Abstract
Background
A torn plantar plate (PP) is important pathologic anatomy related to a dislocated or subluxated metatarsophalangeal joint (MTPJ). Traditionally, a torn PP was treated with Weil osteotomy through a dorsal approach. However, because of the limited visualization of the dorsal approach, PP repair through a plantar approach has been proposed as a new technique. This study aimed to radiologically evaluate the outcome of PP repair through the plantar approach using an improved MTPJ overlap distance (MOD) on an anteroposterior view and the degree of subluxation on an oblique view. We also aimed to investigate the potential factors affecting the recurrence of MTPJ instability.
Methods
In this study, we included 31 patients who had a subluxated or dislocated MTPJ of the second or third toe and underwent surgical PP repair. PP repair was performed via a plantar approach after shortening metatarsal (MT) osteotomy with a dorsal approach for longer MT bone. We assessed the severity of MTPJ subluxation by measuring the MOD and subluxation subtype on radiographs. Radiologic recurrence was defined as an increase in MOD or change from subluxation type A to subluxation type B. The relationship of recurrence with clinical and radiologic factors was evaluated by comparing the recurred group against the non-recurred group.
Results
Shortening MT osteotomy was performed in 26 of 31 cases (84%). Repeated measures analysis of variance comparing preoperation, pin removal, and the latest follow-up MOD values revealed the effectiveness of PP repair through the plantar approach (p < 0.001). The MOD did not significantly change after pin removal and the latest follow-up (p = 0.130), indicating that reduction was well maintained. None of the clinical and radiologic factors were significantly related to recurrence. However, 3 of 12 rheumatoid arthritis (RA) feet (25%) recurred and 3 of 5 recurred cases (60%) were RA feet. This result suggests that RA indicated a tendency for recurrence.
Conclusions
PP repair through the plantar approach has the advantage of excellent visualization of a torn PP and direct repair. We, therefore, recommend using the plantar approach for PP repair of the MTPJ.
Keywords: Foot, Joint dislocation, Metatarsophalangeal joint, Plantar plate tear
Metatarsophalangeal joint (MTPJ) dislocation can be surgically corrected via soft-tissue balancing, shortening osteotomy of the metatarsal (MT) bone, or a combination of techniques.1) Studies have suggested repairing a torn plantar plate (PP), a fibrocartilaginous tissue formed from the aponeurosis and joint capsule-stabilizing component of the MTPJ.2,3,4,5) Traditional PP repair through a dorsal incision with MT osteotomy was preferred because Weil osteotomy and PP repair could be performed through a single incision. However, this approach often results in inadequate fixation because of poor visualization.2,6,7) Similarly, PP repair through a plantar approach has several limitations, including concerns about plantar scar pain, the risk of plantar neurovascular injury, and unfamiliarity with the technique. However, in 2013, McAlister and Hyer2) proposed that PP repair through the plantar approach has remarkable advantages, such as the ability to achieve precise correction through direct repair and tighten attenuated PPs. Prissel et al.3) demonstrated its effectiveness based on patient-reported subjective outcomes. Sharpe et al.8) also showed the safety of the plantar approach. However, there were no studies evaluating the radiologic outcomes of plantar approach of PP repair. In this study, we radiologically evaluated the outcomes of PP repair through the plantar approach for a dislocated or subluxated MTPJ. We also analyzed and identified the factors affecting the recurrence of subluxation or dislocation after PP repair.
METHODS
The study protocol was approved by the Institutional Review Board of Asan Medical Center (IRB No. 2022-1656). Informed consent was waived due to the retrospective nature of this study.
Patients
Patients whose PP was surgically repaired through the plantar approach for the subluxated or dislocated MTPJ were included in this retrospective study. Their data were collected by reviewing medical records registered at a single medical center from January 2014 to December 2020. The inclusion criteria were patients with subluxated or dislocated MTPJ of the second or third toe, concomitant rheumatoid arthritis (RA), hallux valgus surgery, or lesser MT shortening osteotomies. The exclusion criteria were the first, fourth, and fifth MTPJ, neuromuscular disease, history of MT bone fracture, and infection sequelae.
Data Collection
Each patient was radiologically evaluated, and complications (e.g., recurrence, painful plantar scar, ischemia, and wound problem) were assessed. PP tear patterns were classified into 3 groups according to intraoperative findings: attenuation, transverse, and L-shaped, which were based on the modification of the classification proposed by Doty and Coughlin9) (Fig. 1).
Fig. 1. Modified classification of plantar plate tear patterns based on surgical findings, as proposed by Doty and Coughlin9). This classification categorizes tear patterns as attenuation when the tear is elongated without complete separation (A), transverse when a horizontal tear site is present (B), and L-shaped when a longitudinal tear accompanies the transverse tear (C). Arrow: plantar plate, asterisk: plantar surface of the metatarsal head.
The relative MT length was radiologically evaluated using Morton’s method (Fig. 2).10) The relative MT length had a positive value if the involved MT was longer than the first MT and a negative value if the involved MT was shorter than the first MT. It was measured preoperatively, after pin removal, and at the latest follow-up. The presence and severity of MTPJ dislocation were assessed by measuring the MTPJ overlap distance (MOD) on radiographs. MOD was defined as the distance between the most distal point of the convex MT head and the most proximal point of the concave proximal phalanx along the MT axis. Therefore, depending on the roundness and thickness of the articular cartilage of the MT head, a well-reduced MTPJ could yield a zero and a negative value11) (Fig. 3). In mild subluxation cases, where the difference in MOD appeared to be negligible, further classification was applied based on the oblique radiograph; specifically, subluxation types A and B correspond to subluxation of < 25% and 25%–50%, respectively (Fig. 4). A radiologic recurrence was defined as an increase in MOD or change from subluxation type A into subluxation type B on an oblique radiograph.
Fig. 2. Weight-bearing anteroposterior foot radiograph illustrating Morton’s method. Relative metatarsal bone length via Morton’s method involves the measurement of a distance (a) from the second metatarsal head to the point (arrowhead) intersected by the longitudinal axis of the second metatarsal and the vertical line from the longitudinal axis of the second metatarsal to the most distal point of the first metatarsal head.
Fig. 3. Metatarsophalangeal overlap distance (MOD) measurement by Ohashi et al.11) On an anteroposterior foot radiograph, MOD (double-headed arrow) was defined as the distance between the tip of the metatarsal head (line A) and the most proximal point of the base of the proximal phalanx (line B) along the metatarsal axis, which is the line through the center of the proximal joint surface (◆) and the center of the metatarsal head (•). MOD can be measured as a positive value (A), zero (B), and a negative value if the positions of line B and line A are reversed (C).
Fig. 4. Subtypes of metatarsophalangeal joint subluxation on oblique radiographs. The solid line represents the line connecting half of the articular surface of the metatarsal head along the axis of the metatarsal bone indicating 50% subluxation. The dotted line divides the remaining half into 2, indicating 25% subluxation. Subtype A denotes subluxation < 25% (A), while subtype B denotes subluxation ranging from 25% to 50% (B).
Radiologic evaluation was performed at 3 stages: preoperation, pin removal at 4 weeks after the operation day, and the latest follow-up (Fig. 5). In a few cases, magnetic resonance imaging was taken to evaluate the pathologic PP tear. Radiographic measurement was conducted twice by 1 resident (CHD) and 1 foot specialist fellow (SK) with a 2-week interval, and the mean of the 2 measurements was used. Kappa was interpreted as proposed by Cohen to evaluate the interobserver reliability. The interobserver agreement remained at an acceptable level (p < 0.001).
Fig. 5. Serial foot anteroposterior radiographs. Preoperative radiograph (A) showing the hallux valgus and second metatarsophalangeal joint (MTPJ) dislocation. (B) Radiograph obtained after Kirchner wire pin removal at 4 weeks after surgery. (C) Radiograph obtained at 27 months after surgery showing the reduced second MTPJ and improved hallux valgus deformity.
Outcome
The primary objective of this study was to evaluate the restored alignment radiologically, as evidenced by the MOD and subluxation subtypes on oblique radiographs. The secondary objective was to assess the rate of complications such as the recurrence rate, wound problem, infection, and postoperative scar pain. Lastly, demographic factors, including age, sex, RA, body mass index (BMI), hallux valgus angle (HVA), and relative MT length, were analyzed to determine their relationship with recurrence.
Statistical Analysis
The patients’ demographic characteristics and radiologic outcomes are described as means, standard deviations, and ranges for continuous variables; frequencies and percentages for categorical variables. Repeated measures analysis of variance was conducted to interpret MOD at the variable time (pre-operation, pin removal, and latest follow-up) and evaluate the procedure’s effectiveness. The relationship of recurrence with clinical and radiologic factors was evaluated by comparing the recurred group against the non-recurred group via an independent sample t-test and Kruskal-Wallis test for continuous variables and via Fisher’s exact test for categorical variables. Data were statistically analyzed using IBM SPSS version 22.0 (IBM Corp.), and data with p < 0.05 were considered significant.
Operation Procedures
The patients were instructed to lie on an operating table, and a tourniquet was applied to the operated limb. If the patient had a concurrent hallux deformity, distal chevron metatarsal osteotomy procedures were performed first. A Weil shortening osteotomy was performed through a dorsal approach if the involved MT bone was longer than the first MT bone. One 2.0-mm-diameter cortical screw was used for fixation of MT osteotomy. Then, a 3–4 cm curved incision was made on the plantar side of the MTPJ. The plantar fat pad was retracted, and the flexor digitorum longus (FDL) tendon was exposed. After the FDL tendon was retracted, the PP was exposed. In the case of a transverse or L-shaped PP tear, the retracted proximal part of the torn PP was pulled distally and sutured with the distal part of the torn PP by using an absorbable #2 suture. For the attenuation type, after 3–5 mm width of the redundant PP was transversely resected, it was sutured in the same manner. The suture was not tightened at this time. A Kirschner wire (K-wire) was inserted from the base of the articular surface of the proximal phalangeal bone toward the toe tip. After the MTPJ was manually reduced, the previously inserted K-wire was advanced into the MT bone to fix the reduced MTPJ; the sutured PP was tightened after the MTPJ was fixed with a K-wire (Fig. 6). The skin was stitched, and a postoperative shoe was applied after dressing.
Fig. 6. Intraoperative photograph of the surgical technique. The plantar plate was exposed after the flexor digitorum longus tendon was retracted. For the plantar plate with pathology, the plantar plate was sutured with an absorbable #2 suture. Kirschner wire was inserted to fix the metatarsophalangeal joint (MTPJ); then, it was manually reduced and inserted via a retrograde approach. The plantar plate was tightened after the MTPJ was fixed.
Postoperative Rehabilitation
In the postoperative recovery period, the patient started walking with tolerable weight-bearing without crutches the day after the surgery. In the outpatient clinic, the K-wire for MTPJ fixation was removed at 4 weeks after the surgery. Then, ROM exercises of the MTPJ were initiated.
RESULTS
Demographic Information
According to the inclusion and exclusion criteria, 31 cases operated by a single surgeon (HSL) in a single center were included. The mean follow-up was 14.19 months (range, 12–65 months). The mean age of the included patients was 60.83 years (range, 26–75 years). Of the 31 cases, 26 were female. The mean BMI was 22.07 kg/m2 (range, 18.52–33.70 kg/m2). The second toe was corrected in 28 cases, while the third toe was corrected in only 3 cases. RA was combined in 12 patients.
Radiographic Outcome of MTPJ Dislocation
MOD had mean ± standard deviation of 6.59 ± 3.17 mm, 0.39 ± 0.72, and 1.31 ± 1.54 mm before surgery, at the time of pin removal, and at the latest follow-up, respectively. The evaluation of dislocation severity through MOD measurement revealed improvement at each time point. The comparison between preoperation and pin removal indicated a significant difference (p < 0.001). Similarly, the comparison between preoperation and latest follow-up showed significant differences (p < 0.001). The MOD at the time of pin removal and the latest follow-up had no significant differences (p = 0.130) (Table 1, Fig. 7). These results implied that the reduction at the time point between pin removal and the latest follow-up was maintained well.
Table 1. Radiologic Measurements.
| Variable | Value (n = 31) | |
|---|---|---|
| HVA (°) | ||
| Preoperative | 33.25 ± 15.20 (6.00 to 59.00) | |
| Latest follow-up | 11.00 ± 7.64 (2.00 to 31.00) | |
| MT length (mm)* | ||
| Preoperative | 1.32 ± 2.89 (–4.36 to 8.75) | |
| Postoperative | –1.68 ± 2.76 (–6.36 to 3.5) | |
| MOD measurement (mm)† | ||
| Preoperative | 6.59 ± 3.17 (0.10 to 13.63) | |
| Pin removal (POD 4 wk) | 0.39 ± 0.72 (0.10 to 3.00) | |
| Latest follow-up | 1.31 ± 1.54 (0.10 to 5.55) | |
| Subluxation grade (subtype A/subtype B) | ||
| Preoperative | 0/7 | |
| Pin removal (POD 4 wk) | 24/4 | |
| Latest follow-up | 22/6 | |
Values are presented as mean ± standard deviation (range) or number.
HVA: hallux valgus angle, MT: metatarsal bone, MOD: metatarsophalangeal joint (MTPJ) overlap distance, POD: postoperative day.
*Relative MT length measured by Morton’s method. †MOD measurement shows the severity of MTPJ dislocation.
Fig. 7. Individual plot of the metatarsophalangeal overlap distance (MOD) value in each case. The MOD value was measured preoperatively, after pin removal, and at the latest follow-up. The comparison between preoperation and pin removal indicated a significant difference (p < 0.001). Similarly, the comparison between preoperation and latest follow-up showed significant differences (p < 0.001). The MOD at the time of pin removal and the latest follow-up had no significant differences (p = 0.130).
Hallux Valgus
Distal chevron MT osteotomy (with or without Akin osteotomy) was performed in 26 cases. The HVAs during pre-operation and at the latest follow-up were 33.25° ± 15.20° and 11.00° ± 7.64°, respectively (Table 1). The intermetatarsal angle during preoperation and at the latest follow-up were 15.98° ± 3.52° and 7.52° ± 1.58°, respectively. The distal metatarsal articular angle during preoperation and at the latest follow-up were 29.24° ± 13.94° and 7.35° ± 6.05°, respectively.
Relative Length of MT Bone
The relative MT length was measured via Morton’s method. The mean pre- and postoperative MT lengths were 1.32 ± 2.89 mm and –1.68 ± 2.75 mm, respectively (Table 1). MT shortening osteotomy was performed in 26 cases. According to the PP tear pattern, the involved MT bone that was longer than the first MT bone was more common in the transverse type tear (76.5%) than in the attenuation type (71.4%) or L-shaped type (71.4%) (Table 2).
Table 2. Characteristics Based on the Tear Pattern of the Plantar Plate for RA and MT Length.
| Variable | Attenuation (n = 7) | L shape (n = 7) | Transverse (n = 17) | p-value* | |
|---|---|---|---|---|---|
| RA | 6 (85) | 2 (28.5) | 4 (23) | 0.015 | |
| Recurrence | 1 (14.3) | 2 (28.5) | 2 (11.8) | 0.803 | |
| MT length (mm)† | 1.40 (–4.09 to 8.75) | 0.87(–4.36 to 3.82) | 1.47 (–2.96 to 6.72) | ||
| Involved MT < 1st MT | 2 | 2 | 4 | ||
| Involved MT > 1st MT | 5 | 5 | 13 | 0.950 | |
Values are presented as number of cases (%) or mean (range).
RA: rheumatoid arthritis, MT: metatarsal bone.
*Fisher’s exact test for categorical variables. A p < 0.05 was considered significant. †Relative MT length measured by Morton’s method.
Tear Pattern
Transverse, L-shaped, and attenuation tear patterns were observed in 17, 7, and 7 cases, respectively. Among them, 4 patients (23%) with a transverse tear pattern, 2 patients (28.5%) with an L-shaped tear pattern, and 6 patients (85%) with an attenuation tear pattern had RA. These findings had remarkable implications for clinical practice, suggesting that RA was associated with PP attenuation tear patterns (p = 0.015). However, the recurrence rate did not significantly differ in terms of tear type (p = 0.803) (Table 2).
Risk Factor for Recurrence
Recurrence occurred in 5 of 31 cases (16%), MOD increased in 3 cases, and subluxation subtype changed from A to B in 2 cases. Recurrence was not correlated statistically with BMI, sex, age, HVA, relative MT length, and tear pattern. According to tear pattern, 2 cases had a transverse tear, 2 cases had an L-shaped tear, and 1 case had an attenuation tear among the 5 recurrent cases. However, 3 of 12 RA feet (25%) recurred and 3 of 5 recurred cases (60%) were RA feet. This result suggested that RA indicated a tendency for recurrence (Table 3).
Table 3. Factors Associated with Recurrence.
| Variable | Recurrent (n = 5) | Non-recurrent (n = 26) | p-value* | ||
|---|---|---|---|---|---|
| Demographics | |||||
| Age (yr) | 54.00 (26 to 63) | 62.09 (34 to 75) | 0.132 | ||
| BMI (kg/m2) | 22.07 (19.11 to 24.35) | 25.49 (18.52 to 33.70) | 0.105 | ||
| Male sex | 0 | 5 (19.2) | 0.561 | ||
| RA (n = 12) | 3 (60.0) | 9 (34.6) | |||
| Tear pattern | 1 (20.0) | 6 (23.1) | 0.088 | ||
| Attenuation | |||||
| L-shape | 2 (40.0) | 5 (19.2) | |||
| Transverse | 2 (40.0) | 15 (57.7) | |||
| Radiologic measurement | |||||
| MOD measurement (mm)† | |||||
| Preoperative | 6.61 (3.50 to 9.35) | 6.59 (0.10 to 13.63) | 0.990 | ||
| Pin removal (POD 4 wk) | 0.10 (0.10 to 0.10) | 0.45 (0.10 to 3.00) | 0.030 | ||
| Latest follow-up | 2.77 (0.10 to 5.55) | 1.04 (0.10 to 4.38) | 0.015 | ||
| HVA (°) | |||||
| Preoperative | 29.40 (13.00 to 46.00) | 34.00 (6.00-59.00) | 0.545 | ||
| Latest follow-up | 11.80 (6.00 to 21.00) | 10.85 (2.00-31.00) | 0.803 | ||
| MT length (mm)‡ | |||||
| Preoperative | 0.77 (–4.36 to 8.75) | 1.42 (–4.09 to 6.72) | 0.652 | ||
| Postoperative | –1.82 (–4.67 to 2.64) | –1.65 (–6.36 to 3.57) | 0.902 | ||
Values are presented as mean (range) or number of cases (%).
BMI: body mass index, RA: rheumatoid arthritis, MOD: metatarsophalangeal joint (MTPJ) overlap distance, POD: postoperative day, HVA: hallux valgus angle, MT: metatarsal bone.
*Independent sample t-test and Kruskal-Wallis test for continuous variables and Fisher’s exact test for categorical variables. A p < 0.05 was considered significant. †MOD measurement shows the severity of MTPJ dislocation. ‡Relative MT length measured by Morton’s method.
Treatment for Recurrence
Of the 5 recurrent cases, 2 were patients with RA that eventually underwent resection arthroplasty. The 3 cases with mild subluxation diagnosed radiologically required no further surgical treatment because they did not complain of any discomfort.
Complication
Recurrence was observed in 5 of 31 cases (16%). Among them, 1 case of superficial infection was improved after conservative management, and 1 case had an ischemic change after deformity correction, i.e., ischemia improved immediately after K-wire removal. No instances of plantar nerve injury, flexor tendon damage, and postoperative plantar scar pain were recorded.
DISCUSSION
In cases of MTP joint dislocation accompanied by a PP tear, longer MT bone is an important pathology. Therefore, in many cases, MT shortening osteotomy is necessary. However, a torn PP is unlikely to heal spontaneously even after MT shortening osteotomy alone. Thus, PP repair is necessary, but effective PP repair is challenging with the dorsal approach due to poor visualization. Our findings showed that PP repair significantly decreased the MOD compared with preoperative measurements; thus, the plantar approach was effective for the PP repair of the subluxation of a dislocated MTPJ. In addition, MOD measurements after pin removal slightly differed from those at the latest follow-up, but no significant differences were found. Therefore, reduction was maintained well after surgery.
In another study, the digital stability of 92% of patients improved after PP repair through the dorsal approach.4) Conversely, PP repair through the plantar approach resulted in the following: 87.1% had improved digital stability, 7.6% experienced recurrence, and 2% required surgery.3) However, 5 of 31 cases (16.1%) experienced recurrence in our study. The recurrence rates were relatively higher likely because of the following 2 reasons. First, a strict radiologic evaluation was used to define recurrence: 3 cases were defined as recurrence by MOD values, and 2 cases were defined as recurrence by a subgroup on oblique radiographs. Conversely, only clinical examination was performed to define recurrence in a previous study. Second, patients with instability were included in a previous study. However, in the present study, only patients with radiologic evidence of subluxation and dislocation were included because of possible ambiguity in the diagnostic criteria for instability.
Previous studies recommended the dorsal approach because of the risk of infection and painful operation scars on the sole. In a previous study involving a plantar approach, wound complications occurred in 4.2% cases of the toe.3) Sharpe et al.,8) who proposed the clinical viability of plantar-based incisions, recorded 8.3% symptomatic scars and 6.8% superficial complications. However, our study showed no painful operation scars and no severe complications, such as plantar nerve or flexor tendon damage. Other previous studies reported positive outcomes for patients who underwent the plantar approach for interdigital neuroma, with high satisfaction levels and without painful scarring or wound infection.12,13,14) Moreover, the direct plantar approach has significant advantages over the standard dorsal approach; for instance, through the direct plantar approach, direct visualization can be performed, and the precision of correction is improved.2) The torn PP can be directly repaired, and attenuated redundant PP can be shortened or tightened.
The incidence of recurrence was higher in patients with RA than in patients without RA. These findings suggested that RA might be a risk factor for recurrence possibly because of its chronic inflammatory process, causing joint destruction and leading to the laxity and disintegration of the tendon and ligament.15,16) However, further studies with larger sample sizes should be performed to establish a statistically significant relationship between RA and recurrence after PP repair.
This study examined the correlation between tear type and RA. Of the patients with an attenuation tear pattern, 6 (85%) had RA; this result indicated that the proportion of RA in the attenuation tear pattern was significantly higher than that in the other tear patterns (p = 0.015). The observed association between RA and the attenuation tear pattern may be attributed to the known tendency of RA to cause synovitis and joint laxity.15,16)
This study had some limitations. First, it had a small sample size; as such, a causal relationship between the factors of PP rupture and recurrence could not be established. Second, the follow-up period was 14.19 months (range, 12–65 months), which was insufficient to show a causal relationship. Additionally, the comparative analysis of the effect of PP repair alone was limited because 26 cases were subjected to Weil osteotomy. Lastly, magnetic resonance imaging evaluations were not performed in every case because of cost concerns and the belief that physical examinations and radiographs were sufficient for assessment.
In conclusion, our study demonstrated that shortening osteotomy of long MT with PP repair is needed for reduction of dislocation and subluxation of the MTPJ. PP repair through the plantar approach is safe and has the advantage of excellent visualization of a torn PP and direct repair. Considering these benefits, we recommend using the plantar approach for PP repair of the MTPJ.
Footnotes
CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.
References
- 1.Shirzad K, Kiesau CD, DeOrio JK, Parekh SG. Lesser toe deformities. J Am Acad Orthop Surg. 2011;19(8):505–514. doi: 10.5435/00124635-201108000-00006. [DOI] [PubMed] [Google Scholar]
- 2.McAlister JE, Hyer CF. The direct plantar plate repair technique. Foot Ankle Spec. 2013;6(6):446–451. doi: 10.1177/1938640013502723. [DOI] [PubMed] [Google Scholar]
- 3.Prissel MA, Hyer CF, Donovan JK, Quisno AL. Plantar plate repair using a direct plantar approach: an outcomes analysis. J Foot Ankle Surg. 2017;56(3):434–439. doi: 10.1053/j.jfas.2016.12.002. [DOI] [PubMed] [Google Scholar]
- 4.Fleischer AE, Klein EE, Bowen M, McConn TP, Sorensen MD, Weil L., Jr Comparison of combination Weil metatarsal osteotomy and direct plantar plate repair versus weil metatarsal osteotomy alone for forefoot metatarsalgia. J Foot Ankle Surg. 2020;59(2):303–306. doi: 10.1053/j.jfas.2019.08.023. [DOI] [PubMed] [Google Scholar]
- 5.Dohle J, Marques A. Reconstruction of the plantar plate of the metatarsophalangeal joint using a dorsal transarticular approach. Oper Orthop Traumatol. 2021;33(5):422–429. doi: 10.1007/s00064-021-00701-2. [DOI] [PubMed] [Google Scholar]
- 6.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. [DOI] [PubMed] [Google Scholar]
- 7.Highlander P, VonHerbulis E, Gonzalez A, Britt J, Buchman J. Complications of the Weil osteotomy. Foot Ankle Spec. 2011;4(3):165–170. doi: 10.1177/1938640011402822. [DOI] [PubMed] [Google Scholar]
- 8.Sharpe BD, Ebaugh MP, Philbin TM, et al. Direct plantar approach to plantar plate repair and associated wound complications. Foot Ankle Spec. 2022:19386400221118500. doi: 10.1177/19386400221118500. [DOI] [PubMed] [Google Scholar]
- 9.Doty JF, Coughlin MJ. Metatarsophalangeal joint instability of the lesser toes. J Foot Ankle Surg. 2014;53:440–445. doi: 10.1053/j.jfas.2013.03.005. [DOI] [PubMed] [Google Scholar]
- 10.Morton DJ. The human foot: its evolution, physiology and functional disorders. J Am Med Assoc. 1936;106(17):1516–1517. [Google Scholar]
- 11.Ohashi H, Nishida K, Nasu Y, et al. A novel radiographic measurement method for the evaluation of metatarsophalangeal joint dislocation of the lesser toe in patients with rheumatoid arthritis. Int J Environ Res Public Health. 2021;18:7520. doi: 10.3390/ijerph18147520. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Johnson JE, Johnson KA, Unni KK. Persistent pain after excision of an interdigital neuroma: results of reoperation. J Bone Joint Surg Am. 1988;70:651–657. [PubMed] [Google Scholar]
- 13.Karges DE. Plantar excision of primary interdigital neuromas. Foot Ankle. 1988;9(3):120–124. doi: 10.1177/107110078800900305. [DOI] [PubMed] [Google Scholar]
- 14.Akermark C, Crone H, Saartok T, Zuber Z. Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton’s neuroma. Foot Ankle Int. 2008;29(2):136–141. doi: 10.3113/FAI.2008.0136. [DOI] [PubMed] [Google Scholar]
- 15.Sharif K, Sharif A, Jumah F, Oskouian R, Tubbs RS. Rheumatoid arthritis in review: clinical, anatomical, cellular and molecular points of view. Clin Anat. 2018;31(2):216–223. doi: 10.1002/ca.22980. [DOI] [PubMed] [Google Scholar]
- 16.Wada M, Imura S, Baba H, Shimada S. Knee laxity in patients with osteoarthritis and rheumatoid arthritis. Br J Rheumatol. 1996;35(6):560–563. doi: 10.1093/rheumatology/35.6.560. [DOI] [PubMed] [Google Scholar]