Correction of 2nd MTP Instability Utilizing a Weil Osteotomy and Dorsal Approach Plantar Plate Repair – A New Technique & Early Results

Correction of 2nd MTP Instability Utilizing a Weil Osteotomy and Dorsal

Approach Plantar Plate Repair – A New Technique & Early Results

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM


WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

The plantar plate is the principal sagittal plane stabilizer of the metatarsal-phalangeal joint (MTP) and any compromise to the integrity of the plate can lead to wearing and rupture of this joint. Plantar plate tears often contribute to metatarsalgia, leading to chronic instability, subluxations, and dislocations. A plantar plate rupture can be either acute, due to a hyperextension injury, or chronic in nature, secondary to chronic metatarsal overload. Primary repair of a plantar plate tear has been performed for years, although the etiology of a non-traumatic, isolated primary plantar plate injury has not been clearly understood.1,2,3 The traditional repair of the plate from a plantar approach is both difficult and does not address the underlying etiology of those cases caused by chronic pathology: an elongated or sub-located lesser metatarsal.

We present a new technique and early results that incorporate a Weil Metatarsal Osteotomy and primary repair of the plantar plate through a DORSAL approach. We have utilized this technique for over two years with promising early results. This unique surgical technique addresses and allows for correction of both the metatarsal deformity and plantar plate pathology through one, minimally invasive, surgical approach.

Surgical Technique

• A curvi-linear incision is made overlying the 2nd MTPJ exposing the metatarsal head and base of the proximal phalanx.
• A Weil metatarsal osteotomy is performed and the capital fragment is retrograded under the distal one third of the metatarsal, and is held in temporary position with a smooth .045 wire. This allows for exposure to the plantar plate and flexor tendon, when visible. The redundant dorsal bone surface is resected about 3-4 mm and smoothed to normal anatomical contour (FIG. 3).
• The plantar plate is visualized and noted to be torn (in this case) and/or attenuated (in other cases) at the insertion in the base of the proximal phalanx. The plantar plate is fully mobilized distally and freed of any residual attachments. (FIG. 4).
• Using the Smart Stitch System*, #2 Magnum wire is used to grab and fixate the plantar plate proximally with a mattress suture (FIG. 5, 6, 7).
• Two drill holes are then made with .062 threaded k-wires in the base of the proximal phalanx; one dorsal-medial to central and the other dorsal-lateral to central (FIG. 8). Using monofilament wire through the bone tunnels, the sutures securing the plantar plate are passed from the plantar to the dorsal surface of the base of the proximal phalanx.
• The temporary pin fixating the Weil osteotomy is removed and the 2nd metatarsal head is reduced, properly aligned to create corrected positioning and fixated with a 2.4mm threaded head screw or two .062 threaded k-wires (FIG. 9, 11).
• The suture on the dorsal surface of the proximal phalanx is now tied dorsally with the digit held in plantarflexion, and the 2nd MTP is reduced and stabilized
  (FIG. 10, 11, 12).

*Arthrocare Opus

Function and Daily Activities

11 out of 13 patients (84.6%) reported similar or improved post-operative functioning. All patients were able to return to their routine daily activities at an average of 14.7 weeks (SD=7.4, range=4-24 weeks).

Pain

Patients reported a 71.9% (SD=36.4) improvement in pain post-operatively. There was a significant reduction in patient report pain rating (t=6.824, df=13, p=< 0.0001). The average change in pain rating (0-10) was a 4.9 point decline (SD=2.7, range 2-8 reduction). Pre-operatively, patients reported an average pain score (0-10) of 6.7 (SD=1.7, range=2-9). Post-operatively, patients reported an average pain score (0-10) of 1.6 (SD=1.4, range 0-4).

Conclusions

Metatarsophalangeal joint instability/dislocation can be a very difficult problem for patients and surgeons. Until recently, repair of the plantar plate was limited to soft tissue correction without addressing the bony etiology of the deformity.

Through a dorsal approach, a Weil Osteotomy is performed and the plantar plate tear is visualized and primarily repaired, advanced, and strongly anchored into bone using a shoulder arthroscopy knotless system, addressing and correcting the true etiology of plantar plate pathology.

Despite the small sample size, this procedure has been shown to yield consistent and favorable early results across the domains of patient satisfaction, pain, function and daily activities, as well as ACFAS & AOFAS Scoring Scales

References

1. R.B. Johnston III, J. Smith and T. Daniels, The plantar plate of the lesser toes: an anatomical study in human cadavers, Foot Ankle Int 15 (1994), pp. 276–282.
2. Blitz, DPM, et al. Plantar Plate Repair of the Second Metatarsal Phalangeal Joint: Technique and Tips. Journal of Foot & Ankle Surgery. Vol. 43, Issue 4. 266-270.
3. Bouché DPM, FACFAS, Heit DPM, FACFAS Combined Plantar Plate and Hammertoe Repair with Flexor Digitorum Longus Tendon Transfer for Chronic, Severe, Saggital Plane Instability of the Lesser MPJ’s: Preliminary Observations. Journal of Foot & Ankle Surgery. Vol. 47, Issue 2, 2008. 125-37.

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Treating a Fracture with Positive Results

I had surgery with Dr. Weil on November 16, 2009 to fix a bad fracture with tissue and nerve damage on my right foot. I already had surgery with another doctor a year before at Northwestern Hospital and my foot was becoming deformed and I was in a lot of pain. Well my surgery with Dr. Weil, Sr. was very successful and after 8 weeks I no longer have any doctor appointments. One thing I think made my surgery a success is I listened to him after each appointment. Dr. Weil stressed to me to keep weight off and always wear the boot when walking and use the machine called Vital Wrap to ice the foot. Well I wore the boot 24/7 except going to bed and taking a shower. Vital Wrap is wonderful for instant relief. Listening to the doctor and taking it seriously by not walking on the foot too soon made the difference. My post x-rays showed the healing and after sometime the swollen will go down. My only advice is to listen to the doctor, take his directions seriously and you will have success. Don't work out too early, it will come soon enough. The other note I would like to say is Dr. Weil is a specialist for feet, not hip replacements, knee replacements, etc. Also his stafff is the best I have ever seen and his nurse, Pam is such a huge asset for Dr. Weil.

Sue
Des Plaines, IL

Treating Heel Pain with ESWT: Our Happy Patients

Hey Doc! I am writing to let you know of my ESWT and office visits from start to finish. When I got there on my first visit I liked the fact that you were straight forward and didn’t try to sell me ESWT and let me know it was not a covered (insurance) item. I had just gotten a shot from my referring doctor so my foot was feeling good. You introduced me to Jennifer and said when and if I decide to do something please call her and she will take care of it from start to finish. She did.

I called several months later and came in and got my first treatment followed by the 3 other two a few weeks apart and we talked every time and I did feel like you were really listening and wanted to let you know I appreciated that. Still and all my foot was not feeling as good as I would have liked. Once again you took the time to listen and we talked about a moving forward game plan. From here is where I really to emphasize my treatment by your staff; in particular Jennifer (She was great!!). The plan was to send in for insurance approval for orthotics. Jen had me get molded so that if they approved them then you get them done and I could come back when complete and be good to go. She said if they say no, we will go to Plan “B” which was using my fourth “freebie” ESWT, and then see how that took and go from there to Plan “C”, which was surgery.

I was called the next day by someone and told that insurance wouldn’t cover the ortoics and if I wanted I would have to pay $550 now. I said to hold them and I will think more on them and get back with them. Then I asked to speak to Jen and schedule the fourth ESWT treatment. I really thought this would be a hassle or was thinking something would be less than before being on you. It was not and you handled it just like normal and one of the things I want to report in this letter is the fourth time was the charm and my foot has felt 100% better since.

Everything seemed great until…I got a bill wanting me to pay approx. $125 for my part of the bill for work that was never done and what the insurance didn’t cover on the orthotics that they did pay for. I called and talked to someone who I’m sure was more than happy to hand this over to Jen to take care of. (I was not happy) The first thing Jen said was will take off everything on this bill that’s not right and make everything right.

She had me come in for another fitting which did not have the office co-pay since I was there before for that. (A cheap guy like me appreciates that). Made the next appointment for the fitting and said if I had any issues on the bill we will finalize them after the fitting. Today after the fitting she walked me out to the waiting area, spoke to Lindsay personally and had her correct the bill to what made sense and then had Lindsay (who was also very nice) go over the bill with me in detail. Then Jen stopped back in and made sure I was a “happy camper”. This was the right thing to do, the professional thing to do, and the nice thing to do. They took a wrong and made it right. Please accept my compliments on your work, Lindsay’s work, and especially Jennifer’s work. She is the best! Please feel free to share this and use me for any reference.

Thanks,
Bob
Franklin Park, IL

Teamwork to Treat Complex Cases: a Patient Testimonial

Dear Dr. Baker and Dr. Bongiovanni,

I would like to sincerely thank the both of you for your service and dedication put forth in the healing of my foot. I would not be where I am today without your expertise, guidance, and diligent care.

I had back surgery as an infant, which resulted in neuropathy in my foot and three toe amputations and countless infections. When I first came to your office back in August, I was quite frustrated with the medical care (or lack thereof) that I’d been receiving. My problems were recurring, and I felt as though I was getting nowhere, or even going backwards. I searched locally for another doctor for a second opinion, and was repeatedly told that the doctors didn’t see patients with a condition like mine. I originally found out about Weil Foot & Ankle Center by doing some online research on a Saturday morning, reading about Charcot. When I dug a little further, I realized that your offices were in Illinois thus I immediately picked up the phone to call to make an appointment. I cannot explain the excitement that I felt going to get another opinion in such a well-regarded establishment.

I have only wonderful things to say about Dr. Baker and Dr. Bongiovanni. They have both been a true testament of what a doctor should be: honest, caring, practical, down-to-earth, and just plain nice! I have felt comfortable around the both of them and respect their immense knowledge of properly caring for the foot. They both were not only concerned with treating the existing problem but finding ways of prevention to avoid future problems. They took the time to ask me questions about my lifestyle and gave me practical solutions that fit appropriately. They did not just come in, look at my foot, offer a few phrases and leave; they spent on average 20-25 minutes each visit to talk about what was presently at hand.

Since then, I have visited your office on several occasions. All of the staff are so kind and really put forth the extra effort to accommodate me. I live about 75 miles away, and each visit was scheduled to see both of my doctors within a short time period to save on having to make two trips.

I would like to sincerely thank Dr. Baker , Dr. Bongiovanni, all the nurses and staff for the exemplary care I that I received. I would highly recommend Weil Foot & Ankle Center to anyone looking for a physician. Thank you again.

Cordially,

Kate
Wauwatosa, WI

A Successful Bilateral Scarf Procedure

Hi, Dr. Weil,

I know you're busy, so I'll try to make this brief...

My name is Trip Swindell (Major Swindell), and you performed a bilateral scarf on me in 2001 (I was the patient with hypermobility, or "double-jointedness").

I live in Houston, now, and just yesterday, I had to choose a local podiatrist to extract a shard of glass from my foot. It just so happened that I was seen by Dr. Michael Mineo, who was amazed by your work and the range of post-surgical mobility I have. He told me that he's known you for many years, and his son is currently gaining internship experience as a volunteer in your office.
He went further to tell me that you are the top podiatry surgeon in the country... perhaps the world!

What a small world, huh?!

Thank you for everything you've done to make my life what it is today... I'm completely pain-free and more physically active than I've ever been.

Trip Swindell
Houston, TX

Relieving Heel Pain with Orthotics and the Arizona Brace

Dear Dr. Bongiovanni: (or as known in my office "Dr. BonJovi")

I thought I would drop you an email to give you an update on my progress with my new orthotics and Arizona brace.

Honestly, I was a little apprehensive when I left your office with my new devices. They initially felt obtrusive and uncomfortable. Within an hour I felt very secure and comfortable in the Arizona brace and actually left it on all day. (as you suspected I went all out!)

I have worn it every day with the exception of the last two days because I was in Phoenix for a night and wore shorts and topsiders. Even being without it my left ankle and foot felt much better, better than they have in years. I still have slight heel pain but much less than before. I cannot tell you how liberating the feeling is. I have seen over three different Podiatrists and Orthopedic Surgeons and nobody was able to give me the level of relief that you and Dr. Weil have given me. I would just like to express my deepest gratitude to you. Your help is so greatly appreciated.

Thank you for your honesty and professionalism and more importantly, your talent! You should be very proud. You guys are awesome.

Sincerely,

Dr. James Kakos
one happy patient!!!:-)

My Weight Loss Success Story - 172 pounds lighter!

I was always on the heavier side once I graduated from High School and was on my own. I really never paid attention to my weight just figuring I had the rest of my life to get healthy. So why do anything about it right now when I can just enjoy myself.

In January of 2007 I had surgery on my right ankle by Dr. Weil, Jr because I wasn’t stable when I walked and I would sometimes fall. Dr Weil told me that one of the reasons I am having so much of a problem was because of the extreme amount I weighed and the pressure that weight placed on the ankle. He said losing weight would help.

I saw my General Practitioner and she did blood work for cholesterol and took my blood pressure, and heart rate. My cholesterol was off the charts at a whopping 386, my blood pressure was 189/99 and my resting heart rate was 112. She was very worried about me, told me losing weight would help me increase my overall health.

I decided that enough was enough and to get going on a weight loss program. When I weighed in I just cried when the scale read 404 pounds!

I set my goals small because I didn’t want to think of the larger picture. My sights were set on losing 5 lbs at a time, then my first 10%. I followed the plan, began exercising and the weight started to fall off; before I knew it I lost 100 lbs by Christmas of 2007!

My biggest focus was to become healthier and fit for the rest of my life now and not later when it would be harder to do. I wanted to live an active, fun, healthy life and not have my weight hold me back from doing anything.

I went back to the doctor in March of 2008 to be re-tested and my doctor was shocked by my new look! When the tests came back, my cholesterol had dropped 240 points to 146, my blood pressure went down to 112/78 and my resting heart rate is at an average of 38!

Now I am able to walk almost 6 miles a day, feel fit and really feel great about how I look. And my friends and co-workers are seeing me as the inspiration to lose weight and get healthier for themselves.

Total inches lost since I started in Feb of 2007:

Waist – 33 inches

Hips – 27 inches

Chest – 19 inches

I have gone from a size 6x to a 16 in tops/blouses!

I have gone from a size 32 to a 14 in pants/jeans!

I have gone from a size 34 to a 12 in a swim suit!

The most important thing I am proud of is the hard work that I have done to make sure that I never see myself be at where I was in weight ever again.

My thanks goes to all the people that have helped me along the way from personal trainers ( Cindy Huber) my weight loss leaders, Dr. Weil Jr., Dr. David, family, friends and the 110% of support from my husband Brian without whom I couldn't have done this!

TOTAL WEIGHT LOST SINCE FEBRUARY 2007 172 pounds!!!

Sincerely,

Heather
Mount Prospect, IL