[Reconstruction of the plantar plate of the metatarsophalangeal joint using a dorsal transarticular approach]

OBJECTIVE

Reconstruction of the plantar plate to stabilize a dislocated or instable lesser metatarsophalangeal joint using a dorsal approach in combination with a Weil osteotomy.

INDICATIONS

Dislocated or instable lesser metatarsophalangeal joint with rupture of the plantar plate.

CONTRAINDICATIONS

Infection, circulatory disorders, symptomatic degenerative arthritis lesser metatarsophalangeal joint.

SURGICAL TECHNIQUE

Weil osteotomy using a dorsal approach. Temporary dislocation of the metatarsal head as proximal as possible. Inspection of the plantar plate. Assessment and classification of type and extent of the rupture. Suturing of the plantar plate to the plantar bases of the proximal phalanx. Fixation of the Weil osteotomy with correction of the metatarsal alignment.

POSTOPERATIVE MANAGEMENT

Weight bearing in a postoperative shoe as tolerated. X‑ray control 6 weeks postoperative. Full weight bearing in a conventional shoe after bony consolidation.

RESULTS

A total of 23 surgical reconstructions of the plantar plate (complete plantar plate repair) between 12/2012 and 10/2014 were performed. The mean follow-up was 18.6 (12-30) months. Five secondary dislocations were observed: one deep postoperative infection, one early dislocation of unknown cause, one secondary dislocation caused by severe hallux valgus recurrence, one massive foreign body reaction to the non-resorbable sutures, and one late secondary dislocation occurred between 6 weeks and 1 year postoperative. Normal function of the reconstructed joint was achieved in 13 of the 23 reconstructions (57%). A reduced toe purchase was observed in 3 reconstructions (13%). A floating-toe resulted after 7 reconstructions (30%).

Ultrasonography Features of the Plantar Fascia Complex in Patients with Chronic Non-Insertional Achilles Tendinopathy: A Case-Control Study

Purpose: The goal of the present study was to assess, by ultrasound imaging (USI), the thickness of the plantar fascia (PF) at the insertion of the calcaneus, mid and forefoot fascial locations, and the calcaneal fat pad (CFP) in patients with Achilles tendinopathy (AT). Methods: An observational case-control study. A total sample of 143 individuals from 18 to 55 years was evaluated by USI in the study. The sample was divided into two groups: A group composed of the chronic non-insertional AT (n = 71) and B group comprised by healthy subjects (n = 72). The PF thicknesses at insertion on the calcaneus, midfoot, rearfoot and CFP were evaluated by USI. Results: the CFP and PF at the calcaneus thickness showed statistically significant differences (P < 0.01) with a decrease for the tendinopathy group with respect to the control group. For the PF midfoot and forefoot thickness, no significant differences (P > 0.05) were observed between groups. Conclusion: The thickness of the PF at the insertion and the CPF is reduced in patients with AT measured by USI.

Preliminary results of a plantar plate for Lapidus arthrodesis

The TMT I arthrodesis is an established procedure for the correction of hallux valgus deformity associated with the instability of the TMT-I joint. A risk of transfer metatarsalgia is reported in the literature associated with persistant elevation of MT-I. Detailed information for ideal positioning of the arthrodesis is missing so far. Clinical, radiological and padobarografical results and their correlations were analyzed with special consideration of the elevation position of the MT-I in a TMT-I arthrodesis using the plantar plate osteosynthesis. Postoperative changes in plantar pressure and force distribution occured after TMT-I arthrodesis. A postoperative increase of the load under the medial forefoot and the dependence on the positioning of MT-I in the sagittal plane has been shown. The authors suggest, that increased load of the medial forefoot and constant pressures and forces under the central forefoot may lead to a relative relief of the area, which might explain the postoperative reduction of metatarsalgia.

Accuracy of Sonography in Plantar Plate Tears in Cadavers

OBJECTIVES

Sonography is often used in the evaluation of forefoot disorders, and its use has been suggested in the diagnosis of plantar plate tears. This study aimed to assess the accuracy of sonography in the diagnosis of plantar plate tears of the lesser digits using gross dissection as the reference standard.

METHODS

The second through fifth digits of 6 cadavers were examined with sonography to evaluate for plantar plate tears. The examination was performed by a single musculoskeletal radiologist in longitudinal and short axes, and plates were graded as torn or intact. The digits were then dissected by a single podiatrist blinded to the prior sonographic results to assess the integrity of the plates.

RESULTS

Ten plantar plates were graded as torn by sonography, all occurring in the distal plate near the phalangeal insertion. Seven of these plates were identified as torn on direct inspection. Fourteen plantar plates were found to be intact on sonography, 12 of which were intact on gross inspection. Overall, the accuracy, sensitivity, and specificity of sonography were 79.2%, 77.8%, and 80.0%, respectively. No correlation was seen between the accuracy of sonography and plate size, using plate number as a surrogate marker for plate size (P = .822).

CONCLUSIONS

Sonography is an appropriate modality in the setting of suspected plantar plate tears, with acceptable accuracy, sensitivity, and specificity. No decline in accuracy was seen with smaller plates. Thus, sonography may be especially useful when small anatomy or technical factors make magnetic resonance imaging challenging to perform and interpret.