Evaluation and Treatment of Lesser Metatarsophalangeal Joint Instability: The Repair of Plantar Plate Insufficiency Through a Dorsal Approach

Instability of the metatarsophalangeal (MTP) joints of the lesser toes can present commonly as ill-defined pain in the forefoot. The initial presentation is often characterized by pain and swelling, but without deformity of the involved digit. With time, this often progresses to distinct malalignment in both a coronal and transverse plane. In severe cases, MTP joint dislocation may occur. Historically, treatment has centered on indirect surgical reconstruction, with the use of ligamentous and capsular soft tissue release and reefing, flexor and extensor tendon transfers, and periarticular osteotomies to decompress and realign the MTP joint. Recent developments in the understanding of the pathologic nature of plantar plate tears has led to the development of both a clinical staging and an anatomical grading system. A dorsal surgical approach provides an exposure of the plantar plate using a Weil osteotomy, which allows the surgeon to visualize and access the plantar plate. Direct repair of a torn plantar plate may be a significant advancement in both the stabilization and realignment of forefoot deformities associated with lesser MTP joint instability.