken and there will be a concomitant loosening of the flexor and extensor tendon complexes. These will all tighten to some extent as weight bearing flattens the arch, but will be limited by other restraints such as the intermetatarsal ligaments. The plantar plate repair itself acts exclusively on the distal part of this
mechanism by repairing the attenuated or failed distal portion of the plantar plate back onto the base of the proximal phalanx. The repair re-tensions this static restraint to the base of the proximal phalanx and in doing so favours plantar flexion over dorsiflexion at the MTPJ thus preventing the floating toe described after a Weil osteotomy alone. Post-operatively, not all the toes of our patients ended up in a normal anatomical alignment, with two feet experiencing increased inclination angles. This also occurred with Thompson and Deland [19] and Coughlin [12] with their flexor tendon transfer. As with Gazdag and Cracchiolo [3] and Thompson and Deland [19], we observed post-operative stiffness of the repaired metatarsophalangeal joints. The feeling of stiffness was unacceptable in two of the feet; these results are similar to Gazdag and Cracchiolo [3] who reported that the majority of his patients were satisfied with their level of stiffness. Pre-operative pain was moderate to severe in 21 of the feet, post-operatively only 1 patient reported moderate pain. The remainder had only mild discomfort or no pain at all. With 11 patients reporting an excellent result, 10 a fair result, and 2 reporting a poor result, the procedure was successful in relieving pain, but was not without its shortcomings. Loss of control of the toes and stiffness were problems. Thompson and Deland [19] suggested encouraging patients to achieve 208 passive dorsiflexion post-operatively and removal of the wire at 2 weeks to reduce stiffness. A technique that excludes the use of the K-wire all-together, rather the taping of the MTPJ’s may be a better alternative that may result in reduced stiffness. Previous theories relating to tendon lengthening has given the impression that tendons recover well from reduction or extension surgery. Our results of poor extension capability could be considered a complication of the scar. Periarticular swelling may be associated with the suture reaction, perhaps causing aggravation to the joint and may need to be reviewed. Recurrence of metatarsophalangeal joint subluxation of greater than 50% was reported in one foot, and two others reported only mild sagittal extension. This number compares well with the tendon transfer as reported by Gazdag and Cracchiolo [3] with a third of the patients experiencing measurable subluxation. Gazdag reported the tendon-transfer and modified tendon transfer with total OAFAS scores of 84 and 83, respectively [3]. Thompson and Deland [19] reported a similar percentage to experience subluxation, but in their case all of which were equal to or greater than 50%. The AOFAS results of the combined Weil and plantar plate repair (88.9) compares well with Weil procedures alone reported by Garcia-Rey et al. [20], 86.1 and Trnka et al. [21] and Migues et al. [9] both reporting scores of 81 for the relief of metatarsalgia. The actual repair of the plantar plate appears to be effective with a high level of pain relief, improved activity levels and low level of significant joint subluxation. Early reports are promising with satisfactory results in most patients.
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
References [1] Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clin North Am 1989;20:535–51. [2] Deland JT, Lee KT, Sobel M, DiCarlo EF. Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint. Foot Ankle Int 1995;16:480–6. [3] Gazdag A, Cracchiolo A. Surgical treatment of patients with painful instability of the second metatarsophalangeal joint. Foot Ankle Int 1998;19:137–43. [4] Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987;8:29– 39. [5] Coughlin MJ, Mann RA, editors. Lesser toe deformities. In: Surgery of the foot and ankle. St. Louis: Mosby Year Book; 1992. p. 341– 411. [6] Jahss MH. Miscellaneous soft tissue lesions. In: Disorders of the foot and ankle: medical and surgical management.. Philadelphia: W.B. Saunders; 1982. p. 843. [7] Klaue K, Hansen ST, Masquelet AC. Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relationship to hallux valgus deformity. Foot Ankle Int 1994;15: 9–13. [8] Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics 1987;10:83–9. [9] Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int 2004;25:609–13. [10] Kitaoka H, Alexander I, Adelaar R. Clinical rating system for the ankle, hindfoot, hallux and lesser toes. Foot Ankle Int 1994;15: 349–53.
121
[11] Ford LA, Collins KB, Christensen JC. Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate. Foot Ankle Surg 1998;37:217–22. [12] Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle 1993;14:309–19. [13] Clayton ML, Smyth CJ. Management of the rheumatoid foot. In: Clayton ML, editor. Surgery for rheumatoid arthritis. New York: Churchill Livingstone; 1992. p. 307–44. [14] Deland JT, Sobel M, Arnoczky SP, Thompson FM. Collateral ligament reconstruction of the unstable metatarsophalangeal joint: an invitro study. Foot Ankle 1992;13:391–5. [15] Kuwada GT, Dockery GL. Modification of the flexor tendon transfer procedure for the correction of flexible hammertoes. J Foot Surg 1980;19:38–40. [16] Mann RA, Chou LB. Surgical management for intractable metatarsalgia. Foot Ankle Int 1995;16:322–7. [17] Slovenkai MP, Linehan D, McGrady L, Lim TH, Harris GF, Shereff MJ. Comparison of two fixation methods of oblique lesser metatarsal osteotomies: a biomechanical study. Foot Ankle Int 1995;16:437–9. [18] Yu GV, Judge MS, Hudson JR, Seidelmann FE. Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. J Am Podiatr Med Assoc 2002;92:182–97. [19] Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993;14:385–8. [20] Garcia-Rey E, Cano J, Guerra P, Sanz-Hospital FJ. The Weil osteotomy for median metatarsalgia. A short-term study. Foot Ankle Surg 2004;10:177–80. [21] Trnka HJ, Gebhard C, Muhlbauer M, Ivanic G, Ritschl P. The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints. Acta Orthop Scand 2002;73:190–4.
Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability Julie Gregg a,b,*, Morry Silberstein a, Callum Clark c, Tim Schneider d a
Department of Medical Imaging, Faculty of Medicine, Monash University, Clayton, Vic., Australia b Symbion Health, Vaucluse Hospital, 82 Moreland Road, Brunswick 3056, Vic., Australia c Wexham Park Foot and Ankle Unit, Wexham Park Hospital, UK d Melbourne Orthopaedic Group, Melbourne, Vic., Australia Received 11 July 2006; received in revised form 13 November 2006; accepted 23 January 2007
Abstract This study reviews results of the combined Weil osteotomy and direct plantar plate repair for instability of the lesser metatarsals. Between 6th June 2002 and 4th February 2004, patients with an unstable, or multiple unstable metatarsophalangeal joints, underwent a Weil osteotomy and plantar plate repair operation for degenerative rupture. Thirty-five plantar plate repairs were performed on 23 feet, with or without PIP arthrodesis. Twelve feet also underwent concomitant hallux valgus corrections. The American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal scale was used for outcome rating. Early reports are promising with satisfactory results in most patients. # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Weil; Plantar plate; Metatarsophalangeal; Hammertoe
1. Introduction Instability of the metatarsophalangeal (MTP) joints is a common cause of forefoot pain and deformity. Previous reports suggest that the plantar plate is the stabilising structure for the metatarsophalangeal joint. Plantar plate disruption, acute or chronic, will result in MTP joint instability [1–3]. The plantar plate, a fibrocartilaginous structure, with a relatively loose proximal attachment to the diaphysis of the metatarsal neck, has a firm attachment to the proximal phalanx, resisting hyperextension of the MTP joint [3]. Factors such as hallux valgus deformity, a long second ray or hypermobile joints all overload the lesser metatarsals. This leads to synovitis and eventual stretching and rupture of the plantar plate [4–8]. The surgical management of plantar plate rupture and its sequelae may involve soft tissue, bony * Corresponding author at: Symbion Health, Vaucluse Hospital, 82 Moreland Road, Brunswick 3056, Vic., Australia. Tel.: +61 6 03 93836266; fax: +61 6 03 9384 0235. E-mail address: [email protected] (J. Gregg).
or combined procedures, and may preserve or excise the MTP joint. The correction of extension, subluxation and dislocation deformities of the MTP joint are progressively more challenging. Excision arthroplasty procedures will leave a floppy toe, and so the Weil shortening osteotomy has gained popularity. The main drawback of this procedure is residual extension deformity or ‘‘floating toe’’ [4,9]. The senior author has devised a procedure to reconstruct the plantar plate in conjunction with a Weil osteotomy, and hypothesises that this will result in a lower incidence of floating toe deformity. This study reviews results of the combined Weil osteotomy and direct plantar plate repair for instability of the lesser metatarsals.
2. Methods All patients undergoing plantar plate repair between 6th June 2002 and 4th February 2004 were identified from the senior author’s database. Patients with diabetes, neurological disorders or rheumatoid arthritis were excluded, leaving
1268-7731/$ – see front matter # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2007.01.001
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
only degenerative plantar plate ruptures. Patients were excluded if they were unavailable for post-operative followup. Twenty-one patients (23 feet) with an unstable, or multiple unstable metatarsophalangeal joints, underwent a Weil osteotomy and plantar plate repair operation for degenerative rupture. Before surgery, all patients had been conservatively treated with orthotics, cortisone intraarticular injection or a combination of these. Pre-operative data were obtained retrospectively from review of the notes, and pre-operative radiographs. Clinical follow-up was performed at a mean of 26 months (range, 19– 36 months). Of these, 17 were followed-up clinically and the remainder by telephone by an independent surgeon (CC). Thirty-five plantar plate repairs were performed on the 23 feet, with or without proximal interphalangeal (PIP) arthrodesis (Table 1). Twelve feet also underwent concomitant hallux valgus corrections. There were 19 women and 2 men, with an average age at surgery of 59 years (range, 42–76 years). At follow-up, subjective results were recorded for pain, activity limitations, footwear requirements, toe mobility, and level of satisfaction. Physical examination included the inspection of the forefoot for presence of callus or any deformity of the toes, and performance of the Lachmann test. Range of motion of the MTPJ was assessed and categorised as normal to mild restriction, moderate restriction or severe. The assessment of the operation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) score [10].
117
Follow-up weight-bearing radiographs were obtained in the anteroposterior and lateral projections. The hallux valgus and intermetatarsal angles were measured. Varus/valgus inclination of the proximal phalanx in relation to the metatarsal shaft of the affected toe/s was recorded. The second metatarsal length was evaluated in relation to a line plotted between the distal articular surfaces of the first and third metatarsals, with a positive value denoting excess length.
3. Operative procedure A dorsal incision was made over the related interspace and a longitudinal capsulotomy performed at the affected MTP joint. Extensor digitorum brevis was divided, then a ‘‘Z’’ tenotomy performed on extensor digitorum longus. This was followed by a full collateral release of the MTP joint. Using a microsagittal saw, a small wedge of bone was resected, and then provisionally fixed in a maximally shortened position with a 1.2 mm K-wire. By pulling on the toe, the plantar plate could now be inspected. When a partial or total disinsertion of the plantar plate into the base of the proximal phalanx was found, the plantar rim of the proximal phalanx was freshened. Two drill holes were made, running from the dorsal cortex to the plantar rim of the proximal phalanx, medially and laterally using a 1.6 mm K-wire. A single bite of 1/0 ethibond suture was passed across the plantar plate proximal to the disruption
Table 1 Pre-operative presentation, plantar plates repaired and level of post-operative pain Age
Pain level
Hallux valgus
MT excess length
MTPJ sagittal alignment
MTPJ varus or valgus deviation
Plantar plates repaired
Post-operative pain
60 59 72 72 60 69 76 57 63 47 52 57 62 42 59 47 61 56 52 52 69 53 64
Mild Mild Moderate Moderate Moderate Moderate Moderate Moderate Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe Severe
0 + + + 0 0 0 0 + + 0 + 0 0 0 + 0 + 0 0 0 0 0
+ + + + + + + + 0 + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + + + + + + + + +
0 0 + 0 + 0 0
2 2 2 2 2, 2, 2 2, 2 2, 2, 2 2, 2, 2 2, 2, 2 2 2 2, 2, 2
Mild No pain No pain No pain No pain No pain No pain No pain No pain Mild No pain Moderate No pain No pain Mild No pain No pain No pain No pain No pain No pain Mild No pain
0 + 0 0 0 + 0 0 0 0 0 0 0
3 3 3, 4 3 3 3 3 3 3
3 3
Hallux valgus: present (+), normal alignment (0). Metatarsal excess length: excessive (+), normal (0). MTPJ sagittal alignment: extended (+), normal (0), flexed ( ). MTPJ varus/valgus deviation: varus (+), normal (0), valgus ( ).
118
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
and passed back through the holes in the proximal phalanx (Fig. 1). The Weil osteotomy was then formally fixed in optimal position with a 1.3 mm titanium ‘Twist-off’ screw (DePuy/Johnson & Johnson, Leeds, UK). Finally, the two suture ends were tied over the dorsal phalangeal cortex, thus advancing the plantar plate onto the base of the proximal phalanx. A 1.6 mm K-wire was then passed through the toe, and across the MTP joint, holding the toe in a neutral position. Post-operative care included elevating the foot and inspection of the wound at 7–10 days. For the first 6 weeks, weight-bearing was allowed in a multipurpose medicalsurgical shoe. The K-wire was removed at 4 weeks.
4. Results Patients initially presented with an insidious on-set of pain averaging 32 months (range, 4–96 months). Pain was graded as severe in 15 feet, moderate in 6, and mild in 2 (Table 1). Physical examination revealed a varying degree of swelling over the metatarsophalangeal joint/s. All feet had a degree of extension deformity at the MTP joint/s, and 16 feet had significant callosities. Post-operatively the Lachmann test detected one MTPJ with >50% subluxation, nine toes with mild subluxation and the remainder with no subluxation (out of 35 toes). One foot showed evidence of callus recurrence. Sagittal extension
Fig. 1. Diagrammatic representation of the plantar plate repair. Dorsal (a) and sagittal (b) views. Resection of a small wedge of bone allowed inspection of the plantar plate. Drill holes were positioned medially and laterally through the dorsal cortex of the proximal phalanx. Suture was passed across the plantar plate to the disruption and passed back through the holes. (c) Photograph of the placement of drill holes through the proximal phalanx.
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
119
Table 2 Subjective results (post-operative pain level, activity limitations, joint stiffness, footwear requirements, and satisfaction) Post-operative pain level
Activity limitations
Stiffness
Footwear
Satisfied
No pain (n = 18)
8 None, 9 noticeable, 1 impairs 3 Noticeable, 1 impairs
Moderate pain (n = 1)
1 Intermittent
1 Noticeable
9 3 2 1 1
16 Satisfied, 2 dissatisfied
Mild pain (n = 4)
11 No limitation, 6 occasional, 1 intermittent 2 No limitation, 2 intermittent
was within normal limits for most patients, with mildly increased sagittal extension in two metatarsophalangeal joints, and marked in one joint, starting to overlap the third toe. Eighteen patients were pain-free, four mildly painful and one moderately painful. All patients noted an improvement in their pain. Thirteen patients reported no limitation in their activities, six occasional and four intermittent limitation (Table 2). Furthermore, 12 were wearing normal footwear, 7 were restricted to flat shoes and 4 to extra-wide/deep shoes. Eight patients felt there was no stiffness in their toes, nine occasional stiffness, four noticeable stiffness and two felt their function was impaired by toe stiffness. AOFAS scores were made at each MTPJ undergoing plantar plate repair, and the mean post-operative AOFAS score was 88.9 (range, 63–100). Feet with associated hallux valgus correction had a mean AOFAS score of 86.9 versus 90.8 without. At telephone follow-up, patients were asked whether they were generally satisfied or dissatisfied with the surgery. Seventeen reported that they were satisfied and six were dissatisfied with their surgery. The length of the second metatarsal pre-operatively was determined to be high in 96% of the feet (n = 22). Sixteen pre-
Normal, 6 sensible/flat, wide Normal, 1 sensible/flat, wide Normal
1 Satisfied, 3 dissatisfied 1 Dissatisfied
operative and 18 post-operative radiographs were available for review (Fig. 2). The mean pre-operative hallux valgus angle was 218 (range, 58 to 358), post-operatively the hallux valgus angle was 128 (range, 58 to 298). The intermetatarsal angle pre-operatively was 108 (range, 5–188) and post-operatively 68 (range, 0–138). The mean pre-operative inclination of lesser metatarsals was 108 valgus (range, 168 varus to 428 valgus). Post-operative inclination of the lesser metatarsals was 108 valgus (range, 58 varus to 258 valgus). Pre-operatively, varus deviation of a lesser metatarsal was present in four feet and valgus deviation in three. Post-operatively, no varus or valgus deviation was present. Pre-operatively, metatarsophalangeal joint rotation was present in two of the feet; post-operatively, rotation was reported in one foot. Post-operative infection occurred in four feet which were successfully treated with oral antibiotics and local care. In two feet the screws were irritating the adjacent extensor tendon and were removed. There were no complications related to K-wires. Periarticular swelling was experienced in three feet and was successfully treated with articular steroid injections. Three patients complained that their toes did not grip the floor, one complained of night cramps in the toe, and one transfer lesion to the adjacent toe.
Fig. 2. Fifty-two-year-old female presenting with severe pain (a) pre-operative radiograph which demonstrates moderate rotation and valgus displacement of the second and third phalanges. (b) Post-operative radiograph with corrected alignment and plantar plate repairs of the second and third MTPJs.
120
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
5. Discussion Acute trauma or chronic microtrauma can cause disruption of the plantar plate [11]. It is often associated with use of high-heeled shoes but may also occur in athletes. Thompson and Hamilton [8] suggested the presence of a short first ray and long second ray predisposed patients to metatarsophalangeal joint instability. Coughlin [12] has also reported that a long second metatarsal increases the amount of weight carried through ambulation, increasing the stress on the second plantar plate. Although metatarsophalangeal joint instability may be associated with hallux valgus, Coughlin reported that it may also be present without any hallux deviation. Sixty-one percent (n = 14) of our patients had either previous hallux valgus deformity surgery or underwent hallux correction at the same time as repair to the lesser metatarsal instability. Ninety-six percent of our patients had a long second/third metatarsal. Proponents of this type of surgery often state that the second and third metatarsals act as a pair, and that they should be shortened together. It is the feeling of the senior author that this is not strictly the case and that it is preferable to leave the third if it is not specifically indicated. The decision to operate on the second or the second and third MTPJ was based on the presence of clinical symptoms at that joint and the relative length of the second to the third. Patients who demonstrated well localized second MTPJ pain combined with an excessively long metatarsal and radiological evidence of overload with metatarsal shaft hypertrophy or an isolated hyperextension deformity only had the second MTPJ operated upon. It was seen to be important to maintain reasonably normal relative metatarsal lengths. Previous literature describes either tendon transfers or a primary plantar repair [3,11–18]. We present a new or previously undocumented technique in the repair of the plantar plate. By performing bony decompression in combination with plantar plate repair and addressing other concurrent foot deformities such as hallux valgus and hammertoe, we have attempted to correct biomechanics. The mechanisms at play with the correction of these deformities are complex. The plantar plate attaches distally to the base of the proximal phalanx. It forms part of the articulation for the metatarsal head when weight bearing and is involved in positioning of the MTPJ by providing a static restraint as well as a coupling to the more proximal plantar fascia and contributions by the short flexors. Proximal to this the plantar fascia is attached to the metatarsal. The plantar fascia limits flattening of the longitudinal arch and depresses the metatarsal head. By displacing the MTPJ proximally, the ‘‘windlass’’ for that toe will slacken and there will be a concomitant loosening of the flexor and extensor tendon complexes. These will all tighten to some extent as weight bearing flattens the arch, but will be limited by other restraints such as the intermetatarsal ligaments. The plantar plate repair itself acts exclusively on the distal part of this
mechanism by repairing the attenuated or failed distal portion of the plantar plate back onto the base of the proximal phalanx. The repair re-tensions this static restraint to the base of the proximal phalanx and in doing so favours plantar flexion over dorsiflexion at the MTPJ thus preventing the floating toe described after a Weil osteotomy alone. Post-operatively, not all the toes of our patients ended up in a normal anatomical alignment, with two feet experiencing increased inclination angles. This also occurred with Thompson and Deland [19] and Coughlin [12] with their flexor tendon transfer. As with Gazdag and Cracchiolo [3] and Thompson and Deland [19], we observed post-operative stiffness of the repaired metatarsophalangeal joints. The feeling of stiffness was unacceptable in two of the feet; these results are similar to Gazdag and Cracchiolo [3] who reported that the majority of his patients were satisfied with their level of stiffness. Pre-operative pain was moderate to severe in 21 of the feet, post-operatively only 1 patient reported moderate pain. The remainder had only mild discomfort or no pain at all. With 11 patients reporting an excellent result, 10 a fair result, and 2 reporting a poor result, the procedure was successful in relieving pain, but was not without its shortcomings. Loss of control of the toes and stiffness were problems. Thompson and Deland [19] suggested encouraging patients to achieve 208 passive dorsiflexion post-operatively and removal of the wire at 2 weeks to reduce stiffness. A technique that excludes the use of the K-wire all-together, rather the taping of the MTPJ’s may be a better alternative that may result in reduced stiffness. Previous theories relating to tendon lengthening has given the impression that tendons recover well from reduction or extension surgery. Our results of poor extension capability could be considered a complication of the scar. Periarticular swelling may be associated with the suture reaction, perhaps causing aggravation to the joint and may need to be reviewed. Recurrence of metatarsophalangeal joint subluxation of greater than 50% was reported in one foot, and two others reported only mild sagittal extension. This number compares well with the tendon transfer as reported by Gazdag and Cracchiolo [3] with a third of the patients experiencing measurable subluxation. Gazdag reported the tendon-transfer and modified tendon transfer with total OAFAS scores of 84 and 83, respectively [3]. Thompson and Deland [19] reported a similar percentage to experience subluxation, but in their case all of which were equal to or greater than 50%. The AOFAS results of the combined Weil and plantar plate repair (88.9) compares well with Weil procedures alone reported by Garcia-Rey et al. [20], 86.1 and Trnka et al. [21] and Migues et al. [9] both reporting scores of 81 for the relief of metatarsalgia. The actual repair of the plantar plate appears to be effective with a high level of pain relief, improved activity levels and low level of significant joint subluxation. Early reports are promising with satisfactory results in most patients.
J. Gregg et al. / Foot and Ankle Surgery 13 (2007) 116–121
References [1] Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clin North Am 1989;20:535–51. [2] Deland JT, Lee KT, Sobel M, DiCarlo EF. Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint. Foot Ankle Int 1995;16:480–6. [3] Gazdag A, Cracchiolo A. Surgical treatment of patients with painful instability of the second metatarsophalangeal joint. Foot Ankle Int 1998;19:137–43. [4] Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987;8:29– 39. [5] Coughlin MJ, Mann RA, editors. Lesser toe deformities. In: Surgery of the foot and ankle. St. Louis: Mosby Year Book; 1992. p. 341– 411. [6] Jahss MH. Miscellaneous soft tissue lesions. In: Disorders of the foot and ankle: medical and surgical management.. Philadelphia: W.B. Saunders; 1982. p. 843. [7] Klaue K, Hansen ST, Masquelet AC. Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relationship to hallux valgus deformity. Foot Ankle Int 1994;15: 9–13. [8] Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics 1987;10:83–9. [9] Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int 2004;25:609–13. [10] Kitaoka H, Alexander I, Adelaar R. Clinical rating system for the ankle, hindfoot, hallux and lesser toes. Foot Ankle Int 1994;15: 349–53.
121
[11] Ford LA, Collins KB, Christensen JC. Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate. Foot Ankle Surg 1998;37:217–22. [12] Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle 1993;14:309–19. [13] Clayton ML, Smyth CJ. Management of the rheumatoid foot. In: Clayton ML, editor. Surgery for rheumatoid arthritis. New York: Churchill Livingstone; 1992. p. 307–44. [14] Deland JT, Sobel M, Arnoczky SP, Thompson FM. Collateral ligament reconstruction of the unstable metatarsophalangeal joint: an invitro study. Foot Ankle 1992;13:391–5. [15] Kuwada GT, Dockery GL. Modification of the flexor tendon transfer procedure for the correction of flexible hammertoes. J Foot Surg 1980;19:38–40. [16] Mann RA, Chou LB. Surgical management for intractable metatarsalgia. Foot Ankle Int 1995;16:322–7. [17] Slovenkai MP, Linehan D, McGrady L, Lim TH, Harris GF, Shereff MJ. Comparison of two fixation methods of oblique lesser metatarsal osteotomies: a biomechanical study. Foot Ankle Int 1995;16:437–9. [18] Yu GV, Judge MS, Hudson JR, Seidelmann FE. Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. J Am Podiatr Med Assoc 2002;92:182–97. [19] Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993;14:385–8. [20] Garcia-Rey E, Cano J, Guerra P, Sanz-Hospital FJ. The Weil osteotomy for median metatarsalgia. A short-term study. Foot Ankle Surg 2004;10:177–80. [21] Trnka HJ, Gebhard C, Muhlbauer M, Ivanic G, Ritschl P. The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints. Acta Orthop Scand 2002;73:190–4.