Etiology and Management of Lesser Toe Metatarsophalangeal Joint Instability

Doty, Jesse F.; Coughlin, Michael J.; Weil, Lowell; Nery, Caio

doi:10.1016/j.fcl.2014.06.013

Cited by 50 publications

(36 citation statements)

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“…Any biomechanical abnormality leading to overload of the lesser metatarsals may result in plantar plate deterioration and subsequent MTPJ instability; this includes a long second metatarsal, first ray hypermobility, hallux abducto valgus, hallux rigidus, and pes planus [4,9].…”

Section: Pathophysiologymentioning

confidence: 99%

“…Interestingly, patients with rheumatoid arthritis tend to demonstrate plantar plate insufficiency at the fourth and fifth MTPJs more so than the second [3]. Other deformities are often present in conjunction such as hallux abducto valgus (Figure 1), hallux rigidus, and hallux varus [4]. This review will focus on plantar plate anatomy, pathology, and the diagnosis, treatment and outcomes of plantar plate tears.…”

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Plantar Plate Pathology: A Review Article

Maier¹

2016

MOJOR

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Submit Manuscript | http://medcraveonline.com this condition including metatarsalgia, pre-dislocation syndrome, lesser metatarsophalangeal joint (MTPJ) instability, and crossover toe deformity [1]. It is important to recognize that these diagnoses are common manifestations of plantar plate dysfunction.The second MTPJ is the most frequently affected with the incidence of this condition highest among women over the age of 50 [2]. Interestingly, patients with rheumatoid arthritis tend to demonstrate plantar plate insufficiency at the fourth and fifth MTPJs more so than the second [3]. Other deformities are often present in conjunction such as hallux abducto valgus (Figure 1), hallux rigidus, and hallux varus [4]. This review will focus on plantar plate anatomy, pathology, and the diagnosis, treatment and outcomes of plantar plate tears. AnatomyThe plantar plate is a fibrocartilaginous, intracapsular structure composed of primarily type 1 collagen measuring approximately 20mm, 16mm, and 2-5mm in length, width, and thickness, respectively [5]. The plantar plate inserts firmly to the bases of the proximal phalanges ( Figure 2) and serves as an important distal attachment of the plantar fascia [6]. It is anchored to the distal metaphyseal region of the lesser metatarsals by the collateral ligaments and each plantar plate apparatus is coupled together by the deep transverse metatarsal ligament [7]. The plantar plate is in direct contact with the lesser metatarsal heads during gait and functions as the primary static stabilizer of the lesser MTPJs [8]. The structure and function is analogous to the menisci of the knee by resisting compressive forces during weight bearing [5]. PathophysiologyThe etiology of plantar plate pathology is multifactorial [9][10][11][12]. Any biomechanical abnormality leading to overload of the lesser metatarsals may result in plantar plate deterioration and subsequent MTPJ instability; this includes a long second metatarsal, first ray hypermobility, hallux abducto valgus, hallux rigidus, and pes planus [4,9].When the plantar plate ruptures and dorsal displacement of the proximal phalanx occurs, the ability of the intrinsic and extrinsic musculature to provide dynamic stability of the lesser MTPJs is impaired. Changes of the biomechanical axes of the primary flexors of the lesser MTPJs (the interosseous muscles) in addition to the lumbricals, flexor digitorum brevis, and flexor digitorum longus result in a defective restraint to prevent dorsal subluxation of the toe [10]. The chronic inflammatory state of synovial tissues in rheumatoid arthritis and other systemic arthritic diseases causes soft tissue and bone destruction which progresses to joint insufficiency and often frank dislocation of the lesser MTPJs [11]. Less commonly, acute trauma produces this condition [12]. DiagnosisPhysical examination is paramount in the diagnosis of plantar plate dysfunction. Forefoot pain and specifically discomfort involving the metatarsal heads can arise from a variety of pathologies. During physical examinat...

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Section: Pathophysiologymentioning

confidence: 99%

mentioning

confidence: 99%

Plantar Plate Pathology: A Review Article

Maier¹

2016

MOJOR

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“…3,[8][9][10][11][12][13] Nevertheless, the dorsal approach often relies on complex instrumentation and it can only provide a limited view of the involved structures. 2,3,[8][9][10][11][12][13] Plantar plate tenodesis has been described to correct the claw toe deformity by stabilizing the attenuated plantar plate through suturing the plantar plate with the extensor tendon. [14][15][16] This can be performed under arthroscopic assistance, which can provide adequate visualization even without metatarsal osteotomy.…”

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“…Concomitant procedures, for example, periarticular soft tissue release, extensor tendon lengthening, and Weil metatarsal osteotomy, can be performed together with repair of the plantar plate through the same dorsal incision. 3,[8][9][10][11][12][13] Nevertheless, the dorsal approach often relies on complex instrumentation and it can only provide a limited view of the involved structures. 2,3,[8][9][10][11][12][13] Plantar plate tenodesis has been described to correct the claw toe deformity by stabilizing the attenuated plantar plate through suturing the plantar plate with the extensor tendon.…”

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“…5 Tears of the plantar plate can be treated by primary repair with or without the use of suture anchor or distal advancement of the plate to the base of the proximal phalanx through bone tunnels. 8 It can be performed through the plantar 2,7 or dorsal 3,[8][9][10][11][12][13][14][15][16][17] approaches. The plantar approach can reach the plantar plate directly.…”

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Correction of Crossover Toe Deformity by Arthroscopically Assisted Plantar Plate Tenodesis

Lui¹

2016

Arthroscopy Techniques

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Plantar plate deficiency is the major pathology causing metatarsophalangeal joint instability. As the joint subluxates dorsally, the lumbrical is tethered at the medial side of the joint by the deep metatarsal ligament and becomes a deforming force for the development of crossover toe deformity. Plantar plate repair or reconstruction is a logical surgical treatment option. This can be performed through a dorsal or plantar approach. The purpose of this technical note is to report a minimally invasive technique of crossover toe deformity correction by suturing the plantar plate to the extensor tendon. It is indicated for symptomatic crossover toe deformity that is not responsive to nonsurgical treatment. It is contraindicated if the metatarsophalangeal joint is degenerated, destructed, or dislocated, or there is interdigital neuroma at the sides of the deformed toe, or the deformity is caused by bony deformities of the metatarsal head or the proximal phalanx.C rossover second toe is one of the common forefoot deformities. Plantar plate insufficiency is the most common cause. It may progress with time to toe coronal and sagittal plane malalignment and even frank metatarsophalangeal (MTP) joint dislocation. 1,2 Conservative treatment including the toe splint can rarely delay the progression. Surgical treatments of this deformity include soft tissue balancing procedures to stabilize the MTP joint (plantar plate repair, tendon release or transfer, and periarticular soft-tissue release) and/or bony procedures (metatarsal/phalangeal osteotomy, arthrodesis, and excisional arthroplasty), and even toe amputation. 3 The Girdlestone-Taylor flexor-to-extensor tendon transfer is an effective method to stabilize the sagittal alignment of the MTP joint, but it may not be able to restore a normal coronal alignment of the MTP joint in crossover toe deformity. [4][5][6] Postoperative toe stiffness is also common after the transfer. 2,5,7 Plantar plate repair has the advantage of addressing the plantar plate insufficiency that is the primary pathology of instability of the MTP joint. It has been shown that plantar plate repair is as effective as tendon transfer in stabilization of the MTP joint with less postoperative stiffness and discomfort. 5 Tears of the plantar plate can be treated by primary repair with or without the use of suture anchor or distal advancement of the plate to the base of the proximal phalanx through bone tunnels. 8 It can be performed through the plantar 2,7 or dorsal 3,8-17 approaches. The plantar approach can reach the plantar plate directly. However, blunt dissection at the plantar wound may disrupt the organized fat septae resulting in extensive plantar scarring. 7 The dorsal approach has the advantage of avoidance of plantar dissection and scar formation. Concomitant procedures, for example, periarticular soft tissue release, extensor tendon lengthening, and Weil metatarsal osteotomy, can be performed together with repair of the plantar plate through the same dorsal incision. 3,[8][9][10][11][12...

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