Foot radiologic morphology as a predictor of pseudo-jones fractures: A retrospective case-control study.

BACKGROUND: Fifth metatarsal basis fractures are common injuries. Zone 1 fractures are also known as pseudo-jones fractures. This study aimed to elucidate the impact of foot radiologic morphology on pseudo-Jones fractures. METHODS: Patients with pseudo-Jones fractures formed the case group and individuals with ankle sprains but no fractures formed control group. Weight-bearing anteroposterior and lateral radiographs were evaluated for pre-determined measurements: metatarsus adductus angle (MAA), intermetatarsal angles (1-2, 4-5), calcaneal inclination (CI) angle, and fifth metatarsal base angle. All measurements were performed by a single investigator using digital PACS tools. Statistical analysis compared these radiographic parameters between the groups. RESULTS: The fracture group demonstrated a significantly lower 4-5 intermetatarsal and calcaneal inclination angles than the control group (p < 0.05). Notably, no statistically significant difference was found in the metatarsus adductus angle. CONCLUSION: This study demonstrates a potential association between foot radiographic morphology and pseudo-Jones fractures. Patients with a lower 4-5 IMA and calcaneal inclination angle may be at a higher risk for developing pseudo-Jones fractures. However, these requires future prospective studies. LEVEL OF EVIDENCE: Level III case control study.

Anthropometric measurements of the foot cannot predict the screw diameter for fifth metatarsal fractures intramedullary fixation.

PURPOSE: The present study aimed to evaluate the accuracy of anthropometric foot measurements in predicting the diameter of the intramedullary screw for fifth metatarsal fracture fixation. Secondary aim was to identify whether the fifth metatarsal intramedullary canal diameter is correlated to the fifth metatarsal length and the foot dimensions. METHODS: In 29 cadaveric feet, the maximum length of the plantar surface of the foot (PL) and the perimeter of the foot at the level of the fifth metatarsal base (PBFM) were measured using a measuring tape. Subsequently, the fifth metatarsal was excised. Using Computed Tomography scan, the metatarsal length (FML), and the horizontal (HDI) and vertical diameter (VDI) at the isthmus level were measured. The HDI values were grouped in 5 mm increments to correspond to the recommended screw diameter (RSD) for intramedullary fixation. A univariate linear regression analysis considered RSD and HDI as the dependent variables and FML, PL, PBFM as the independent variables. A multivariate regression analysis was performed to examine the predictive value of the two anthropometric measurements. A p-value < 0.05 was considered statistically significant. RESULTS: All six univariate analyses revealed that the dependent variable was significantly correlated with the independent variable. However, the multivariate regression models showed that the anthropometric measurements were not significantly correlated with the RSD and HDI. CONCLUSION: The current study found an association between the fifth metatarsal intramedullary canal diameter and the fifth metatarsal length and foot anthropometric dimensions. However, the anthropometric measurements of the foot presented a low predictive value for the decision of an intramedullary screw diameter in the treatment of fractures of the base of the fifth metatarsal.

Rare Reconstruction of Four Metatarsals Using Kirschner Wires After a Severe Crushing Injury: Surgical Decision Making and Prognosis.

Metatarsal fractures are one of the most common injuries after foot trauma. It is debilitating, as the metatarsals are one of the most crucial bones for any weight-bearing movement. This report demonstrates the beneficial outcome of using Kirschner wires (K-wires) in a trauma setting and the complicated healing process. A 56-year-old gentleman was brought into the emergency department after a reinforced cement pipe fell onto the patient's steel-toe boots, striking his left foot immediately proximal to the steel portion of the boot. The patient had sustained displaced comminuted fractures of the left second, third, fourth, and fifth metatarsals with an extensive open wound (Gustilo type II open fracture). Open reduction with internal fixation (ORIF) was performed using K-wires to restore and preserve the anatomical and functional integrity of the foot. Following the surgery, the patient developed a hammer toe of the left fifth metatarsophalangeal (MTP) joint two months after the ORIF; we performed resection arthroplasty to relieve discomfort and further aid the recovery process. Following the resection arthroplasty, eschar had formed at the surgical site, extending from the lateral aspect of the left foot to the plantar surface, for which we had performed a skin graft after excisional debridement of the necrotic tissue. After one year of close follow-ups with rigorous physical therapy exercises, the patient had a fair recovery process and is now able to ambulate without any assistive devices. As such, using K-wires remains a viable option for reducing misaligned metatarsal fractures and providing fairly good outcomes even in the setting of severe foot trauma.

Spontaneous Fracture of the Fifth Metatarsal Secondary to Gout Tophus in a Young Patient: A Case Report.

Gout is a common disease, and its prevalence is increasing. After several years of untreated gout, in very rare cases tophi may cause a spontaneous fracture. This type of fracture may be difficult to distinguish from others, especially when gout is not yet diagnosed. We present a case of a pathological fracture caused by tophus in a young man, which led to the diagnosis of gout.

Short-Term Outcomes of Jones-Specific Implant Versus Intramedullary Screw and Plate Fixation for Proximal Fifth Metatarsal Fractures.

Although intramedullary screw fixation is commonly performed for proximal fifth metatarsal fractures, high rates of nonunion, refracture, and hardware prominence have been reported. The Jones Specific Implant (JSI) is a novel surgical implant which contours to the native curvature of the fifth metatarsal allowing for a more anatomic fixation. The purpose of this study was to compare short-term complication rates and outcomes of patients treated with the JSI to other fixation types such as plates and intramedullary screws. Electronic records were queried for adult patients with proximal fifth metatarsal fractures who underwent primary fixation from 2010 to 2021. All patients were treated by a foot and ankle fellowship-trained surgeon with intramedullary screws, plates, or JSI (Arthrex Inc., Naples, FL). Visual analog scale (VAS) and the American Orthopedic Foot and Ankle Score (AOFAS) were recorded and compared using univariate statistics. Eighty-five patients underwent fixation using intramedullary screw (n = 51, 60%), plate (n = 22, 25.9%), or JSI (n = 12, 14.1%) with a mean follow-up of 11.1 ± 14.6 months. The total cohort demonstrated a significant improvement in VAS pain (p < .0001) as well as AOFAS (p < .0001) scores. When comparing the cohort treated with JSI and the cohort treated with all other types of fixation, there were no significant differences in postoperative VAS or AOFAS scores. Only 3 complications, one with JSI (3.5%) required removal of the symptomatic hardware. The JSI is a novel treatment for proximal fifth metatarsal fractures, with similar early outcomes and complication rates when compared with intramedullary screw and plate fixation.

Surgical Management of Jones Fractures in Athletes: Orthobiologic Augmentation: A Systematic Review and Meta-analysis of 718 Fractures.

BACKGROUND: The use of orthobiologics is expanding. However, the use of orthobiologic augmentation in primary fracture fixation surgery remains limited. Primary fracture fixation of the fifth metatarsal (Jones) in athletes is one of the rare situations where primary orthobiologic augmentation has been advocated. PURPOSE: To determine the effect of orthobiologic augmentation on the outcome of surgically managed Jones fractures in athletes. STUDY DESIGN: Systematic review; Level of evidence, 4. 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 March 2021 to identify studies reporting on surgically managed Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the return to play (RTP) rate and time to RTP, whereas the secondary outcomes were time to union, union rate, and refractures. Data were presented by type of treatment (biologically augmented fixation or fixation alone). RESULTS: In the biologically augmented fixation group, successful RTP was reported in 195 (98.98%) of 197 fractures (odds ratio [OR], 97.5%; 95% CI, 95.8%-100%; I2 = 0), with a mean time to RTP of 10.3 weeks (95% CI, 9.5-11.1 weeks; I2 = 99%). In the group that received fixation without biological augmentation, successful RTP was reported in 516 (99.04%) of 521 fractures (OR, 98.7%; 95% CI, 97.8%-99.7%; I2 = 0], with a mean time to RTP of 9.7 weeks (95% CI, 7.84-11.53 weeks; I2 = 98.64%]. In the biologically augmented fixation group, fracture union was achieved in 194 (98.48%) of 197 fractures (OR, 97.6%; 95% CI, 95.5%-99.7%; I2 = 0%), with a mean time to fracture union of 9.28 weeks (95% CI, 7.23-11.34 weeks; I2 = 98.18%). In the group that received fixation without biological augmentation, fracture union was achieved in 407 (93.78%) of 434 fractures (OR, 97.4%; 95% CI, 96%-98.9%; I2 = 0%), with a mean time to fracture union of 8.57 weeks (95% CI, 6.82-10.32 weeks; I2 = 98.81%). CONCLUSION: Orthobiologically augmented surgical fixation of Jones fractures in athletes is becoming increasingly common, despite the lack of comparative studies to support this practice. Biologically augmented fixation of Jones fractures results in higher fracture union rates than fixation alone but similar rates of RTP and time to RTP. Although the current evidence recommends primary surgical fixation for the management of Jones fractures in athletes, further high quality comparative studies are required to establish the indication for orthobiologic augmentation.

Biomechanical Comparison of Cannulated Screw Osteosynthesis With Tension-Band Wiring for Proximal Fractures of the Fifth Metatarsal (Jones Fracture).

Jones fractures, which lie at the junction of the diaphysis to the metaphysis of the fifth metatarsal, are a well-described clinical issue. There are various surgical approaches, including the commonly performed cannulated screw osteosyntheses, and the less frequently used tension-band approach. The aim is to compare the biomechanical stability of these osteosyntheses. We performed an osteotomy on 16 fresh frozen fifth metatarsal bones from body donors representing a Jones fracture. The fractures were treated pairwise with screw osteosynthesis or tension-band wiring. This was followed by cyclic axial bending until osteosynthesis failure. Stability under axial bending force was higher in the screw osteosynthesis (mean: 70.0 ± 66.5 N) compared to the tension-band wiring (mean: 35.7 ± 23.3 N) group although not reaching statistical significance (p = .116). The study shows no statistically significant difference in biomechanical stability under axial loading between screw osteosynthesis and tension band wiring. Based on the data obtained, no differences can be observed from a biomechanical point of view. The study supports the established method of treating Jones fractures primarily with screw osteosynthesis. In addition, the data suggest that tension band wiring may be a good alternative osteosynthesis, for example, after failed casting treatment or failure of primary osteosynthesis.

Jones Fracture in the National Football League.

Background: Jones fracture, or proximal fifth metatarsal fracture, is a common injury in National Football League (NFL)-caliber athletes. Combine draft performance can greatly impact the long-term success of these athletes, and substantial emphasis has been placed on early return to play (RTP) and the minimization of post-operative complications after Jones fracture in these athletes. To date, no study has specifically described the treatment and outcomes of this injury specifically in NFL-caliber players, considering factors relevant to this unique population. Thus, the purpose of this review is to delve into Jones fracture in NFL-caliber athletes, evaluating the diagnostic, treatment, and RTP considerations. Methods: We searched Medline (PubMed), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCOhost) for the concept of Jones fractures in the NFL. Using the PRISMA guidelines, a team of three reviewers conducted abstract screenings, full-text screenings, and the extraction of studies describing Jones fractures specifically in the NFL. Results: Of the 1911 studies identified, 6 primary retrospective studies met the inclusion and exclusion criteria. The heterogeneity of the outcome reporting precluded a meta-analysis; thus, a qualitative review of manuscripts describing Jones fracture was carried out. Classification, diagnosis, and treatment considerations, RTP statistics and outcomes, and complications were discussed. Amongst the primary studies, there were 285 Jones fractures, all athletes were able to RTP, and the average time to RTP ranged from 6 weeks to 27 weeks. For complications, with operative treatment, the refracture rate ranged from 4 to 12%, and incomplete healing ranged from 7 to 50%. RTP was 15 weeks for refractures. There were no patient-reported outcomes. Conclusions: The vast majority of Zone 2/3 Jones fractures are treated with IM screw fixation with or without adjunctive orthobiologics, such as bone marrow aspirate concentrate, in NFL-caliber athletes. The six major series investigating outcomes after the operative treatment of Jones fractures in NFL players reveal very positive findings overall with regard to RTP, reoperation, and career continuation.

Reliability of Fifth Metatarsal Base Fracture Classifications and Current Management.

BACKGROUND: Classification of fifth metatarsal base fractures has been a source of confusion since originally described by Jones in 1902. Zone classifications have been described but never evaluated for reliability. The most recent classification, metaphyseal vs meta-diaphyseal, may be unknown to many surgeons. The purpose of this study was to evaluate reliability of American Orthopaedic Foot & Ankle Society (AOFAS) members classifying fifth metatarsal base fractures and current management of these fractures. METHODS: A survey was emailed to AOFAS members including radiographs of 18 fifth metatarsal base fractures. Demographic information was collected in addition to evaluation of the radiographs. Interrater reliability was assessed for each measurement: presence of Jones fracture, zone classification, and metaphyseal vs metaphyseal-diaphyseal, using Fleiss kappa. After 3 weeks, a second email was sent to the members asking to retake the survey to evaluate intrarater reliability. Respondents were asked which region is a Jones fracture, which classification is used, if symptomatic zone 2 and 3 fractures are treated similarly, and what fractures are operative in healthy symptomatic acute fractures. RESULTS: A total of 223 AOFAS members, with a median time in practice of 12 years (range 0-50), completed the initial survey. Eighty members (36%) repeated the survey for intrarater comparison. Interrater reliability was moderate for Jones and zone classification but substantial for the 2-zone metaphyseal/meta-diaphyseal classification. The median intrarater kappa was 0.78, 0.75, and 0.78 for Jones, zone, and metaphyseal/meta-diaphyseal respectively. Seventy percent of respondents treat zones 2 and 3 similarly, and approximately 60% consider an acute symptomatic fracture identified as Jones, zone 2 or zone 3 operative. CONCLUSION: A 2-zone system may be the best available classification for fifth metatarsal base fractures given high interrater reliability and 70% of AOFAS members treat zones 2 and 3 in similar fashion. LEVEL OF EVIDENCE: Level III, diagnostic study.

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.

The Clinical Outcomes of Operative Treatment Versus Conservative Treatment for Dancer's Fractures: Protocol for a Retrospective Cohort Study.

BACKGROUND: Fifth metatarsal fractures are one of the most common foot fractures, and 11% to 25% of such fractures are Dancer's fractures (distal spiral fractures). Conservative therapy while wearing a cast and operative treatment have been used as preferred modes of treatment in the limited literature available. However, we often see healing problems, such as delayed union and nonunion, when Dancer's fractures are treated nonoperatively, resulting in a need for secondary intervention. In our institution, treatment has changed over the years from predominantly conservative treatment to mostly operative treatment. To investigate whether our hypothesis holds true that primary surgical treatment is beneficial, a retrospective study was designed. OBJECTIVE: The objective of the study is to compare differences between outcomes (delayed union and nonunion) of conservative and operative treatments for Dancer's fractures. METHODS: A retrospective comparative cohort study will be conducted in a level II trauma center (Zaandam Medical Center). Patients who experienced a Dancer's fracture in the period of 2012 to 2021 will be included and divided into 2 cohorts-the conservative (2012-2015) and operative (2016-2021) treatment cohorts. The primary outcome will be the differences in percentages of delayed union and nonunion between the two groups. The secondary outcomes will be the percentage of primary conservative treatment failure, the need for secondary operative treatment, complications (infection and hardware failure), and functional outcomes. If 118 patients are included in each group, sufficient power is expected to be reached, depending on the age distribution of patients. The percentages of delayed union and nonunion among the two groups will be calculated and statistically compared via chi-square statistics. A logistic regression analysis will be used to investigate possible associations between patient characteristics and failed conservative treatment. A Mann-Whitney U test will be used to compare functional outcomes between groups. An independent, 2-tailed t test will be used to compare mean 12-Item Short Form Survey scores if they are normally distributed, and a Wilcoxon rank sum test will be used if they are nonnormally distributed. RESULTS: In total, 2134 potentially relevant health insurance codes have been extracted from the hospital's register. We expect to find a total of 236 Dancer's fractures in this data set. CONCLUSIONS: Our study has limitations due to it being a single-center study and data collection being performed retrospectively. However, it covers a large time period and may provide the possibility to show treatment outcome differences (delayed union and nonunion, complications, and functional outcomes) in 2 reasonably large cohorts (conservative and operative treatment cohorts), which has not been done before in literature on Dancer's fractures. If our hypothesis that surgery is beneficial for Dancer's fractures is proven true by our study, we plan to further corroborate it by conducting a prospective randomized controlled trial. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37171.

Orthosis and Foot Structure Affect the Fifth Metatarsal Principal Strains During Simulated Level Walking.

BACKGROUND: Fractures of the proximal fifth metatarsal bone are common injuries in elite athletes and are associated with high rates of delayed union and nonunion. Structural features of the foot may increase fracture risk in some individuals, emphasizing the need for intervention strategies to prevent fracture. Although orthotic devices have shown promise in reducing fractures of the fifth metatarsal bone, the effect of orthosis on fifth metatarsal strains is not well understood. PURPOSE: To quantify the effects of different foot orthotic constructs on principal tensile strains in the proximal fifth metatarsal bone during cadaveric simulations of level walking. An additional purpose was to investigate the relationships between structural features of the foot and corresponding strains on the fifth metatarsal bone during level walking. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 10 midtibial cadaveric specimens were attached to a 6 degrees of freedom robotic gait simulator. Strain gauges were placed at the metaphyseal-diaphyseal junction (zone II) and the proximal diaphysis (zone III) during level walking simulations using 11 different foot orthotic configurations. Images of each specimen were used to measure structural features of the foot in an axially loaded position. The peak tensile strains were measured and reported relative to the sneaker-only condition for each orthotic condition and orthotic-specific association between structural features and principal strains of both zones. RESULTS: In total, 2 of the 11 orthotic conditions significantly reduced strain relative to the sneaker-only condition in zone II. Further, 6 orthotic conditions significantly reduced strain relative to the sneaker-only condition in zone III. Increased zone II principal strain incurred during level walking in the sneaker-only condition showed a significant association with increases in the Meary's angle. Changes in zone III principal strain relative to the sneaker-only condition were significantly associated with increases in the Meary's angle and fourth-fifth intermetatarsal angle. CONCLUSION: The use of orthotic devices reduced principal strain relative to the condition of a sneaker without any orthosis in zone II and zone III. The ability to reduce strain relative to the sneaker-only condition in zone III was indicated by increasing values of the Meary's angle and levels of the fourth-fifth intermetatarsal angle. CLINICAL RELEVANCE: Clinicians can use characteristics of foot structure to determine the proper foot orthosis to potentially reduce stress fracture risk in high-risk individuals.

Conservative management of Jones fractures with immediate weight-bearing in a walking boot demonstrates healing.

Jones fractures, or proximal metatarsal fractures at the level of the fourth and fifth intermetatarsal junction, have a high risk for nonunion due to a vascular watershed region. Classically, treatment consists of weight bearing restrictions in a cast or surgical fixation. Some studies have assessed immediate weight bearing following a Jones fracture. Due to conflicting results, the most appropriate treatment method remains unclear. This study analyzes outcomes after treating adults with acute Jones fractures non-operatively without weight bearing restrictions in a walking boot. This study hypothesizes that patients will not require future operative intervention following functional treatment. A retrospective review of 55 adult patients who sustained acute, closed Jones fractures was conducted. 47 were treated weight bearing as tolerated (WBAT) in a walking boot and eight were treated non-weight bearing (NWB) in a cast. They were followed radiographically by an orthopedic surgeon for an average of 6.4 and 15.5 months, respectively. Three patients in each group (6.4% WBAT, 37.5% NWB) developed painful nonunion leading to surgical fixation. Thirty (66.7%) patients in the WBAT group demonstrated radiographic union on final radiographs. Only two (13.3%) of the 15 patients with partial union were seen at least six months from time of injury, one of whom had ongoing pain but declined surgery. The remaining 13 patients were asymptomatic at their final clinic appointment. Controversy still exists as to the best treatment methodology for acute Jones fractures. Due to a lack of clear guidelines, it can be difficult for the multiple medical specialties involved to evaluate and treat this injury. Our study suggests that non-operative management of minimally displaced Jones fractures, in the adult, low demand population, without weight bearing restrictions in a walking boot offers similar outcomes to cast immobilization with weight bearing restrictions, resulting in bony union or asymptomatic fibrous nonunion.

Less Invasive Surgery With Autologous Bone Grafting for Proximal Fifth Metatarsal Diaphyseal Stress Fractures.

Surgery with autologous bone grafting for proximal fifth metatarsal diaphyseal stress fracture has a potential to decrease nonunion, but it is not performed widely as the primary surgery because of donor-site morbidity. We have devised and performed a less invasive surgical procedure with autologous bone grafting and aimed to investigate the clinical and radiologic outcomes of this procedure. The data for 73 patients who underwent primary intramedullary screw fixation with autologous bone grafting from the fifth metatarsal base for proximal fifth metatarsal diaphyseal stress fractures were investigated retrospectively. The clinical and radiologic outcomes were evaluated. The mean time to bone union, starting running, and return to play was 11.8, 6.3, and 13.4 weeks, respectively. Bone union was achieved in 76 of the 78 cases. Intramedullary screw fixation with autologous bone grafting from the fifth metatarsal base showed good outcomes. It may be a useful surgical option for patients with proximal fifth metatarsal diaphyseal stress fractures.

Screw Length Associated With Fracture Gapping of Fifth Metatarsal Base Fracture With Intramedullary Screw Fixation: A Cadaveric Study.

Intramedullary screw fixation is a well-established surgical treatment for fifth metatarsal Jones fractures, due to its minimally invasive nature, and potential early return to activity. Due to the curvature of the fifth metatarsal, optimal length of the screw is needed to prevent gapping at the fracture site. The placement of a straight screw induces straightening of a naturally curved bone. The purpose of this study was to aid surgeons in determining an appropriate screw length for intramedullary fixation of a fifth metatarsal Jones fracture in order to prevent fracture gapping. A transverse osteotomy of the fifth metatarsal was made in 10 cadaver specimens at the level of a traditional Jones fracture. Inserted screws were sequentially increased in length until plantar gapping at the fracture site was noted. The angle (degree) of plantar gapping was measured with each increase in screw length and diameter. The mean length of the cadaveric fifth metatarsals was 73.76 mm (range 67.42-81.73). The mean screw length that caused gapping at the fracture site was 49.89 mm (range 44-55), representing 67.05% (range 61.26-75.35) of the fifth metatarsal length. The correlation coefficient revealed that gapping of the fracture site is most likely to occur when the screw length is 66% the length of the metatarsal length (rs = 0.66; 95% confidence interval: 0.06-0.91; p = .04). The angle of the initial gapping was 2.85° (range 2°-4°). With an incremental increase in screw length, the angle was 3.85° (range 3°-6°), and with an incremental increase in screw diameter, the angle was 3.70° (range 2°-5°). Our study demonstrated that screw lengths exceeding 66% of the metatarsal length lead to plantar fracture gapping. Additionally, gapping was accentuated with larger diameter screws due to angle variance.

Functional outcome of 103 fractures of the proximal fifth metatarsal bone.

BACKGROUND: Metatarsal fractures are common skeletal injuries of the lower extremity in adults. The majority involves the proximal fifth metatarsal bone. In the current literature, there still exists controversy regarding treatment recommendations for the different fracture entities. METHODS: All patients suffering from single fractures to the proximal fifth metatarsal bone between 2003 and 2015 were enrolled in this retrospective analysis. Only patients with a minimum follow-up of 12 months were included. The fractures were classified according to Lawrence and Botte (L&B). Data were collected via patient registry, radiographs and a standardized questionnaire (Foot and Ankle Outcome Score = FOAS). For outcome analysis, the nonparametric Mann-Whitney U test was performed and Spearman's rank correlation coefficient calculated. RESULTS: In total, the functional outcomes of 103 patients suffering from fractures to the proximal fifth metatarsal bone were analyzed. L&B type I fractures (n = 13) had a FAOS score of 91 ± 23, L&B type II (n = 67) presented a score of 91 ± 15 and L&B type III (n = 23) a score of 93 ± 11. Surgically treated patients with an L&B type II fracture had no statistically significant better functional outcome in comparison to conservative management (p = 0.89). Operatively treated L&B type III fractures tended to have a better functional score (p = 0.16). The follow-up time was 58 (min: 15; max: 164) months. CONCLUSIONS: Overall, the functional outcome following fractures to the proximal fifth metatarsal bone is satisfactory. Conservatively treated L&B type II fractures showed an equivalent functional outcome compared to surgical management. Patients with an L&B type III fracture mainly were treated surgically, but difference in FAOS score did not reach level of significance.

The Fifth Metatarsal Shaft Fracture Is Well Treated With Benign Neglect.

Background. Spiral fifth metatarsal fractures have been studied previously in professional dancers. However, little has been reported about outcomes of these injuries in the general population. The objective of this study was to examine patient demographics of those who sustain this injury and their functional outcomes, as stratified by treatment type. Methods. A total of 186 "nonprofessional dancer" patients with a fifth metatarsal fracture who were treated by one orthopaedic surgeon at our academic medical center were identified through chart review. All patients were allowed to weight bearing as tolerated (WBAT). Time to healing, persistence of pain, range of motion, and complications were recorded. Independent samples t tests, 1-way analysis of variance, and Fisher exact tests were used for analysis. Results. Thirty-seven of the 186 patients with fifth metatarsal fractures reviewed were identified as having a spiral fifth metatarsal fracture with appropriate follow-up. The cohort was 78.4% female with a mean age of 50.3 years. Twenty-two were initially treated in a controlled ankle motion (CAM) boot, 14 in a postoperative shoe, and 1 continued in their own shoes. All patients were allowed to WBAT. All fractures healed by a mean of 3.1 months. By the end of the follow-up period, 67.6% of patients had full range of ankle motion, with 5.4% reporting feeling stiff, 27.0% reporting mild persistent pain, and 2.7% reporting significant persistent pain. Conclusion. Fifth metatarsal shaft ("Dancer's") fractures occur within the general population, not only among professional dancers. Without operative fixation and regardless of nonoperative treatment selected, these fractures heal reliably and do so without clinically relevant complication.Level of Evidence: Level III: Retrospective comparative study.

Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures.

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.

Epidemiology of dancers fracture.

BACKGROUND: Dancer's fracture is a spiral, oblique fracture of the diaphysis of the fifth metatarsal. Although it is a well-known fracture in high performance athletes, it is less studied in a general population. The article investigates the epidemiology within an adult population consulting a regional trauma and orthopedic center in the United Kingdom. METHODS: Study population included all patients older than 16 years presenting with a dancer's fracture. Recorded data were age, sex, side and energy of trauma mechanism, applied treatment and time of healing. RESULTS: Of all fifth metatarsal fractures, 25% was found to have a dancer's fracture. About 80% were women, and about 80% was older than 40 years. In the +40 y age group, all patients had a low energy trauma mechanism, where in the -40y age group this was only 27%. All patients were treated conservatively and no correlation was found between type of treatment (walker boot, stiff soled shoe) and time of healing. The time of healing was similar in both age groups and in general 1 out of 3 patients needed longer than 6 weeks to heal. CONCLUSION: There is an increased incidence of dancer's fracture observed in the female general population +40y age. A strong correlation was found between the +40y age group and low-energy trauma mechanism. This shows the importance of treating dancer's fracture as a fragility fracture. LEVEL OF EVIDENCE: Retrospective cohort study: level 3.

Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures.

AIMS: Many advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy. MATERIALS AND METHODS: 3D CT-scan reconstructions were made of 21 cadaveric MT5s, followed by meticulous mapping of the PB and PF onto the reconstructions. Based on bone length, shape, narrowest intramedullary canal (IMC) diameter, and surrounding anatomy, two traditional debated screw positions were modeled for each reconstruction: (1) an anatomically positioned screw (AP), predicated on maximizing screw length by following the IMC for as long as possible, and (2) a clinically achievable screw (CA), predicated on maximizing screw length without violating the fifth tarso-metatarsal joint or adjacent cuboid bone. Fixation parameters were calculated for all models. RESULTS: The PB and PF extended into the JF site in 29% and 43%, respectively. AP's did not affect PB and PF footprint but required screw entry through the cuboid and fifth tarso-metatarsal joint in all specimens. CA screw entry sites, avoiding the cuboid and fifth tarso-metatarsal joint, partially compromised the PB and PF insertions in 33% and 62% with a median surface loss of 1.6%%(range 0.2-3.2%) and 0.81%%(range 0.05-1.6%), respectively. Mean AP screw length was 64±3.6mm and thread length 49±4.2mm. Mean CA screw length was 48±5.8mm and thread length 28±6.9mm. CONCLUSION: This study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints - although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction.