Plantar plate repair for lesser metatarsophalangeal joint instability: a systematic review of outcomes

INTRODUCTION

Lesser metatarsophalangeal joint instability is a frequent cause of forefoot pain, or metatarsalgia, and of acquired digital deformity that ranges from a subtle crossover of the second toe to a fixed dorsal dislocation.(1,2) Metatarsalgia is among the most common complaints in foot and ankle practice, and plantar plate injury is now recognized as one of its principal structural causes, second only to metatarsal length imbalance in some series.(2,3) The plantar plate, a fibrocartilaginous thickening of the plantar capsule that anchors the proximal phalanx to the metatarsal head, is the principal static stabilizer of the lesser metatarsophalangeal joints together with the collateral ligaments, and its attenuation or rupture under repetitive load permits dorsal subluxation of the proximal phalanx.(4,5)

The deep transverse metatarsal ligament contributes to the transverse restraint of adjacent digits, so the competence of that ligament modulates how a unilateral plate lesion deforms the forefoot and explains why the second ray is affected more frequently than the others.(6) Because the plate is loaded at every toe-off and has a limited intrinsic blood supply, attritional tears progress once they begin, which makes the condition a mechanical rather than an inflammatory problem and limits the capacity of nonoperative measures to reverse it.(4,5) The second metatarsophalangeal joint is affected more often than the third or fourth because its metatarsal is usually the longest, which concentrates load on its plate during propulsion.(2,3) Recognition of this anatomy has moved the diagnostic emphasis from the metatarsal head to the plantar plate over the past decade, and the plate is now examined as a primary stabilizer rather than as an incidental capsule.(5)

Patients usually present with weightbearing pain beneath the affected metatarsal head, a positive drawer test and, as the lesion advances, a clinically visible deviation of the toe in the transverse plane.(3,7) Magnetic resonance imaging and dynamic ultrasound allow the tear to be graded and the collateral ligaments and interdigital nerves to be assessed, and this information guides the choice between conservative and surgical treatment.(8,9) The condition is classified into grades of instability that extend from a painful but reduced joint to a frank dislocation, and the grade determines whether a direct repair remains technically feasible or whether a reconstructive alternative is required.(10)

Early grades are still managed with metatarsal pads, footwear modification, taping and corticosteroid injection, whereas higher grades and displaced joints are referred for surgery.(3,11) The drawer test, performed by translating the proximal phalanx dorsally while the metatarsal head is stabilized, is the clinical reference for instability, and its positivity correlates with the grade of tear confirmed at surgery.(3,7) Pain without instability, by contrast, may reflect an intact but inflamed plate, which is the population best served by conservative care.

For decades the surgical answer was indirect, because a shortening metatarsal osteotomy decompresses the joint without restoring the plantar structures, and it leaves the torn plate unrepaired.( 2) The development of dorsal and plantar approaches that expose and suture the torn plate directly changed that paradigm, and several reconstruction variants, including imbrication, flexor tendon reinforcement and tenodesis, were added for attenuated or unrepairable plates.( 12-14)

Each approach carries a different profile of exposure, adjunct procedures and wound-related risk: the dorsal approach is combined with a Weil osteotomy to gain visualization but risks stiffness and floating toe, whereas the plantar approach exposes the tear directly but places a scar on the weightbearing surface.(13,14) The choice between these routes remains empirical, because no trial has compared them directly, and the comparative evidence that does exist contrasts repair against osteotomy rather than one approach against another.(14) Distinguishing the primary outcome of this surgery, the recovery of joint stability, from its secondary outcomes, the relief of pain and the improvement of function, is essential to interpret the published series, because the two can diverge when a stable but stiff or painful joint results.(15)

Two earlier systematic reviews summarized plantar plate repair and concluded that the technique is effective, but both mixed direct repair with indirect and reconstructive procedures, pooled heterogeneous instruments and preceded several of the larger contemporary series.(16,17) A further narrative review updated the surgical alternatives without a structured appraisal of outcomes.( 18)

The present review therefore aimed to synthesize the clinical outcomes, recurrence and complication rates reported after surgical plantar plate repair for lesser metatarsophalangeal joint instability, with joint stability prespecified as the primary outcome and pain, function, recurrence and complications as secondary outcomes. A further aim was to establish which secondary outcomes move independently of joint stability, so that future studies can select instruments that capture the effect most sensitive to change.

METHODS

RESULTS

DISCUSSION

The main finding of this review is that surgical plantar plate repair restores lesser metatarsophalangeal joint stability in roughly eight to nine of every ten treated joints, with consistent secondary gains in pain and function and a modest burden of recurrence and wound complications. Maintenance of reduction or clinical stability ranged from 80% to 95% across fifteen reporting series, and the five comparative studies each favored direct repair over the indirect alternative, which supports a genuine treatment effect rather than a publication artifact.( 27,28,37-39) The finding is robust to the exclusion of the comparative studies, because the single-arm series alone reproduce the same band of estimates. These figures are best interpreted as an envelope rather than as a point estimate, because the definition of stability varied, but even the lower bound of 80% represents a useful success rate for a deformity that, left untreated, progresses toward fixed dislocation.( 1)

This synthesis agrees with earlier systematic reviews that concluded plantar plate repair is effective, while extending them with the larger series published after 2017.(16,17) Those reviews pooled a smaller body of predominantly level IV evidence and noted the same limitation that dominates the present data, namely that the procedure has been evaluated almost entirely in retrospective single-surgeon series. The stability rates observed here are also consistent with the early dorsal and plantar outcome studies, which reported maintenance of alignment in the same 80% to 90% band.(23,30) Where the present review differs is the separation of the primary stability outcome from the secondary functional outcomes, which makes the hierarchy of evidence explicit rather than merging heterogeneous instruments into a single effect. It also demonstrates that the secondary functional gains accompany the stability gain rather than replacing it, a point that earlier reviews could not make because they pooled both types of outcome. This distinction carries practical weight, since a procedure that stabilized the joint without relieving pain, or vice versa, would require a different interpretation and a different measure of success than the combined reports suggest.

The primary outcome was measured in three ways, and this heterogeneity explains part of the spread from 80% to 95%. The clinical definition of stability differed across series, from a negative drawer test to patient-reported satisfaction to a radiographic overlap distance.(23,29,31) Radiographic recurrence after plantar-approach repair reached 16%, higher than the 7.6% clinical recurrence reported by the largest plantar series, which indicates that radiographic and clinical definitions do not identify the same patients.(30,31) Rheumatoid arthritis was present in three of the five radiographic recurrences, a signal that an inflammatory substrate compromises the repair despite adequate technique.(31) Studies that defined stability clinically therefore tend to overstate the durability of the repair, and a radiographic or drawer-test definition should be preferred in future series. The spread also reflects differences in case mix. Series that treated grade 0 and grade 1 lesions, such as the imbrication cohorts, reported smaller absolute gains because the joints were near-normal at baseline.(33,34) Series that treated dislocated or grade IV tears faced the most hostile tissue bed and reported the highest rates of secondary displacement.(25) Between these extremes, the dorsal and plantar repair series enrolled a mix of grades, which is the most representative of routine practice but the least informative about the effect of grade on outcome.(23,30)

The secondary outcomes were more consistent. AOFAS scores improved by 28 to 43 points and postoperative VAS pain settled at 1.5/10 or less wherever it was reported, magnitudes that exceed the accepted minimal clinically important differences for forefoot instruments.(23,24,26,29) The biologically plausible explanation is that reattaching the plate restores the static constraint that the plantar plate and collateral ligaments normally provide, which is supported by the vascular studies that documented residual perfusion of the proximal plate and a microvasculature capable of supporting healing after suture.(41,42) Repair by imbrication produced smaller score changes than direct suture, which is expected because that technique was reserved for grade 0 and grade 1 lesions with less room for improvement.(33,34) The similarity of the functional gains across dorsal, plantar and arthroscopic routes suggests that the reconstruction of the plate, not the exposure, is the active ingredient.

The superiority of repair over osteotomy alone is also consistent with the known biomechanics of the joint. A shortening osteotomy relieves submetatarsal pressure but does not re-establish the plantar restraint, so the digit can still drift dorsally once weightbearing resumes.(2,4) The comparative series that measured alignment support this interpretation, because the repair arms showed better stability than the osteotomy arms even when the same metatarsal shortening was performed.(27,28) The collateral ligaments bear part of the joint load together with the plate, and this load sharing accounts for the finding that repairs which reattach the plate but leave a deficient collateral ligament can still fail; the anatomic reconstruction series addressed both structures in the same sitting.(6,29) This dual-restraint principle also underlies the flexor tendon augmentation tested in the largest prospective series, in which the added sagittal restraint reduced floating toe beyond the effect of the plate repair alone.(37)

Complications differed by approach. The plantar approach delivered a 15% wound-related complication burden in 204 repairs, although the events were mostly superficial infections and painful scars rather than deep problems, and the reoperation rate remained below 2%.(22) The dorsal approach avoids the plantar scar but requires an osteotomy or extensive joint release to expose the plate, and it carried a 22% secondary dislocation rate in one transarticular series, a trade-off that is rarely quantified against the plantar alternative in the same cohort.(25,42) Tobacco use increased the odds of wound complications more than seven-fold, which argues for preoperative counseling in this population.(22) The absence of deep infections across the largest series is reassuring and indicates that the plantar scar, when managed carefully, does not translate into major morbidity. The infection profile was dominated by superficial wound problems rather than deep sepsis, a distinction that matters when the procedure is offered to patients with diabetes or neuropathy, although the source series reported those subgroups as too small to analyze separately.( 22)

The comparative studies provide the strongest evidence available. Combined Weil osteotomy and plate repair produced better foot-specific quality of life and pain than osteotomy alone, and anatomic reconstruction produced greater digital stability than traditional rebalancing, both findings that point to the plate rather than the bone as the structure that must be addressed.(27,39) Adding flexor tendon repair to plate repair in the Russian prospective series reduced floating toe and residual hyperextension, which suggests that the sagittal stabilizers contribute beyond the plate itself.(37) These comparisons remain non-randomized, and surgeon allocation may have placed higher-grade tears in the repair arm, a bias that the Weil-alone comparison explicitly acknowledged.(27) The moderate risk of bias in these five studies means that the direction of the effect is credible even though its exact magnitude remains uncertain.

The results map onto the instability grades in the expected direction. The radiofrequency series treated grades 0 and 1 and achieved stability in 83% of joints, the imbrication series treated the same low grades with a smaller score change, and the reconstruction series addressed grade IV tears with the highest rate of secondary displacement.(25,26,33) This gradient supports the classification that underpins patient selection, although the included studies reported the grade too inconsistently to test the association formally.(10) Future series should state the grade at surgery for every toe, because the grade rather than the surgical route may be the dominant determinant of recurrence.

CONCLUSIONS

Plantar plate repair restores lesser metatarsophalangeal joint stability in the large majority of operated joints and improves pain and function, with recurrence and revision rates below one in five and a complication burden dominated by superficial wound events. Direct repair outperformed indirect osteotomy and traditional rebalancing in every comparative study, which indicates that the plate itself is the structure that must be addressed.

The certainty of these estimates is limited by retrospective, single-surgeon designs and by heterogeneous instruments and short follow-up. Comparative and randomized studies with blinded outcome assessment and a common validated patient-reported instrument are required to confirm the magnitude of the benefit, to identify the patients most likely to recur and to define the durability of stability beyond two years. Until that evidence exists, the consistency of the current data is sufficient to justify repairing the plate when it is torn at surgery, while accepting that the exact success and recurrence figures remain provisional.

References

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