The plantar plate is made of a 2 - 5 mm thick layer of connective tissue originating on the plantar aspect of the distal metatarsals and inserting on the plantar base of the proximal phalanx. This stout structure serves as the main stabilizer supporting the MTP joints. Through chronic microtrauma or dynamic imbalance, this tissue can become inflamed, attenuated, tear or rupture. This results in pain, MTP joint instability, crossover toes, or dislocations.

Foot and Ankle

Procedure

The majority of plantar plate injuries are treated with traditional lesser MTPJ rebalancing procedures, including sequential release of soft tissue, tendon transfers, metatarsal osteotomies, and temporary MTPJ pinning. These approaches, while quick and inexpensive, do not address the underlying issues of loss of toe purchase and the high incidence of reoccurrence often associated with performing an indirect repair. Direct repair of the plantar plate with Arthrex’s family of solutions delivers improved patient outcomes and higher patient satisfaction scores.
Arthrex’s continuous evolution in plantar plate repair has led to the development of a family of products capable of addressing any stage of lesser toe instability, from a partial plantar plate tear with mid-dorsal plane instability to a complete rupture and attenuation of the plantar plate with a crossover toe deformity. Below is the summary of our current offerings:
<ul>
 <li>CPR™ System With the Mini Scorpion™ and Pigtail Lasso Suture Passer</li>
 <li>CPR System With the Viper™ Suture Passer</li>
 <li>CPR System With Forefoot InternalBrace™ Repair</li>
</ul>
 
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

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CPR™ Complete Plantar Plate Repair System

The CPR, or Complete Plantar Plate Repair System, treats plantar plate tears and attenuation from a dorsal incision. The CPR Micro SutureLassos™ and Mini Scorpion™ DX provide suture passing options in the plantar plate, while the Mini Joint Distractor aids in visualization and access to the confined space. The surgical treatment that we describe reconstructs the anatomic structure that leads to the instability of the second MTP joint. A plantar plate repair and lateral soft tissue reefing can restore the normal alignment of the joint with anatomic repair.

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CPR™ Complete Plantar Plate Repair

The operative approach to a repair of the planar plate starts with a dorsal longitudinal incision, either in the inner space or directly over the MTP joint. We plantar flex the toe, and here we see a simulated tear on the lateral aspect of the planar plate. Mcglamery elevator is used to release the proximal capsule, and then this allows actually our osteotomy to be translated in a proximal direction. And it actually brings the plate a little more accessible at it by bringing it down into the MTP joint space itself. Now we fixed that translated osteotomy with a vertical K-wires. And then I think it's helpful to measure the length of that dorsal flare. And we'll mark it. And we'll also see what it measured on that measuring device. And then we'll take about three millimeters from that flare. That gives us just a little bit more exposure. Then a second vertical K-wires is placed in the base of the proximal phalanx. And then we can distract the joint itself. We release the deforming contracted capsule on the medial aspect. And so that totally frees up the planar plate. We roughen the insertion site. And then using the micro Scorpion, we pass a suture through the planar plate. And then again we see that we've created a horizontal mattress suture. Another way is to use the pigtail or micro SutureLasso in a tight space. Or if you have a longitudinal tear, then we place drill holes in an oblique fashion or vertically on the medial and lateral aspect of the proximal phalanx. And here's where we will secure our sutures. We use the suture passer with a nitinol loop and bring the sutures through that drill hole. And that's where we will secure the plantar plate. Eventually we'll go ahead and reduce to a certain extent the proximal phalanx. Then we'll place the while with the shortening that we desire, which is usually 2 to 3mm. Holding the osteotomy with a compression clamp and then fixing it with two spin screws. The suture is then tied over the bony bridge, finishing the repair of the planar plate.

Michael Coughlin, MD, (Boise, ID) presents the CPR Viper™ animation. A crossover second toe is a common forefoot condition. A shortening (Weil) osteotomy may be indicated for a vast majority of lesser toe instability pathologies. A long metatarsal is often the underlying cause of these tears; however, there may be instances where an osteotomy is not necessary or indicated (e.g., revision surgery). This CPR Viper animation depicts treating plantar plate pathology with or without the need for shortening osteotomies.

CPR Viper™

A crossover. Second toe is a common forefoot condition, and the primary pathology we found is a planar plate tear. Now, shortening osteotomy may be indicated for a vast majority of these lesser toe instability patterns, but along metatarsal. While it's often the underlying cause of these tears, there may be times when it's not necessary to do an osteotomy. I can think specifically of, for example, where a prior osteotomy has been performed and you're doing reduce or revision surgery, or in a metatarsal that's really not overly long or say in the third or fourth metatarsal, which often do not need to be osteotomy. So we have developed a technique called the CPR Viper technique, which treats plantar plate pathology. And one can expose the joint with or without the need for a shortening osteotomy. A dorsal incision is centered over the second metatarsophalangeal joint. After exposing the soft tissue, the toe is plantar flexed and the mcglamery elevator is recommended to aid in the proximal mobilization of the planar plate and Arthrex, small joint fracture is used to expand the joint. We use either a 1.1 or 1.6 millimeter K wire to secure the device, and then we open the distractor, exposing the plantar plate. We release the medial and lateral collateral ligaments off of the base of the proximal phalanx. We recommend that you release the planar plate from the base of the proximal phalanx with sharp dissection, with care taken to protect the flexor tendons. It's important to release the plantar plate as close as possible to its insertion into the proximal phalanx. The use of a rasp or a rongeur may be used to roughen the surface, where the planar plate has been released. The use of a preloaded Viper enables us to pass a suture in the lateral planar plate. You can reload the Viper with o FiberWire and pass a second synch type stitch in the medial plantar plate. Past the suture as deep as possible in the plantar plate. Proximal word. In order to really gain control of the planar plate and place the suture in stout tissue. If you are too close to the leading edge of the plantar plate, you may not have secure tissue or a secure suture. You can also pass additional sutures with the Viper in the medial and lateral collateral ligaments if desired. Sometimes the Viper is used to place 1 or 2 horizontal mattress sutures. If the surgeon so desires this, the distractor and K-wires are removed from the metatarsal and phalanx. Next, will you then use a small 90 degree towel clip around the phalanx to maximally plantar flex the phalanx when drilling the cross 1.6mm drill tunnels in the phalanx. It is critical to see the K-wires exit on the plantar surface. Then, using the Arthrex peak tube and suture passers to pass the sutures from planter to dorsal, we actually pass those sutures through the tunnels in the proximal phalanx. Then, when securing the plantar plate to the proximal phalanx, the toe should be plantar flexed and held in about 10 or 15 degrees of plantar flexion, with the articular surface of the proximal phalanx touching the articular surface of the metatarsal head. As the sutures are tied, we usually try to place four to 5 to 6 surgeon knots with the O FiberWire. The collateral ligament reefing is carried out on the deficient side can easily be used to improve transverse plane deformity.

Dr. Michael Coughlin (Boise, ID) performs a plantar plate repair from a dorsal approach utilizing the new Arthrex Complete Plantar Plate Repair (CPR) instrumentation set and implant kit. The CPR instrumentation allows for the direct repair of a torn or attenuated plantar plate with a selection of innovative suture passing devices and fixation devices designed specifically for plantar plate repairs.

Plantar Plate Repair of Lesser Metatarsophalangeal Joints

This is the technique of a planar plate repair. The exposure to the second metatarsophalangeal joint occurs dorsally, and we deepen this down either in the inner space or directly over the involved metatarsal. We like to develop a plane between the two extensor tendons, exposing the metatarsal head and mcglamery elevator is used to release the proximal attachments of the plantar plate. This really doesn't cut any of the tissue that affords circulation to the medial or lateral aspect of the metatarsal head, and I think that's an important point. We then do a while osteotomy, and we try to push that capital fragment approximately between 5 and 10mm. We use a pusher to calibrate about how much we've advanced it proximally. And then pin it with A062 K-wires. I like to measure the length before we trim that dorsal flare, because we end up often shortening the metatarsal 2 to 3mm. Now, these are one of the means that we will pass our sutures. These are micro SutureLasso. They're hollow. And they have a suture that we pass inside the hollow instrument. And it actually will. Then with this loop, we can pass a suture through it. Now I'm just using a simulated planar plate which is made out of just some surgical tape, and we're passing the SutureLasso through it. Now we'll pass our suture through that loop, and then we'll pull it back toward and pull the suture out. Then we'll make another pass. This is a very sharp instrument so that you can actually punch through That planar plate will then pass the suture through the loop. Then we'll bring the loop through the simulated planar plate and pull the suture through. Depending upon whether it's a left or a right foot, you may use a curved left or a curve right of the suture. Lassos. Now this is back to our case. And we have a longitudinal tear in the planar plate. This is a grade three tear. And we're using our suture lasso to pass that suture in the transverse fashion. And now we're tying our suture to bring those two edges together. This actually is a complex tear. And there's a tear distally as well as a longitudinal tear. And we've actually fixed those with the SutureLasso. Now we see we're using the micro Scorpion, which is a much faster way to pass the sutures. And we'll do that for our transverse tiers, which characteristically occur at the base of the planar plate, right where it attaches at the base of the proximal phalanx. Note how we place that scar Scorpion right underneath that planar plate. Pass the suture through and make a U type suture or a horizontal mattress. And I like to do two of those so you can see us passing a second colored FiberWire suture through our simulated planar plate. One point I'd like to make is that we take down the distal attachment of the planar plate completely from the base of the proximal phalanx. So if there's a partial attachment, we complete the detachment, and we actually free it up from the flexor tendon sheath as well. Now we're using the micro Scorpion and passing our second suture, our second horizontal mattress, into the planar plate itself. I usually will make one proximal horizontal mattress and one distal horizontal mattress. Now we have our colored FiberWire suture on either side so that we can tie them in place. After we drill our drill holes in the base of the proximal phalanx. You can either do cross drill holes, or you can do two vertical drill holes through the base of the proximal phalanx. Once you've done this, you then will pass those sutures through the base using a nitinol passer. We'll see that nitinol passer. We bring the sheath up to that drill hole and pass right through it onto the undersurface of the proximal phalanx. We pull out that loop and then pass two of the sutures, either the ones on the medial or lateral aspect through that loop, and then pull it through the drill hole in the proximal phalanx. We do that on both sides. So now you see the sheath being brought up to our prepared drill hole. We bring out the loop on the planar aspect. Place a clamp through it and then bring our two sutures, in this case on the lateral aspect of the phalanx, and then pass them through the base of the proximal phalanx. Now we see the simulated sawbones model making that drill hole. Now we do the same thing on the medial aspect of the proximal phalanx. Then back to the sawbones. We're passing our nitinol loop through this. Place our sutures into the loop and advance it through the drill hole in the proximal phalanx, completing the passage of the second set of sutures. Now, back to our case. We're just doing exactly what we did in the sawbones model. The loop goes through the clamp, brings the sutures through that loop. And now we'll pull them up through the base of the proximal phalanx. Now we have our sutures in place. We'll reduce the the while osteotomy, often shortening it about 2 to 3mm a while. Clamp is provided in our set, which can certainly help hold that in compression as you place the two spin screws. We then snap off the peg on the spin screw. And now, since we've shortened it actually a couple of millimeters, we can advance that planar plate beneath the base of the proximal phalanx. We then tighten up our sutures and tie them one by one so that they're color coded. So the white sutures are tied. The the blue sutures are tied. And that completes, really the tying of these sutures. Now, one thing that we have here, as you see now in the case we're completing. The tying of these sutures, the first one and the second one. One thing we have here is that we really do completely eliminate a draw sign. This gives you very good stability of this digit, but note there's still a little medial deviation of that second toe. And this is where I'll do a touch up where I'll take A20 absorbable suture. Remember that capsule is still attached to the metatarsal head. We have not taken that off. And I'll engage the capsule that's on the base of the proximal phalanx and do a over and over suture. And then we'll go ahead and tie this. And note that when I've reached that lateral collateral ligament. Now the alignment of that second toe really is spot on. And notice with the draw we have a very stable digit at this point. The closure in a interrupted fashion. And the post operative radiographs show we did a while of both two and three.

David Macias, MD (Columbus, MS), answers the question “Where are we now?” in the clinical and surgical treatment of lesser toe instability. Through the lens of clinical publications, Dr. Macias explores the foot and ankle surgeon’s journey from indirect repairs (osteotomies and softtissue reconstruction), where results ranged from mediocre to somewhat successful, to 8 years of clinical success with direct repair using Arthrex’s CPR™ system, as demonstrated by a reduction in pain and improved toe alignment.

Clinical Consideration of Plantar Plate Repair: What Have We Learned?

Hi. Good morning. Thank you everyone for coming out. And thank you to Arthrex for putting on these talks. My name is David Macias and I'm going to talk today about paper plate repair using the Arthrex CPR system. Hopefully at the end of this talk I can show you that can be beneficial both to you and to your patients. And so it was a crossover to I think at this point, we understand that the main stabilizer of the lesser MTP joints is the planar plate. And numerous anatomic studies have shown that. And when you lose that stability you can get pain, swelling and dysfunction loss of toe purchase into the ground and you can fail the tissue pull out test as you see this patient failing it here. And so why is this important? Well, if we look on the high end, estimates of prevalence of lesser toe deformity and instability are up to 20%. And so if we look at the US, it would be like saying that the entire population is of California and Texas. The two most populous states in the nation have lesser toe instability and deformity. And so this is a lot of patients. And so you may not see a lot of forefoot in your clinic personally, but these patients are seeing you and they need our help to get better. Well how is this treated traditionally. Traditionally it was treated with non anatomic reconstructions. And so you could do a wild osteotomy. But that can lead to the classic floating toe in 30 to 50%. Also can lead to transfer metatarsalgia just kind of kicking the can down the road. It's been treated with a flexor extensor tendon transfer traditionally as well. But again this is a non anatomic reconstruction and doesn't directly address the pathology of the plantar plate tear. And so what does the literature say about these anatomic reconstructions. Well this is a paper out of the UK in 2012. And the authors looked at 154 toes. 55 were treated operatively with a combination of osteotomies and flexor extensor tendon transfers, and 99 treated with conservative measures. And what they found was that there were no statistically significant differences in terms of satisfaction scores and pain, and they actually just recommended just don't operate on these people, just don't treat them. Similarly, in 2005, this article by Mark Meyerson and Hongzheng looked at 64 second toes that were treated with flexor extensor tendon transfer. And what they found was that almost 40% had residual dorsiflexion. About a third had some residual coronal plane deformity, and about a third either worsened morphologically or didn't get better. And they found that achieving normal alignment was actually quite difficult, and any functional improvements they had were mainly related to pain relief, but not to restoration of function. And so why did these things fail? Well, much as we've moved away from non anatomic reconstructions at the lateral ankle to direct repair using ArthroBrostrom technique to directly address the pathology, we've moved away from non anatomic reconstructions of the lesser MTP joints to direct repair using the CPR system, so that we're again directly addressing the pathology. And this has been supported in the literature. And this is the largest study that I'm aware of looking at plantar plate repair. And we looked at 138 toes that were treated with the CPR system. And what we found was that at one year follow up, we had a statistically significant improvement in scores, Vas pain and our clinical draw. We also have statistically significant improvement in toe contact and in patients that were able to pass the tissue paper pull out test. And our patient satisfaction was rated as good to excellent and 80%. Now, a couple of things to know about this study. One, it took the entire experience of the senior author into account, and there is definitely a learning curve for this procedure. The second thing to know is that we know a lot of patients were getting stiff. And so towards the end of this procedure we started to move to Accelerated Rehabilitation Protocol. And I'm going to talk about that a little bit more in a minute. But I think if you repeat this study today, you would actually get even better results than these. Similarly, long term follow up has shown good results as well. And this is average two year follow up in 66 patients that were treated with this algorithm that you see to the left and had statistically significant improvement across all the metrics that they measured. But something that was very interesting with this study was that grade one tiers were treated with a wide osteotomy alone and radiofrequency shrinkage. They did not have a direct repair, but those actually did worse in terms of toe purchase, ground touch and stability when compared to the grade two tiers that were treated with a direct repair. Showing us that, you know, we need to treat these tiers even when they're low grade tiers, in order to improve their outcomes. And those findings were echoed in this paper in 2020 by Lowell Lo Wall Junior and his group, where they looked at lesser toe instability in 86 patients, and the authors made an intraoperative decision to treat with a while osteotomy alone or a while with a CPR repair. And what they found was that those treated with a while and a CPR repair had a statistically significant improvement in terms of pain and ankle and foot related quality of life measures when compared to the osteotomy alone. Now, this is despite the fact that those treated with a while alone had a median grade one tear, and those treated with the while and CPR had a median grade three tear, again showing us that even low grade tears need to be treated aggressively in order to get good results. And so in my practice, this is my treatment algorithm. And it's very straightforward. If they have a painful draw we try non-operative therapies. If they fail that then we discuss a plan or plate repair. If they improve we can continue with conservative care. But if at any point they start to fail that, then we again discuss plan or plate repair. This is part of my post-operative protocol, and I think this is really crucial to getting good results. As I said before, if you don't get these patients moving quickly, they get stiff and they really don't like that. And so I get all my patients moving actively and passively on their own starting on starting on postoperative day one, and at three weeks, all of my patients are going to formal physical therapy in order to get as much motion to that joint. Much as we start moving our Achilles as fast as we can and our lateral ankle ligaments, we want to start moving these toes as well. And so in my practice, I've performed the CPR in over 50 patients, about 64 toes. And I've tried to collect these all these metrics at pre-op three months six months and 12 months. And so the Viper this unpublished data, but with at least a three month follow up, I found an almost 23 point improvement and I am scores, almost four point improvement in Vas pain scores. And I think partly because of the stability that I get with the CPR repair, coupled with the Accelerated Rehabilitation protocol, a 60% improvement in my patients have passed the tissue paper pull out test. And so here's one case. This is a 52 year old pharmacist who had been training for a half marathon, and she had developed forefoot pain, and she was injected multiple times by an outside provider. While she was actually running the half marathon. She felt a felt a pop in her foot and had a lot of pain. And she came to my clinic like this and you can see she's totally dislocated at the second MTP joint, almost dislocated at the third, and the fourth was grossly unstable. And so she underwent a direct repair using the C.P.R. system. And at three months postoperatively you can see her joints are nicely reduced. She had restored her toe purchase to the ground and she was able to get back to jogging. And so, in conclusion, tears affect a large percentage of patients and the treatment of choice is direct repair using the C.P.R. system. There is a learning curve to this, but it is worth it for our patients. And much like there's a learning curve for Mis, there's a learning curve to this, but I think it's really worth it in order to get better results. When you're doing plant plate repairs, make sure that you're trained on all the options. The CPR system has the Scorpion as well as the pigtail parser. The Viper is excellent for small spaces, or if you don't want to do a wide osteotomy but have a backup plan as well. The four foot internal brace. If the tissue is just not of good quality, and make sure that you have aggressive post-operative rehabilitation protocols, because I do believe that those are essential for good outcomes. Thank you.

Plantar plate injury is a progressive deformity that requires a different surgical solution for each stage. Ryan B. Rigby, DPM (Logan, UT), discusses Arthrex’s family of plantar plate solutions and provides guidance on which systems are best for each grade of tear.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

Continuum of Care: Plantar Plate Deformity

Hello, I'm Ryan Rigby from Logan, Utah, highlighting today the continuum of care for second MTP plantar plate deformity. This is one of my own patients in the operating room ready for surgery. Obvious instability of the second MTP. The anatomic structures are insufficient for this patient. I will admit I used to be tempted and often would do a while osteotomy to decompress this and put a wire across it in hopes that it would scar down taking it out down the road. I was always disappointed that the instability persists. We find ourselves in difficult situations with the second MTP, and to get good outcomes we have to address the anatomic structures. We have to repair those and bring stability back for good outcomes. Fortunately, Arthrex has us covered from A to Z. All the different situations we find us in. We have the instruments and the tools to treat those. Everything from a dorsal planar plate repair to augmenting poor tissue with a four foot internal brace. As I mentioned, sometimes it's tempting to just do the while osteotomy. It's a straightforward procedure, but the data supports and shows that we really should be addressing the planar plate, the underlying etiology. And if we do so, we're really addressing the source of pain and giving our patients better short term outcomes and long term pain relief. It's debatable on whether a while osteotomy is needed on every single case, and I don't think it really is, but I find it's often the underlying etiology. And this paper actually highlights that there's a correlation between the length of the metatarsal and a planar plate disruption. So we need to be cognizant of what is really causing this in the end. What is the etiology. It may be a bunion. It may be a hypermobile first ray. It might be that long metatarsal. But I think we've all seen and realized as we've watched patients come in and present at varying stages, this is progressive. And as it progresses through the different phases and grading and there's several different systems here. We find advanced instability, we find more deformity, and it becomes a little more challenging to treat. So honestly, I've started I have a lower threshold now to take these patients to the Or if they failed non-operative treatment in the early phases, when there's just a little bit of instability and a little bit of deformity, say maybe a grade one or grade two, I find to have better tissue to work with and I get better outcomes. Still very treatable in grade three and four, but grade one and two is where I really like to live in the Or because of the outcomes and the repair. So my algorithm really matches the staging, how the patient presents. So even in a stage zero, if there's no deformity and no instability, you're catching it early. If they have a long second metatarsal, I'll do a simple osteotomy. And and sometimes there's pathology of the plantar plate. And the metatarsal is not long. And you can do a repair of the plate without doing that. While I think that's a little less common, I usually find a while is necessary. It's not always the case. And then in stage one and two, I'll do an osteotomy and then repair the plantar plate using the CPR kit, restoring the necessary structures so they have a functioning second MTP. And then in stage three and four the tissues become a little more tenuous. You can't rely on them as well. And so fortunately we have the four foot internal brace to augment and better support those structures. And then a hammertoe repair if need be. So here's an example a stage two. It's not the most severe deformity, but these patients have symptoms. It doesn't function well. They hurt. There's deformity. And this is where I employ that CPR kit or a planar plate repair from a dorsal approach. And basically here's a two weeks post-op and a two months post-op showing the position's been restored. But you really, truly don't know until they wake bare. So on the far right, you see a picture of weight bearing. That's where the structures really have to work. And here you see that it's staying in position. I'm happy with the outcome. By restoring and addressing the underlying root cause and the structures that need to be repaired to get that outcome for the patient. This one's more advanced. Stage three and four. This is challenging. This is a hard deformity. There's a lot that needs to happen here. But in the end this absolutely can be addressed. What I really like and I find is when the tissues, you know, when you get in there, that's not going to be a great place. They may not have much of a plate left, but the forefoot internal brace really allows me to augment after my repair and bring a lot of just structural support and augmentation to that repair. This was kind of unique because the patient actually had some tissue to still work with. So I did my planar plate repair using the CPR kit, and I had stability, but there was still a medial drift that I just couldn't balance around the capsule. And so I augmented this with an ETB transfer. And as you add the tape, you bring a lot of stability and a lot of augmentation as you address the repair and you lock it in with a screw in the phalanx, it's all knotless. It's pretty slick. And then there's a before and after showing the interop stability, and then the real true test down the road showing a before and after that things are holding and they're holding because we've really restored structural support to those soft tissues. Post operative weight bearing. This is where you really see that everything's been repaired, that needs to be repaired as the patient walks and loads this for a good functional outcome. My post-op protocol is pretty straightforward. I keep them off until their first visit. I have them walk in a boot for about 3 to 4 weeks. I do find it helpful to splint the toe into plantar flexion during the postoperative course, to prevent any soft tissue scarring and contracture. Usually, these return back to shoes at about six weeks. I do put a carbon fiber plate in their shoes to protect that repair as they get back into activity. We start some physical therapy early on, basically working on plantar flexion strength. I keep the plate inside their shoes until week 12, and then they can return back to regular activity in sports and exercise. I do have them wear the little plate inside their shoes until about six months, just for higher impact exercise and sports. In summary, this is a progressive pathology. Again, just to emphasize I find better outcomes if I catch these patients earlier. My procedure really matches the stage. Fortunately, we have the internal brace to help augment those more difficult cases. Consider repairing these earlier on for better outcomes. It's a challenging pathology, but it's still a very treatable pathology for our patients. Thank you.

Plantar Plate Tears

Plantar Plate Repair