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Plantar Plate Repair of the First Metatarsophalangeal Joint (Turf Toe)


  • Capsular-ligamentous injuries of the first metatarsophalangeal (MTP) joint are caused by sudden hyperextension of the joint while playing sports or during motor vehicles accidents, as well as when falling from a height.

  • Traditionally, stretching and partial tears are managed by conservative treatments, whereas totally detached and avulsion fractures are treated using surgical intervention. However, there is a controversial dilemma of treatment on athlete’s moderate instability.

Indications

  • Large capsular avulsion with unstable joint and positive Lachman test

  • Avulsion fracture of the inferior rim of the proximal phalanx of the hallux complex and unstable joint

Indications Pitfalls

  • Positive magnetic resonance imaging scans without instability

  • Osteochondral lesions of one or both joint surfaces

Indications Controversies

  • Loose bodies of the joint

  • Avulsion injuries with moderate instability in high-profile athletes

Examination and Imaging

  • Ecchymosis and edema after a hyperextension trauma of the first MTP joint ( Fig. 16.1 ) should be examined.

    FIG. 16.1

  • A positive result in Lachman test.

  • Comparative range of motion should be assessed.

  • X-rays should show comparative proximal migration of sesamoids as well as displacement of accessory sesamoids with dorsiflexion in the anteroposterior view ( Fig. 16.2 ).

    FIG. 16.2

  • Rule out sesamoid fracture, avulsion fracture, and osteochondral lesion ( Fig. 16.3 ).

    FIG. 16.3

  • Magnetic resonance imaging should include a short-TI inversion recovery sagittal view of the joint to confirm clinical and x-ray findings ( Fig. 16.4 ).

    FIG. 16.4

Treatment Options

  • Rest, ice, and compression with elevation in a 90° large brace is used initially.

  • Conservative treatment using tapping or a cast with the toe spica in plantar flexion.

  • Perform surgery when severe instability or fractures are present in the original lesion or conservative treatment fails.

Surgical Anatomy

  • Plantar plate structure related to the sesamoids: the complex also includes the collateral ligaments, the distal insertion of the flexor hallucis brevis tendon, the adductor and abductor hallucis, and the intersesamoid ligament.

  • The plantar plate runs from the metatarsal neck to the plantar aspect of the proximal phalanx and limits hyperextension of the MTP joint ( Fig. 16.5 ).

    FIG. 16.5

  • Plantar digital nerves and vessels at risk ( Fig. 16.6 ).

    FIG. 16.6

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