Prediction of Plantar Plate Injury using MRI

Twitter: @jaysung#foot2011

www.weil4feet.comlwj@weil4feet.com

Prediction of Plantar Plate Tear by Magnetic Resonance Imaging with

Correlation to Intra-Operative Findings

• Authors: Wenjay Sung, DPM, Lowell Weil, Jr., DPM, Lowell Scott Weil, Sr., DPM, and Richard Rofles, MD.

Disclosures

My disclosure is in the Final AOFAS Program Book.

My co-authors have their disclosures in the Final AOFAS Program Booklet.

Our presentation was funded by a research grant from the American College of Foot and Ankle Surgeon’s Clinical and Scientific Research Committee (2010).

PurposeBackground

Diagnostic studies have developed enhanced protocols to detect specific injury to the plantar plate2,5,6.

Principle stabilizer of the MTP joint

The integrity is essential to stabilize the proximal phalanx of the lesser toes4.

Descriptions of plantar plate ruptures on MRI have been well documented by Yao et al1,2

Gregg et al3 found that MRI was high in sensitivity but low in specificity in cadavers.

Purpose

To assess the utility of magnetic resonance imaging (MRI) in diagnosing injury of the plantar plate ligament to the second metatarsophalangeal (MTP) joint

To determine the reliability of MRI as a diagnostic tool with correlation to intra-operative observations as a reference standard.

Prospective, diagnostic study EBM Level of evidence: II (prospective

diagnostic)

Methods

IRB approved

Prospectively enrolled consecutive adult subjects after clinical suspicion of plantar plate pathology Power analysis for this

research has determined the need for at least 45 subjects

Alpha level = 0.05, Observed R2 = 0.15, Observed Power = 0.80).

Sensitivity, specificity, positive predictive values and negative predictive values were calculated using this model.

All statistical analysis were performed by an outside consultant statistician using SPSS version 14.0 (SPSS Science Inc, Chicago, Ill).

MethodsInclusion Criteria

Clinical diagnosis

Healthy male or female, ages 18-75

Failed at non-operative treatments for a period of at least three months

Elected for surgical correction

Exclusion Criteria

Previous surgery to 2nd MTP joint region

Known allergy to contrast dye

Chronic kidney disease

Women who are pregnant

Any contraindications to MRI, including history of implanted pacemaker, loose shrapnel, ocular implants, or ventricular stents

Methods

MRI to be performed at 0.31 T (O-Scan Extremity MRI, Biosound Esaote Inc, Indianapolis, IN).

Evaluation included coronal T1-weighted images coronal T2-weighted images coronal fast-spin-echo short tau

inversion recovery images sagittal T1-weighted images sagittal T2-weighted images sagittal fast-spin-echo short tau

inversion recovery images

One fellowship-trained musculoskeletal radiologist created the protocol and evaluated the MRI data

Two different attending surgeons performed the surgeries.

One foot & ankle fellow was present to observe all intra-operative findings.

ResultsDemographics

From August 2010 until May 2011, 41 patients (45 feet) underwent MRI scan for suspected plantar plate pathology.

Thirty eight were female and three male with an average age of 52.4

All 41 patients (45 feet) elected to have surgery to the case foot

ResultsMRI Reading

39 cases were read as “tear”

6 cases were read as “no tear”

Visual inspection

All 39 were confirmed “tear”

4 of 6 were confirmed “no tear”

2 of 6 were in fact “tears”

ResultsTable 1 - Tear Diagnosed on MRI vs Tear Actually Present

Cross-tabulation—Positive and Negative Predictive Values

Tear Actually Present

TotalNo YesTear Diagnosed on MRI

Yes Count 0 39 39% within Tear Diagnosed on MRI

0.00% 100.00% 100.00%

No Count 4 2 6

% within Tear Diagnosed on MRI

66.67% 33.33% 100.00%

Total Count 4 41 45% within Tear Diagnosed on MRI

8.89% 91.11% 100.00%

Results Sensitivity = 95%

Specificity = 100%

Positive Predictive Value = 100%

Negative Predictive Value = 67%

Discussion

MRI appears to be good a “ruling-in” test for a tear

MRI does not appear to give false positives.

However, MRI may not be as accurate for “ruling-out” a tear.

Accurate predictive values from MRI results may be meaningful for those who: Wish to repair the plantar

plate ligament May not recognize the

prevalence of this pathology in lesser MTP joint deformities.

DiscussionStrength

Prospective, diagnostic

Power analysis to determine needed sample size

Statistical analysis

Simple, reproducible study

Weakness

Assessor bias

No blinding

Conclusions

We hope with these protocols more clinicians can assess the utility of magnetic resonance imaging in the diagnosis of injury to the plantar plate ligament

We are planning to evaluate the utility of diagnostic ultrasound vs MRI in assessing plantar plate tears

References

1. Yao L, Cracchiolo A, Farahani K, et al. Magnetic resonance imaging of plantar plate rupture. Foot Ankle Int. 1996;17:33-36.

2. Yao L, Do HM, Cracchiolo A, et al. Plantar plate of the foot: findings on conventional arthrography and MR imaging. AJR Am J Roentgenol. 1994;163:641-644.

3. Gregg JM, Silberstein M, Schneider T, et al. Sonography of plantar plates in cadavers: correlation with MRI and histology. AJR Am J Roentgenol. 2006;186:948-955.

4. Yu GV, Judge MS, Hudson JR, et al. Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. J Am Podiatr Med Assoc. 2002;92:182-199.

5. Powless SH, Elze ME. Metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management. J Foot Ankle Surg. 2001;40:374-389.

6. Karpman RR, MacCollum MS, 3rd. Arthrography of the metatarsophalangeal joint. Foot Ankle. 1988;9:125-129.

7. Weil Jr L, Sung W, Weil Sr LS, et al. Anatomic Plantar Plate Repair. Tech Foot Ankl Surg. 10(1):33-39, March 2011.

Prediction of Plantar Plate Injury using MRI

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