Michael Coughlin, MD - Plantar Plate Repair Surgical Tips and Pearls
Dr. Michael Coughlin has noted that in his two year prospective study he is seeing good long term results and high patient satisfaction following direct plantar plate repairs.
Surgical repair of plantar plate tears using CPR Viper™
Plantar plate tears of the lesser metatarsophalangeal joints are common, and painful conditions that can lead to substantial deformities of the involved digits. Early on conservative treatment may relieve discomfort, but with the passage of time, these conditions tend to worsen with the development of angular deformities of the toes, and in time, development of a fixed hammertoe.
The CPR Viper™ is a unique concept that allows exposure of the plantar plate through a dorsal approach without the use of a Weil metatarsal osteotomy. While typically a plantar plate repair necessitates the combined shortening of the involved lesser metatarsal with the plantar plate repair, there are situations where shortening is not necessary. Often an involved 3rd or 4th MTP joint does not require shortening, and in revision cases where an osteotomy has previously been performed, an osteotomy may not be indicated or desired.
When the conditions do indicate shortening, such as a long second metatarsal, a Weil osteotomy may be performed in conjunction with the use of the Mini Scorpion™.
Step 1: The involved MTP joint is approached through a dorsal longitudinal incision and deepened in the interval between the two extensor tendons. The collateral ligaments are taken down from their phalangeal attachment, and a McGlamry elevator is used to release the proximal plantar plate attachments from the metatarsal metaphysis.
Step 2: Vertical Kirschner wires are placed in the base of the proximal phalanx and the metatarsal head, and the Arthrex small joint retractor is used to distract the joint. (Typically a 4-5 mm interval is achieved). The plantar plate tear is visualized, and if incomplete, is taken down, completing the tear transversely. (This allows for easier passing of the sutures).
Step 3: The Arthrex® CPR Viper is then used to pass two sets of horizontal FiberWire© sutures securing the distal plantar plate. These sutures are then passed through two oblique drill holes in the base of the proximal phalanx.
Step 4: With the toe held in 20° of plantar flexion, the sutures are tied over the bony bridge. The skin is closed in a routine fashion. (Jastifer and Coughlin* report passing of these sutures without Weil osteotomy in a cadaveric study with 100% success.)
The views expressed in this post reflect the experience and opinions of the presenting surgeon and do not necessarily reflect those of Arthrex Inc.
