A versatile method for dorsal-approach plantar plate repair using standard operative instruments

Background The plantar plate is an important static stabilizer of the lesser metatarsophalangeal joints, and disruptions of the plantar plate can lead to significant instability and lesser toe deformities. In recent years, direct plantar plate repair has been proposed. Although direct repair via a dorsal approach is attractive, a torn plantar plate is small and difficult to access using regular instruments in a restricted operative field. Methods In this report, a unique method for plantar plate repairs was used to repair various configurations of plantar plate tears with standard operative instruments that are available in most operating rooms. Results Using this method, 10 patients underwent plantar plate repairs, and the mean follow-up period was 24 (range, 14–38) months. The mean visual analog scale score for pain preoperatively was 4.1 (range, 0–6) and decreased to 0.6 (range, 0–3) at last follow-up. Postoperatively, the mean visual analog scale score for satisfaction was 9.6 (range, 8–10) and the mean American Orthopedic Foot and Ankle Society forefoot score was 88.8 (range, 75–100). Conclusions Our study proposes an inexpensive and versatile method for plantar plate repair via a dorsal approach that uses standard operative instruments. Trial registration ClinicalTrials.gov, NCT04949685. July 2, 2021 - Retrospectively registered, Level of clinical evidence 4

High-resolution 3T magnetic resonance imaging and histological analysis of capsuloligamentous complex of the first metatarsophalangeal joint

Background There are discrepancies in the understanding of the structure of the capsuloligamentous complex of the first metatarsophalangeal joint (MTPJ); this study aims to investigate the differences with previous anatomical reports of high-resolution 3T magnetic resonance imaging (MRI) and histological analysis in illustrating the structure of the capsuloligamentous complex of the first MTPJ. Methods Nine fresh frozen cadaveric feet specimens (from two women and three men; aged 32 to 58 years) were used in this study. All specimens underwent MR examination with T1-weighted imaging and T2-weighted spectral attenuated inversion recovery in three planes. Subsequently, all cadaveric feet specimens were sliced into 2-mm-thick sections. The MRI features of the capsuloligamentous complex of the first MTPJ were analyzed in these specimens. Hematoxylin–eosin and Masson’s trichrome staining methods were used to explore the histologic features of the capsuloligamentous complex of the first MTPJ. Results Different from most previous studies, our results showed that the plantar plate could be divided into four portions including the central portion of the plantar plate, the intersesamoid, the sesamoid phalangeal and the metatarsosesamoid ligaments. The normal central portion of the plantar plate could be clearly visualized in the sagittal and coronal plane MR images. The intersesamoid ligament is a continuation of the central portion of the plantar plate on the sagittal plane on the gross specimen, the MR imaging, and the histological examination. On the coronal plane of the gross specimen and MR imaging, the sesamoid phalangeal ligaments and the central portion of the plantar plate can be seen as separate ligaments, but they appeared interwoven with the same continuous collagenous fibers on the histological analysis. Conclusion High-resolution 3T MRI allows accurate demonstration of the different anatomical details of the capsuloligamentous complex of the first MTPJ from previous anatomical reports. The histological analysis provides further understanding of the structures of the capsuloligamentous complex of the first MTPJ from previous studies.

6 Plantar plate repair – a single centre, single procedure case series

AimThe plantar plate (PP) is an important structure that maintains stability of the metatarsophalangeal joints1 and is commonly injured in athletes such as sprinters and ballet dancers. However, clinical outcomes following plantar plate repair are limited due to the lack of studies and the heterogeneity of surgical procedures.2 This retrospective case series reviews the pre- and post-operative outcomes of a single-procedure PP repair series.MethodsPatients who underwent PP repair using the Arthrex Complete Plantar Plate Repair System (CPR™) were identified in a single academic hospital centre. Pre- and post-operative outcomes were compared using clinical notes, radiological evaluation and the national podiatry surgery clinical outcomes database (PASCOM-10). Parameters measured included PP rupture grading, congruence, alignment, joint stability and Manchester-Oxford Foot Questionnaire (MOXFQ) scores.ResultsA total of 20 patients with confirmed PP rupture underwent CPR™ procedure with a team comprising 4 surgeons. Post-operative congruence correction was achieved in 95% of patients, whereas average alignment score (range 0–4) improved from 2.7 to 0.5 and joint stability score (range 0–4) from 2.6 to 0.25. MOXFQ functional outcome scores were available for 65% of patients, showing a 42%, 53% and 42% improvement for weightbearing (W/S), pain and social interaction (SI) domains respectively.ConclusionsThis is the first single-centre, single procedure PP repair case series. Objective radiological and clinical measures showed good improvement in the majority of patients. Functional outcome scores were more heterogeneous and limited by incomplete data collection. Our results appear replicable with no difference between surgeons performing the same procedure.ReferencesNery C, Coughlin M, Baumfeld D, Raduan F, Mann TS, Catena F. How to classify plantar plate injuries: parameters from history and physical examination. Rev Bras Ortop 2015; 50(6):720–728.Elmajee M, Shen Z, A’Court J, Pillai A. A Systematic Review of Plantar Plate Repair in the Management of Lesser Metatarsophalangeal Joint Instability. The Journal of Foot & Ankle Surgery 2017; 56(6):1244–1248.

Objectification of indications for surgical restoration of the plantar plate in the treatment of multiplanar static foot deformities accompanied by hammertoe deformity of the lesser toes using ultrasound

Introduction Progressive multiplanar static deformity of the forefoot can result in hallux valgus, metatarsus primus varus, transverse flat foot and associated overload of the metatarsophalangeal joints (MTPJ) with plantar plate degeneration and rupture of MPT joints of the lesser toes leading to hammertoe deformity. Diagnostic ultrasound in the identification of plantar plate tears is easy to use at any medical center of the Russian Federation with orthopaedic services and provide a relatively inexpensive option compared with other advanced imaging modalities. The goal was to present ultrasound technology for accurate evaluation of the severity of plantar plate injury which may provide guidance for surgical treatment of hammertoe deformity of the lesser toes in patients with multiplanar static forefoot deformity. Material and methods The study recruited 88 participants with multiplanar static deformity of the forefoot, who underwent ultrasound evaluation according to the original method (RF Patent No. 2699383 "Method for determining the type of degenerative rupture of the plantar plate of the metatarsophalangeal joint due to overload metatarsalgia”) to objectify the results of a physical examination with the Hamilton-Thompson test performed for identifying the degree of instability of the MTPJ, and nonparametric analysis was produced with Pearson's Chisquare test. Results Evaluation of the severity of plantar plate injury in the study group of patients (n = 88) with the Hamilton-Thompson test and ultrasound imaging showed diagnostic error in 22.8 % of cases with the use of clinical methods that allowed reasonable reduction of surgical intervention in 2.3 % and substantial correction of the treatment approaches in 20.5 % preventing a complete plantar plate tear. Discussion The ultrasound scanning introduced in the algorithm for diagnosing the degree of plantar plate rupture facilitated an objective approach to the choice of the most appropriate treatment strategy for complicated multiplanar forefoot deformities accompanied by a non-rigid hammertoe deformity of lesser toes. Conclusion Preoperative ultrasound imaging of the plantar surface of the foot for detecting the severity of plantar plate injury should be included in the diagnostic algorithm for patients with complicated multiplanar forefoot deformities accompanied by a non-rigid hammertoe deformity of lesser toes.

Presence of Neovascularization in Torn Plantar Plates of the Lesser Metatarsophalangeal Joints

Background: Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears, yet it remains unknown whether the plantar plate has the biological capacity to heal these repairs. Therefore, a better understanding of the plantar plate vasculature in response to injury may provide further insight into the potential for healing after anatomic plantar plate repair. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano–computed tomographic (CT) imaging methods. Methods: Seven fresh-frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging, the second through fourth toe metatarsophalangeal joints of 7 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and 11 toes remained. The plantar plate microvasculature for these 11 toes was analyzed, and calculation of vascular density along the plantar plate was performed. Using analysis of variance (ANOVA), this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal. A power analysis was performed, determining that 11 experimental toes and 35 control toes would be adequate to provide 80% power with an alpha of 0.05. Results: Significantly greater vascular density (vascular volume/tissue volume) was found along the entire length of the plantar plate for the torn plantar plates compared to intact plantar plates (ANOVA, P < .001). For the first quartile of length (proximal to distal), the vascular density for the torn plantar plates was 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it was 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it was 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile was 0.600 (SD 0.183) vs 0.319 (SD 0.082). Conclusion: Torn plantar plates showed increased vascular density throughout the length of the plantar plate with an increase in density most notable in the region at or just proximal to the attachment to the proximal phalanx. Our analysis revealed that torn plantar plates exhibit neovascularization around the site of a plantar plate tear that does not exist in normal plantar plates. Clinical Relevance: The clinical significance of the increased vascularity of torn plantar plates is unknown at this time. However, the increase in vasculature may suggest that the plantar plate is a structure that is attempting to heal.