Surgical Treatment of Metatarsalgia and Severe Instability of Lesser Metatarsophalangeal Joints.

The main object of this prospective cohort study was to compare surgical treatment options for primary metatarsalgia and the severe instability of lesser metatarsophalangeal joints. The outcomes of triple Weil osteotomy combined with direct plantar plate repair and triple Weil osteotomy, performed with proximal interphalangeal joint arthrodesis, are analyzed and compared. One hundred thirteen patients (117 feet) were enrolled in the study. They were split into 2 groups. In the first group, undergoing Weil osteotomy, combined with the plantar plate repair, good results, including complete pain reduction, elimination of hyperkeratosis, and American Orthopedic Foot and Ankle Society Score improvement, were achieved in 84.7% of the cases. The second group, where the combination of Weil osteotomy and proximal interphalangeal joint K-wire arthrodesis was used, demonstrated good results in 52.4% of the cases. Weil osteotomy, combined with the plantar plate repair, achieves better results in comparison to osteotomy, performed with the interphalangeal joint arthrodesis.

Grade III Turf Toe Injury in a Cowboy.

Turf toe injuries are common, particularly in athletes competing on artificial turf. This debilitating injury and its associated sequelae can affect the long-term performance of athletes and others. In this case is presented an atypical cause for development of grade III turf toe. This case presents an acute injury with significant damage to the plantar first metatarsophalangeal joint, with plantar plate rupture and tibial sesamoid retraction secondary to injury involving working calves on a ranch. The anatomy, mechanism, and associated treatments are reviewed. The anatomical and functional interplay with this injury is discussed.

Indications and possible limitations using medio-plantar plate systems in tarsometatarsal 1 fusions - A cadaveric study.

BACKGROUND: The tarsometatarsal 1 arthrodesis is an adequate treatment for moderate to severe hallux valgus deformity and instability of the first ray. Plantar plating arthrodesis has been shown to provide better mechanical stability and fewer postoperative complications than screw fixation or medial plating. The medio-plantar plate is a new plate design for Lapidus arthrodesis. It could combine the biomechanical advantages of the plantar plate and the anatomical overview of a medial plate. However, the implanted material can cause irritation of the tibialis anterior, which in some cases may require removal of the material. The purpose of this study was to examine the possibility of tendon irritation following medio-plantar first tarsometatarsal joint arthrodesis using cadaveric specimens. METHODS: The study involved the simulated surgical procedure of medio-plantar plate arthrodesis on 30 lower extremities. After the plates were fixed, a thorough examination of the feet was conducted to assess any tendon irritation and to determine a recommendation for placement of the medio-plantar plate based on the Olewnik classification. RESULTS: Irritation of the tibialis anterior tendon components with the medio-plantar plate depends mainly on the anatomic norm variant, classified according to Olewnik et al. A medio-plantar plate is particularly recommended in TA tendon Olewnik type 3 and type 5. The positioning of a medio-plantar plate in Olewnik type 1 and type 2 tendons depends on the anatomic fit of the medio-plantar plate and the bony configuration of the TMT 1 joint. A large portion of the TA tendon must be detached, so a different plate design may be preferred in these patients. CONCLUSIONS: TMT 1 arthrodesis with medio-plantar plating of the first tarsometatarsal joint should be performed considering the anatomic TA tendon variations. LEVEL OF EVIDENCE: Level V, Expert Opinion includes Case Reports and Technique Tips.

Lesser Metatarsophalangeal Joint Plantar Plate Degeneration and Tear and Acute First Metatarsophalangeal Joint Capsuloligamentous Injury: What the Surgeon Wants to Know.

Injuries to the plantar plate complex of the first toe and the lesser toes, although closely related anatomically, differ significantly in their pathogenesis. Lesser metatarsophalangeal joint plantar plate degeneration and tear typically presents as an attritional pattern of capsuloligamentous deficiency in middle-aged patients, whereas first metatarsophalangeal joint capsuloligamentous injury is typically acute and occurs in younger adult athletes engaged in sports involving repetitive running and jumping. Consequently, considerations regarding surgical decision-making also differ. Knowledge of the anatomy, pathophysiological basis, common patterns, grading and classification of these injuries, and indications for surgery, will aid imaging interpretation in the preoperative setting. The acuity and extent of injury, tissue quality and functional requirements of the patient (such as timely return to sport) influence clinical decision-making with respect to conservative versus surgical management and are informed by the use of optimized multimodal imaging. This section will provide an overview of these injuries in 2 parts, separated into those affecting the first toe and the lesser toes, and will highlight imaging findings relevant to surgical decision-making.

First MTP joint injuries: MR imaging findings in surgically managed patients.

OBJECTIVES: Determine whether MR imaging findings or demographics predict surgical management in patients with first MTP joint injuries. MATERIALS AND METHODS: Retrospective study of 161 forefoot MRs for traumatic first MTP injury (M:F 92:69, mean age 33 ± 13 yrs.). Two radiologists reviewed imaging for ligamentous, osseous, and tendinous injuries. Ligaments and tendons were graded as 0:normal, 1:sprain or strain, 2:partial tear, 3:complete tear. Osseous injuries were classified as edema, fracture, or cartilage injury. Clinical data obtained included sex, age, injury acuity, sport participation, level of sport, and treatment. Imaging findings and demographic data were assessed to determine predictive factors for surgical management. Statistics included kappa, chi-squared, Fisher's exact, and logistic regression. RESULTS: Logistic regression (odds ratio [95% CI], p-value) showed that grade 2 or 3 injuries of the plantar ligamentous complex (2.87, [1.10, 7.48], p = 0.031), grade 2 or 3 injuries of the medial collateral ligament (3.24, [1.16, 9.08], p = 0.025), and participation in collegiate or professional sports (4.34 [1.64, 11.52], p = 0.003) were associated with an increased rate of surgical intervention. k = ligamentous injury (0.71-0.83), osseous trauma (0.88-0.95), and tendon injury (0.78). All other imaging findings and demographic factors were not significant predictors of surgery (p > 0.05). CONCLUSION: Participation in collegiate or professional sports and tears of the plantar ligamentous complex or medial collateral ligament predicted surgical management in patients with first MTP trauma.

Differential contribution of lateral plantar foot ligaments to lateral column stability - A cadaver based sectioning analysis.

Lateral column (LC) instability occurs in adult acquired flatfoot deformity (AAFD). Differential ligament contribution to LC stability is unknown. The primary aim was to quantify this by using cadaver sectioning of lateral plantar ligaments. We also determined the relative contribution of each ligament to dorsal translation of the metatarsal head in the sagittal plane. 17 below-knee cadaveric specimens, preserved by vascular embalming method, were dissected to expose plantar fascia, long/short plantar ligaments (L/SPL), calcaneocuboid (CC) capsule and inferior 4th/5th tarsometatarsal (TMT) capsule. Dorsal forces of 0 N, 20 N and 40 N were applied to the plantar 5th metatarsal head after sequential ligament sectioning in different orders. Pins provided linear axes on each bone, allowing relative angular bone displacements to be calculated. Photography and ImageJ processing software were then used for analysis. The LPL (and CC capsule) had the greatest contribution to metatarsal head motion (107 mm) after isolated sectioning. In the absence of other ligaments, sectioning these resulted in significantly increased hindfoot-forefoot angulation (p ≤ 0.0003). Isolated TMT capsule sectioning demonstrated significant angular displacement even when other ligaments remained intact (with intact L/SPL, p = 0.0005). CC joint instability required both LPL and capsular sectioning for significant angulation to occur, whilst TMT joint stability was largely dependent on its capsule. The relative contribution of static restraints to the lateral arch has not yet been quantified. This study provides useful information on relative ligament contribution to both CC and TMT joint stability, which may in turn improve understanding of surgical interventions used to restore arch stability.

Morphology of the Lisfranc Joint Complex.

Lisfranc injuries are complicated injuries of the tarsometatarsal joint with high rates of sequelae. Both anatomy and injury of the Lisfranc joint are variably documented. Descriptions of these injuries and their associated structures vary greatly. The most injured structures are those of the Lisfranc joint complex, which involves the medial cuneiform, second and third metatarsals, and the dorsal, interosseous, and plantar Lisfranc ligaments. This study sought to examine morphology of the Lisfranc joint in cadavers. Twenty-two embalmed cadaveric feet were dissected (13 male, 9 female, 80.3 years ± 14.03) to isolate the bones and ligaments of the Lisfranc joint complex. The dorsal, interosseous, and plantar Lisfranc ligaments were present in each specimen. Each ligament was measured and morphology noted. The dissected dorsal Lisfranc ligament had consistent morphology (mean = 10.8 mm ± 1.79). The interosseous Lisfranc ligament had a consistent path, but 11/17 of specimens possessed a connection to the plantar Lisfranc ligament. The plantar Lisfranc ligament demonstrated wide variability with a Y-variant (n = 3) and a fan-shaped variant (n = 14). Ligament thickness was greatest in the interosseous Lisfranc ligament (mean = 13.74 ± 3.08) and least in the dorsal Lisfranc ligament (mean = 1.36 ± 0.42). While the objective of defining joint and ligament morphology was achieved, further questions were raised. Variations of the interosseous and plantar Lisfranc ligament may play a role in susceptibility to joint injury, and arthritic changes to the joints examined raise questions regarding the prevalence of arthritis in the uninjured Lisfranc joint.

Proximal Plantar Plate of Lesser Toe Metatarsophalangeal Joint Vascular Supply.

BACKGROUND: The plantar plate is a major stabilizing structure of the metatarsophalangeal (MTP) joint with instability frequently occurring after a tear or attenuation of this structure. Commonly, a McGlamry elevator is used to strip the plantar plate from the plantar surface of the metatarsal to improve exposure of the MTP joint. The anatomy of the proximal plantar plate and vascular consequence of stripping the plantar plate from the metatarsal is not yet well understood. The purpose of this study is to describe the proximal attachment of the plantar plate anatomically and quantify the relative contribution of blood supply to the proximal plantar plate from both the metatarsal and the plantar fascia. METHODS: For anatomic evaluation, 6 lower extremity cadaver specimens without any gross evidence of foot and ankle deformity were utilized. For imaging analysis, 16 fresh frozen human adult cadaveric lower extremity specimens were used for this study, resulting in 35 MTP joints without deformity and 11 lesser MTP joints with cockup and/or crossover deformities. The specimens were prepared as described previously by Finney et al.5. RESULTS: From gross anatomic dissection, the plantar plate origin consists of a stout fibrous pedicle distinct from the surrounding synovial-type tissue that firmly anchors the plantar plate to the metatarsal. Based on nano-computed tomographic imaging, an average of 63.5% of the vascular supply to the proximal portion of the plantar plate entered from the metatarsal pedicle. The remaining 36.5% of the vascular supply entered from the plantar fascia. CONCLUSION: The proximal attachment of the plantar plate includes a stout fibrous pedicle anchoring the proximal portion of the plantar plate to the notch between the medial and lateral plantar condyles of the metatarsal head. The vascular supply of the proximal plantar plate is supplied from both the metatarsal pedicle and plantar fascia. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Plantar Plate Repair for Metatarsophalangeal Joint Instability of the Lesser Toes.

The plantar plate is a known stabilizer of the lesser toe metatarsophalangeal (MTP) joint. MTP instability is a known common cause of metatarsalgia, most commonly in the second toe. In the last decade, clinical staging and anatomic grading mechanisms have been published to guide the surgeons on the treatment of MTP instability; this has also led to an understanding of how plantar plate tears relate to MTP joint instability. Direct surgical repair of the plantar plate has been described, short-term outcomes have been published, and the results are not perfect, but promising with respect to patient satisfaction and pain relief.

Anatomy: Plantar Plate.

The fibrocartilaginous component of the plantar plate offers stability at the metatarsophalangeal joint. In conjunction with the attachments of the deep transverse metatarsal ligaments and collateral ligaments, the plantar plate complex resists tensile forces anchored by the plantar fascia and compression forces under the metatarsal heads.

Nonoperative Treatment of Plantar Plate Tears.

The plantar plate is a critical structure involved in stabilizing the metatarsophalangeal joint. Its disruption can not only be painful for the patient but also may lead to subsequent structural deformities. There are several conservative treatment modalities available to help mitigate symptoms including splinting, offloading, and intraarticular injections. That being said, once the pathology progresses to advanced stages, these treatments are not efficacious. Reported success with conservative treatment modalities is limited to case studies and series with a low level of clinical evidence. As such, this represents an area where further investigation is needed to evaluate the true efficacy of conservative treatment and to allow for development of a more standardized approach.

Operative Management: Plantar Plate.

The plantar plate is a vital structure for maintaining lesser metatarsophalangeal joint (MPJ) stability. Its primary role is to provide static stabilization of the MPJs, working in conjunction with the long and short flexor and extensor tendons. When insufficiency or attenuation of the plantar plate occurs, a sagittal plane deformity will slowly develop, eventually leading to a "crossover toe" transverse plane deformity. Coughlin coined this descriptive term to describe the later stages of deformity, most commonly affecting the second MPJ. Shortly after, Yu and Judge elaborated on this condition describing it as "predislocation syndrome," an inflammatory condition affecting the plantar plate causing pain and instability, which could progress to subluxation at the MPJ.

Diagnostic accuracy of magnetic resonance imaging (MRI) versus dynamic ultrasound for plantar plate injuries: A systematic review and meta-analysis.

BACKGROUND: Previous literature has suggested both MRI and ultrasound can accurately diagnose plantar plate tears. There is a significant cost difference between these two modalities, sparking interest for which should be the preferred method for diagnosis. PURPOSE: The purpose of this study was to examine the diagnostic accuracy of MRI and dynamic, musculoskeletal ultrasound for lesser metatarsal plantar plate injuries using a systematic review and meta-analysis. METHODS: MEDLINE, CINAHL, and Clinicaltrials.gov were searched thru May 2020. We included studies evaluating the diagnostic accuracy of MRI or ultrasound for detecting plantar plate tears, using intraoperative confirmation as the gold standard comparison. Sensitivity and specificity were obtained and pooled from included studies. Summary receiver operating curves were formed for each diagnostic test to compare accuracy. Study quality was assessed using the QUADAS-2 scoring system. RESULTS: Eleven studies met our inclusion criteria, representing 227 plantar plates for MRI and 238 plantar plates for ultrasound. MRI displayed a pooled sensitivity of 89% (95% CI 0.84, 0.93) and specificity of 83% (95% CI 0.64, 0.94). Ultrasound displayed a sensitivity and specificity of 95% (95% CI 0.91, 0.98) and 52% (95% CI 0.37, 0.68), respectively. CONCLUSION: MRI was superior to ultrasound in diagnosing plantar plate injuries overall, however, ultrasound was more sensitive than MRI, suggesting a negative ultrasound would likely rule out a plantar plate injury in the presence of an equivocal physical exam. Determining the grade of the injury is best served with MRI which can provide added insight into the joint's supporting structures (e.g. collateral ligaments) and integrity.

Degenerative injuries of the metatarsophalangeal plantar plate on magnetic resonance imaging: a new perspective.

OBJECTIVE: The magnetic resonance imaging diagnostic criteria for a complete tear of metatarsophalangeal plantar plate are well-established. However, more subtle abnormalities can also occur and be a source of pain. The objective of this study is to determine the prevalence of degenerative plantar plate injuries in patients with metatarsalgia who underwent forefoot magnetic resonance imaging and describe the main abnormalities found. The hypothesis is that mild capsular fibrosis will have high sensitivity but low specificity for plantar plate degenerative injuries. METHODS: A retrospective cross-sectional study was conducted with 85 patients (105 feet) with metatarsalgia who underwent forefoot magnetic resonance imaging using a specific protocol to study metatarsophalangeal plantar plate. The experiment observer classified second toe plantar plate as normal, complete rupture or degenerative lesion and described the main magnetic resonance imaging findings. RESULTS: A normal plantar plate was observed in 75 (71.4%) of the 105 feet assessed, in 25 (24%) feet there were degenerative plantar lesions, and in 5 (4.6%) feet there were complete ruptures. Degenerative injury of the plantar plate was best identified in coronal short axis intermediate-weighted images, with high sensitivity (92%). Pericapsular fibrosis below the intermetatarsal ligament was identified in 96% of cases, with high sensitivity (96%) for diagnosis of degenerative plantar plate injury. CONCLUSION: Degenerative lesions of the metatarsophalangeal plantar plate were more prevalent than complete ruptures and were best viewed in coronal short axis intermediate-weighted sequences. Pericapsular fibrosis below the intermetatarsal ligament was the indirect finding most strongly associated with degenerative plantar plate injury.

Lesser Metatarsophalangeal Plantar Plate Repair.

Lesser toe plantar plate injuries at the metatarsophalangeal (MTP) joint are a common source of metatarsalgia. Chronic pain with weight-bearing is the common presentation of lesser toe instability. Deformity occurs when the plantar plate is torn or attenuated. Crossover toe and MTP instability often occur with multiplane deformity, most commonly with dorsal contracture of the second toe and medial drift over the Hallux. In this article, the authors present a comprehensive stepwise approach to diagnosing and treating plantar plate injuries using both dorsal and plantar approach techniques.

Treatment of Lesser Metatarsophalangeal Joint Instability With Plantar Plate Repair: A Systematic Review and Meta-Analysis.

Recognition of metatarsophalangeal joint plantar plate injuries has improved over time as the condition has become more widely understood and identified. With the diagnosis of a plantar plate injury as a subset of metatarsalgia becoming more common place, there are multiple surgical options that have been utilized to address the condition. Direct repair of the plantar plate has emerged as the treatment of choice for foot surgeons with a tendency to favor a direct dorsal approach for the repair. We performed a systematic review and meta-analysis using preferred reporting items for systematic reviews and meta-analysis guidelines, to determine the magnitude of change that can be expected in visual analog scale pain and American Orthopedic Foot and Ankle Society scores postoperatively. A total of 12 studies involving 537 plantar plate tears were included who underwent direct repair of the plantar plate through either a dorsal (10 articles) or plantar approach (2 articles). Summary estimates were calculated which revealed improvement in visual analog scale pain (pooled mean change of -5.01 [95%CI -5.36, -4.66] pre-to postoperative) and improvement in American Orthopedic Foot and Ankle Society scores (pooled postoperative mean improvement 40.44 [95%CI 37.90, 42.97]) of patients within the included studies. Random effects models were used for summary estimates. I2 statistic was used to assess for heterogeneity. We concluded there is a predictable level of improvement in pain and function in patients undergoing a direct dorsal approach plantar plate repair with follow-up out to 2 years.

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.

Presurgical Perspective and Postsurgical Evaluation of Plantar Plate and Turf Toe.

Capsuloligamentous injury of the first metatarsophalangeal (MTP) joint (eponymously called "turf toe") mostly occurs in athletes and involves acute trauma, whereas tears of the lesser MTP joint plantar plate typically are an attritional-degenerative condition. This article reviews the anatomy, pathophysiology, mechanism and patterns of injury, grading and classification of injury, imaging appearances (pre- and postoperative), and management of first MTP joint capsuloligamentous injuries and lesser MTP joint plantar plate tears. These two distinct pathologies are discussed in separate sections.

Transverse laxity of the forefoot.

BACKGROUND: Splay of the forefoot reflects the loss of tension in the soft tissues and indicates failure of the biomechanics of the tie-bar system. By identifying and quantifying the soft tissue structures involved in the destruction of forefoot stability we could increase the understanding of forefoot pathologies. METHODS: We investigated the transverse forefoot laxity on healthy feet, feet with forefoot pathology and cadaveric feet undergoing sequential dissection. RESULTS: Statistical difference in transverse laxity was seen between healthy feet (n = 160) and feet with symptomatic forefoot pathology requiring surgery (n = 29). Presence of lesser ray pathology is associated with increased transverse laxity. For the dissected cadaveric feet (n = 9) sequential sectioning the plantar plate causes a progressive evolution of transverse laxity. The repair of plantar plates greatly improves transverse stability. CONCLUSIONS: Forefoot pathology causes increased transverse laxity. In case of a major transverse laxity of the forefoot a plantar plate lesion should be suspected.

Lesão da Placa Plantar da Articulação Metatarsofalangeana do 1º raio: um relato de caso / Injury of the Plantar Plate of the Metatarsophalangeal Joint of the 1st ray: a case report

Introdução: A placa plantar do hálux, localizada na articulação metatarso falangeana(MTF) é o principal estabilizador estático e dinâmico dessa articulação, sua lesão traumática é de difícil diagnóstico e pode levar ao enfraquecimento e/ou lesão da cápsula, além de instabilidade articular, com subsequente deformidade do dedo e queixas álgicas importantes. Relato do Caso: O relato descreve o caso de paciente do sexo masculino, com 33 anos de idade, admitido na unidade de atendimento imediato do Hospital do Servidor Público Municipal (HSPM), com queixa de dor na região plantar do primeiro metatarso do pé direito há 2 dias, com história de trauma em hiperextensão do hálux direito ao descer de escada. Apresentou edema 2+/4+ na região plantar do primeiro raio, equimose região plantar do primeiro raio, dor a palpação dos sesamoides. Flexão ativa interfalangiana do hálux presente. Teste da gaveta dorso plantar positivo e instabilidade em varo e valgo com amplitude de movimento normal. No exame de Raio X (RX), foi evidenciado região sem fraturas, com assimetria do sesamoide lateral. Assim, como conduta complementar foi solicitado a realização Ressonância Magnética (RNM) para melhor elucidação e diagnóstico da lesão da placa plantar. O resultado da RNM apresentou "sinais de lesão da placa plantar e capsulo-ligamentar metatarsofalângicas do hálux, com rotura de espessura total do ligamento sesamoidefalângico medial e rotura parcial de alto grau do ligamento colateral medial, de aspecto recente (Turf Toe)". O paciente então foi encaminhado para procedimento cirúrgico(reparo da placa plantar com reinserção dos sesamoides) e após o procedimento e período pós cirúrgico para tratamento fisioterápico. Discussão: a placa plantar do primeiro raio é, portanto, a principal estrutura estabilizadora da articulação MTF devido à sua localização central e múltiplas fixações importantes, e as indicações cirúrgicas tem obtido resultados favoráveis aos pacientes. Assim, evitando complicações graves como instabilidade, metatarsalgia, artrose e até deformidade do primeiro raio. Conclusão: Paciente sem dor ou instabilidade, segue em acompanhamento fisioterapêutico. Palavras-chave: Articulação Metatarsofalângica. Metatarsalgia do primeiro raio. Placa Plantar. Turf Toe.