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Current Concepts in Plantar Plate Repair
Podiatry Today, April 2012
Lowell Weil Jr., DPM, MBA, FACFAS
Erin E. Klein, DPM, MS, AACFAS
With any surgical procedure, there are problems and complications. The most commonly discussed
problem associated with the Weil osteotomy is the “floating toe.” Studies had identified the floating toe to
occur 15 to 50 percent of the time following a Weil osteotomy1-3 .The floating toe does not touch the floor
with neutral weight-bearing after undergoing a metatarsal osteotomy.
Additionally, there is weakness and decreased ability to actively plantarflex the toe. Many have theorized
as to the cause of floating toe and have suggested modifications to the procedure in order to prevent its
occurrence4-7. However, most of these changes have not altered the outcome and increased other
complications (transfer metatarsalgia, stiffness, edema, etc.) and disability postoperatively.
For years, we have been trying to find a solution to
the problem, whether it is making sure to perform
the procedure in the articular surface to prevent
plantar translation, performing appropriate dorsal
soft tissue release, encouraging early physical
therapy (seven days postoperative) and
emphasizing plantarflexion strength and night
splinting of the toe. Nonetheless, floating toe still
occurred, although at rates much lower than cited
in the literature. In our most unstable
metatarsophalangeal joints (MPJs), we started
trying to repair the plantar plate in conjunction with
the osteotomy but with limited success due to the
difficulty of exposure from the dorsal approach.
In the fall of 2007, the lead author had given a
lecture on the Weil osteotomy at a Podiatry
Institute conference in Florida. Immediately
following the lecture, Craig Camasta, DPM, gave a
This photo shows the common clinical presentation of a lecture on plantar plate pathology and repair. Dr.
plantar plate injury with medial deviation of the toe and Camasta was one of the real leaders in discussing
the plantar plate and he made a very compelling
incisional placement. argument as to the role of the plantar plate in
lesser metatarsophalangeal joint problems. Listening to Dr. Camasta’s rationale made the lead author
strongly consider the possibility that plantar plate insufficiency may have more to do with the painful
metatarsalgia entity and postoperative floating toe problems than previously appreciated. It also made
him think that combining the Weil osteotomy with a plantar plate repair would be the best of both worlds.
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Later in the exhibit hall, the lead author came
across a company that was showing bone anchor
concepts that were the standard of care for
arthroscopic rotator cuff repair at the time. The
delivery system for repairing the rotator cuff was
something with which he was totally unfamiliar but
he watched the salesman demonstrate the
placement of sutures into tissue in a tight space. At
that moment, he realized that he now had a way to
suture the plantar plate through the same dorsal
exposure as the Weil osteotomy.
The following week, the lead author and his
Fellow, Jason Glover, DPM, tried different
combined Weil osteotomy/plantar plate repairs on
cadavers and came up with a reproducible
technique. They started performing the procedure
for patients with the most unstable, painful metatarsalgia and closely followed the patients and their
results. The lead author presented the first series of cases at the International Federation of Foot and
Ankle Surgeons the following fall in Brazil with very encouraging early results showing high function and
diminished incidence of floating toe.
Position a McGlamry elevator to mobilize the plantar plate with preservation of collateral ligaments. WHY SHORTEN THE METATARSAL?
Metatarsalgia is one of the most common problems we see as foot and ankle specialists. Typically, the
position and length of the second metatarsal (and occasionally the third) has created a biomechanical
imbalance in the forefoot, causing pain and subsequent injury to the surrounding soft tissue structures,
particularly the plantar plate. During the propulsive phase of gait, an elongated metatarsal will be
overloaded with every step. Over time, that overload will cause attrition to the plantar plate and
surrounding soft tissue structures, leading to pain, swelling, deviation of the joint, crossover toe deformity,
hammertoe and ultimately dislocation.
Radiographically, this manifests as a subtle difference in the length of the second metatarsal in
comparison to the contralateral foot (for unilateral pathology) or in comparison to the expected normal
second metatarsal protrusion distance (for bilateral pathology). In our patients with unilateral plantar plate
tears, the side with the plantar plate pathology had a second metatarsal protrusion distance of 4.4 + 1.0
mm, which is 0.6 mm longer than the contralateral/non-pathological side (3.8 + 1.0 mm)8.
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It is necessary to correct the underlying deformity
by shortening the metatarsal. Without metatarsal
shortening, soft tissue corrections will fail over
time. Not correcting the metatarsal in this situation
is much like addressing a posterior tendon
dysfunction solely by repairing the tendon without
changing the structural component with
appropriate calcaneal osteotomies, arthroereisis or
fusion procedures.
WHY REPAIR THE PLANTAR PLATE?
This is a cadaveric cross‐section with a corresponding sagittal MRI demonstrating the plantar plate (pink arrows) and association with flexor tendons (yellow arrows). The earliest description of the plantar plate can be
credited to Cruveilhier, who described the plantar
plate as a static structure that served to “protect”
the lower portion of the lesser MPJ while
increasing joint space area9. More recently,
authors have theorized the plantar plate to serve
as both a static and dynamic structure having
attachments to the deep transverse intermetatarsal
ligament, the lateral collateral ligaments and the
plantar fascia10.
The plantar plate is one of the main stabilizers of
the lesser metatarsophalangeal joint. In concert
with the collateral ligament complex, the plantar plate maintains stability at the level of the MTPJ.
Sectioning of the plantar plate will decrease the amount of force necessary to dislocate the MPJ by 30
percent11. Sectioning of the collateral ligaments will decrease the amount of force to dislocate the MPJ by
45 percent. Sectioning of both structures will decrease the amount of force needed to dislocate the MPJ
by 79 percent11.
It stands to reason, therefore, that pathology of the
plantar plate needs repair in order to restore
stability to the lesser MPJ. This concept is similar
to that of a Brostrom procedure for lateral ankle
stabilization. When the primary stabilizing structure
of a joint undergoes repair, the joint becomes more
stable.
HOW COMMON IS PLANTAR PLATE
PATHOLOGY?
In the experience of our institution, plantar plate
pathology is responsible for much of the lesser
This photo demonstrates visualization of the plantar MPJ pain/metatarsalgia in our patients. As many
plate (black arrow) from a dorsal approach with a as 50 percent of our patients with metatarsalgia
distraction device in place. present to our clinic seeking a second opinion as
they had previously seen physicians who
diagnosed another pathology (generally capsulitis or a second interspace neuroma) that was resistant to
treatment.
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Interestingly, while conducting a cadaveric study earlier this year aimed at elucidating the cross-sectional
anatomy of the metatarsal neck and the proximal attachment of the plantar plate, researchers found 80
percent (16 of 20) of these randomly selected specimens had one of four types of plantar plate tears12.
HOW TO DETERMINE PLANTAR PLATE PATHOLOGY
A thorough clinical examination can isolate the possibility of plantar plate pathology. Patients will typically
present with pain to the ball of the foot that is progressive in nature. They may complain of some
numbness into the area, which is likely due to swelling putting pressure on the nerves in the area. The toe
may be changing position over time by becoming more dorsally aligned or with lateral or, more commonly,
medial deviation. There can be concomitant first ray pathology (hallux valgus or hallux rigidus), but this is
not always present.
In the most severe cases, there may be a crossover toe deformity or MPJ dislocation. Hammertoe
deformities may or may not be present. In early manifestations of disease, swelling at the plantar aspect
of the MPJ may be present. However, in the situation of complete tear, this may be absent. There will be
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pain at the plantar aspect of the MPJ or distal aspect of the metatarsal head. A modified drawer test may
yield instability in comparison to the contralateral foot or in comparison to the “expected normal” when
bilateral disease is present. A drawer test will be painful in the patient with an incomplete tear but often
painless with complete tear. There may be weakness of plantarflexion of the affected toe.
X-ray findings of bilateral weightbearing films will often show an altered metatarsal pattern with the
second metatarsal being slightly longer in comparison to the contralateral foot, transverse plane deviation
of the digits, splaying of the digits and a subtly increased metatarsus adductus angle. Interestingly, 60
percent of our patients had splaying of the second and third digits, and did not have an interdigital
neuroma. In the past, advanced diagnostics were inconsistent at best. Magnetic resonance images (MRI)
of a MPJ would rarely provide more than one or two slices through the joint and visualization of the
plantar plate was inadequate. More recently, MRI techniques have allowed a much higher level of
appreciation of the MPJ.
The plantar plate (black arrow) is completely detached from the proximal phalanx with flexor tendons in close plantar proximity (green arrow). Note the thickness of the plantar plate. Our previous Fellow, Wenjay Sung, DPM, led our
ACFAS Research Grant Award to determine MRI
correlation to intraoperative findings of plantar plate
pathology. The overall accuracy of MRI in
determining if plantar plate pathology was present
was 96 percent. This study also revealed a
sensitivity of 95 percent, a specificity of 100
percent, a positive predictive value of 100 percent
and a negative predictive value of 67 percent. This
MRI study occurred without IV contrast and without
intra-articular contrast, as had been done previously
in the literature13,14. Sung’s MRI study was the 2011
poster award winner at the American Orthopedic
Foot and Ankle Surgeons Annual Summer Meeting,
and will be published in the Journal of Foot and
Ankle Surgery in 201215.
We also have an ongoing study looking at
diagnostic ultrasound in comparison to MRI findings
and intraoperative findings. The early results from this study suggest that ultrasound evaluation of the
plantar plate is highly technician dependent. Although the ability of the ultrasound and technician to detect
the presence of plantar plate pathology is relatively high (75 percent), the ability to accurately detect the
location of the plantar plate pathology is very low (31 percent).
A GUIDE TO PERFORMING THE COMBINED PLANTAR PLATE REPAIR AND WEIL
OSTEOTOMY
To rectify plantar plate pathology and metatarsal deformity, we have developed a combined procedure to
perform a dorsal approach anatomic plantar plate repair and a Weil osteotomy.
Make a linear incision overlying the extensor apparatus extending from the distal third of the metatarsal
shaft to the midshaft of the proximal phalanx centering over the MPJ. After performing dissection down to
the extensor apparatus, create an incision between the extensor digitorum longus and brevis to the level
of bone from the distal metatarsal to the proximal phalanx shaft. Place a self-retaining retractor deep to
the extensor tendons and expose the MPJ. Reflect the medial and lateral collaterals off the proximal
phalanx base, making sure to preserve their metatarsal head attachments.
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Then carefully place a small or medium McGlamry type elevator into the MPJ and advance it proximally
(hugging the bone) to release adhesions and mobilize the proximal plantar plate attachment at the
metatarsal neck. This allows improved exposure to the plantar plate in later steps. Only use the elevator
plantarly and do not carry it to the medial or lateral side of the metatarsal head. This helps maintain
collateral attachments as these attachments provide the most important blood supply to the metatarsal
head.
Perform a Weil osteotomy in the affected
metatarsal. The osteotomy starts in the dorsal (2 to
3 mm) articular surface of the metatarsal. The
angle of the osteotomy is as close to parallel to the
weightbearing surface as possible. This angle is
important to prevent plantar displacement of the
metatarsal head as one creates shortening.
After completing the osteotomy, use a metatarsal
pushing device to push the metatarsal head
proximally 7 to 15 mm and temporarily fixate it with
a 1.6-mm threaded K-wire.
Place a mini-joint distraction device over the pin to
fixate the metatarsal head and then place a second
pin from dorsal to plantar, 5 mm distal to the base
of the proximal phalanx. After placing the
distractor, open it to gain dorsal access to the MPJ and visualize the plantar plate.
The Mini‐Scorpion (Arthrex) grasps the plantar plate and engages the suture. This photo shows the plantar plate with a mattress suture in place. One can confirm plantar plate pathology with direct
visualization of this structure. We have observed
several different types of plantar plate injuries.
These injuries include attenuation/attrition,
longitudinal buttonhole tears, partial transverse
tears or complete ruptures. The most common
pattern, in cadavers and our patients alike, is the
incomplete transverse tears at the attachment into
the proximal phalanx. These tears can be visible at
the medial plantar plate attachment or, more
commonly, the lateral plantar plate attachment.
With more advanced disease, the entire plantar
plate will be torn. Coughlin published an anatomic
study of plantar plate tears and a modified version
of our grading scale12,16.
If the plantar plate has pathology, one must
carefully dissect the entirety of the plantar plate off the base of the proximal phalanx. The flexor tendons
run in close plantar (deep) proximity to the plantar plate at this level and one must take care not to cut
them. After resecting the plantar plate off the phalanx, carry dissection proximally to create a full
thickness flap of the plantar plate for advancement. A Freer elevator may be helpful to maintain a
consistent level of tissue during this dissection.
After completely mobilizing the plantar plate, utilize a Mini-Scorpion device from the Complete Plate
Repair Kit (Arthrex) to create a wide three-stitch mattress. Remove the distraction device and place a
right angle towel clamp around the sides of the proximal phalanx. Perform manual
distraction/plantarflexion to expose the base of the proximal phalanx. Remove any soft tissue
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attachments on the plantar surface of the proximal phalanx base. Using a small curette, roughen the
plantar bony surface to facilitate plantar plate reattachment.
Create crossed bone tunnels in the proximal
phalanx from distal dorsal medial to proximal
plantar lateral. Create a second tunnel by drilling
from distal dorsal lateral to proximal plantar medial.
Then pass the sutures attached to the plantar plate
from plantar to dorsal through the bone tunnels in
the phalanx.
Proceed to remove the temporary fixation for the
metatarsal head and pull the metatarsal head to its
desired length. It is rare to shorten more than 3
mm. After achieving accurate alignment, fixate the
osteotomy with one or two Snap-Off screws.
Here one can see an oblique bone tunnel with a suture passer in place to pass the suture, securing the plantar plate into the proximal phalanx. Plantarflex the phalanx to approximately 15 to 20
degrees. Then pull the sutures tightly to advance
the plantar plate into the base of the proximal
phalanx. Tie the sutures dorsally to secure the
plantar plate position. The toe will appear plantarflexed. Then reapproximate deep tissue and skin, and
apply a bulky compressive bandage holding the second toe in plantarflexion. This bandage should remain
in place for seven to 10 days with guarded partial weightbearing in a surgical shoe.
After removing the bandages, instruct the patient to
return to a supportive athletic shoe with guarded
weightbearing. The patient receives a night brace
to reduce swelling. This brace (AFTR DC brace
with osteotomy strap, BioSkin) will serve as a night
splint to hold the toe in plantarflexion. This night
splinting technique helps prevent dorsal
contracture and scar tissue formation that can lead
to limited postoperative plantarflexion.
Secure the sutures in place through bone tunnels, pulling the plantar plate into the proximal phalanx. Aggressive physical therapy begins at seven to 10
days postoperatively with particular emphasis on
plantarflexion strength. Passive and active range of
motion of the short and long flexor tendons —
often under the direction of a physical therapist —
two to three times a week is often included in the
postoperative regimen.
Patients are able to return to normal shoe gear six
to eight weeks postoperatively and begin
aggressive weightbearing activities.
HOW PATIENTS HAVE FARED
FOLLOWING THE PROCEDURE
Here one can see the proper position of the toe after fixation of the osteotomy and securing the sutures dorsally. Our early results of this procedure were published
in Foot and Ankle Specialist in 2011.17
Postoperative Visual Analogue Scale scores
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decreased from 7.3 + 1.6 to 1.7 + 1.8. Eighty-five percent of patients reported improved function and 77
percent of patients were satisfied or very
satisfied with the outcome of the procedure. For this group of patients, there were two complications:
painful hardware and continued metatarsalgia. There were no incidences of dehiscence, malunion, nonunion or recurrent MPJ subluxation or dislocation.
Since the time of that study’s publication, we have performed many more procedures, all with similar and
significant reduction in pain level postoperatively. There have been a few patients who have sustained
significantly painful post-op stiffness that has resolved after a joint manipulation with the patient under
anesthesia. Further results will be available with longer follow-up of this larger cohort of patients.
IN CONCLUSION
Through our research, we conclude that the incidence of plantar plate pathology is far more prevalent
than commonly appreciated. In a randomized group of 20 cadavers, 80 percent of specimens had plantar
plate tears12. Anytime we see a painful metatarsalgia with plantar swelling at the MPJ, we suspect a
plantar plate tear.
An appropriate clinical exam and radiographs can
help detect plantar plate problems. Magnetic
resonance imaging and ultrasound can help
accurately define the presence and location of
plantar plate deficits.
Previously, surgeons would have to choose
whether to realign the metatarsal position or repair
the plantar plate. Both procedures provide
successful outcomes but have limitations as
neither addresses the entire pathology involved.
The dorsal approach for anatomic plantar plate
repair provides a combined alternative to fully
correct the complex nature of both a plantar plate
repair and metatarsal deformity. The dorsal
approach of this procedure allows the surgeon
appreciation of both severe and subtler plantar
plate injuries that may not be clearly evident from a
plantar approach. This approach also allows for
metatarsal realignment and prevention of a plantar
scar.
This is the postoperative brace with a strap holding the toe in a plantarflexed position. We believe that with further attention and research,
we can better understand, diagnose and treat
plantar plate problems to provide surgeons and
patients alike with the most optimal results.
Dr. Weil is the President and Fellowship Director of
the Weil Foot, Ankle and Orthopedic Institute. He
also serves as the Editor of Foot and Ankle Specialist. Dr. Weil is a Fellow of the American College of
Foot and Ankle Surgeons.
Dr. Klein is the Reconstructive Foot and Ankle Surgical Fellow at the Weil Foot, Ankle and Orthopedic
Institute.
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