Today on the Doc On The Run podcast, we’re talking about three different techniques for primary repair plantar plate ligament surgery.
What exactly is primary repair of the planter plate? Well, that’s a surgery where we actually go in and sew it back together. We fix it. We repair it. We do something to actually make it strong and hopefully heal again, so you can get back to running.
But we’re going to talk about three different methods for actually doing that and some of them are kind of similar. They’re different approaches and they have different risks and benefits. But we’ll talk about each of these briefly, so you can better understand them, so that if you see a doctor, and they tell you need surgery for your plantar plate, you can ask some more informed questions and frankly, make a better decision.
It’ll also help you because if you understand these procedures before you see your doctor, before they try to sell you on surgery, and you know which one of these options they’re trying to give you, then, when you get a second opinion, you’ll be better able to get a lot better questions out of that second opinion visit anyway. So whether it’s you haven’t seen a doctor or you’ve already seen a doctor, this will help you understand it.
Here’s what we’re talking about. We’ve got in the foot where you have the second metatarsal bone coming down toward the second toe. You’ve got the plantar plate ligament that gets injured. All right, now we’re going to talk about that. Now, I draw a lot of pictures. My pictures are terrible, but my handwriting’s even worse, so don’t worry. You’ll figure it out anyway. These will be helpful.
What we’re looking at is the second toe. The second metatarsal bone comes down to the ball of the foot, and then you have the proximal phalanx bone, the intermediate phalanx bone, and the distal phalanx in the end of the toe and then the plantar plate ligament is actually down here, holding these two together and helping keep the toe down against the ground.
When it becomes ruptured or torn or split, then you have an issue and there’s a couple of different ways to go about fixing this. If you look at the bottom of the foot, and you’re looking at the second metatarsal here; that’s this bone, of course. Then you have the proximal phalanx and the intermediate phalanx and the distal phalanx in there. Well, the planter plate ligament is down here on the bottom and if you have a rip in the planter plate ligament, like that and like that, you want to fix the rip, right? You want to repair it. You want to sew it back together. You want to fix it.
The first procedure is actually primary repair from a plantar approach. Plantar means “bottom; toward the ground.” The way that we do this is we actually make an incision on the bottom of the foot. We actually open the incision, so that we can see in there and then we look in, and we actually sew it up. We literally put some suture across there to sew it up and sew it together. There are two varieties of that. Option number one is just suture or just stitches, basically repairing it.
Second option is with an anchor and there’s a variety of different anchors, but sometimes what we will do is we actually put the suture through there, and we actually drill a little hole in the bone here and then we put the suture in there. Then we put in this thing called an interference screw.
As you take the interference screw, and you actually twist it down, it pulls the suture further and further into the bone and it allows the surgeon to dial in the correction, to actually put more tension as they pull the toe down, to get it in a better position and theoretically, hold it a little bit more stable, just with that added support of the reinforcement in the bone. That’s the second approach.
You’ve got the suture with an anchor and then, the other one is a dorsal approach and a dorsal is just on the top of the foot, just like a dorsal fin on a shark. So, a dorsal approach is the opposite. If you’re looking at the top of the foot, what you’ve got is the second metatarsal and this is the top of the foot here and you have the bones in the toe. When the ligament is torn, we make an incision on top of the foot up here and then, we’re trying to grab the ligament and fix it.
There are lots of different medical device companies that have made gizmos and instruments to try to help this. But the idea is that, when you’re looking at this from the side view, this is the toe here and that’s the ball of the foot, and you have the plantar plate ligament that is basically down here, and it’s torn; it’s no longer attached. Then what we do is we come in through the top with a grasping instrument, and we grab it, and we pull it up.
When we pull it up here, so the surgeon can actually see the end of it, then it’s sitting up here and we’re holding it with that instrument here. Then we basically put some stitches through it; put it back down there and then we drill a couple of holes through this bone and then run the suture up through the bone and tie it on the top. So, you wind up with two holes here. The ligament is stretched out, putting back in its regular position. And then we tie the suture on top of the bone.
Now, what’s the advantage and disadvantage of these? Well, if you have a scar on the bottom of the foot, you have to walk on the bottom of the foot and if that hurts, that’s a real problem. Now, you can see the scar on the top of your foot. So, it might look worse, because you’re going to see it in sandals and flip flops and stuff. But there’s no risk that’s really going to become a painful scar just because of the pressure from weightbearing when you actually walk.
However, interestingly, even though this is a long scar on the bottom of the foot, and it always makes us as foot surgeons nervous to have a big incision right down the bottom of the foot, where you’re going to step on it and potentially make it painful, it seems to rarely cause a problem. More of a problem if you smoke, actually, because you can get these little things that most runner don’t smoke, so it doesn’t really matter that much. But the incision on the bottom of the foot is not really that likely to become painful, but it could.
Any surgeon that tries to offer you this procedure will tell you there’s a risk that you could develop a painful scar. That’s also true, actually, if it’s on the top of the foot from a dorsal approach. So, there’s an advantage and a disadvantage to each. The advantage of the plantar approach is that it’s a little bit easier for the surgeon to actually get to it, to actually sew it up and to dial in the tension on the toe, pulling it downward than from the approach on the top because you just don’t have as good access. It’s hard to work all the way down in there.
If you look at your toe, and you just pull your toe out and see that dimple and imagine trying to look all the way down in there to the bottom, get the ligament, pull it up, put sutures through it and feed it up through holes in the bone, that you’ve drilled, technically, it’s more difficult, I think. But it all depends on which your surgeon prefers.
It doesn’t mean one is right or wrong. In medicine, nothing’s free. There’s always a good thing and a bad thing. So, you’ve got to talk to your doctor, figure out exactly which procedure that you’re going to have, what the risks are to you specifically as a runner. Make sure you ask that. Not “how do all your patients do?” when they’re all old people in the waiting room. You want to ask them, “How do your runners do with this procedure? How many people have you had, that are runners, that don’t do well after this procedure?”
Then if you know that, you can take that information,; you can get a second opinion from somebody who is not going to try to sell you a surgical procedure but will explain those details and how they actually relate to your ability to run, so that you’re better armed to make a decision about what’s really right for you.
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