Direct Plantar Plate Repair for Second Metatarsal Phalangeal Joint Instability: Outcomes from 196 Cases with Long-Term Follow-up.

Abstract

Lesser metatarsophalangeal (MTPJ) joint instability, often presenting as second crossover toe deformity, commonly results from plantar plate attenuation. Indirect surgical approaches, such as metatarsal osteotomy or tendon transfer, can correct alignment but often lead to complications like floating toe, transfer metatarsalgia, and stiffness. The direct plantar approach allows for anatomic repair but is underutilized due to concerns about scar-related pain. To evaluate outcomes of second plantar plate repair via a direct plantar approach, focusing on pain, alignment, satisfaction, and scar morbidity. Retrospective case series. We reviewed 196 primary second plantar plate repairs performed from 2013-2023. All patients had at least 12 months of follow-up (mean 48 months). Adjunctive procedures included Hohmann osteotomy and proximal interphalangeal joint arthrodesis. Outcomes included Numeric Pain Rating Scale (NPRS) scores, scar symptoms, satisfaction, symptom improvement, and willingness to recommend the procedure. Radiographic alignment was assessed in sagittal and transverse planes on weightbearing views. Radiographic correction averaged 24.0° sagittal and 3.6° transverse (11.7° with osteotomy). Mean NPRS pain scores improved from 5.4 to 0.4. 88% of patients were "very satisfied," and 91% would recommend the procedure. Scar-related pain occurred in 2.0% of cases. Plantar callus improved in 52%, and 6.1% reported postoperative stiffness. Direct plantar plate repair provides durable correction, considerable pain relief, and high satisfaction with minimal scar morbidity. This is the largest, longest follow-up study of its kind.