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AngryOrthopod

Plantar plate repairs & the pre-dislocation syndrome: what the f$@% (Part 1)




God bless the Beverly Hillbillies. Doubtlessly one of the best scenes depicting their countryfied ignorance was when the doorbell would ring and Jethro would say to Jed, “Uncle Jed, there goes that bell again, next thing you know someone’s gonna come a-knockin' at the door.” Classic!

angry orthopod upload Plantar Plate Repairs

Well, the way my colleagues, both fellowship trained foot and ankle orthopaedic surgeons and my step brothers, podiatrists, are approaching the spectrum of 2nd MTP synovitis, eventual hammertoe formation, and even more eventual second MTP dislocation is really no different than Jethro and Jed on the doorbell.


Most everyone is waiting for the knock at the door because they don’t know what the doorbell is about. Not a clue!


They are waiting way too long to deal with this problem, but they don’t know it. Pity…for you. In the case of foot and ankle orthopods, they at least are not waiting until the MTP joint dislocates. Currently, most of us have gone on a rampage of doing a Weil osteotomy combined with repair of plantar plate ruptures, the precursor to dislocation and part of a hammertoe. In fact, there are whole systems developed by both Smith & Nephew, and Arthrex to name two for just this purpose. All I have to say about these innovations is “If you build it they will come.”

Angry Orthopod & pre-dislocation syndrome

The “pre-dislocation syndrome,” a term used by many, is full of mystery and intrigue.


How would one pose this concept to a patient anyway? The doctor says to the patient: “The pain, swelling, and hammertoe you have is called pre-dislocation syndrome. We don’t know what it is or what caused it (which means we don’t know how to treat it), but we do know what will eventually happen, your toe is going to dislocate.” Speaking of letting the cat out of the bag.


Here is another favorite line I hear way too often from my patients: “They told me the reason for my problem is that my 2nd metatarsal has grown too long, so it has to be shortened.” And this is said with a straight face. Seriously, a 2nd metatarsal that has grown too long? Believe me when I say something has changed to force this situation, but it is definitely not the magical growth of one's 2nd metatarsal metatarsal.


By the way, the podiatrists have gotten fully on board and are performing these procedures with reckless abandon. Everybody is joining in on the party. But I will say they are much more in tune with the damaging effects of equinus. The orthopaedic surgeons...not so much.


…letting the cat out of the bag.


Unfortunately, this whole issue is where medicine and technology goes haywire all too often today.


Systems and techniques like this are developed mostly because we can.


They seem like a good idea on paper. But do they really work?

In our profession, these same docs continually yell out the mantra “where’s the evidence?” Well, I’m going to call them on this one and say, “where’s your evidence?” That would be a big Blutarsky, zero-point-zero. If and when the evidence comes forth it will be mostly about semi-straight toes and little about patient satisfaction or problem resolution.

…where’s your evidence



I would estimate that in excess of 1000 of these reconstructive procedures are being done every day in the U.S…based on nothing. I am also going to go out on a limb and say this concept is doomed and in time will not be the answer. That is if we ever get any clinical evidence to tell us how they are doing.


So all the while we will continue to merrily cut away…until we find out it was not a good idea.


“Okay, Mr. AO smarty pants, what is the reason we develop 2nd MTP synovitis and a hammertoe?” Stay tuned while I think about it and I will be back with an answer in a few days.


Stay healthy my friends,


AO


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7 Comments


AngryOrthopod
Nov 18

Archived Comments

Below is a collection of comments from previous versions of the blog. They are preserved for historical context and the richness they add to our discussions. If I lost them I would be angry indeed.

See Comments Blog

Keep moving, my friends,

AO

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AngryOrthopod
Nov 18

Phil on May 16, 2020 at 8:21 pmHi AO. 


I hope you are well. I’m hailing here from Sydney Australia. 41 year old male. I have Morton’s neuroma both feet, and they bother me for the first 2-3 steps each morning and that’s it.But more to the point, I have mild/moderate bunions which have never given me problems till recently. I wear 4e shoes for the last 3 years (since MN diagnosis), but have started running in the last 6 months. Bunions only just starting to feel sore.


The podiatrist said I had most of my windlass mechanism in place, but had lost some flexibility in the big toe.


Would calf stretching be of any benefit to me?


Much appreciated

Phil


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AngryOrthopod
Nov 18

Laura Joseph on October 20, 2019 at 12:56 pm


I really like your insight on the issue of metatarsal pain. I believe I am one of those typical 56ish year old women who walk in your door. I have the 2nd MTP synovitis as described so clearly by you. I have been to my podiatrist a dozen times and my pain is only getting worse increasing from one foot to the other. Like many of us, I have high arches, a small bunion, the beginning of arthritis, but also a plantar fibroma. That was the original reason for my visit to the 2nd young podiatrist I chose. He successfully reduced its size with Vitrase enzyme shots.


Now back to my real…


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AngryOrthopod
Nov 18

Sheri Smith on June 27, 2019 at 2:03 pm


Thank you for your insights. I would love your opinion. I am a 42 year old active physical therapist. I have seen 2 Orthopaedics and 2 podiatrists for opinions. I have not had an MRI but I think I have a plantar plate tear. My second toe is medially deviated, has a hammer toe and is trying to crossover my great toe. I have pain with any walking over metatarsal head. Even at rest, it throbs. I cannot walk with a normal gait. I have tried conservative treatment. I wear Hoka’s, tried taping, custom orthotics, metatarsal pad. I am to the point that I am ready for surgery due to pain and…


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AngryOrthopod
Nov 18

Marc on June 15, 2019 at 9:19 am


PDS is linked to a long or plantarflexed /plantar prominent 2nd met. But it rarely needs surgery. Orthotics or a prefab support with a 2nd met recess in a rocker sole shoe (like MBT), to prevent the hyper-extension of the toe that forces the metatarsal condyle plantarly into the “plantar plate”.

The scorpion suture repair of the plantar plate is pretty ingenious though. Nice toy!!

My own 2 cents based on anecdotal bias confirming selective recognition of limited follow ups on busy clinic days is this: Weil’s generally “work”, as do plantar condylectomies. Tendons can heal without our help if the deforming/ damaging factors are removed or reduced enough to let the body…


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