Rate of Delayed Union With Early Weightbearing Following Intramedullary Screw Fixation of Jones Fractures

Zone 2 Fifth Metatarsal Fractures Treated Nonoperatively Have Similar Time to Healing to Those Treated Operatively

OBJECTIVES

To quantify the rate of union and time to clinical and radiographic healing in Zone 2 proximal fifth metatarsal (MT) fractures and compare these outcomes between Zone 2 fractures treated operatively and nonoperatively.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level I Trauma Center.

PATIENT SELECTION CRITERIA

Patients with fifth MT fractures who presented between December 2012 and April 2022 and confirmed to have Zone 2 fractures (defined as fractures entering the proximal 4-5 MT articulation on the oblique radiographic view) were included in the study analysis in either the operative or nonoperative cohort.

OUTCOME MEASURES AND COMPARISONS

Nonunion, time to clinical healing by, and time to radiographic healing between operative and nonoperative treatment.

RESULTS

Among the 499 included patients, 475 patients (95.2%) were initially treated nonoperatively and 24 patients (4.8%) were treated operatively. Both groups were similar in demographics. There was no difference in the proportion of patients with nonunions between groups (6.1% in the nonoperative group vs. 3.8% in the operative group, P = 1.000). In addition, there was no statistically significant difference between groups with respect to the time to clinical healing (9.9 ± 8.3 weeks for the nonoperative group vs. 15.4 ± 15.0 weeks for the operative group, P = 0.117) or the time to radiographic healing (18.7 ± 12 weeks for the nonoperative group vs. 18.5 ± 16.6 weeks for the operative group, P = 0.970).

CONCLUSIONS

Zone 2 fifth MT base fractures were successfully treated with nonoperative management. There was no evidence in this study that operative treatment leads to significantly faster clinical or radiographic healing.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute, isolated fractures of the metatarsal bones: an epidemiologic study

INTRODUCTION

Although metatarsal fractures are common, the significance of previous epidemiologic studies is limited to specific fracture entities, subpopulations, or heterogeneous fracture aetiologies. The aim of the study was to assess the epidemiology of isolated metatarsal fractures in an adult population at a level-1 trauma centre.

MATERIALS AND METHODS

Radiological and clinical databases were searched for a five-year period. Eligible were all patients with acute isolated metatarsal fractures over the age of 18 years with radiographs in two planes available. Stress fractures, injuries affecting Lisfranc joint stability, and concomitant injuries to other regions than the metatarsals were excluded. Data collection included general demographics, mechanism of injury, season of the trauma and fracture details.

RESULTS

Out of 3259 patients, 642 patients met the inclusion criteria and were included for the analysis. The patients' mean age was 44.5 ± 18.9 years, 50.6% were female. 83.3% suffered an isolated, 16.7% multiple metatarsal fractures. Single metatarsal fractures occurred predominantly at the fifth metatarsal bone (81.3%), their frequency decreased with increasing age, with a seasonal peak during the summer. Patients suffering multiple metatarsal fractures were significantly older (51.6 ± 21.2 vs. 43.0 ± 18.1 years; p < 0.001) and the injury resulted significantly more often from a high-energy trauma (6.7% vs. 23.4%; p < 0.001). Multiple metatarsal fractures occurred evenly throughout all metatarsals but revealed a focus on female population with no seasonal differences.

CONCLUSION

Single metatarsal fractures predominantly occurred at the fifth metatarsal bone and showed a seasonal, gender and age dependency. Multiple metatarsal fractures were homogeneously distributed between the different metatarsals with distinct age-dependent gender differences.

LEVEL OF EVIDENCE

Level III.

Avoiding Fifth Metatarsal Intramedullary Screw Head Cuboid Impingement: A Weightbearing Computed Tomography Anatomic Study

BACKGROUND

Multiple case reports of fifth metatarsal (MT) intramedullary fixation highlight symptomatic hardware with screw head impingement on the cuboid. We developed a fifth MT intramedullary screw trajectory model using weightbearing computed tomography data. The goal was to assess for cuboid impingement with simulated intramedullary screw position.

METHODS

For 20 weightbearing foot computed tomographs (CTs), an automated tool was used to simulate fifth MT screw fixation in the ideal trajectory down the shaft and with a 7-mm screw head. (1) The closest distance from the simulated ideal trajectory to the cuboid in 3 dimensions was measured. A measurement less than 3.5 mm (the radius of the screw head) indicated screw head impingement on the cuboid if not countersunk into the metatarsal. (2) In 3 dimensions, a simulated screw head was then advanced from the proximal tip of the metatarsal distally into the metatarsal until it was entirely avoiding the cuboid.

RESULTS

In this model, 95% (19/20) of the patients would have cuboid impingement if the screw was not countersunk. The average ideal pin start distance was 0.15 mm (SD 2.4 mm) inside the cuboid. In this cohort, the screw head would have to be countersunk an average of 8.1 mm (SD 2.7 mm) relative to the proximal tip of the metatarsal to avoid cuboid impingement. For all cases, the simulated fluoroscopic oblique view was a reliable indicator of cuboid impingement, demonstrating visible overlapping of the screw with the cuboid. The overlap resolved on the oblique foot view once the screw was sufficiently countersunk, confirmed on 3-dimensional imaging.

CONCLUSION

The ideal guidewire placement for fifth MT intramedullary fixation is directly against the cuboid. Approximately 95% of patients would have cuboid impingement if the screw is not countersunk. The oblique fluoroscopic view of the foot is a reliable assessment of screw head impingement on the cuboid.

LEVEL OF EVIDENCE

Level III, retrospective study.

Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review

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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.

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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.

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Avulsion fractures of the tuberosity of the base (zone 1) generally heal well, and nonoperative treatment is commonly recommended.

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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.

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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.

The Fifth Metatarsal Bone Fracture in Athletes - Modalities of Treatment Related to Agility in Soccer Players

The 5^th 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 5^th metatarsal fracture among professional soccer players. We followed the surgical and rehabilitation path of 21 professional soccer players from the Polish League (I^st and II^nd divisions) who suffered from the 5^th 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.

Revisiting Union: A New Perspective on an Old Outcome

BACKGROUND

To present the inherent and unique challenges associated with utilizing fracture healing as an outcome measure in foot and ankle orthopedics, specifically the statistical methods used in assessing time to union.

METHODS

In a previously published manuscript assessing the effect of delayed weightbearing on time to union following intramedullary (IM) screw fixation of Jones (Zone 2 fifth metatarsal base) fractures, patients were divided into early weightbearing (EWB, n=20) and delayed weightbearing (DWB, n=21) cohorts (within or beyond 2 weeks, respectively). Time to union was determined and compared between the 2 cohorts using cumulative link model analysis, with delayed union (12.5 weeks) defined from established literature.

RESULTS

Cumulative link model analysis demonstrated no significant differences in time to union (EWB: 25% by 6th week, 55% by 12th week; DWB: 33% by 6th week, 43% by 12th week; P = .819) or delayed unions (EWB, 20% vs DWB, 24%; P > .999).

CONCLUSION

Our analysis using cumulative link models, or ordinal regression, in the statistical analysis of time to union, determined that that early weightbearing following IM screw fixation in Jones fractures appeared to be safe without delaying fracture healing. This statistical approach can be considered when describing a continuous outcome captured by infrequent observations.