The OrthoIllustrated® animation for plantar plate repair is an educational tool to help patients better understand the diagnosis and treatment of this orthopedic condition.

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PAN1-0458-EN | D | Toe Dislocation Repair with CPR™ Implant System

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Patient Education Animations

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Toe Dislocation Repair with CPR™ Implant System

Foot and Ankle

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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 the Forefoot InternalBrace™ Repair</li>
</ul>

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CPR™ Complete Plantar Plate Repair System Surgical Technique CPR Complete Plantar Plate Repair I 02 CPR™ Complete Plantar Plate Repair Introduction Arthrex is pleased to add the CPR Viper™ implant system to the CPR complete plantar plate repair system. Developed in conjunction with leading experts, this system solves one of the common difficulties encountered by foot and ankle surgeons, lesser MTP joint instability. The CPR Viper can be used with or without a metatarsal osteotomy. The CPR plantar plate repair system was designed to help prevent floating toe, treat crossover toe, and repair an attenuated or torn plantar plate using a dorsal incision. Historically, techniques to treat a torn plantar plate have used a plantar approach, but many surgeons do not advocate this method because of the amount of dissection, complications with wound healing, and restrictions on postoperative ambulation. The CPR implant system and instrument set is a comprehensive solution to treat plantar plate pathology. The Mini Scorpion™ DX, Micro SutureLasso™ and Viper™ suture passers provide state-of-the-art options for passing suture into the plantar plate, while the small joint distractor aids in visualization of the plantar plate. The surgical treatment we describe reconstructs the anatomic structures that lead to the instability of the lesser MTP joints. Plantar plate repair, lateral soft-tissue reefing, and metatarsal shortening can restore the normal alignment and function of the joint. Incision/Dissection Place the patient in a supine position on the OR table. Center a dorsal longitudinal incision over the 2nd MTP joint and carry surgical dissection down to the extensor apparatus, where the extensor digitorum longus and brevis are split. Place a self-retaining retractor deep between the extensor tendons to expose the MTP joint. The collateral ligaments are released from the base of the proximal phalanx, but the collateral ligament attachments on the metatarsal head are left intact. 1 I CPR Complete Plantar Plate Repair03 CPR™ Complete Plantar Plate Repair System Metatarsal Head Pusher Once the osteotomy is complete, translate the capital fragment about 5 mm to 10 mm using the metatarsal head pusher. Temporarily fix the capital fragment in that shortened position with a vertical 0.062 in/1.6 mm K-wire. The K-wire should not penetrate the plantar surface of the capital fragment. Optional: The metatarsal measuring device can be slid over the K-wire and marked to identify the length of the dorsal shelf. Based on this operative measurement, some of the dorsal shelf may be resected to further aid in visualization of the plantar plate. Osteotomy Use the McGlamry elevator to release the proximal portion of the plantar plate. This will aid in the necessary exposure and advancement of the plantar plate. Leave the accessory collateral ligaments intact on the medial and lateral side of the metatarsal head while releasing the proper collateral ligaments to aid in proper exposure of the plantar plate. The Weil osteotomy originates 1 mm to 2 mm below the dorsal aspect of the metatarsal articular surface. The angle of the osteotomy should be parallel to the weight-bearing surface of the foot. This angle is important to prevent plantar translation of the capital fragment as shortening is performed. If an osteotomy is not indicated, we recommend the CPR Viper suture passer for passing suture through the plantar plate. 3 2 CPR Complete Plantar Plate Repair I 04 Joint Distraction Use the small joint distractor to gain access to the plantar plate. Secure the device to the metatarsal component by using the initial 1.6 mm K-wire. Place another 1.6 mm K-wire from dorsal to plantar 5 mm distal to the base of the proximal phalanx to secure the second arm of the device. Once the distractor is placed, it can be opened to gain dorsal access to the MTP joint and the plantar plate can be clearly visualized. Alternative Distraction A right angle towel clamp placed along the sides of the proximal phalanx can be used to create manual distraction. The most common tear patterns are partial and complete distal transverse tears at the distal insertion of the plantar plate. Make the partial tear a complete tear close to the insertion of the plantar plate to the proximal phalanx using a Beaver® 6400 Mini-Blade®*, being careful to avoid the flexor tendons. This reflects the plantar plate off the flexor tendon sheath and allows further mobilization of the plantar plate. *Beaver and 6400 Mini-Blade are trademarks of BVI. CPR™ Complete Plantar Plate Repair System 4 I CPR Complete Plantar Plate Repair05 CPR™ Complete Plantar Plate Repair System Pass Sutures Mini Scorpion™ DX Suture Passer Technique When the plantar plate has been completely mobilized, load the Mini Scorpion DX suture passer with 0 FiberWire® sutures. Use a pick-up to stabilize the plantar plate as the Mini Scorpion DX suture passer is inserted into the MTP joint and grasp the plantar plate medially or laterally by pulling the trigger with your fingers. With the Mini Scorpion DX suture passer in place, squeeze the instrument with the palm of your hand, advancing the needle and suture through the tissue. The needle will retract when the handle is released. Surgical Pearl When ready to engage the needle and pass the suture in the plantar plate, rotate your hand 30°-45° to prevent the needle from hitting the plantar surface of the metatarsal. When passed through the plantar plate, the suture locks into the “trap-door” feature of the Mini Scorpion DX suture passer, allowing for easy retrieval and “blind” shots. Retract the Mini Scorpion DX suture passer from the tissue and release the suture. The free end of the 0 FiberWire suture is reloaded into the Mini Scorpion DX suture passer and a second stitch is thrown into the plantar plate 3 mm to 5 mm medial or lateral to the initial stitch placement. 5A CPR Complete Plantar Plate Repair I 06 CPR™ Complete Plantar Plate Repair System Pass Sutures (Cont’d) Plantar Plate Pigtail Technique With Micro SutureLasso™ Suture Passer Once the plantar plate has been completely mobilized, place the right (red) or left (lime) Micro SutureLasso suture passer into the MTP joint. Use a pick-up to stabilize the plantar plate while applying the suture passer to puncture down and up in the plantar plate. Once inserted, push the black lasso forward and pass one of the 0 FiberWire® suture limbs through the loop. Pull the suture passer out, passing an inverted mattress with the suture. CPR™ Viper™ Implant System When an osteotomy is not performed, use the preloaded CPR Viper suture passer to pass a cinch stitch in the lateral plantar plate. Reload the suture passer with 0 FiberWire suture and pass a second cinch stitch in the medial plantar plate. 5B 5C I CPR Complete Plantar Plate Repair07 CPR™ Complete Plantar Plate Repair System Pass Sutures Through the Phalanx Place the suture retrieval funnel into one of the holes and then insert either the nitinol loop from the Pigtail Micro SutureLasso instrument or the stout nitinol suture passer with loop through the retrieval funnel. Pass a baby mosquito clamp through the nitinol loop and pass the FiberWire® suture through the bone tunnel. If two sutures are used, they should be color- coded (1 blue and 1 white). Various suture patterns may be used depending on tears encountered. Additional sutures can be placed to add stability to the repair. Bone Tunnels Remove the small joint distractor and the K-wire in the phalanx. Use a right-handed towel clamp to plantarflex the phalanx. Roughen the plantar edge of the proximal phalanx using a rongeur, curette, or rasp to prepare the surface for reattachment of the plantar plate. Based on surgeon preference, create two parallel or two crossing drill holes with a 1.6 mm K-wire. It is critical to see the K-wire exit the plantar phalanx just below the articular surface. This will allow for easier suture passing. 7 6 CPR Complete Plantar Plate Repair I 08 CPR™ Complete Plantar Plate Repair System QuickFix™ Cannulated Screw System Remove the K-wire from the metatarsal. Move the Weil osteotomy to the corrected position, holding it with the QuickFix clamp. Affix with one or two 2 mm x 11 mm and 2 mm x 13 mm snap-off QuickFix screws, typically with only 2 mm of shortening at the osteotomy site. The clamp helps prevents rotation of the capital fragment and plantar gapping of the osteotomy. Suture Tying With the toe held reduced, plantarflex the toe 30° while making sure to pull out any slack in the suture before tying. Next, tie the sutures over the cortical bridge between the two drill holes, thereby advancing the plantar plate onto the proximal phalanx base. 8 9 Post-op Protocol Following surgery, a gauze and tape compression dressing is used to cover the forefoot. Ambulation is permitted in a postoperative shoe with full weightbearing on the heel for 6 weeks. Physical therapy is initiated at 7-10 days following surgery. At day 10 manual exercises commence (passive stretching and active exercises), with emphasis on increasing plantar flexion strength of the involved toe. Full forefoot weightbearing in an athletic shoe is allowed at 6 weeks after surgery, although if the osteotomy heals quickly, weightbearing may be allowed earlier. Activity may progress as tolerated, with aggressive walking at 8 weeks, and jogging or running allowed at 12 weeks. 10 I CPR Complete Plantar Plate Repair09 CPR™ Mini Scorpion™ DX and Micro SutureLasso™ Implant System The CPR Mini Scorpion DX and Micro SutureLasso implant system (AR-8690DS) includes the necessary materials for the complete plantar plate repair. Scientific Support ■ Coughlin MJ, Schutt SA, Hirose CB, et al. Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. Foot Ankle Int. 2012;33(2):133-140. doi: 10.3113/FAI.2012.0133 ■ Coughlin MJ, Baumfeld DS, Nery C. Second MTP joint instability: grading of the deformity and description of surgical repair of capsular insufficiency. Phys Sports Med. 2011;39(3):132-141. doi: 10.3810/ psm.2011.09.1929 ■ Nery C, Coughlin MJ, Baumfeld D, Mann TS. Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot Ankle Int. 2012;33(4):301-311. doi: 10.3113/FAI.2012.0301 ■ Weil L Jr, Sung W, Weil LS Sr, Malinoski K. Anatomic plantar plate repair using the Weil metatarsal osteotomy approach. Foot Ankle Spec. 2011;4(3):145- 150. doi: 10.1177/1938640010397342 ■ Coughlin MJ. Lesser toe deformities. In: Coughlin MJ, Mann CL, Saltzman CL. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:363-464 ■ Cooper MT, Coughlin MJ. Sequential dissection for exposure of the second metatarsophalangeal joint. Foot Ankle Int. 2011;32(3):294-299. doi: 10.3113/ FAI.2011.0294 ■ Nery C, Coughlin MJ, Baumfeld D, Mann TS, Yamada AF, Fernandes EA. MRI evaluation of the MTP plantar plates compared with arthroscopic findings: a prospective study. Foot Ankle Int. 2013;34(3):315- 322. doi: 10.1177/1071100712470918 ■ Flint WW, Macias DM, Jastifer JR, et al. Plantar plate repair for lesser metatarsophalangeal joint instability. Foot Ankle Int. 2017;38(3):234-242. doi: 10.1177/1071100716679110 CPR Viper™ Implant System– AR-8692DS CPR Complete Plantar Plate Repair I 10 Loading of the Scorpion™ Suture Passer Once the Scorpion suture passer has been loaded, the next steps are to grasp, pass, and retrieve, as indicated in the adjacent illustrations. The Mini Scorpion™ DX suture passer has FastPass technology to automatically retrieve FiberWire® suture after passing through soft tissue. The instrument works well under direct visualization, as well as during “blind” passes through the plantar plate tissue, where access and visualization are often limited. Grasp Pass Retrieve This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals in the usage of specific Arthrex products. As part of this professional usage, the medical professional must use their professional judgment in making any final determinations in product usage and technique. In doing so, the medical professional should rely on their own training and experience and should conduct a thorough review of pertinent medical literature and the product’s directions for use. Postoperative management is patient-specific and dependent on the treating professional’s assessment. Individual results will vary and not all patients will experience the same postoperative activity level or outcomes. View U.S. patent information at www.arthrex.com/corporate/virtual-patent-marking © 2020 Arthrex, Inc. All rights reserved. | www.arthrex.com | LT1-0458-EN_E Ordering Information Mini Scorpion™ DX CPR Instrument Set (AR-8690S) Product Description Item Number Instruments Mini Scorpion DX Suture Passer AR-8999 Small Joint Distractor AR-8690SJD McGlamry Metatarsal Elevator, 11 mm AR-8930M QuickFix™ Clamp AR-8930MC Small Handle w/ AO Connection AR-2001AOT Driver Shaft for QuickFix Screw, 2 mm AR-8930D QuickFix Screw Cutter, 2 mm AR-8930R Metatarsal Head Pusher AR-8690P Mini Scorpion Instrument Case AR-8690C Accessories (must be ordered separately) Mini Scorpion DX AR-8999 Mini Scorpion, curved AR-8999C Small Joint Distractor AR-8690SJD QuickFix Clamp AR-8930MC SutureLasso Pigtail Suture Passer, left, curved AR-8690SLL SutureLasso Pigtail Suture Passer, right, curved AR-8690SLR 0 FiberWire Suture AR-7254 Disposables Guidewire w/ Trocar Tip, 0.062 in (1.6 mm) AR-8941K Guidewire w/ Trocar Tip, threaded, 0.062 in (1.6 mm) AR-8941KT Guidewire w/ Trocar Tip, 0.078 in (2 mm) AR-8945K Guidewire w/ Trocar Tip, threaded, 0.078 in (2 mm) AR-8945KT CPR Mini Scorpion DX and Micro SutureLasso Suture Passers Implant System (AR-8690DS) Product Description Item Number Mini Scorpion DX Needle SutureLasso Pigtail Suture Passer, right, curved SutureLasso Pigtail Suture Passer, left, curved QuickFix Screw, 2 mm × 11 mm QuickFix Screw, 2 mm × 13 mm Metatarsal Measuring Guide Suture Retriever, plantar plate, qty. 2 Suture Retriever, 1.5 in funnel, qty. 2 Ruler, 6 in SutureTape, white SutureTape, blue 0 FiberWire® Suture, blue 0 FiberWire Suture, white 0 TigerWire® Suture w/ Needle, 38 in, white/green CPR Viper™ Implant System (AR-8692DS) Product Description Item Number SutureTape, white Viper Suture Passer, w/ SutureTape, blue 0 FiberWire® Suture, blue 0 FiberWire Suture, white 0 FiberWire Suture w/ Needle, 38 in, blue Suture Retriever, 1.5 in funnel, qty. 2 Suture Retriever, plantar plate Ruler, 6 in

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.

CPR™ Complete Plantar Plate Repair

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™

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

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?

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

Complete Plantar Plate Repair System (CPR™)

Implant System, CPR Mini Scorpion DX

Implant System, CPR Mini Scorpion Dx and Micro SutureLasso

Sistema de implante, Mini Scorpion DX CPR

Sistema de implante, CPR Mini Scorpion Dx

Finished Product

Implantatsystem, CPR-Viper mit SutureTape, weiß / blau, 1.3 mm

Implant system, CPR Viper with SutureTape, white / blue, 1.3 mm

Mini Scorpion DX CPR Instrument Set

Child (D)

Procedure

A long lesser metatarsal can lead to common toe problems. A metatarsal shortening osteotomy can help prevent future complications, including plantar plate tears leading to crossover toe deformities, as well as hammer toes and claw toes. Once these complications have occurred, the surgeon may choose a metatarsal shortening osteotomy to decompress the MTP joint and decrease the tension on dynamic soft tissues.

Metatarsal Shortening Osteotomy 

Plantar Plate Repair

Forefoot InternalBrace Implant System, PEEK

InternalBrace-Vorfußimplantatsystem, PEEK

Forefoot InternalBrace Implant System, PEEK

Toe Dislocation Repair with CPR™ Implant System

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