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Keller M, Saltrick B, Gull L, Reade B. Fifth Metatarsal Fractures. Clin Podiatr Med Surg 2024; 41:391-405. [PMID: 38789160 DOI: 10.1016/j.cpm.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Fifth metatarsal features are the most common fractures in the foot. They have a long history that has resulted in many classification systems and little consensus on appropriate treatment. Although there is some agreement among experts, there are also many questions yet to be answered. There is a general consensus that dancer's fractures and zone 1 fractures can generally be treated nonoperatively. There is much more debate about zone 2 and 3 fractures and appropriate treatment guidelines. The authors review the current literature and give the recommendation for treatment based on their experience in a community-based private practice.
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Affiliation(s)
| | | | - Logan Gull
- Health Alliance Hospital, Kingston, NY, USA
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Su KC, Yen YC, Wang CH, Wang YL, Wang SP. Biomechanical comparisons of F.E.R.I. techniques with different type of intramedullary screws fixation for Jones fractures. Front Bioeng Biotechnol 2024; 12:1389127. [PMID: 38751865 PMCID: PMC11094221 DOI: 10.3389/fbioe.2024.1389127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction: Jones fractures frequently fail to unite, and adequate fixation stability is crucial. This study aimed to elucidate the biomechanical stability of various intramedullary screw fixation constructs. Methods: Jones fracture model over the proximal 5th metatarsal of artificial bone was created in all specimens. Six groups were divided based on varied screw constructs with different screw lengths, either 30 or 40 mm, including cannulated screws-C30 and C40 groups, one high-resistance suture combined with intramedullary cannulated screws (F.E.R.I. technique)-CF30 and CF40 groups, and second-generation headless compression screws (SG-HCS) -HL30 and HL40 groups. Mechanical testing was conducted sequentially, and the maximal force (N) and stiffness (N/mm) of all constructs were recorded. Results: The maximal force (N) at 1.0 mm downward displacement in C30, C40, CF30, CF40, HL30, and HL40 groups were 0.56 ± 0.02, 0.49 ± 0.02, 0.65 ± 0.02, 0.49 ± 0.01, 0.68 ± 0.02, and 0.73 ± 0.02, respectively, and the stiffness (N/mm) in subgroups were 0.49 ± 0.01, 0.43 ± 0.01, 0.67 ± 0.01, 0.42 ± 0.01, 0.61 ± 0.01, and 0.58 ± 0.02, respectively. SG-HCS subgroups exhibited greater maximal force and stiffness than conventional cannulated screws. Screws of 30 mm in length demonstrated better stability than all 40 mm-length screws in each subgroup. In C30 fixation, the stiffness and maximum force endured increased by 1.16 and 1.12 times, respectively, compared with the C40 fixation method. There were no significant differences between CF30 and SG-HCS groups. Only the F.E.R.I technique combined with the 4.5 mm cannulated screw of 30 mm in length increased the biomechanical stability for Jones fractures. Discussion: These biomechanical findings help clinicians decide on better screw fixation options for greater stability in Jones fractures, especially when large-diameter screws are limited in use. However, this biomechanical testing of intramedullary screw fixation on Jones fracture model lacks clinical validation and no comparisons to extramedullary plate fixations. Moving forward, additional clinical and biomechanical research is necessary to validate our findings.
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Affiliation(s)
- Kuo-Chih Su
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medical Equipment Development and Application, HungKuang University, Taichung, Taiwan
| | - Yu-Chun Yen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Hsiang Wang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Lun Wang
- Stella Matutina Girls’ High School, Taichung, Taiwan
| | - Shun-Ping Wang
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
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Kim C, Shin DY, Kim J. Is Surgical Treatment Necessary for the Treatment of a Jones Fracture?: A Retrospective Study. Clin Orthop Surg 2024; 16:335-341. [PMID: 38562636 PMCID: PMC10973620 DOI: 10.4055/cios23333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/17/2023] [Indexed: 04/04/2024] Open
Abstract
Background Jones fractures are common injuries that can be treated conservatively or surgically. However, the optimal treatment approach remains controversial. This study aimed to compare the clinical outcomes of conservative and operative treatments for Jones fractures and determine whether surgical treatment is necessary. Methods A retrospective study was conducted on 69 patients with Jones fractures treated at our hospital. The patients were divided into 2 groups: conservative (C group; n = 46) and operative (O group; n = 23) treatments. Patients were followed up after 2, 6, and 12 weeks, and every 3 months thereafter. However, outpatient follow-ups were conducted between 8 and 10 weeks as needed. The mean follow-up period was 14.5 weeks (range, 12-24 weeks). In group C, the patients were treated with a non-weight-bearing cast for 4-6 weeks, followed by additional weight-bearing boot immobilization before returning to exercise. In group O, patients were treated surgically using a bicortical screw or intramedullary internal fixation. Time to radiologic union, clinical union, return to sports, visual analog scale (VAS), Foot Function Index-Revised Short Form (FFI-RS), and American Orthopedic Foot and Ankle Society (AOFAS) scores were evaluated. Results Sixty-nine patients were included in the analysis. There were statistically significant differences in the time to radiologic union and return to sports, VAS score in the second week, and FFI-RS score in the 12th week. In group C, favorable outcomes were observed in terms of the time to return to sports, VAS score in the second week, and FFI-RS score in the 12th week. Contrastingly, in group O, better results were observed in time to radiologic union. The AOFAS score was excellent at the final follow-up, with no significant differences between groups. Complication rates were 10.8% and 13% in groups C and O, respectively. Conclusions Surgical treatment is sometimes necessary for Jones fractures, but conservative treatment should also be considered because of the favorable outcomes. Conservative treatment can be a good option for patients who are risk-averse and place a high value on fracture healing without surgery.
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Affiliation(s)
- Changsu Kim
- Department of Orthopaedic Surgery, Kosin University Gospel Hospital, Busan, Korea
| | - Dong Young Shin
- Department of Orthopaedic Surgery, Kosin University Gospel Hospital, Busan, Korea
| | - Jiyoun Kim
- Department of Orthopaedic Surgery, Kosin University Gospel Hospital, Busan, Korea
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Paavana T, Rammohan R, Hariharan K. Stress fractures of the foot - current evidence on management. J Clin Orthop Trauma 2024; 50:102381. [PMID: 38435398 PMCID: PMC10904895 DOI: 10.1016/j.jcot.2024.102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/06/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
Stress fractures are a consequence of repeated submaximal loads with inadequate time for recovery and biologic repair or remodelling. The foot and ankle complex (FAC) represents a common site for development of stress fractures. Whilst the overall incidence of stress fractures is low, they are prevalent in athletes and military personnel causing significant time away from sports or work. Within these populations, certain stress fractures directly correlate to specific activities. Factors that commonly influence these fractures include an acute increase in new repetitive physical activity combined with muscle fatigue, training errors or improper athletic techniques, which challenge the regenerative and remodelling capacity of bone. Depending on the site that is subject to repetitive loading, various biomechanical factors can result in abnormal concentration of forces to specific areas of the FAC resulting in stress fracture. Decreased bone marrow density (BMD) is a major biologic cause for developing stress fractures. The female athlete triad comprising eating disorder, amenorrhea and osteoporosis in competitive athletes also predisposes to stress fractures. Vitamin D deficiency is also postulated to be the cause of these fractures and may contribute to poor healing. Clinical presentation is usually with vague pain of insidious onset which worsens with activity and improves with rest. Diffuse tenderness over the affected bone is common with only a minority having any visible swelling. Plain radiographs are the first line of investigation but rarely reveal an obvious fracture. MRI scans aid in diagnosis and CT scans help in treatment and characterisation of the fracture and monitor healing. Management relates to the site of injury, which stratifies them into high or low-risk. Stress fractures of the calcaneus, cuboid and cuneiforms are classed as low-risk fractures as they usually heal with simple activity modification or short duration of non-weight bearing. Stress fractures of the navicular, talus and hallucal sesamoids are classed as high-risk fractures due to higher rates of non-union and prolonged recovery time. Metatarsal fractures can be considered high or low-risk depending on location. These warrant aggressive management, often requiring surgical intervention. Adjuncts such as vitamin D supplements, external shockwave therapy, low-intensity pulsed ultrasound therapy have been used with varying success but there remains little supportive evidence of superiority in the available literature.
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Affiliation(s)
- Thumri Paavana
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom
| | - R. Rammohan
- The Grange University Hospital, Cwmbran, United Kingdom
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Wen Y, Zhu D, Wang Q, Song B, Feng W. Compression screw internal fixation versus non-weight-bearing cast immobilization for Jones fractures in children. Injury 2024; 55:111213. [PMID: 37984010 DOI: 10.1016/j.injury.2023.111213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Several methods have been used to treat pediatric Jones fractures, but there has been no consensus about the optimum method. The purposes of this study were to compare the clinical outcomes between compression screw and non-weight-bearing techniques used in pediatric Jones fractures and clarify the most suitable treatment option for this population. METHODS Twenty-one patients who presented with Jones fractures between January 2015 and June 2021 were analyzed retrospectively. They were divided into the compression screw group (n=10) and cast immobilization (n=11) group. The following parameters were compared between them: demographic data; times to radiographic union, full weight bearing, and return to daily life; and the American Orthopaedic Foot and Ankle Society (AOFAS) foot scores at 3 months postoperatively and the final follow-up. RESULTS The two groups did not differ significantly with respect to age, sex, laterality, and preoperative displacement. The mean immobilization time and times to radiographic union, full weight bearing, and return to daily life were significantly shorter in the compression screw group than in the cast immobilization group. The AOFAS scores at the final follow-up did not differ significantly between the two groups. One case of refracture and delayed union each were observed in the non-weight-bearing cast group. However, no patients experienced nonunion. CONCLUSIONS Compression screw and non-weight-bearing cast techniques are effective methods for treating pediatric Jones fractures. The complication rate was lower in pediatrics than in adults. However, compared with the non-weight-bearing cast technique, the compression screw technique has the advantages of a shorter radiographic union time, shorter immobilization times, and earlier return to full weight bearing and daily life. We recommend compression screw fixation for widely displaced fractures and school-age and active adolescents to avoid delays in healing, nonunion, disruption to daily living, and time off school. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yuwei Wen
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, 100045 Beijing, China
| | - Danjiang Zhu
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, 100045 Beijing, China
| | - Qiang Wang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, 100045 Beijing, China.
| | - Baojian Song
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, 100045 Beijing, China
| | - Wei Feng
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, 100045 Beijing, China
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Pettersen PM, Radojicic N, Grün W, Andresen TKM, Molund M. Proximal Fifth Metatarsal Fractures: A Retrospective Study of 834 Fractures With a Minimum Follow-up of 5 Years. Foot Ankle Int 2022; 43:602-608. [PMID: 35125016 DOI: 10.1177/10711007211069123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal fifth metatarsal fractures are common fractures. Treatment strategies have been debated. We wanted to investigate whether Lawrence and Botte's classification has prognostic value because of time to fracture union, and evaluate if weightbearing as tolerated (WBAT) and nonweightbearing (NWB) treatment strategy had effect on time to fracture union in nonoperatively treated fractures. METHODS Computerized database search, patients diagnosed between January 1, 2003, and December 31, 2015. RESULTS We identified 834 fractures; 510 (61.2%) zone 1, 157 (18.8%) zone 2, and 167 (20.0%) zone 3. Most (94.4%) were treated nonoperatively; time to fracture union was 7.5 (SD 7.7), 7.7 (5.6), and 9.2 (8.1) weeks for zone 1, 2, and 3, respectively, which gave a significant longer time to union for zone 3 compared to zone 1 fractures (P = .04). There was no difference in time to fracture union when comparing WBAT and NWB for all fracture zones. Failure to union, defined as crossover to surgery and/or delayed union, was found in 13 (2.7%) zone 1, 5 (3.2%) zone 2, and 6 (3.8%) zone 3 fractures. Refracture during follow-up was found in 3 (0.6%) zone 1 and 14 (8.9%) zone 3 fractures. CONCLUSION Proximal fifth metatarsal fractures have high union rates with nonoperative treatment. No difference in time to union could be found between WBAT and NWB treatment strategies for all fracture zones. We observed a significantly longer time to fracture union for zone 3 fractures compared to zone 1 fractures. Refracture occurs in a nonnegligible share of nonoperatively treated zone 3 fractures.
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Barnds B, Heenan M, Ayres J, Tarakemeh A, Schroeppel JP, Mullen S, Vopat BG. Comparison of the rate of delayed/nonunion in fifth metatarsal fractures receiving anti-inflammatory medications. J Exp Orthop 2021; 8:115. [PMID: 34894299 PMCID: PMC8665954 DOI: 10.1186/s40634-021-00435-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/22/2021] [Indexed: 11/12/2022] Open
Abstract
Purpose Controversy exists regarding the acute effect of non-steroidal anti-inflammatory drugs (NSAIDs) on early fracture healing. The purpose of this study was to analyze the rate of nonunion or delayed union in patients with fifth metatarsal (5th MT) fractures. We hypothesize that the use of NSAIDs would increase the rate of nonunion/delayed union in 5th MT fractures. Methods Using PearlDiver, a national insurance database was analyzed. ICD codes were used to identify patients diagnosed with 5th MT fracture from 2007-2018. Patients were grouped by initial management (nonoperative vs. open reduction and internal fixation (ORIF) or non/malunion repair within 60 days) and sub-grouped by whether they had been prescribed at least one pre-defined NSAID. Subsequent ORIF or nonunion/malunion repair operative intervention was used as a surrogate for fracture nonunion/delayed union. Results Of the 10,991 subjects with a diagnosis of 5th MT, 10,626 (96.7%) underwent initial nonoperative treatment, 1,409 of which (13.3%) received prescription NSAIDS within 60 days of diagnosis. 16/1,409 (1.14%) subjects who received anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis while 46/9,217 (0.50%; P=0.003483) subjects who did not receive anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis. In the 365 subjects who underwent early repair/ORIF (within 60 days), there was no significant difference in the rate of nonunion/delayed union. Conclusion The rate of nonunion/delayed union of 5th MT fractures was significantly higher in subjects receiving NSAIDs within 60 days of initial diagnosis in patients managed non-operatively. Level of evidence Level III
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Affiliation(s)
- Brandon Barnds
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Matt Heenan
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Jack Ayres
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, 66160, USA.
| | - Armin Tarakemeh
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - J Paul Schroeppel
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Scott Mullen
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Bryan G Vopat
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, 66160, USA
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Bušková K, Bartoníček J, Rammelt S. Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202110000-00004. [PMID: 34673663 DOI: 10.2106/jbjs.rvw.21.00010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
» Fractures of the proximal fifth metatarsal (PFMT) are one of the most common foot injuries, accounting for 61% to 78% of all foot fractures, but full consensus on their classification, diagnosis, and treatment has not yet been reached. » The most commonly accepted classification is that of Lawrence and Botte, who divided the location of PFMT fractures into 3 zones with respect to their healing potential. » Avulsion fractures of the tuberosity of the base (zone 1) generally heal well, and nonoperative treatment is commonly recommended. » Internal fixation may be considered for displaced fractures that extend into the fourth-fifth intermetatarsal joint (zone 2) as well as for nondisplaced fractures in athletes or high-demand patients, with the aims of reducing the healing time and expediting return to sport or work. » Stress fractures of the proximal diaphysis (zone 3) are preferably treated operatively, particularly in the presence of signs of delayed union. With nonoperative treatment, supportive measures such as ultrasonography or external/extracorporeal shockwave therapy have been demonstrated to have limited potential for the enhancement of fracture-healing.
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Affiliation(s)
- Kamila Bušková
- Department of Orthopaedics, First Faculty of Medicine Charles University and Military University Hospital Prague, Prague, Czech Republic
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine Charles University and Military University Hospital Prague, Prague, Czech Republic
- Department of Anatomy, First Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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Attia AK, Taha T, Kong G, Alhammoud A, Mahmoud K, Myerson M. Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:3422-3436. [PMID: 33740393 DOI: 10.1177/0363546521990020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population. PURPOSE To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures. STUDY DESIGN Meta-analysis. METHODS Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures. RESULTS Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%). CONCLUSION The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.
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Affiliation(s)
| | - Tarek Taha
- Weill Cornell Medical College, Doha, Qatar
| | - Geraldine Kong
- Orthopedic Surgery Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Karim Mahmoud
- Department of Orthopaedics, Emory University Hospital, Atlanta, Georgia, USA
| | - Mark Myerson
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Goodloe JB, Cregar WM, Caughman A, Bailey EP, Barfield WR, Gross CE. Surgical Management of Proximal Fifth Metatarsal Fractures in Elite Athletes: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211037647. [PMID: 34552993 PMCID: PMC8450619 DOI: 10.1177/23259671211037647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/03/2021] [Indexed: 12/28/2022] Open
Abstract
Background As a result of the high physical demand in sport, elite athletes are particularly prone to fifth metatarsal fractures. These injuries are typically managed surgically to avoid high rates of delayed union and allow for quicker return to play (RTP). Purpose To review studies showing clinical and radiographic outcomes, RTP rates, and complication rates after different surgical treatment modalities for fifth metatarsal fractures exclusively in elite-level athletes. Study Design Systematic review; Level of evidence, 4. Methods A systematic search was conducted within the PubMed, Scopus, and Cochrane databases from January 2000 to January 2020. Inclusion criteria consisted of clinical outcome studies after operative management of fifth metatarsal fractures in elite athletes. Exclusion criteria consisted of nonoperative management, high school or recreational-level athletic participation, nonclinical studies, expert opinions, and case series with <5 patients. Results A total of 12 studies met inclusion and exclusion criteria, comprising 280 fifth metatarsal fractures treated surgically. Intramedullary screw fixation was the most common fixation construct (47.9%), and some form of intraoperative adjunctive treatment (calcaneal autograft, iliac crest bone graft, bone marrow aspirate concentrate, demineralized bone matrix) was used in 67% of cases. Radiographic union was achieved in 96.7% of fractures regardless of surgical construct used. The overall mean time to union was 9.19 weeks, with RTP at a mean of 11.15 weeks. The overall reported complication rate was 22.5%, with varying severity of complications. Refracture rates were comparable between the different surgical constructs used, and the overall refracture rate was 8.6%. Conclusion Elite athletes appeared to have a high rate of union and reliably returned to the same level of competition after surgical management of fifth metatarsal fractures, irrespective of surgical construct used. Despite this, the overall complication rate was >20%. Specific recommendations for optimal surgical management could not be made based on the heterogeneity of the included studies.
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Affiliation(s)
- J Brett Goodloe
- Department of Orthopaedic Surgery and Physical Rehabilitation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William M Cregar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander Caughman
- Department of Orthopaedic Surgery and Physical Rehabilitation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Evan P Bailey
- Department of Orthopaedic Surgery and Physical Rehabilitation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William R Barfield
- Department of Orthopaedic Surgery and Physical Rehabilitation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christopher E Gross
- Department of Orthopaedic Surgery and Physical Rehabilitation, Medical University of South Carolina, Charleston, South Carolina, USA
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Stone JA, Miranda AD, Gerhardt MB, Mandelbaum BR, Giza E. Outcomes of Surgically Treated Fifth Metatarsal Fractures in Major League Soccer Athletes. Am J Sports Med 2021; 49:3014-3020. [PMID: 34357826 DOI: 10.1177/03635465211030279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sports-related fractures of the fifth metatarsal are common in professional athletes. Data regarding outcomes of surgical management including refracture, complications, and return-to-play statistics are available for other professional American sports with a notable exception of soccer. PURPOSE To quantify the burden of operative fifth metatarsal fractures in Major League Soccer (MLS) athletes, to compare outcomes as well as refracture and complication rates with other professional sports, to analyze factors that may contribute to treatment failure, and to report on return-to-play characteristics for affected players. STUDY DESIGN Case series; Level of evidence, 4. METHODS We searched all injuries in the prospectively collected HealtheAthlete database for MLS for operative fifth metatarsal fractures for seasons 2013 to 2017. Additional information regarding each fracture including demographics, treatment, postoperative course, and return-to-play statistics were compiled from HealtheAthlete and supplemented by teams' chief medical officers, coaches, trainers, and online sources. RESULTS There were 21 fractures in 18 players during the study period. Mean time to radiographic healing was 8.5 weeks (n = 17). Mean time to return to play was 11.1 weeks (n = 19). Of 21 fractures, 20 (95%) players returned to sport. Of 18 players, 4 (22.2%) experienced refracture. Of 18 players, 5 (27.8%) and 2 (11.1%) reported previous stress injuries on the contralateral and ipsilateral limb, respectively. Player performance characteristics showed small declines in the first year of return that improved by the second year. CONCLUSION MLS athletes who sustain a sports-related fifth metatarsal fracture can expect a high rate of return to sport with time to radiographic healing and return to play as well as risk of refracture similar to other professional cohorts.
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Affiliation(s)
| | | | - Michael B Gerhardt
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Bert R Mandelbaum
- Kerlan-Jobe Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eric Giza
- University of California, Davis, Sacramento, California, USA
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12
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Stress Fractures of the Foot and Ankle. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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The Fifth Metatarsal Bone Fracture in Athletes - Modalities of Treatment Related to Agility in Soccer Players. J Hum Kinet 2021; 79:101-110. [PMID: 34400990 PMCID: PMC8336555 DOI: 10.2478/hukin-2020-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The 5th metatarsal fracture is a common foot fracture which could exclude a player from competition for several months and significantly affect his or her career. This manuscript presents the treatment and rehabilitation of professional soccer players who had acute fractures of the 5th metatarsal bone and a cannulated screw fixation. The main purpose of the analysis was to determine the minimum time necessary for a permanent return to the sport after a 5th metatarsal fracture among professional soccer players. We followed the surgical and rehabilitation path of 21 professional soccer players from the Polish League (Ist and IInd divisions) who suffered from the 5th metatarsal bone fracture. All players underwent standard percutaneous internal fixation with the use of cannulated screws. The total inability to play lasted for 9.2 (± 1.86) weeks among players treated only surgically (n = 10), 17.5 (± 2.5) weeks in the conservative and later surgery group, excluding players with nonunion (n = 6), and 24.5 (± 10.5) weeks for nonunion and switch treatment (n = 4) players. Prompt fracture stabilization surgery is recommended for athletes, enabling the implementation of an aggressive rehabilitation protocol as soon as possible. Early limb loading after surgery (from week 2) does not delay fracture healing or hinder the bone union, thus rehabilitation plays a crucial role in shortening the time of RTP (return to play) and is obligatory for each athlete who undergoes surgical treatment.
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14
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Grant MJ, Molloy AP, Mason LW. The Use of Percutaneous Screw Fixation Without Fracture Site Preparation in the Treatment of Fifth Metatarsal Base Nonunion. J Foot Ankle Surg 2021; 59:753-757. [PMID: 32171444 DOI: 10.1053/j.jfas.2019.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 07/04/2019] [Accepted: 08/09/2019] [Indexed: 02/03/2023]
Abstract
Nonunion after a proximal fifth metatarsal fracture can cause considerable pain, with high morbidity and loss of work. Although many authors advocate early surgical management of zone 3 injuries (Jones fractures), zone 1 and 2 fractures are generally expected to heal with conservative management. Uncommonly, zone 1 and 2 fractures can develop nonunions. The aim of this study was to evaluate the efficacy of closed intramedullary screw fixation for nonunions of the fifth metatarsal base. We performed a prospective study involving all fifth metatarsal base nonunions treated in our department over 2 years. Only minimally displaced adult fractures were considered for this study. The fracture pattern was categorized using the Dameron classification (zone 1, styloid process; zone 2, metadiaphyseal area; zone 3, proximal diaphysis). All nonunions were fixed percutaneously under radiographic guidance, without fracture site preparation. Zone 1 injuries were fixed using a 3-mm headless compression screw, and those of zones 2 and 3, with an intramedullary 4-mm screw. Of 30 patients included in this study, a minimum 6-month clinical follow-up was obtained. The average time from injury to treatment was 5.9 months (range 3 to 36). There were no smokers in this patient cohort. There were 12 zone 1 injuries, 9 zone 2 injuries, and 9 zone 3 injuries. All patients achieved union by 3 months after screw fixation, with 29 of 30 achieving union by 6 weeks. All patients had resolution of symptoms. There were no complications. We conclude that percutaneous fixation of fifth metatarsal base nonunions, without fracture site preparation, achieves excellent results. We believe that the screw alters the strain of the fracture, thus promoting fibrous-to-osseous conversion and therefore union.
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Affiliation(s)
- Michael J Grant
- Specialty Trainee, University Hospital Aintree, Longmoor Lane, Liverpool, United Kingdom; Specialty Trainee, Health Education North West (Mersey) Regatta Place, Liverpool, United Kingdom.
| | - Andy P Molloy
- Consultant Foot & Ankle Surgeon, University Hospital Aintree, Longmoor Lane, Liverpool, United Kingdom
| | - Lyndon W Mason
- Consultant Foot & Ankle Surgeon, University Hospital Aintree, Longmoor Lane, Liverpool, United Kingdom
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15
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Stress Fractures of the Fifth Metatarsal in Athletes. J Am Acad Orthop Surg 2021; 29:507-517. [PMID: 33826553 DOI: 10.5435/jaaos-d-20-01060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/04/2021] [Indexed: 02/01/2023] Open
Abstract
Stress fractures of the fifth metatarsal (zones 2 and 3) remain a challenging clinical problem. It has been well established that nonsurgical treatment has unacceptably high nonunion and refracture rates. Surgical fixation remains the treatment of choice in the athletic cohort, and intramedullary screw fixation with a solid screw has been established as the most predictable means of achieving a successful outcome. Recently, the use of a plantar plate has also been advocated as has been shown in some studies to be more biomechanically advantageous. The use of bone grafting at the primary surgery and morphology and screw type are also important decisions to be made when treating these patients. This review will discuss our management of both primary fractures and refractures of the fifth metatarsal in athletes.
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Baertl S, Alt V, Rupp M. Surgical enhancement of fracture healing - operative vs. nonoperative treatment. Injury 2021; 52 Suppl 2:S12-S17. [PMID: 33234264 DOI: 10.1016/j.injury.2020.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/02/2023]
Abstract
Although the success story of surgical fracture treatment led to a tremendous improvement of treatment outcome for certain fractures such as femur or tibia shaft fractures, the overall benefit of surgical versus conservative treatment remains controversial for several types of fractures. For this sake, we carried out a narrative review of high-level of evidence studies comparing treatment outcomes in fractures with controversial debates on the value of surgical therapy in clavicle, proximal humerus, olecranon, ankle, calcaneus and Jones fractures. We identified eight studies (Level-I and -2) with functional and quality of life outcomes in these fractures. Only in Jones fractures of the fifth metatarsal bone, bone healing and functional outcomes were significantly better after surgical compared to conservative treatment. In terms of patient-related quality of life, surgical treatment was not found to be superior compared to conservative treatment in all the above-mentioned fractures. In many trials, lower nonunion rates after surgical treatment were offset by complications due to the surgical procedure. Nonunion after conservative treatment often seemed to have only limited impact on functional results. However, the comparability of studies was limited due to age-differences between patients. Therefore, we emphasize the need for further investigations to determine which patient-related factors favor a conservative treatment approach and for whom surgery is the best option.
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Affiliation(s)
- Susanne Baertl
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany.
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17
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Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures. J Orthop Surg Res 2021; 16:209. [PMID: 33752730 PMCID: PMC7986515 DOI: 10.1186/s13018-021-02331-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Zones 2 and 3 fifth metatarsal fractures are often treated with intramedullary fixation due to an increased risk of nonunion. A previous 3-dimensional (3D) computerized tomography (CT) imaging study by our group determined that the screw should stop short of the bow of the metatarsal and be larger than the commonly used 4.5 millimeter (mm) screw. This study determines how these guidelines translate to operative outcomes, measured using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Radiographic variables measuring the height of the medial longitudinal arch and degree of metatarsus adductus were also obtained to determine if these measurements had any effect on outcomes. And lastly, this study aimed to determine if morphologic differences between males and females affected surgical outcomes. METHODS We retrospectively identified 23 patients (14 male, 9 female) who met inclusion criteria. Eighteen patients completed PROMIS surveys. Preoperative PROMIS surveys were completed prior to surgery, rather than retroactively. Weightbearing radiographs were also obtained preoperatively to assist with surgical planning and postoperatively to assess interval healing. Correlation coefficients were calculated between PROMIS scores and repair characteristics (hardware characteristics [screw length and diameter] and radiographic measurements of specific morphometric features). T tests determined the relationship between repair characteristics, PROMIS scores, and incidence of operative complications. PROMIS scores and correlation coefficients were also stratified by gender. RESULTS The average screw length and diameter adhered to guidelines from our previous study. Preoperatively, mean PROMIS PI = 57.26±11.03 and PROMIS PF = 42.27±15.45 after injury. Postoperatively, PROMIS PI = 44.15±7.36 and PROMIS PF = 57.22±10.93. Patients with complications had significantly worse postoperative PROMIS PF scores (p=0.0151) and PROMIS PI scores (p=0.003) compared to patients without complications. Females had non-significantly worse preoperative and postoperative PROMIS scores compared to males and had a higher complication rate (33 percent versus 21 percent, respectively). Metatarsus adductus angle was shown to exhibit a significant moderate inverse relationship with postoperative PROMIS PF scores in the overall cohort (r=-0.478; p=0.045). Metatarsus adductus angle (r=-0.606; p=0.008), lateral talo-1st metatarsal angle (r=-0.592; p=0.01), and medial cuneiform height (r=-0.529; p=0.024) demonstrated significant inverse relationships with change in PROMIS PF scores for the overall cohort. Within the male subcohort, significant relationships were found between the change in PROMIS PF and metatarsus adductus angle (r=-0.7526; p=0.005), lateral talo-1st metatarsal angle (r=-0.7539; p=0.005), and medial cuneiform height (r=-0.627; p=0.029). CONCLUSION Patients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. Screws larger than 4.5mm did not lead to hardware complications, including screw failure, iatrogenic fractures, or cortical blowouts. Females had non-significantly lower preoperative and postoperative PROMIS scores and were more likely to suffer complications compared to males. Patients with complications, higher arched feet, or greater metatarsus adductus angles had worse functional outcomes. Future studies should better characterize whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.
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18
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Adequate union rates for the treatment of acute proximal fifth metatarsal fractures. Knee Surg Sports Traumatol Arthrosc 2021; 29:1284-1293. [PMID: 32474612 PMCID: PMC7973408 DOI: 10.1007/s00167-020-06072-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/14/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare the bone healing, clinical, and return to daily activity outcomes after either surgical or conservative management of acute zone 1, 2, and 3 fifth metatarsal fractures. METHODS A literature search was performed to identify studies published from the earliest record to January 2019 using EMBASE (Ovid), MEDLINE via PubMed, CINAHL, and Web of Science. All articles assessing clinical outcomes of acute proximal fifth metatarsal fractures were included. Bone healing and clinical outcomes were thereafter calculated using a simplified pooling method. RESULTS Thirty-two articles comprising of a total of 1,239 fractures were included, of which one was a randomized controlled trial, seven were prospective studies, and 24 were retrospective studies. 627 zone 1 fractures demonstrated union rates of 93.2% following conservative treatment and 95.1% following surgical treatment. Conservatively managed zone 1 fractures were displaced 49.5% of the time, compared to a rate of 92.8% for the surgically treated cases. For Jones' (zone 2) fractures, bone healing outcomes of conservative versus surgical treatment showed union rates of 77.4% versus 96.3%, refracture rates of 2.4% versus 2.1%, and mean time to union of 11.0 weeks versus 9.4 weeks, respectively. Only ten proximal diaphyseal (zone 3) fractures were reported, with a mean return to work of 8.2 weeks. CONCLUSION Acute zone 1 fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management. In contradistinction, acute zone 2 fractures demonstrate higher union rates and faster time to union when treated surgically. The outcomes of acute zone 3 fractures are rarely reported in the literature, so treatment recommendations remain unclear. Further research of proximal fifth metatarsal fractures is warranted to provide more definitive conclusions, but current findings can aid surgeons during the shared clinical decision making process. LEVEL OF EVIDENCE IV.
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Khurana A, Alexander B, Pitts C, Brahmbhatt A, Cage B, Greco E, McGwin G, Shah AB. Predictors of Malreduction in Zone II and III Fifth Metatarsal Fractures Fixed With an Intramedullary Screw. Foot Ankle Int 2020; 41:1537-1545. [PMID: 32795095 DOI: 10.1177/1071100720947411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proper implant selection and placement is crucial during fixation of zone II and III fifth metatarsal fractures to avoid postoperative complications. This study examined the effects of screw parameters and placement on malreduction, delayed union, nonunion, and refracture rate. METHODS A retrospective review of zone II and proximal zone III fifth metatarsal fractures managed with intramedullary screw fixation was conducted. Comparisons were made between cortex distraction (gap) and ratios of screw length, diameter, and entry point. Further analysis was carried out between time to union and distraction in the lateral and plantar cortices. RESULTS The plantar and lateral gaps were both associated with the mean entry point ratio on the lateral and anteroposterior (AP) views (P < .001 for both views). No association between the plantar and lateral gaps and the screw diameter ratio (P = .393 for AP and P = .981 for lateral) or the screw length ratio (P = .966 for AP and P = .740 for lateral) was identified. The ratio of postoperative to preoperative apex height on AP and lateral views was correlated with the presence of lateral and plantar fracture gaps (P < .001). The presence of a plantar gap was associated with increased time to union (P = .022). A majority of fractures showed radiographic union at 12 weeks (38/43). Only 5 of 38 patients had delayed union. There were no refractures or nonunions as per available records. CONCLUSION Plantar or lateral fracture site distraction (gap) was not influenced by screw diameter ratio or screw length ratio. The entry point ratio had a significant effect on plantar and lateral gaps on postoperative radiographs, with lateral and inferior placement leading to fracture site distraction. Patients with a plantar gap did have an increased risk of delayed union. The results of this study emphasize the significance of the entry point when managing zone II and III fifth metatarsal base fractures. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ankit Khurana
- Department of Orthopaedic Surgery, Dr. BSA Medical College, Rohini, Delhi, India
| | - Bradley Alexander
- Department of Orthopaedic Surgery, University of Alabama, Birmingham, AL, USA
| | - Charles Pitts
- Department of Orthopaedic Surgery, University of Alabama, Birmingham, AL, USA
| | - Ashish Brahmbhatt
- Department of Orthopaedic Surgery, University of Alabama, Birmingham, AL, USA
| | - Benjamin Cage
- Department of Orthopaedic Surgery, University of Alabama, Birmingham, AL, USA
| | - Elise Greco
- Department of Orthopaedic Surgery, University of Alabama, Birmingham, AL, USA
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama, Birmingham, AL, USA
| | - Ashish B Shah
- Department of Orthopaedic Surgery, University of Alabama, Birmingham, AL, USA
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20
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Qi R, Li B, Xie T, Yin H. Surgical versus conservative management of fifth metatarsal fractures in adults: A protocol of retrospective study. Medicine (Baltimore) 2020; 99:e22800. [PMID: 33080753 PMCID: PMC7571944 DOI: 10.1097/md.0000000000022800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND At present, the treatment of base fractures of the fifth metatarsal, especially the area I fractures, is still a controversial topic. The objective of our work was to assess the radiological and clinical outcomes of displaced avulsion fractures of the fifth metatarsal base after treated with conservative treatment or intramedullary screw. METHODS All of the fifth metatarsal fractures patients underwent surgery by the senior authors in our hospital from January 2017 to December 2019 were reviewed. Institutional Review Board in the Subsidiary Hospital of Guizhou Medical University approved this study. Patients with the following conditions can be included:Patients with the following conditions will be excluded: follow-up less than 6 months; open fracture; pathological fracture; osteoporotic fracture; patients have the history of ankle or foot surgery. Radiographs were taken at 1, 3, 6 and 12 months in outpatient follow-up. The following outcomes were assessed in the follow-up: functional outcomes, the score of patient satisfaction, as well as the motion range, and complications. All the statistical analyses were implemented via applying the software of SPSS Version 12 (SPSS Inc, Chicago, IL). RESULTS We hypothesized that there was no remarkable difference between two groups in the outcomes after operation. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry6024).
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21
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Wang Y, Gan X, Li K, Ma T, Zhang Y. Comparison of operative and non-operative management of fifth metatarsal base fracture: A meta-analysis. PLoS One 2020; 15:e0237151. [PMID: 32790794 PMCID: PMC7425975 DOI: 10.1371/journal.pone.0237151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/21/2020] [Indexed: 01/13/2023] Open
Abstract
Fracture to fifth metatarsal's base is one the most common injury experienced at the foot. Studies have for long debated the use of operative and non-operative interventions for the management of the fracture, especially owing to its peculiar vasculature. However, to date, no attempt has been made to synthesize the evidence comparing the efficacy of operative and non-operative interventions for managing the fifth metatarsal's base fracture. To meta-statistically compare the effects of operative and non-operative management of fifth metatarsal base fracture. A systematic identification of literature was performed according to PRISMA guidelines on four academic databases: MEDLINE, Scopus, EMBASE, and CENTRAL. A meta-analysis evaluated the influence of operative and non-operative interventions on rate of non-union, mean duration of union, duration of return to activity, duration of return to sport, visual analog scale, and the American orthopedic foot & ankle scale. Out of 1,170 records, 11 articles including 404 participants (mean age: 29.8 ± 7.4 years) were included in this review. This systematic review presents a 1b level of evidence supporting the use of operative interventions for enhancing fracture union as compared to non-operative interventions. The meta-analysis reveals beneficial effects for operative interventions by demonstrating medium to large effect reduction of rate of non-union (Hedge's g: -0.66), duration of union (-1.7), duration of return to activity (-2.07), visual analog scale (-0.86), and enhancement of the American orthopedic foot & ankle scale score (0.73) as compared to non-operative intervention. The current systematic review and meta-analysis recommend the use of operative interventions for managing the fifth metatarsal's base fracture. The review reports beneficial effects of operative interventions as compared to non-operative interventions for reducing the rate of non-union, duration of union, duration of return to activity, duration of return to sport, visual analog scale, and increasing the American orthopedic foot & ankle scale score.
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Affiliation(s)
- Yanming Wang
- Zaozhuang Hospital of Traditional Chinese Medicine, Zaozhuang, Shandong, China
| | - Xu Gan
- Zaozhuang Hospital of Traditional Chinese Medicine, Zaozhuang, Shandong, China
| | - Kai Li
- Zaozhuang Hospital of Traditional Chinese Medicine, Zaozhuang, Shandong, China
| | - Tao Ma
- Zaozhuang Hospital of Traditional Chinese Medicine, Zaozhuang, Shandong, China
| | - Yongxiang Zhang
- Zaozhuang Hospital of Traditional Chinese Medicine, Zaozhuang, Shandong, China
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Ismat A, Rupp M, Knapp G, Heiss C, Szalay G, Biehl C. Treatment of proximal fifth metatarsal fractures with an ulna hook plate. Foot (Edinb) 2020; 42:101653. [PMID: 32035401 DOI: 10.1016/j.foot.2019.101653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/06/2019] [Accepted: 10/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Fractures of the base of the fifth metatarsal bone present one of the commonest fractures of the metatarsal bones. Conventionally intramedullary screws and tension band wiring have been used as internal fixation methods. Lately hook plates have also served as an alternative fixation method. We hereby report on our experience with the hook plate used in treating fractures of the proximal fifth metatarsal. METHODS 21 patients treated with the hook plate for proximal fifth metatarsal fractures were assessed clinically and radiologically. RESULTS Average time to union in primarily treated fractures (n=18) was 7.7 weeks (range 4.5-16 weeks). Average time to return of activities of daily living (ADLs) was 10.3 weeks (range 4.5-37 weeks). The average AOFAS midfoot score was 30.4 preoperatively and 95.2 postoperatively (p<0.01). CONCLUSION The ulna hook plate presents a suitable and adequate method of osteosynthesis used to primarily treat proximal fifth metatarsal fractures requiring surgical intervention with satisfactory post-operative outcomes.
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Affiliation(s)
- Abdullah Ismat
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany.
| | - Markus Rupp
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
| | - Gero Knapp
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
| | - Christian Heiss
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
| | - Gabor Szalay
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
| | - Christoph Biehl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen-Marburg GmbH, Campus Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
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Jones Fractures in Sumo Wrestlers: Three Case Reports. Case Rep Orthop 2019; 2019:9051327. [PMID: 31772802 PMCID: PMC6854976 DOI: 10.1155/2019/9051327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/09/2019] [Indexed: 11/18/2022] Open
Abstract
Jones fractures sometimes occur in athletes and are known to have complications, such as nonunion, delayed union, and recurrence, even with treatment. We describe three cases of Jones fractures in sumo wrestlers with treatment-related difficulties. All patients discontinued treatment at their own discretion. The two conservative cases had nonunion or delayed union, and the operative case had a broken screw. However, all patients continued sumo wrestling, with little impact on their careers. The risk factors of Jones fractures in sumo wrestling may be heavy weight, and training or competition characteristics unique to sumo wrestling. In cases of a complete Jones fracture, operative treatment is most commonly selected, as the risk for nonunion or refractures is less than that for conservative treatment. However, in the case of sumo wrestlers, there are risks of infection and problems with treatment compliance. As taking a rest may result in a lowered rank, completing a sufficient duration of treatment is difficult. Treatment is difficult and controversial in sumo wrestlers; all three patients discontinued treatment of their own accord. These cases suggest that it is important to thoroughly inform sumo wrestlers of the treatment options, and to decide the most appropriate treatment method for each patient.
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Anderson R, Parekh S, Braid-Forbes MJ, Steen RG. Delayed Healing in Metatarsal Fractures: Role of Low-Intensity Pulsed Ultrasound Treatment. J Foot Ankle Surg 2019; 58:1145-1151. [PMID: 31548075 DOI: 10.1053/j.jfas.2019.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 01/11/2019] [Accepted: 03/25/2019] [Indexed: 02/03/2023]
Abstract
The most common fracture in primary care is metatarsal fracture, but it is controversial whether to treat this fracture conservatively or surgically. We performed a cohort study to contrast metatarsal fractures that heal normally with fractures that show delayed healing. We analyzed 5% Medicare Standard Analytic Files, selecting all metatarsal fractures in 2011 to 2013, excluding patients with multiple fractures. Delayed healing was defined as treatment >14 days postfracture with either low-intensity pulsed ultrasound or surgery. Treatment for delayed healing was identified using the Current Procedural Terminology and International Classification of Diseases, Revision 9, Clinical Modification codes. Among 9482 metatarsal fractures, 256 (2.7%) showed delayed healing. Patients with delayed healing were younger (p < .0001); more likely to receive specialist referral (p < .001); more likely to have obesity (p = .005), psychosis (p = .003), chronic lung disease (p = .012), or iron deficiency anemia (p = .016); and more likely to receive surgery before ultrasound (p < .0001). Patients more likely to be treated with surgery than ultrasound included younger patients (p < .0001), obese patients (p = .02), and patients who first see a specialist (p < .05).
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Affiliation(s)
| | - Selene Parekh
- Professor of Orthopaedic Surgery, North Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery, Duke University, Durham, NC
| | | | - R Grant Steen
- Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Louisiana State University Health Science Center, New Orleans, LA.
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25
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Miller D, Marsland D, Jones M, Calder J. Early return to playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union but does not increase the risk of long-term non-union. Knee Surg Sports Traumatol Arthrosc 2019; 27:2796-2801. [PMID: 30167755 DOI: 10.1007/s00167-018-5104-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 08/10/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE 5th metatarsal stress fractures are frequently encountered in professional football. There is concern that early return to play following intra-medullary screw fixation may lead to an increased risk of delayed union. The purpose of the study was to assess whether an early return to play after surgical fixation of 5th metatarsal fractures in professional football players is a risk factor for delayed union and the effect of this on the ultimate clinical outcome. METHODS Retrospective review of prospectively collected data of a series of 37 professional football players following intramedullary screw fixation of 5th metatarsal stress fractures. End points included time of return to play and to radiological union of the fracture. RESULTS At a minimum follow-up of 24 months the mean return to play was 10.5 weeks and mean time to complete radiological union was 12.7 weeks. Return to play at 8 weeks or less resulted in a higher risk of delayed radiological union (24% at 3 months), but this neither prevented the athlete from continuing to play football nor did it affect the ultimate risk of non-union (3% overall). A re-fracture occurred in 1 patient (3%) at 10 months who previously had complete radiographic union at 9 weeks. CONCLUSION Intramedullary screw fixation of 5th metatarsal stress fractures leads to a predictable time of return to play and a low rate of non-union. If players return to play at 8 weeks or less a persistent line may be expected in up to a quarter of patients. However, if asymptomatic this radiological finding does not mean that athletes must avoid playing football as ultimately a good outcome is expected with low rates of non-union and refracture. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- David Miller
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.
| | - Daniel Marsland
- Royal Hampshire County Hospital, Romsey Rd, Winchester, SO22 5DG, UK
| | - Mary Jones
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK
| | - James Calder
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.,FORCE Sports Research Centre, Department of Bioengineering, Imperial College, South Kensington, London, SW7 2AZ, UK
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26
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Geerling J, Ellwein A, Lill H. Möglichkeiten und Grenzen der konservativen Therapie: Fuß und Sprunggelenk. MANUELLE MEDIZIN 2019. [DOI: 10.1007/s00337-019-0527-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Waverly BJ, Sorensen MD, Sorensen TK. Early Weightbearing Protocol in Operative Fixation of Acute Jones Fractures. J Foot Ankle Surg 2018; 57:489-493. [PMID: 29685559 DOI: 10.1053/j.jfas.2017.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Indexed: 02/03/2023]
Abstract
The treatment of Jones fractures has been controversial in terms of nonoperative versus operative management, given the high incidence of nonunion secondary to the delicate blood supply to the proximal fifth metatarsal. We report a retrospective review of a patient cohort treated with an early weightbearing protocol after operative intramedullary fixation in acute Jones fractures. Thirty-one consecutive patients with an acute Jones fracture underwent operative fixation with a single intramedullary solid screw. The postoperative protocol consisted of immediate weightbearing in a controlled ankle motion boot for 2 weeks with a gradual transition to regular shoes at 2 weeks postoperative. At 2 weeks, the patients were allowed to perform low-impact activities such as walking, swimming, biking, or elliptical training. Patients were allowed to return to all activities, as tolerated, regardless of radiographic healing, at 6 weeks postoperatively. Serial postoperative radiographs were taken at 2-week intervals to determine radiographic union. Our patient population consisted of 24 males (77.42%) and 7 females (22.58%), with a mean average age of 37.5 ± 12.59 years and mean average body mass index of 25.7 ± 2.32 kg/m2. Fracture union was observed in all 31 patients (100%) at a mean average of 5.7 ± 1.47 (range 4 to 10) weeks. Two (6.5%) patients required hardware removal, with one (3.2%) experiencing sural neuritis. This review of patients undergoing early weightbearing after operative fixation of an acute Jones fracture demonstrated a satisfactory incidence of union compared with traditional postoperative protocols at a mean follow-up duration of 18.58 ± 5.66 months.
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Affiliation(s)
- Brett J Waverly
- Fellowship Trained Foot and Ankle Surgeon, Orthopedic Specialty Clinic, Fredericksburg, VA
| | - Matthew D Sorensen
- Fellowship Trained Foot and Ankle Surgeon, Weil Foot and Ankle Institute, Des Plaines, IL.
| | - Tyler K Sorensen
- Podiatric Medical Student, Des Moines University, Des Moines, IA
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28
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Payo-Ollero J, Álvarez Goenaga F, Elorriaga Sagarduy G, Ruiz Nasarre A, Olmos-García MA, Villas Tomé C. Stress Fracture of the Fifth Metatarsal in Foot Deformity Secondary to Neuromuscular Disease: Experiences of Deformity Correction Treatment-A Report of 3 Cases and Review of the Literature. Foot Ankle Spec 2018; 11:177-182. [PMID: 29172689 DOI: 10.1177/1938640017744642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
UNLABELLED Fractures at the proximal metaphyso-diaphyseal junction of the fifth metatarsal are associated with high rates of delayed union. When these fractures are the result of repeated stress in patients with equinovarus hindfoot, which in turn is caused by neurological disorders, delayed union is the rule. Therefore, in neurological patients with stress fractures, optimal treatment would be to achieve a plantigrade foot enabling them to relieve the fifth metatarsal overload, which prevents the consolidation. We report 3 cases of fifth metatarsal stress fracture resulting from an equinovarus hindfoot deformity caused by a neuromuscular disease. Our surgical indication was to correct the foot deformity with no direct action on the fracture. Once a good alignment (plantigrade foot) was obtained, stress causing the fracture disappeared, and union was achieved with optimal biomechanical function in all 3 fractures. When stress fracture of the fifth metatarsal is caused by a secondary foot deformity, treating the deformity can lead to healing the fracture efficiently and should be considered prior to indicating surgical stabilization of the fracture itself. Primary treatment of the fracture with no correction of the deformity leads to therapeutic failure. LEVELS OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Jesús Payo-Ollero
- University Clinic of Navarra, Orthopedic Surgery and Traumatology Department, Pamplona, Navarra, Spain (JP-O, MAO-G, CVT).,San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Barcelona, Catalunya, Spain (FAG, ARN).,University Cruces Hospital, Orthopedic Surgery and Traumatology Department, Baracaldo, Vizcaya, Spain (GES)
| | - Fernando Álvarez Goenaga
- University Clinic of Navarra, Orthopedic Surgery and Traumatology Department, Pamplona, Navarra, Spain (JP-O, MAO-G, CVT).,San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Barcelona, Catalunya, Spain (FAG, ARN).,University Cruces Hospital, Orthopedic Surgery and Traumatology Department, Baracaldo, Vizcaya, Spain (GES)
| | - Gotzon Elorriaga Sagarduy
- University Clinic of Navarra, Orthopedic Surgery and Traumatology Department, Pamplona, Navarra, Spain (JP-O, MAO-G, CVT).,San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Barcelona, Catalunya, Spain (FAG, ARN).,University Cruces Hospital, Orthopedic Surgery and Traumatology Department, Baracaldo, Vizcaya, Spain (GES)
| | - Alberto Ruiz Nasarre
- University Clinic of Navarra, Orthopedic Surgery and Traumatology Department, Pamplona, Navarra, Spain (JP-O, MAO-G, CVT).,San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Barcelona, Catalunya, Spain (FAG, ARN).,University Cruces Hospital, Orthopedic Surgery and Traumatology Department, Baracaldo, Vizcaya, Spain (GES)
| | - Matías Alfonso Olmos-García
- University Clinic of Navarra, Orthopedic Surgery and Traumatology Department, Pamplona, Navarra, Spain (JP-O, MAO-G, CVT).,San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Barcelona, Catalunya, Spain (FAG, ARN).,University Cruces Hospital, Orthopedic Surgery and Traumatology Department, Baracaldo, Vizcaya, Spain (GES)
| | - Carlos Villas Tomé
- University Clinic of Navarra, Orthopedic Surgery and Traumatology Department, Pamplona, Navarra, Spain (JP-O, MAO-G, CVT).,San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Barcelona, Catalunya, Spain (FAG, ARN).,University Cruces Hospital, Orthopedic Surgery and Traumatology Department, Baracaldo, Vizcaya, Spain (GES)
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29
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Varner KE, Harris JD. The Proximal Fifth Metatarsal Metadiaphyseal Jones Fracture: Intramedullary Screw vs Plantar Plate. OPER TECHN SPORT MED 2017. [DOI: 10.1053/j.otsm.2017.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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30
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Fleischer AE, Stack R, Klein EE, Baker JR, Weil L, Weil LS. Forefoot Adduction Is a Risk Factor for Jones Fracture. J Foot Ankle Surg 2017; 56:917-921. [PMID: 28579126 PMCID: PMC5572316 DOI: 10.1053/j.jfas.2017.04.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Indexed: 02/03/2023]
Abstract
Jones fractures are among the most common fractures of the foot; however, much remains unknown about their etiology. The purpose of the present study was to further examine the risk factors of forefoot and hindfoot alignment on Jones fractures using an epidemiologic study design. We used a retrospective, matched, case-control study design. Cases consisted of patients with acute, isolated Jones fractures confirmed on plain film radiographs seen at our institute from January 2009 to December 2013. Patients presenting with pain unrelated to metatarsal fractures served as controls. Controls were matched to cases by age (±2 years), gender, and year of presentation. Weightbearing foot radiographs were assessed for 13 angular relationships by a single rater. Conditional multivariable logistic regression was used to identify important risk factors. Fifty patients with acute Jones fractures and 200 controls were included. The only significant variables in the final multivariable model were the metatarsus adductus angle (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.08 to 1.25) and fourth/fifth intermetatarsal angle (OR 0.69, 95% CI 0.57 to 0.83)-both measures of static forefoot adduction. The presence of metatarsus adductus (defined as >15°) on foot radiographs was associated with a 2.4 times greater risk of a Jones fracture (adjusted OR 2.4, 95% CI 1.2 to 4.8). We have concluded that the risk of Jones fracture increases with an adducted forefoot posture. In our population, which consisted primarily of patients presenting after a fall (10 of 50; 20%) or misstep/inversion injury (19 of 50; 38%), the hindfoot alignment appeared to be a less important factor.
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Affiliation(s)
- Adam E. Fleischer
- Director of Research, Weil Foot and Ankle Institute, Des Plaines, IL; Associate Professor, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Rebecca Stack
- 4th year student, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Erin E. Klein
- Associate, Weil Foot and Ankle Institute, Des Plaines, IL; Instructor, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Jeffrey R. Baker
- Fellowship Director, Weil Foot and Ankle Institute, Des Plaines, IL
| | - Lowell Weil
- CEO, Weil Foot and Ankle USA, Des Plaines, IL
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31
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Abstract
This review describes the normal healing process for bone, ligaments, and tendons, including primary and secondary healing as well as bone-to-bone fusion. It depicts the important mediators and cell types involved in the inflammatory, reparative, and remodeling stages of each healing process. It also describes the main challenges for clinicians when trying to repair bone, ligaments, and tendons with a specific emphasis on Charcot neuropathy, fifth metatarsal fractures, arthrodesis, and tendon sheath and adhesions. Current treatment options and research areas are also reviewed.
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Affiliation(s)
- Jessica A Cottrell
- Department of Biological Sciences, Seton Hall University, 400 South Orange Avenue, South Orange, NJ 07101, USA.
| | - Jessica Cardenas Turner
- Department of Biomedical Engineering, New Jersey Institute of Technology, 323 Martin Luther King Boulevard, Newark, NJ 07102, USA
| | - Treena Livingston Arinzeh
- Department of Biomedical Engineering, New Jersey Institute of Technology, 323 Martin Luther King Boulevard, Newark, NJ 07102, USA
| | - J Patrick O'Connor
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Medical Sciences Building, Room E-659, 185 South Orange Avenue, Newark, NJ 07103, USA
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