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!

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.”

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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