Early experience with a 3-D printed porous surface, fixed-bearing, total ankle arthroplasty: A minimum of 2-year follow-up.

BACKGROUND: This is a pilot study reviewing patients undergoing ankle replacement with the 3-D printed INFINITY™ with ADAPTIS™ total ankle arthroplasty (TAA) system. METHODS: A retrospective review was conducted of patients with a minimum two-year follow-up who underwent TAA with the INFINITY™ with ADAPTIS™ implant system. Outcome measures include implant survivorship, complications with subsequent reoperations, patient reported outcomes, and radiologic subsidence or radiolucency. RESULTS: Thirty patients were included with median follow-up of 26 months (range, 24-36). Implant survival rate was 90% (27/30). Two patients experienced linear radiolucency > 2 mm: one required a revision TAA secondary to tibial subsidence; the other patient was asymptomatic and nonprogressive on serial radiographs. No cystic radiolucencies > 5 mm were identified. VAS, PROMIS PF, and FADI scores improved significantly. CONCLUSION: TAA performed with the 3-D printed INFINITY™ with ADAPTIS™ implant technology led to ninety percent short term implant survivorship and improvement in patient reported outcomes with comparable results to other 4th generation arthroplasty systems as a treatment modality for end-stage ankle arthritis. LEVEL OF EVIDENCE: Level III, Retrospective cohort study, Prognostic.

Workers' Compensation: The Burden on Healthcare Resource Utilization After Foot and Ankle Surgery.

INTRODUCTION: The purpose of this study is to investigate the amount of healthcare resources dedicated to patients with WC after common foot or ankle procedures compared with a procedure-matched control group. METHODS: A retrospective review was performed of patients with WC and without WC undergoing foot and ankle procedures. Measures of healthcare burden included clinical communications, documents, prescriptions, office visits, and days to return to work and clinic discharge. RESULTS: Collectively, 142 patients met the inclusion criteria. Patients with workers' compensation had increased office communication encounters (P < 0.001), processed documents (P < 0.001), medication prescriptions (P < 0.001), number of office visits (P < 0.001), number of days until return to work (P < 0.001), and days until final disposition from clinic (P < 0.001). Patients with workers' compensation were more likely to have postoperative complications (OR 2.1; 95% CI, 1.0 to 4.3; P = 0.04), secondary surgeries (OR 8.2; 95% CI, 2.3 to 29.4; P < 0.001), and new complaints during the perioperative period (OR 1.9; 95% CI, 0.9 to 4.0; P = 0.07) but were less likely to cancel appointments (OR 0.41; 95% CI, 0.19 to 0.86; P = 0.02). DISCUSSION: When undergoing common foot and ankle orthopaedic procedures, patients with WC demonstrated increased healthcare utilization of resources. This included more office staff work burden dedicated to patients with WC for longer amounts of time, effectively doubling the effort of a non-WC cohort.

Postoperative Infection and Revision Surgery Rates in Foot and Ankle Surgery Without Routine Prescription of Prophylactic Antibiotics.

INTRODUCTION: Surgical site infections (SSIs) are associated with patient morbidity and increased healthcare costs. Limited literature in foot and ankle surgery provides guidance about routine administration of postoperative antibiotic prophylaxis. The purpose of this study was to examine the incidence and revision surgery rates of SSI in outpatient foot and ankle surgeries in patients not receiving oral postoperative antibiotic prophylaxis. METHODS: A retrospective review of all outpatient surgeries (n = 1517) conducted by a single surgeon in a tertiary referral academic center was conducted through electronic medical records. Incidence of SSI, revision surgery rate, and associated risk factors were determined. The median follow-up was 6 months. RESULTS: Postoperative infection occurred in 2.9% (n = 44) of the surgeries conducted, with 0.9% of patients (n = 14) requiring return to the operating room. Thirty patients (2.0%) were diagnosed with simple superficial infections, which resolved with local wound care and oral antibiotics. Diabetes (adjusted odds ratio, 2.09; 95% confidence interval, 1.00 to 4.38; P = 0.049) and increasing age (adjusted odds ratio, 1.02; 95% confidence interval, 1.00 to 1.04; P = 0.016) were significantly associated with postoperative infection. DISCUSSION: This study demonstrated low postoperative infection and revision surgery rates without the routine prescription of prophylactic postoperative antibiotics. Increasing age and diabetes are signficant risk factors for developing a postoperative infection.

Topical Antibiotic Powder and Nonunion Risk in Surgically Treated Tibial Plateau and Pilon Fractures.

INTRODUCTION: High-energy periarticular tibia fractures are challenging injuries with a significant risk of complications. Postoperative infection rates, although improved, remain unacceptable. Intrawound topical antibiotic (TA) application has been popularized to reduce postoperative infections. Although TA may minimize infections, it remains unclear whether TAs have any impact on the development of nonunion. Recent investigations of TA use in fracture care have questioned its efficacy in vivo and suggested a potentially deleterious effect on fracture healing. This study investigates the impact of TA on nonunion rates in surgically treated high-energy periarticular tibia fractures. METHODS: Retrospective analysis of surgically treated periarticular tibia fractures at a single Level 1 trauma center was conducted. Intervention in question was the clinical effect of intrawound TA powder application at definitive closure. A total of 222 high-energy periarticular tibia fractures were included, 114 with TA use and 108 without. The primary outcome was the occurrence of nonunion, with secondary outcomes being superficial and deep postoperative surgical site infections. RESULTS: Twenty-seven patients (12.1%) were diagnosed with nonunions (14 pilons and 13 plateaus). There was no statistically significant difference in nonunion rates among patients who received topical antibiotics (15.8%) versus the group of patients who did not (8.3%) ( P = 0.23). Odds of developing nonunion was significant for open injuries (odds ratio 6.16, P < 0.001) and patients with a provisional external fixator (odds ratio 8.72, P = 0.03) before definitive fixation. No notable difference in the number of superficial and deep infections was identified between groups. CONCLUSION: The use of TA in high-energy periarticular tibia fractures showed no statistically significant increase in nonunion rates but did not conclusively rule out nonunion as a possible effect of intrawound TA. Additional large-scale multicenter prospective studies are needed to confirm these findings. The current body of literature regarding high-energy periarticular tibia fractures does suggest that TAs lower the risk of postoperative infections, but the nonunion risk remains unclear. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Augmented Spring Ligament Repair in Pes Planovalgus Reconstruction.

Patients with pes planovalgus deformity often have coexisting spring ligament pathology. A primary repair of the ligament may fail during weightbearing due to chronic degeneration of the ligamentous tissue. Augmentation with a suture tape has been suggested to strengthen the repair. Limited data exist regarding flatfoot reconstruction with augmented spring ligament repair using a suture tape. This is a review of 57 consecutive patients who had flatfoot reconstruction with concomitant spring ligament augmented repair between July 2014 and August 2017. Weightbearing radiographic parameters were obtained preoperatively and compared to radiographs at an average time of 62 ± 46.5 (range 20-220) weeks postoperative. Significant improvements were seen in the radiographic parameters evaluated. Five patients had subsequent operations including one deep infection, 2 hardware removals remote to the spring ligament augmentation, 1 ankle arthrodesis, and 1 triple arthrodesis. Concomitant spring ligament repair augmented with a suture tape was a safe procedure that contributed to radiographic correction in a consecutive series of 57 patients undergoing flatfoot deformity correction.

Deltoid Ligament Injuries Associated With Ankle Fractures: Arguments For and Against Direct Repair.

Ankle fractures are an extremely common orthopaedic injury treated by surgeons on a routine basis. The deltoid ligament is torn in a large number of these fractures and is commonly seen with associated radiographic changes of medial clear space widening. The clinical relevance of addressing the injured deltoid ligament with acute surgical repair has been debated for decades. The early literature documenting repair or reconstruction of the deltoid ligament dates back to the 1950s. Most commonly, orthopaedic surgeons restore the lateral column directly with fibula fracture fixation. The injury may then be further evaluated intraoperatively by stress testing to ensure syndesmosis integrity and mortise stability with indirect medial column reduction, which allows for secondary healing of the medial deltoid ligamentous complex. This popular treatment paradigm is based primarily on literature from the 1980s and has not been thoroughly evaluated with modern surgical implants, techniques, and research methods. A review and background of the supportive literature for and against deltoid ligament repair in the setting of acute ankle fractures is presented. Undeniably, the deltoid ligament complex has been proven to confer some element of stability to maintaining a congruent ankle mortise. The commonly cited data in favor of not repairing the deltoid ligament warrants careful consideration to allow accuracy in obtaining the best patient outcomes with the most predictable surgical methods available.

Beware of the Dragon: A Case Report of a Komodo Dragon Attack.

Komodo dragon attacks are rare occurrences, especially in the United States. Attacks are believed to be highly infectious and venomous, leading to demise of its prey. We present a case of a 43-year-old female zookeeper attacked by an adult dragon leading to tendon and neurovascular injuries.

Radiographic Outcomes, Union Rates, and Complications Associated With Plantar Implant Positioning for Midfoot Arthrodesis.

BACKGROUND: Midfoot arthrodesis has long been successfully included in the treatment paradigm for a variety of pathologic foot conditions. A concern with midfoot arthrodesis is the rate of nonunion, which historically has been reported between 5% and 10%. Plantar plating has also been noted to be more biomechanically stable when compared to traditional dorsal plating in previous studies. Practical advantages of plantar plating include less dorsal skin irritation and the ability to correct flatfoot deformity from the same medial incision. The purpose of this study is to report the arthrodesis rate, the success of deformity correction, and the complications associated with plantar-based implant placement for arthrodesis of the medial column. METHODS: A retrospective review was undertaken of all consecutive patients between 2012 and 2019 that underwent midfoot arthrodesis with plantar-positioned implants. Radiographic outcomes and complications are reported on 62 patients who underwent midfoot arthrodesis as part of a correction for hallux valgus deformity, flatfoot deformity, degenerative arthritis, Lisfranc injury, or Charcot neuroarthropathy correction. RESULTS: Statistically significant improvement was seen in the lateral talus-first metatarsal angle (Meary angle) and medial arch sag angle for patients treated for flatfoot deformity correction. In patients treated for hallux valgus deformity, there was a reduction in the intermetatarsal angle from 15.4 to 6.8 degrees. The overall nonunion rate was 6.45% in all patients. The rate of nonunion was higher at the NC joint compared to the TMT joint and with compression claw plates. One symptomatic nonunion required revision surgery (1.7%). There were no nonunions when excluding neuroarthropathy patients and smokers. The odds ratio (OR) for nonunion in patients with neuroarthropathy was 6.05 (P < .05), and in active smokers the OR was 2.33 (P < .05). CONCLUSION: Plates placed on the plantar bone surface for midfoot arthrodesis achieved and maintained deformity correction with rare instances of symptomatic hardware for a variety of orthopedic conditions. An overall clinical and radiographic union rate of 94% was achieved. The radiographic union rate improved to 100% when excluding both neuroarthropathy patients and smokers. The incidence of nonunion was higher in smokers, neuroarthropathy patients, naviculocuneiform joint fusions, use of compression claw plates, and when attempting to fuse multiple joints. Incisional healing complications were rarely seen other than in active smokers. LEVEL OF EVIDENCE: Level IV, case series.

Anatomic Risk to the Neurovascular Structures With a Medially Based All-Inside Syndesmosis Suture Button Technique.

Recent evidence suggests that the use of suture button devices for ankle syndesmosis fixation is increasing. Multiple studies have shown some concern about damaging the greater saphenous neurovasculature with placement of the anchor point on the medial tibial cortex. We hypothesized that an all-inside button deployment technique would allow for a low risk to medial soft tissue structures. A total of 40 syndesmosis suture buttons were placed into 10 separate cadaveric lower limbs, using the newly developed technique. Four suture buttons were sequentially placed from distal to proximal in each limb within the zone of typical syndesmosis fixation, using fluoroscopic guidance. A medial incision was then performed to evaluate the relationship of the suture buttons to the medial soft tissue structures and the medial malleolus. Thirteen of 40 suture buttons (32.5%) were placed anterior, 7 (17.5%) posterior, and 20 (50%) with a portion of the button directly deep to the saphenous vein. Two of 40 buttons (5%) were placed within the tibial periosteum, and 38 (95%) were subfascial and directly superficial to the periosteum. Four of 40 (10%) limbs revealed a perforation in the saphenous vein from the guidepin. In conclusion, risks to the medial neurovascular structures exist with the medial deployment technique, but they appear to be mitigated compared with previous publications. The necessity of a medial incision to evaluate for soft tissue entrapment may not be necessary in all patients, as this technique appears to be safe, accurate, and reproducible.

Complications and Early Radiographic Outcomes of Flatfoot Deformity Correction With Metallic Midfoot Opening Wedge Implants.

BACKGROUND: Forefoot varus is a common component of flatfoot deformity that is often surgically addressed. Multiple options exist to plantarflex the medial column, with midfoot fusion and the Cotton osteotomy being the most common. This study analyzes radiographic outcomes and complications when a titanium wedge is used for structural support in a dorsal opening wedge Cotton osteotomy of the medial cuneiform. METHODS: Between December 2016 and May 2018, 32 feet in 31 patients were treated with medial column titanium wedges for residual forefoot varus in association with flatfoot corrections. All participants had preoperative and weight-bearing postoperative radiographs examined for analysis of radiographic correction. The average age of the patients was 41.1 (range: 12-70). The average follow-up time for patients was 12.2 months (8-24). RESULTS: All radiographic parameters were statistically significantly improved from preoperative to postoperative (P < .05). There were no instances of nonunion of the medial cuneiform osteotomy. There was 1 implant that loosened and was revised to a larger implant that healed uneventfully. No wedges were removed for continued pain at the osteotomy site. CONCLUSION: This study suggests that metal wedges are both safe and effective for use in medial column correction based on early follow-up data. Future studies comparing titanium wedges versus traditional bone grafting for Cotton osteotomies may provide further analysis of radiographic correction, operative time, procedure cost, and outcomes. There were no instances of pain over the titanium wedge site. Radiographic outcomes are similar to those reported for opening wedge Cotton osteotomies including bone grafting and wedge plates with screws. Future studies will help determine the long-term maintenance of correction and hardware survivorship. LEVEL OF EVIDENCE: Level IV, case series.

Treatment of Rigid Hammer-Toe Deformity: Permanent Versus Removable Implant Selection.

Hammer-toe deformities that fail nonoperative treatment can be successfully addressed with proximal interphalangeal joint resection arthroplasty or fusion. The goal of surgery is to eliminate the deformity and rigidly fix the toe in a well-aligned position. Hammer-toe correction procedures can be performed with temporary Kirschner wire (K-wire) fixation for 3 to 6 weeks with high success rates. Pain relief with successful hammer-toe correction approaches 90%; patient satisfaction rates approximate 84%. Although complication rates are rare in most series, there remains a concern regarding exposed temporary K-wire fixation, which has led to the development of multiple permanent internal fixation options.

Anatomic Parameters for Instrumentation of the Sacrum and Pelvis: A Systematic Review of the Literature.

INTRODUCTION: Multiple cadaver and radiographic analyses have been performed to define the surgical anatomy of the sacrum and pelvis. We provide a comprehensive review of this information, creating an accurate anatomic guide for practice and research. METHODS: A systematic review was performed to identify publications citing sacral or iliac morphometric parameters based on cadaver or radiographic anatomy. RESULTS: A total of 780 abstracts were evaluated. Fifty-six articles were included for final review and grouped into four sections: (1) bone density, (2) bony corridors, (3) screw length and trajectory, and (4) neurovascular and alimentary anatomy. CONCLUSION: A systematic analysis of the radiographic and gross anatomic features of the sacrum has yet to be published. This review includes details on the spatial arrangement of the S1 and S2 pedicle screws, sacroiliac screws, iliac screws, S2 alar iliac screws, and pelvic neurovascular anatomy. The study can be referenced by clinicians for sacral dissection, implant application, and ongoing advances in orthopaedic research. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level IV.

Peripheral Nerve Blocks in Foot and Ankle Surgery.

Postoperative pain is one of the most important factors in regard to patient outcomes. It has been linked with patient satisfaction, length of stay, and overall hospital costs. Peripheral nerve blocks have provided a safe, effective method to control early postoperative pain when symptoms are most severe. Peripheral nerve blocks, whether used intraoperatively or postoperatively, provide an alternative or adjunct to conventional pain management methods for patients who may not tolerate heavy narcotics or general anesthesia, in particular the elderly and those with cardiopulmonary disease.

Plantar Plate Repair for Lesser Metatarsophalangeal Joint Instability.

BACKGROUND: Lesser metatarsophalangeal (MTP) joint instability is a common cause of forefoot pain. Advances in operative technique and instrumentation have made it possible to anatomically treat plantar plate tears through a dorsal approach. Our goal was to evaluate the subjective, functional, and radiographic outcomes of plantar plate repair (PPR) from a dorsal approach. METHODS: A prospective case series was performed evaluating the results of PPR in 97 feet with 138 plantar plate tears. Patients underwent PPR from a dorsal approach with a Weil osteotomy. We followed patients at regular intervals for 12 months and collected data preoperatively and postoperatively with respect to visual analog scale (VAS) scores, MTP range of motion (ROM), paper pull-out test, American Orthopaedic Foot & Ankle Society (AOFAS) scores, satisfaction, and radiographic measures. RESULTS: Eighty percent of patients scored "good" to "excellent" satisfaction scores at 12 months. The mean VAS pain score preoperatively was 5.4/10, and postoperatively was 1.5/10. The mean AOFAS scores increased from 49 to 81 points following surgery. The mean MTP ROM preoperatively was 43 degrees and postoperatively 31 degrees. Forty-two percent of toes passed the paper pull out test prior to surgery and 54% at 12 months. Mean metatarsal shortening was 2.4/3.1/1.2 mm for the second, third, and fourth metatarsals, respectively. The mean MTP joint angles preoperatively were 2/4.9/-1.3 degrees and postoperatively were 7.4/9.6/0.2 degrees, respectively, for the second, third, and fourth MTP joints. CONCLUSION: We found that the plantar plate could be repaired through a dorsal approach with reliable outcomes. PPR was a viable option to anatomically restore the ligamentous support in the unstable lesser MTP joint. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Biomechanical Evaluation of Custom Foot Orthoses for Hallux Valgus Deformity.

The purpose of the present study was to compare the hallux valgus deformity pressure parameters seen in standard footwear (no orthosis) versus the pressure observed in the same footwear with the addition of 3 different length orthoses. The forefoot pressure at a hallux valgus deformity was recorded with pressure sensors placed on the plantar, medial, and dorsal surface of the first metatarsal head. The participants performed walking trials without an orthosis and with orthoses of 3 different lengths. The average pressure and maximum pressure of each area was recorded for each orthosis, and comparisons were made across the groups. The plantar pressures were decreased in the full length and 3/4 length orthoses, and the dorsal pressures were increased with the use of the full-length and sulcus-length orthoses. Significant changes in medial pressure were not seen with the addition of any orthosis compared with standard footwear alone. However, a trend toward increased medial pressures was seen with the full- and sulcus-length orthoses, and the 3/4-length orthoses exhibited a trend toward decreased medial pressures. We were unable to demonstrate that the use of a custom foot orthosis significantly decreases the medial pressures on the first metatarsal head in patients with hallux valgus deformity. The 3/4-length orthosis was less likely to negatively affect the dorsal or medial pressures, which were noted to increase with the sulcus- and full-length orthoses. Our data suggest that if a clinician uses this treatment option, a 3/4-length orthosis might be a better choice than a sulcus- or full-length orthosis.

Low-Level Laser Therapy at 635 nm for Treatment of Chronic Plantar Fasciitis: A Placebo-Controlled, Randomized Study.

Plantar fasciitis affects nearly 1 million persons in the United States at any one time. Conservative therapies have been reported to successfully treat 90% of plantar fasciitis cases; however, for the remaining cases, only invasive therapeutic solutions remain. This investigation studied newly emerging technology, low-level laser therapy. From September 2011 to June 2013, 69 subjects were enrolled in a placebo-controlled, randomized, double-blind, multicenter study that evaluated the clinical utility of low-level laser therapy for the treatment of unilateral chronic fasciitis. The volunteer participants were treated twice a week for 3 weeks for a total of 6 treatments and were evaluated at 5 separate time points: before the procedure and at weeks 1, 2, 3, 6, and 8. The pain rating was recorded using a visual analog scale, with 0 representing "no pain" and 100 representing "worst pain." Additionally, Doppler ultrasonography was performed on the plantar fascia to measure the fascial thickness before and after treatment. Study participants also completed the Foot Function Index. At the final follow-up visit, the group participants demonstrated a mean improvement in heel pain with a visual analog scale score of 29.6 ± 24.9 compared with the placebo subjects, who reported a mean improvement of 5.4 ± 16.0, a statistically significant difference (p < .001). Although additional studies are warranted, these data have demonstrated that low-level laser therapy is a promising treatment of plantar fasciitis.

Etiology and management of lesser toe metatarsophalangeal joint instability.

The terms crossover toe and lesser metatarsophalangeal joint instability both describe a deterioration of the soft tissue structures that give stability to the lesser MTP joints. Initial treatment regimens focused on indirect repair of the instability without addressing the primary pathology. A staging system of the clinical examination and a grading system of the surgical findings are now available to help surgeons classify and treat the plantar plate insufficiency. Improved imaging techniques and direct surgical repair techniques through a dorsal approach have changed the treatment and possibly the results of this difficult condition.

Sensory Nerve Dysfunction and Hallux Valgus Correction: A Prospective Study.

BACKGROUND: Sensory nerve dysfunction in patients with hallux valgus has been described as both a symptom of the deformity and a complication of the treatment. The purpose of this study was to quantify nerve dysfunction in hallux valgus patients and to prospectively evaluate whether the trauma of surgery or the correction of the deformity had any effect on the sensory nerve function. METHODS: Fifty-seven consecutive feet undergoing operative correction for hallux valgus were prospectively enrolled. Preoperative and 3-, 6-, and 24-month postoperative clinical, radiographic, and detailed sensory examinations were completed. For the sensory examination, a Semmes-Weinstein 5.07 monofilament was used to establish, if present, a geometric area of sensory deficit about the hallux. This area was traced onto calibrated graphing paper and processed with imaging software. A total of 48/57 (84%) went on to complete 24 months of follow-up. RESULTS: Preoperative sensory area deficit improved by a mean of 529 mm2 at 24-month follow-up. The mean preoperative sensory deficit area was 688 mm2 (SD 681 mm2, range: 0 to 2885 mm2) and 24-month postoperative sensory deficit area was 159 mm2 (SD 329 mm2, range: 0 to 1463 mm2). No clinically significant correlation existed between deficit and clinical outcome measures. CONCLUSIONS: This study showed that preoperative sensory deficits exist, and can improve up to 24 months after operative correction of the hallux valgus deformity. This supports the concept that sensory deficit in hallux valgus is at least partially caused by a reversible injury to the sensory nerves, not necessarily a complication of surgery. LEVEL OF EVIDENCE: Level IV, case series.

Osteochondral Lesions in Surgically Treated Hallux Valgus.

BACKGROUND: Patient dissatisfaction following surgical correction of hallux valgus remains a clinical problem. The aim of this study was to investigate articular erosion patterns of the first metatarsal head in patients with hallux valgus, to evaluate if the cartilage damage was associated with the degree of hallux valgus deformity, and to prospectively evaluate the effect on patient outcomes. METHODS: Fifty-six consecutive feet undergoing surgical correction for hallux valgus were prospectively enrolled and followed for 24 months postoperatively. In addition to clinical and radiographic examinations, intraoperative measurements were obtained to quantify osteochondral lesion location, size, and grade of the first metatarsal head cartilage. RESULTS: Fifty-one of 56 feet (91%) had osteochondral lesions. The mean number of zones affected was 2.9, and the mean maximum International Cartilage Repair Society (ICRS) scale lesion grade was 2.9 out of 4. A total of 44/56 (79%) completed a minimum of 24 months of follow-up. The grade of the lesion and the extent of the lesion did not have a strong correlation with the radiographic measures or clinical outcome scores. CONCLUSIONS: This study showed a high prevalence of osteochondral lesions in patients undergoing operative correction of hallux valgus. Since the grade and the extent of the lesions did not have a strong correlation with the severity of the deformity or the clinical outcome, the significance of these lesions remains unknown. LEVEL OF EVIDENCE: Level III, comparative series.

Metatarsophalangeal joint instability of the lesser toes and plantar plate deficiency.

Our understanding of lesser toe metatarsophalangeal joint instability has increased substantially over the past few decades. Some recent articles on the subject have provided detailed anatomic descriptions that help to characterize the primary stabilizing structures of the joint. Some surgeons now advocate the incorporation of a primary repair of the plantar plate into the surgical plan for correction of metatarsophalangeal joint deviation in the sagittal and transverse planes. New surgical techniques have been developed to expose, inspect, and reliably repair the plantar plate, if necessary. Dorsal and plantar approaches have both been used successfully to repair the plantar plate. Tears of the plantar plate can be repaired primarily or advanced on the base of the proximal phalanx through bone tunnels. Outcomes of these procedures are promising, with improvements in pain and function reported along with sustained deformity correction.