Surgical treatment of diaphyseal stress fractures of the fifth metatarsal in competitive athletes: long-term follow-up and computerized pedobarographic analysis.

BACKGROUND: Proximal diaphyseal stress fractures of the fifth metatarsal are common in athletes. Conservative treatment has been shown to result in high rates of delayed union, nonunion, and refracture, so internal fixation has become the treatment of choice in competitive athletes. METHODS: Twenty top-level athletes with diaphyseal stress fractures fixed with intramedullary malleolar screws were evaluated. Functional outcome was assessed by American Orthopaedic Foot and Ankle Society midfoot score. Static and dynamic maximum vertical force and peak plantar pressures were evaluated with a computerized pedobarograph. RESULTS: Mean follow-up from surgery to interview was 10.3 years (range, 3.5-19.0 years). Clinical healing was 95%, and there has been one refracture (5%). The mean time from surgery to return to sport was 9 weeks (range, 5-14 weeks). Twelve athletes (60%) returned to a higher level of training, 7 (35%) to the same level, and 1 (5%) to a lower level compared with the level of training before injury. Average American Orthopaedic Foot and Ankle Society midfoot score was 93.8 (range, 85-100). During the computerized pedobarographic evaluations, 18 patients (90%) presented with varus of the metatarsus and the midfoot and 2 (10%) presented with a normal plantigrade foot. CONCLUSIONS: Intramedullary malleolar screws can yield reliable and effective healing of fifth metatarsal stress fractures in athletes. Varus of the metatarsus and the midfoot were predisposing factors for stress fractures in this population of competitive athletes, and all were recommended to wear orthoses until their competitive careers were completed.

Treatment of hallux valgus with three-dimensional modification of Mitchell's osteotomy: technique and results.

Mitchell's osteotomy gives very good results but there are still some cases where the original method, as well as its modification, cannot address all aspects of deformity. We modified the original Mitchell's method to address pronation and plantar displacement of the first metatarsal. Modification includes formation of lateral and plantar spur with metatarsal displacement and derotation of distal metatarsal fragment in the frontal and horizontal planes with stable screw fixation. We present midterm results of the first 60 patients compared to the original Mitchell method (30 patients). Differences between the groups postoperatively were in declination angle, postoperative metatarsalgia rate, and first metatarsal pronation angle. The technique described eliminated many of the disadvantages of Mitchell's method.

Biomechanical analysis of functional adaptation of metatarsal bones in statically deformed feet.

We analysed the functional adaptation of the first and second metatarsal bones to altered strain in flexible flatfoot. Fifty consecutive women (20-40 years of age) were enrolled: 31 patients with a flexible flatfoot and metatarsalgia (59 feet) and 19 controls with asymptomatic feet (37 feet). They were compared for cortical thickness (medial, lateral, dorsal and plantar) of the two bones. The null hypothesis of no overall difference between the deformed and healthy feet with regard to cortical thicknesses of the two bones was rejected in a multivariate test (p = 0.046). The groups differed significantly only regarding dorsal cortical thickness of the second metatarsal, which was around 18.1% greater in the deformed feet (95% confidence interval: 7.7-28.4%, p < 0.001). Hypertrophy of the dorsal corticalis of the second metatarsal bone appears to be the main metatarsal adaptive reaction to altered strain in the flexible flatfoot.