Objectification of indications for surgical restoration of the plantar plate in the treatment of multiplanar static foot deformities accompanied by hammertoe deformity of the lesser toes using ultrasound

Introduction. Progressive multiplanar static deformity of the forefoot can result in hallux valgus, metatarsus primus varus, transverse flat foot and associated overload of the metatarsophalangeal joints (MTPJ) with plantar plate degeneration and rupture of MPT joints of the lesser toes leading to hammertoe deformity. Diagnostic ultrasound in the identification of plantar plate tears is easy to use at any medical center of the Russian Federation with orthopaedic services and provide a relatively inexpensive option compared with other advanced imaging modalities.

The goal was to present ultrasound technology for accurate evaluation of the severity of plantar plate injury which may provide guidance for surgical treatment of hammertoe deformity of the lesser toes in patients with multiplanar static forefoot deformity.

Material and methods. The study recruited 88 participants with multiplanar static deformity of the forefoot, who underwent ultrasound evaluation according to the original method (RF Patent No. 2699383 "Method for determining the type of degenerative rupture of the plantar plate of the metatarsophalangeal joint due to overload metatarsalgia”) to objectify the results of a physical examination with the Hamilton-Thompson test performed for identifying the degree of instability of the MTPJ, and nonparametric analysis was produced with Pearson's Chisquare test.

Results. Evaluation of the severity of plantar plate injury in the study group of patients (n = 88) with the Hamilton-Thompson test and ultrasound imaging showed diagnostic error in 22.8 % of cases with the use of clinical methods that allowed reasonable reduction of surgical intervention in 2.3 % and substantial correction of the treatment approaches in 20.5 % preventing a complete plantar plate tear.

Discussion. The ultrasound scanning introduced in the algorithm for diagnosing the degree of plantar plate rupture facilitated an objective approach to the choice of the most appropriate treatment strategy for complicated multiplanar forefoot deformities accompanied by a non-rigid hammertoe deformity of lesser toes. Conclusion Preoperative ultrasound imaging of the plantar surface of the foot for detecting the severity of plantar plate injury should be included in the diagnostic algorithm for patients with complicated multiplanar forefoot deformities accompanied by a non-rigid hammertoe deformity of lesser toes.

1. Wang B., Guss A,, Chalayon O,, Bachus K,N,, Barg A,, Saltzman C,L. Deep transverse metatarsal ligament and static stability of lesser metatarsophalangeal joints: a cadaveric study. Foot Ankle Int., 2015, vol. 36, no. 5, pp. 573-578. DOI: 10.1177/1071100714563310

2. Savintsev A.M. Rekonstruktivno-plasticheskaia khirurgiia poperechnogo ploskostopiia [Reconstructive plastic surgery of transverse flatfoot]. SPb., Foliant, 2006, 23 p. (in Russian)

3. Klein E.E., Weil L. Jr., Weil L.S. Sr., Coughlin M.J., Knight J. Clinical examination of plantar plate abnormality: a diagnostic perspective. Foot Ankle Int., 2013, vol. 34, no. 6, pp. 800-804. DOI: 10.1177/1071100712471825

4. Tonogai I., Hayashi F., Tsuruo Y., Sairyo K. Distances from the deep plantar arch to the lesser metatarsals at risk during osteotomy: a fresh cadaveric study. J. Foot Ankle Res., 2018, vol. 11, pp. 57. DOI: 10.1186/s13047-018-0300-3

5. Roddy E., Zhang W., Doherty M. Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum., 2008, vol. 59, no. 6, pp. 857-862. DOI: 10.1002/art.23709

6. Baca E., E. Karaali, A. Duramaz, E. Ercin. Hallux valgus patients, why are they happy? Foot Ankle Orthop., 2017, vol. 2, no. 3. DOI: 10.1177/2473011417S000101

7. Barg A., Courville X.F., Nickisch F., Bachus K.N., Saltzman C.L. Role of collateral ligaments in metatarsophalangeal stability: a cadaver study. Foot Ankle Int., 2012, vol. 33, no. 10, pp. 877-882. DOI: 10.3113/FAI.2012.0877

8. Brogan K., Voller T., Gee C., Borbely T., Palmer S. Third-generation minimally invasive correction of hallux valgus: technique and early outcomes. Int. Orthop., 2014, vol. 38, no. 10, pp. 2115-2121. DOI: 10.1007/s00264-014-2500-1

9. Protsko V.G. Vybor optimalnogo metoda lecheniia valgusnoĭ deformatsii pervogo paltsa stopy. Diss. kand. med. nauk [Choosing the optimal method for treating hallux valgus of the first toe. Cand. med. sci. diss.]. Moscow, 2004, 54 p. (in Russian)

10. Van Doninck D., Verschueren T., Matricali G.A., Van Opstal N., Scheys L., Vandeputte G. Screwless scarf osteotomy for hallux valgus: Evaluation of radiologic correction. Foot Ankle Surg., 2017, vol. 23, no. 4, pp. 255-260. DOI: 10.1016/j.fas.2016.07.002

11. Bock P., Kluger R., Kristen K.H., Mittlböck M., Schuh R., Trnka H.J. The scarf osteotomy with minimally invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results. J. Bone Joint Surg. Am., 2015, vol. 97, no. 15, pp. 1238-1245. DOI: 10.2106/JBJS.N.00971

12. Phisitkul P. Managing complications of lesser toe and metatarsophalangeal joint surgery. Foot Ankle Clin., 2018, vol. 23, no. 1, pp. 145-156. DOI: 10.1016/j.fcl.2017.09.010

13. Pentikainen I., Ojala R., Ohtonen P., Piippo J., Leppilahti J. Preoperative radiological factors correlated to long-term recurrence of hallux valgus following distal chevron osteotomy. Foot Ankle Int., 2014, vol. 35, no. 12, pp. 1262-1267. DOI: 10.1177/1071100714548703

14. Jeuken R.M., Schotanus M.G., Kort N.P., Deenik A., Jong B., Hendrickx R.P. Long-term follow-up of a randomized controlled trial comparing scarf to chevron osteotomy in hallux valgus correction. Foot Ankle Int., 2016, vol. 37, no. 7, pp. 687-695. DOI: 10.1177/1071100716639574

15. Thompson F.M., Hamilton W.G. Problems of the second metatarsophalangeal joint. Orthopedics, 1987, vol. 10, no. 1, pp. 83-89.

16. Lam K., Kong S., Chow Y. Percutaneous chevron osteotomy in treating hallux valgus: Hong Kong experience and mid-term results. J. Orthop. Trauma Rehabil., 2015, vol. 19, no. 1, pp. 25-30. DOI: 10.1016/j.jotr.2014.02.001

17. Lee M., Walsh J., Smith M.M., Ling J., Wines A., Lam P. Hallux valgus correction comparing Percutaneous Chevron/Akin (PECA) and Open Scarf/ Akin osteotomies. Foot Ankle Int., 2017, vol. 38, no. 8, pp. 838-846. DOI: 10.1177/1071100717704941

18. Yu G., Yu Y., Zhang P., Yang Y., Li B., Zhang M. [Surgical repair of chronic tears of the second plantar plate]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi, 2013, vol. 27, no. 12, pp. 1446-1449. (in Chinese)

19. Watson T.S., Reid D.Y., Frerichs T.L. Dorsal approach for plantar plate repair with Weil osteotomy: operative technique. Foot Ankle Int., 2014, vol. 35, no. 7, pp. 730-739. DOI: 10.1177/1071100714536540

20. Johansen J.K., Jordan M., Thomas M. Clinical and radiological outcomes after Weil osteotomy compared to distal metatarsal metaphyseal osteotomy in the treatment of metatarsalgia – a prospective study. Foot Ankle Surg., 2019, vol. 25, no. 4, pp. 488-494. DOI: 10.1016/j.fas.2018.03.002

21. Rivero-Santana A., Perestelo-Pérez L., Garcés G., Álvarez-Pérez Y., Escobar A., Serrano-Aguilar P. Clinical effectiveness and safety of Weil’s osteotomy and distal metatarsal mini-invasive osteotomy (DMMO) in the treatment of metatarsalgia: A systematic review. Foot Ankle Surg., 2019, vol. 25, no. 5, pp. 565-570. DOI: 10.1016/j.fas.2018.06.004

22. Jastifer J.R., Coughlin M.J. Exposure via sequential release of the metatarsophalangeal joint for plantar plate repair through a dorsal approach without an intraarticular osteotomy. Foot Ankle Int., 2015, vol. 36, no. 3, pp. 335-338. DOI: 10.1177/1071100714553791

23. Huerta J.P., Lorente C.A., Carmona G.F.J. The Weil osteotomy: A comprehensive review. Rev. Esp. Podol., 2017, vol. 28, no. 2. DOI: 10.1016/j.repod.2017.10.003.

24. Yeo N.E., Loh B., Chen J.Y., Yew A.K., Ng S.Y. Comparison of early outcome of Weil osteotomy and distal metatarsal mini-invasive osteotomy for lesser toe metatarsalgia. J. Orthop. Surg. (Hong Kong), 2016, vol. 24, no. 3, pp. 350-353. DOI: 10.1177/1602400315

25. Kramer W.C., Parman M., Marks R.M. Hammertoe correction with k-wire fixation. Foot Ankle Int., 2015, vol. 36, no. 5, pp. 494-502. DOI: 10.1177/1071100714568013

26. UK National Diagnostic Reference Levels (NDRLs), 2017. Public Health England. Available at: https://www.gov.uk/government/publications/ diagnostic-radiology-national-diagnostic-reference-levels-ndrls/national-diagnostic-reference-levels-ndrls (accessed June 29, 2018).

27. Cherevtsov V.N., Protsko V.G., Zagorodnii N.V., Ketov M.S., Gorokhov A.V. Sposob opredeleniia tipa degenerativnogo razryva plantarnoi plastinki pliusnefalangovogo sustava vsledstvie peregruzochnoi metatarzalgii [The way of determining the type pf degenerative rupture of the metatarsophalangeal joint plantar plate due to overload metatarsalgia]. Patent RF no. 2699383, A 61 B 8/08, 2019. (in Russian)

28. Glants S. Mediko-biologicheskaia Statistika [Medical-and-biological statistics]. Ed. by N.E. Buzikashvili, D.V. Samoilov. M., Praktika, 1999, pp. 27-45. (in Russian)

29. Milczarek M.A., Milczarek J.J., Tomasik B., Łaganowski P., Nowak K., Domżalski M. Being overweight has limited effect on SCARF osteotomy outcome for hallux valgus correction. Int. Orthop., 2017, vol. 41, no. 4, pp. 765-772. DOI: 10.1007/s00264-017-3419-0

30. Besse J.L. Metatarsalgia. Orthop. Traumatol. Surg. Res., 2017, vol. 103, no. 1S, pp. S29-S39. DOI: 10.1016/j.otsr.2016.06.020

31. Doty J.F., Coughlin M.J. Metatarsophalangeal joint instability of the lesser toes and plantar plate deficiency. J. Am. Acad. Orthop. Surg., 2014, vol. 22, no. 4, pp. 235-245. DOI: 10.5435/JAAOS-22-04-235

32. Fleischer A.E., Hshieh S., Crews R.T., Waverly B.J., Jones J.M., Klein E.E., Weil L. Jr., Weil L.S. Sr. Association between second metatarsal length and forefoot loading under the second metatarsophalangeal joint. Foot Ankle Int., 2018, vol. 39, no. 5, pp. 560-567. DOI: 10.1177/1071100717753829

33. Prissel M.A., Hyer C.F., Donovan J.K., Quisno A.L. Plantar plate repair using a direct plantar approach: an outcomes analysis. J. Foot Ankle Surg., 2017, vol. 56, no. 3, pp. 434-439. DOI: 10.1053/j.jfas.2016.12.002