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Lowell Weil, Jr Dr. Lowell Weil, Jr., DPM, MBA, FACFAS has nothing to disclose
TAPE STARTS – [00:00]
Male Speaker: So we’re going to move on to the forefoot and talk about what really has been my passion for the last 10 years which is trying to unlock the problems of lesser metatarsophalangeal joint instability and issues that I think are one of the most common problems that we deal with on a daily basis and also one of the great enigma for foot and ankle surgeons.
I travel around the world and lecture around the world and in any meeting whether it’s podiatric or orthopedic, this conversation is always one of the most important where people don’t know how to solve or are trying to figure out how to solve those lesser metatarsophalangeal joint problems instability.
And so for the last really 10 years, it’s been my mission to try to unlock this and I think I have to some degree but we can always be better.
But it really me getting to this point has been an evolution with the Weil osteotomy and the problems that came from the Weil osteotomy in trying to solve those problems that we encountered.
When we think of the plantar plate as far back as the mid 1800s when a French anatomist discussed the plantar plate in his anatomy writings. So we know that this has been identified as an issue in the forefoot for almost 200 years. When we look at the literature surrounding plantar plate as the cause of metatarsophalangeal joint deformity, we could see that there’s significant literature that discusses it from the 70s, 80s and into the 90s. The plantar plate is a particular structure. It’s not like the other ligaments in the foot and ankle. It’s made up of a different collagen makeup than our typical ligaments. It’s more analogous to the meniscus in the knee as a shock absorber as well as a stabilizer. And as we know in the knee, the meniscus when it gets damaged in the knee, there’s not a really good way to repair it. It’s usually removed and debrided out because it doesn’t heal on its own. So when we look at plantar plate injuries whether they’re acute or more usual chronic, there’s really not conservative care that’s going to make plantar plate injuries better. You can’t stabilize them for a period of time and expect that they’re going to heal. The collagen makeup of the plantar plate is such that it will not heal. So we have to be aware of that when we start to identify these particular problems. When we look at plantar plate problems, we look at forefoot problems, I think it’s really important to understand how we evaluate, how do we examine, how do we come to a proper diagnosis.
So when you first have a plantar plate injury, you’re going to see a location and subtle deformity of the toe. So we see this picture in the upper right hand. You’re starting to see a little medial deviation of the toe but also the patient’s going to have a loss of toe purchase and plantar edema. So the early injury, there’s going to be some edema in that problem.
When we are actually touching the patient, we’re going to have pain at the metatarsal head and into the sulcus. It’s not necessarily going to be plantar to the metatarsal. It’s going to be more distilled because the plantar plate injury is more at the attachment to the phalanx. So this is where the pain is going to be identified.
But this is also confused with a neuroma very frequently because there isn’t necessarily a plantar callosity or lesion and there are maybe some numbness associated with this with the local swelling putting pressure on the nerve or the local deformity causing pressure on the nerve. So it’s very commonly misdiagnosed as a neuroma.
There will be weakness of plantar flexion and also a painful range of motion. Getting back to the idea of a neuroma, this is a big problem where people will inject maybe a neuroma which actually injures the plantar plate more and actually leads to bigger and bigger problems. So don’t be confused. I don’t think second interspace neuroma exists unless I can be proven wrong on diagnostics.
So be very cautious about the idea of a 2nd interspace neuroma. The most classic way that you can define whether you have a plantar plate problem is through the drawer maneuver. In the bottom left, you’re seeing a normal drawer on this particular patient.
And on the upper right of the left foot, this is an abnormal drawer. It’s unstable. There are several things that you are trying to identify with this test. Number one is you’re looking at gross instability and you can see gross instability in this particular video. However, you’re also looking for pain. So one foot may have a little bit more instability than the other but it may have much more pain, so be appreciative of how much pain there is when you do this test. And it’s very important to compare the left foot versus the right foot when performing this test.
Looking at weight bearing bilateral x-rays is really key. Don’t just take the symptomatic foot and don’t take non-weight bearing x-rays and don’t accept people walking into your office with non-weight bearing x-rays. You cannot fully assess forefoot pathology without weightbearing x-rays.
So what am I looking for? I'm looking for an abnormal metatarsal length, which I'll talk about more in a second. But the abnormal metatarsal length leads to the osseous deformity that causes soft tissue imbalance and ultimately plantar plate lesions.
As this deformity progresses, you’ll start to see more subtle changes such as elevation of the toe, as you can see in these two pictures, more deformity and then a lack of toe purchase.
As it gets really bad, as you have more substantial problems, you’ll start to see fixed deformity, but now you’re not going to have any swelling at all. And the reason you’re not going to have any plantar swelling is the plantar plate is probably completely torn or so attenuated that there’s really no stress on the plantar plate to cause any swelling.
The drawer at this point will be positive but it will be painless, like in ACL injury. A total ACL injury is not painful when they do the drawer test. But when there’s a partial injury, it is painful. So the absence of pain at this point is pretty typical. And now, you’re going to see multiple joint involvement, with crossover toes, dislocations and all of the forefoot is starting to be affected.
This is a study that we presented to American Academy of Orthopedic Surgeons almost 2 years ago. And what we look at was the metatarsal length a precursor to develop plantar plate pathology. And, really, what we found is that a 2nd metatarsal more than 4 mm longer than a 1st metatarsal lead to a 2.5 times greater risk of plantar plate injury than if the metatarsal was shorter than 4 mm longer than the 1st metatarsal. And so this is statistically proven.
That’s not to say that a metatarsal that is only 1, 2 or 3 mm longer than the 1st can’t cause plantar plate problem. But if it’s 4 mm longer, you’re going to get 2.5 times greater chance of a plantar plate lesion. So you need to really look at the difference between the 1st and 2nd metatarsal as you’re assessing the possibility of a plantar plate problem and how you’re going to go about treating it.
This particular research for which we won first place at the American College of Foot and Ankle Surgeons last year for our research. Look at the length of the 2nd metatarsal relative to the 1st as it create plantar plate problems. What we found in this study is that a 2nd metatarsal longer than a 1st was absolutely cause of increased stress in the 2nd metatarsal leading to plantar plate deformity.
I utilize MRI on all of my suspected plantar plate problems. And this an MRI which is only a 0.31 Tesla magnet, which we have in our office, and you can see how clearly you can see the pathology of the plantar plate. Here is a cadaveric specimen compared to an MRI. You can see very clearly that you can see the structures around the 2nd metatarsophalangeal joint in this case and the plantar plate.
Here’s an MRI of a normal plantar plate on the top versus an abnormal plantar plate on the bottom. On the bottom, we’re starting to see discontinuity of the plantar plate. And then we also use musculoskeletal ultrasound, which if you don’t have an MRI in your office and we have multiple MRI’s in our offices, it’s an ultrasound. And you heard the lecture yesterday about ultrasound. Ultrasound is a great way to diagnose plantar plate pathology, but you need to be good at it. It’s very difficult to… you don’t do one or two once in a while. You’ve got to get really good at seeing the plantar plate on ultrasound. And you can really see these structures very nicely if you’re good at ultrasound.
And here’s a study we published that looked at how accurate we can look at plantar plate deformity. An MRI was extremely highly accurate at 96%.
An experienced musculoskeletal ultrasonographer could get their accuracy up to 90%, but those of us who weren’t as adept at ultrasound, we were really below 50% in being able to accurately diagnosed plantar plate lesions, and this is compared to intraoperative findings. So these are ultrasound or MRI and we then we look intraoperatively what those ultrasound or MRIs found.
Here are some additional literature looking at MRI and ultrasound as a way to diagnose plantar plate problems.
So once we’ve been able to identify the plantar plate through our clinical findings, our diagnostics at MRI and ultrasound, we now have to appropriately surgically manage this. As I said, it is very difficult to manage this non-operatively and with all of these clinical findings and diagnostics, I’m able to now move people into a surgical treatment pathway more appropriately.
So when I do this procedure, I usually make a curvilinear session either over the joint itself or if I have to do adjacent metatarsals like in this case, I’m going to go into the interspace as well. And this is typically as I showed before what a typical presentation of a plantar plate pathology is. That second toe is sitting elevated because the plantar plate is not fully engaged. This is an artistic representation of where the tears usually occur. And when I say that this – the tears are usually transverse tears at the base of phalanx, usually 50% tear and sometimes it’s a complete tear. But there are usually a transverse tear with occasional longitudinal extensions, but they are usually transverse right at the base of the phalanx.
The incision is made through the skin and then just to the extensor apparatus and then an incision is made either between the tendons or to one side of the tendons and then retract them. It is not a lot of dissection. It’s literally through skin, through extensor apparatus, get down to the joint and this is the amount of exposure that you initially need.
Then there’s some very, very key things through your dissection that you need to do to get great exposure and I promise you that as I’m taking you through this, these are a bunch of mistakes that I’ve made in the past that I’ve kind figured out. So one of the most important things is releasing the collaterals off of the phalanx. So I release the medial and lateral collateral off of the phalanx, not off of the metatarsal. You need to leave the collaterals fully intact to the metatarsal. The collaterals are important stability and blood supply to the metatarsal head. So I never release the collaterals off the metatarsal. So releasing them off of the phalanx will allow you the exposure which I’ll show you here in a moment.
Then, once we’ve released that, we are then going to do a Weil osteotomy to fully allow the 2nd metatarsal head to retract as far as we possibly can temporarily. So we released the collaterals, we done the osteotomy, we’re pushing it back, 6 mm, 10 mm as far as we possibly can temporarily. Then we fixate it in this temporary position and then we put a second pin into the phalanx and we use a distraction device to open up the joints so that we can fully see the plantar plate and we can get great exposure and see the plantar plate.
Looking at the plantar plate from a dorsal approach, allows you to see subtle injuries to the plantar plate, where if you only go from the plantar, you’re only going to see the more complete tears, not the subtle tears. So as you can see here that we are looking at some subtle tears. Then in this case it was a partial tear. I take a partial tear and I turn it into a complete tear by releasing the entirety of the plantar plate off of the phalanx. Why I do this? Here’s why, when I was developing this procedure, we had to understand in other literature what might be comparable. And the only comparable literature is in rotator cuff. And in rotator cuff, partial tears are turned into complete tears to then fully advance the rotator cuff back into the shoulder. So that is the literature that was comparable to us and so that’s when we take in partial tear and turn them into complete tears to fully advance the plantar plate.
When you release the plantar plate, you have to be very cautious because the flexor tendons run in close proximity and in fact, they have a little bit of a soft tissue attachment so we actually have to release the plantar plate from the flexor tendon.
You can see here the green arrow is showing that flexor tendon really close to the plantar plate. But once I have released the plantar plate, you can see it a very thick, tongue-like structure so it’s not a wispy structure at all. It’s very thick. So we fully release that so that we get a good amount of plantar plate that we can grab and advance. Once, we’ve released the plantar plate, there are devices that many companies now have that you can grab the plantar plate and put sutures into it.
This picture doesn’t completely represent the way in which I would suggest you grab the plantar plate. This shows you just grabbing the edge of the plantar plate. I usually grab somewhere between 6 and 10 mm of plantar plate. I go very deep and grab a lot of plantar plate because I want to advance quite a bit of the plantar plate.
Much like when you do a Brostrom repair of the ankle, you don’t just cut the ATFL and capsule and put them right back together, you do a pants-over-vest. Well, in this case, we don’t really do a pants-over-vest but we’re going grab and advance a significant amount of the tissue. And then we’re going to get these sutures in, and then I’ll show you more in a moment. But this is a device and you can see how deeply I’ve grabbed the plantar plate with this device and put – you can see I’m grabbing what, in this case probably 6 mm of tissue. And then with this device, I’m able to place a suture into the tissue like this.
And with the device that I use, I reload it and I throw another suture and I reload it and I throw another suture. So I have three continuous throws of suture into the plantar plate itself. And that is a very good amount of grab. I can literally pull the foot off the table with this continuous grab and that’s how much security we have in the plantar plate.
Once we’ve got the sutures into the plantar plate, we then drill holes into the phalanx so that we are going to then pass the sutures through the holes in the phalanx to re-engage the plantar plate into the phalanx.
The suture holes are made with K-wires like this and they are crossed. And the reason that they are crossed is I used to do two parallel K-wire and we had cracked the cortex and some osteopenic bone. And by doing these crossed K-wires, you have more cubic area of bone to do and I have never cracked a phalanx in doing it this way.
But the other added benefit is the way the contour of phalanx is you’re actually more perpendicular to the phalanx as opposed to skipping down the side of the phalanx. And this is a much easier way to throw your drill holes.
Once you throw your drill holes, you can use suture passing devices that you pass through the holes and then you engage the suture and pull the suture through the holes in the phalanx like this artistic representation is, and now you’re re-engaging the plantar plate in an advanced way into the phalanx.
Once you’ve gotten your suture through the phalanx, you can then remove your temporary fixation to the metatarsal, and then bring it out to the proper length. And the proper length is only usually less than 3 mm of shortening. So you’re only going to shorten let’s say 1 to 3 mm. If you shorten more than that, you’re going to actually create problems. You’re going to create transfer metatarsalgia, weakness to the whole area, which ultimately leads to the floating toe and problems associated with it. So be very cautious about shortening only less than 3 mm.
In the situation that you have to shorten more than 3 mm, I actually take a second parallel piece of bone right from here to elevate the metatarsal. Because if you shorten more than 3 mm, you’re going to plantar displace the metatarsal fragment, which is going to turn the intrinsic muscles to dorsiflexors and then create a dorsal contracture of the toe. So if you’re more than 3 mm of shortening, take a parallel wedge of bone so that you’re elevating the metatarsal to the proper position.
We get it out to the proper length. We fixate it with one or two screws. And then this is, again, we’re getting this out to the proper length. It’s fixated.
So now, we’ve got our metatarsal in a proper position. We’ve got our sutures through the phalanx. Now, we’re going to maximally plantar flex the toe, engage the plantar plate fully into the phalanx, and then we’re going to tie our sutures on the dorsal aspect of the phalanx.
When we’re done, we want the toe to sit like this. And this feels very down, and it may look very plantar flex to you. But what will happen over time is that, that loosens a little bit and the toe will drift back up to a more neutral position.
And I have done over 600 of these cases in 10 years and I’ve not had but maybe two out of those 600 complain that their toe was too plantar flexed. But I’ve had several people more be unhappy with the toe being a little too elevated. So when I err, I err far more in plantar flexion than not.
This is an example of a patient right when we’ve done their dorsal dissection, and you can see their instability, their gross instability. I haven’t done any dissection other than that dorsal exposure. I haven’t even released the collaterals. This is the exact same patient immediately after we’ve re-engaged the plantar plate and we’re going to use the same amount of force. And you can see here, there’s no instability to that joint once we were done.
Post-operatively, my patients will be put into weight barring with bandages and a surgical shoe for the first 7 to 10 days. At 7 to 10 days postoperatively, we take them out of their bandages, they return to an athletic shoe, a gym shoe that they wore preoperatively, they return one week afterwards into that same gym shoe, we brace their toe in plantar flexion with a brace that you see here. We also start physical therapy one week after surgery. And this is paramount to success, is getting them to actively engage in plantar flexion and trying to relax the dorsal scar tissue that is going to occur not matter what just because of the incisional approach. And we get them doing physical therapy for 4 to 6 weeks after surgery.
We tell people that you’re back to full activity 6 to 8 weeks after surgery and the full recovery for this procedure takes 6 to 12 months. And when I say 6 to 12 months, that’s aches and pains, it’s swelling, and it’s stiffness, and that stiffness can take up to a year to fully resolve. You have to tell your patients pre operatively to expect that.
This is an example of a patient who had a lateral plantar plate injury as well as a collateral injury. And in this case, we medialized the metatarsal, we repaired the plantar plate and lateral collateral ligament. You can see an excellent post-operative alignment.
Here is the patient at one year with active plantar flexion, you can see how they can engage their toe, similar to their contralateral asymptomatic foot.
And here’s another patient who could absolutely get full plantar flexion of their toe post operatively.
And this is really important to get this full plantar flexion. And I’ll tell you that with Weil Osteotomy alone, we did not see this kind of active engaged plantar flexion without the use of the plantar plate repair.
Here’s a long term, a two-year followup on patients, 53 consecutive patients at 2 years follow up. You can see that their pain has reduced substantially, their swelling went from – almost all of them had swelling, to virtually none of them had swelling, their instability went from nearly all, down to none, their strength improved tremendously from preoperatively, and their range of motion improved as well postoperatively.
When we look at their outcome scores and look at all of these different things in the foot and ankle outcome scores, every different parameter was improved from preoperative to post-operative at a 2-year followup.
So when we do the Weil Osteotomy now with the plantar plate repair, we find that it’s a predictable alternative to the treatment of chronic metatarsophalangeal joint pain and instability as well as with dislocation.
It allows us the ability to accurately appreciate the plantar plate and a reproducible method of repair with what I think is really critical, immediate guarded weightbearing. So that people can get on their feet and they can start putting weight down, so that in the situations that is needed, we can do bilateral concurrent repair because that is often a problem with these people.
A common question that I get – and I didn’t really address it right now – is what happens if somebody has a bunion at the same time? I repair the bunion and I repair their plantar plate at the same time. And if the bunion is asymptomatic, I still recommend that the bunion gets repaired because the instability of the 1st ray is a very important part of the development of instability to the 2nd ray. And so ignoring that and just repairing the 2nd ray for me will lead to recurrence in problems. So at all times, if there is a problem with the 1st ray, I repair it.
The way I repair my 1st ray bunions is I do a Scarf-Akin on all of my patients. You may have other methods that you do, but I do a Scarf-Akin with my 1st metatarsal problems in addition to the plantar plate. And it is very common that I will do these bilaterally. So the recovery that I just talked about, back in a gym shoe a week after surgery, back exercising 68 weeks after surgery applies if I do both feet with bunion correction and plantar plate at the same time.
That’s often a question that gets asked so I wanted to address that before that question.
I’ve got about five minutes left in my allotted time and so I want to give people an opportunity to ask questions should you have any before we move on to our next event.
Female Speaker: Have you ever had a time where you did not find a plantar plate?
Male Speaker: It’s a common question I get and I hear people say to me all the time, “Oh, what happens when you get there and there’s no plantar plate?” So I’ve never encountered that. In the more than 600 cases that I’ve done, I’ve never encountered that.
But I have encountered times where I’ve gotten there and I don’t see it and I panic. And the one that comes to mind that I usually use as my reference is I had a physician from Malaysia get referred to me. And she travelled halfway around the world and I opened her up and there was no plantar plate there. And I’m like, “Oh my goodness, this woman just traveled halfway around the world to have me do this surgery and I – what am I going to do?”
So after I panicked for a moment and I got my wits about me, I stopped and I thought, “Okay, where could it be?” And what actually happened with her, she’d had multiple cortisone injections, and with that, she had had a rupture of her plantar plate. And it had retracted and it was adhered to the undersurface of the metatarsal.
So I went in there with a Freer and I teased it away, and I actually freed it up. And it was a very hardy piece of plantar plate that I actually was able to now bring out to length and re-attach. She actually ran a marathon six months after the surgery, so that was pretty incredible.
But I have run into some with multiple cortisone injections that are really beat up. They’re there but they’re beat up. And I can kind of cobble them together. I can repair the longitudinal problems. I can advance them.
But when I find really bad ones like that with the repair that you saw, I’ll also throw the same sutures that I put into the plantar plate, I’ll throw a suture or two in the flexor tendon. I won’t cut the flexor tendon but I’ll throw a suture into it and I’ll bring the entire bundle of flexor tendon and plantar plate into the phalanx and I get a good secure repair. Those people will be a bit more stiff postoperatively but those are often people who have got severe dislocation and getting them realigned with some stiffness is very gratifying to them versus some of the patients I have who a runners and athletes, if you make them really stiff, they’re not happy.
And that’s why I never do a flexor tendon transfer anymore except in the most extreme case because flexor tendon transfers repair the deformity but people hate it, they all hate it. If you ask your patients about what they feel about with flexor tendon repairs, they say, “Well, my toe is down but my toe hurts, it’s stiff, I don’t like it at all.” So I’ve really abandoned 10 years ago flexor tendon transfers for this more anatomical repair.
Male Speaker 1: Which device do you use? What company makes it to grab the plantar plate and put the suture?
Male Speaker: The one that I use is the Arthrex CPR. And while I didn’t mention that during my lecture, I am the inventor of it and I get royalties for it, so I want to be fully open with that. But that is the first system that we developed that was out to the repair the plantar plate from a dorsal approach.
And I can tell you that other people have kind of copied it, which is fine. There were other systems out there. But we, there’s a lot of years of mistakes and thought that went into that system. I’d use some other shoulder arthroscopy devices that just weren’t effective as I’d like them to be, and that’s how we got to that particular one. But there’s a bunch of companies that have similar devices out there. But I would suggest maybe trying the one that I work on the most.
Male Speaker 2: I may have missed this, but what’s your suture of choice?
Male Speaker: My suture? So in that system comes 0 FiberWire. And I use 2.0 FiberWire, 2 FiberWire, and I settled on 0. The two 0 tended to be a little too thin and it would kind of almost cut through the plantar plate. And the 2 was too big and bulky and I felt like it was irritant, so I use 0 FiberWire. And I am not a big FiberWire fan at all. And, in fact, the only time I use FiberWire in my practice is for this.
I’ve pretty much stopped using FiberWire in any other thing that I do, and I can talk more about that. But I used to be a big FiberWire fan and I ran in some troubles with FiberWire, and this is the only time now I use FiberWire.
Male Speaker 3: What are your thoughts on doing the plantar plate repair without the Weil osteotomy?
Male Speaker: Well, part of what I wanted to show you for early on was the literature that has been done to show what is the cause of the problem. And I would say, in our research, it’s pretty clear cut. The metatarsal is the problem. And before I answer your question I would say, would you do a flatfoot reconstruction of only advancing the posterior tibial tendon when there’s hindfoot valgus? Of course not. You’re going to realign the hindfoot. If you’ve got a lateral ankle instability because there’s a cavus foot, are you just going to do a Brostrom? Of course not. You’re going to do a realigning calcaneal osteotomy because otherwise the patient is going to keep having a problem. For a bunion, are you just going to do a soft tissue repair of the bunion? No, it’s a bony problem.
So ultimately, I get it to the fourth thing which is why would you do a soft tissue correction at something that we undisputedly have done research to show is a bony abnormality? So you could do a soft tissue repair without that but I think that you’re doing half of the procedure at that point. So I maybe biased because my name is Weil, but I don’t think I am based on the research that we’ve done to prove that for forager, the metatarsal is the underlying cause of the problem and when people say that’s a normal metatarsal. When we do bilateral x-rays, we see what – one in two line up on the left foot perfectly and on the right foot, it’s 4 mm longer, that’s not a normal metatarsal. There’s something abnormal about that. So obviously I’m pretty passionate about the way I answer that question. But we’ve been very thoughtful on that to come to that conclusion. And it’s not just, “Hey, this is in my hands.” This is research that is backing up that answer.
Male Speaker: Yeah. You don’t. I mean, really. The question is what do you with the patient who hates the flexor tendon transfer? You know, I don’t know that I ever done anything about it because if you cut the flesh in tendon transfer, now you have got nothing in the toe. You’ve got a flail toe. And so I would just tell the person, you know, let’s figure out the right orthotic, the right shoe, whatever it maybe, but there is not a great solution for that at all.
Unfortunately, I don’t run into that too much anymore. The only times I typically running into that is not my own creation. It’ a referral from some other person in the community. But in our community, we’re not really seeing that much, even the orthopedic surgeons aren’t doing too much flexor tendon transfers anymore. They do a plantar point repairs. So I don’t have a great answer for you.
Male Speaker: Yeah. I haven’t really – let me give it some thought. Let’s maybe we’ll talk after and it may take me a couple of days to think through that because I haven’t really have to solve that problem.
TAPE ENDS - [33:38]