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Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability Foot and Ankle Surgery
Volume 13, Issue 3, 2007, Pages 116-121
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.
The purpose of this study was to analyze the early results of a new technique for anatomic plantar plate repair and advancement using a Weil metatarsal osteotomy of the second metatarsal. The authors retrospectively reviewed medical records of 13 consecutive adult patients (15 feet) who underwent this procedure by a single surgeon. The authors recorded visual analog pain scale scores preoperatively and postoperatively and patient-reported clinical outcome measurement surveys during their final follow-up visit. At an average of 22.5 months (range, 13 to 33 months) follow-up, 11 of 13 patients (85%) reported improved function whereas 10 of 13 (77%) were either satisfied or very satisfied with the outcome. Postoperative scores on the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal- Interphalangeal Scale averaged 85.7 on a scale of 100 (SD = 13.1, 95% CI = 79.1-91.5). Patients reported an average preoperative visual analog pain scale of 7.3 (SD = 1.6, 95% CI = 6.4-8.1) versus an average of 1.7 (SD = 1.8, 95% CI = 0.7-2.7) postoperatively. This was a significant reduction in pain rating (P < .0001, t = 8.9, df = 27). Complications included painful hardware and metatarsalgia. There were no cases of dehiscence, malunion, nonunion, or recurrent metatarsophalangeal joint subluxation. This unique surgical technique addresses metatarsal overload and the instability of the second metatarsophalangeal joint while allowing for anatomic repair of the plantar plate pathology.
Anatomical dissection of the second metatarsophalangeal (MTP) joint
suggests that the plantar plate is the major stabilizing structure of
the joint due to its central location and multiple important
attachments. Many surgical procedures have been recommended when
conservative treatment has failed, but some have had limited clinical
success. The aim of our prospective study was to show the results
obtained in the treatment of a group of patients with plantar plate
tears by direct repair through a dorsal approach combined with a Weil
metatarsal osteotomy with a minimum followup of 12 months.
We prospectively treated 28 patients (55 MTP joints) with lesser MTP
joint instability, but only 22 patients (40 MTP joints) were treated by
the direct repair of the plantar plate and were included in the study.
All of them had initial complaints of acute forefoot pain with the
subsequent development of deformity and instability of the MTP joints.
All patients were evaluated clinically, radiographically, (plain
radiographs and MRI exam), and by MTP joint arthroscopy. With this
data, a direct correlation between the clinical staging and the
anatomical grading for plantar plate dysfunction of each patient was
Results: The plantar plate of the second MTP joint was the
most commonly affected joint (63%), and Grade III type tear (transverse
and/or longitudinal extension tear) was the most frequent type. With
the surgical treatment, we were able to markedly improve the parameters
studied (pain, medial or dorsomedial deviation of the toe, joint
stability, muscle balance, and joint congruence) to acceptable levels,
The AOFAS score improved substantially from an average of 52 points
preoperatively to 92 points postoperatively.
Conclusion: The direct
plantar plate repair combined with a Weil osteotomy and lateral soft
tissue reefing can restore the normal alignment of the MTP joint. We
have demonstrated that the anatomic repair of the plantar plate can
correct the deviation of the affected toe (medial, dorsal, dorsomedial
or dorsolateral), which lead to diminished pain with improved