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Finney et al
test.7,16,19,23,28,35,36 There can also be widening of the interdigital space, loss of ground touch, and splaying of the toes
at the MTP joint.28
When nonoperative treatment of MTP joint instability is
not successful, operative therapy may be appropriate.
Various interventions have been described, including synovectomy,23 syndactylization of toes,10 collateral ligament
reconstruction,7,11 tenotomy,7 tendon transfers,4,7,15,26,28,36
osteotomy,12,21 MTP joint fusion,18 thermal shrinkage of the
plantar plate,28,29 and suture tape stabilization.34 These procedures have been somewhat successful in stabilizing the
MTP joint,16 but since they are nonanatomic repairs, there
may be residual deformity at the MTP joint in 25% to
38.5%12,16,26,36 of cases, with 25% of patients reporting that
they are dissatisfied postoperatively.26
Within the past few years, surgeons have begun focusing
on performing anatomic repairs of plantar plates24,27,38,40 to
treat dorsal MTP joint instability.2,4,8,33 Plantar approaches
to the plantar plate have been described13,24; however, this
approach is not preferred because of the extensive dissection through the plantar fat pad and flexor tendons to gain
access to the plantar plate, concerns for scar formation on
the plantar surface of the foot, as well as pain associated
with weight bearing on a plantar incision. Instead, dorsal
approaches to the plantar plate have been popularized
recently as the plantar plate can be accessed through the
MTP joint.38,40 When repairing the plantar plate through a
dorsal approach, 2 suture configurations into the plantar
plate have been described: a "luggage-tag" or "cinch" stitch
or a mattress stitch.38
To our knowledge, the biomechanical properties of different suture configurations in the plantar plate have not
been reported. The purpose of this study was to compare
the biomechanical properties of different suture configurations used for anatomic plantar plate repairs. In addition to
the 2 suture configurations currently employed for plantar
plate repairs, the modified Mason-Allen stitch was chosen
for comparison. The modified Mason-Allen stitch is a
locking stitch that has been shown to have a strong suturetissue interface in the rotator cuff.22 The hypothesis of this
study was that the modified Mason-Allen stitch would
provide a biomechanically superior suture configuration
with respect to axial displacement with cyclic loading and
load to failure compared with horizontal mattress and luggage-tag configurations.
Materials and Methods
Specimen Preparation
The current study was a comparative biomechanical analysis of 27 lesser toe MTP joints comparing the biomechanical properties of horizontal mattress, luggage-tag, and
Mason-Allen suture repairs of the plantar plate. Nine fresh
frozen human cadaver feet were obtained for testing. The
mean age of specimens was 51.8 ± 4.8 years (range, 44-57
years), including 5 men and 4 women. Inclusion criteria
for specimens were donors between the ages of 18 and 65
years with no history of diabetes, inflammatory disease,
peripheral vascular disease, or connective tissue disorders.
To best approximate tissue encountered during clinical
use, fresh-frozen cadaveric tissue was used. Each specimen was maintained in a freezer at −20°C until approximately 24 hours before use and then thawed to room
temperature for testing. Institutional review board
approval was not required because of the use of deidentified cadaveric specimens.
The MTP joints of the second, third, and fourth toes were
dissected from 9 human cadaveric specimens. The plantar
plates of the first and fifth MTP joints were excluded from
testing because of their significant differences in size from
the other toes. The midfoot of each specimen was carefully
dissected, and the metatarsals were transected at the proximal shaft with an oscillating saw. The proximal phalanx
was then sharply excised from the joint with a capsulectomy at the insertion of the plantar plate, ensuring that the
plantar plate was carefully preserved. The proximal cut
aspects of each metatarsal were skeletonized and then potted in polymethyl methacrylate at a 90-degree angle to align
the plantar plate with the axis of load and placed in a custom-made fixture that was rigidly mounted on a test platform composed of a Materials Testing System 858 Mini
Mionix (MTS, Eden Prairie, MN) with a Honeywell 100 lbf
load cell (Honeywell, Columbus, OH) secured to the crosshead. After each suture repair, the free suture ends were
tied, and the loop was secured to a hook attached to the load
cell (Figure 1).
Suture Configuration
Three suture configurations were then tested: (1) a horizontal mattress stitch, (2) 2 interrupted luggage-tag stitches,
and (3) a modified Mason-Allen configuration (Figure 2).
Both the "luggage-tag" or "cinch-type" stitch and horizontal mattress have been described in the plantar plate repair
technique guides.1,32 The modified Mason-Allen stitch,
which is commonly used in rotator cuff repairs, has been
described as one of the strongest suture patterns but not yet
described plantar plate repairs. Specimens were sorted into
3 equal groups such that each suture configuration was
assigned to a different lesser toe in each group to account
for any variation between the second, third, and fourth
plantar plates (Table 1). Therefore, all suture configurations were tested on each foot, and all were assigned
equally to each of the lesser toes being tested. The suture
type used for testing was 0 FiberWire (Arthrex, Naples,
FL), which is commonly used for plantar plate repair.
Sutures were placed 2 mm proximal to the distal insertion
Table of Contents for the Digital Edition of Foot & Ankle International - July 2018
Contents
Foot & Ankle International - July 2018 - Intro
Foot & Ankle International - July 2018 - Cover1
Foot & Ankle International - July 2018 - Cover2
Foot & Ankle International - July 2018 - i
Foot & Ankle International - July 2018 - ii
Foot & Ankle International - July 2018 - Contents
Foot & Ankle International - July 2018 - iv
Foot & Ankle International - July 2018 - v
Foot & Ankle International - July 2018 - vi
Foot & Ankle International - July 2018 - vii
Foot & Ankle International - July 2018 - viii
Foot & Ankle International - July 2018 - 1A
Foot & Ankle International - July 2018 - 1B
Foot & Ankle International - July 2018 - ix
Foot & Ankle International - July 2018 - x
Foot & Ankle International - July 2018 - xi
Foot & Ankle International - July 2018 - xii
Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
Foot & Ankle International - July 2018 - xiii
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Foot & Ankle International - July 2018 - xv
Foot & Ankle International - July 2018 - xvi
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Foot & Ankle International - July 2018 - 3A
Foot & Ankle International - July 2018 - 3B
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Foot & Ankle International - July 2018 - 837
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Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
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