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Kadiyala ML, Kingery MT, Hamzane M, Walls R, Ganta A, Konda SR, Egol KA. Zone 2 Fifth Metatarsal Fractures Treated Nonoperatively Have Similar Time to Healing to Those Treated Operatively. J Orthop Trauma 2024; 38:e157-e161. [PMID: 38206754 DOI: 10.1097/bot.0000000000002766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/05/2024] [Indexed: 01/13/2024]
Abstract
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.
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Affiliation(s)
- Manasa L Kadiyala
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Matthew T Kingery
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Mohamed Hamzane
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Raymond Walls
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
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2
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Ramon S, Lucenteforte G, Alentorn-Geli E, Steinbacher G, Unzurrunzaga R, Álvarez-Díaz P, Barastegui D, Grossi S, Sala E, Martinez-De la Torre A, Mangano GRA, Cuscó X, Rius M, Ferré-Aniorte A, Cugat R. Shockwave Treatment vs Surgery for Proximal Fifth Metatarsal Stress Fractures in Soccer Players: A Pilot Study. Foot Ankle Int 2023; 44:1256-1265. [PMID: 37905784 DOI: 10.1177/10711007231199094] [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] [Indexed: 11/02/2023]
Abstract
BACKGROUND To compare the clinical, radiologic, and functional outcomes between shockwave and operative treatments for proximal fifth metatarsal stress fractures in soccer players in a pilot study. METHODS Between 2017 and 2019, 18 soccer players with fifth metatarsal stress fractures attended at Mutualidad de Futbolistas Españoles-Delegación Catalana were included. Patients were randomly assigned into 2 groups receiving either surgery with an intramedullary screw (group 1) or high-energy focused extracorporeal shockwave treatment (group 2 performed once a week for 3 weeks using 2000 impulses at an energy flux density of 0.21 mJ/mm2 and 4 Hz frequency). Clinical (pain), radiologic (bone healing), and functional (Tegner Activity Scale and American Orthopaedic Foot & Ankle Society [AOFAS] ankle-hindfoot scales) outcomes before and after receiving the treatment were compared between both groups. In addition, ability and time to return to play was also compared between groups. RESULTS No patients were lost to follow-up. There were no statistically significant differences at last follow-up between surgery and extracorporeal shockwave treatment for bone healing, pain relief, AOFAS ankle-hindfoot score, Tegner score, and time return to play. No complications were reported in either of the 2 groups. CONCLUSION In this pilot study, extracorporeal shockwave treatment and operative treatment were found to be equally effective at reducing pain, achieving bone healing, and allowing the soccer players to return to play after proximal fifth metatarsal stress fractures. This study suggests that ESWT may be a good option for the management of proximal fifth metatarsal stress fractures in soccer players. If this approach proves successful in larger trials, the shockwave approach might help avoid known complications of the surgical treatment like wound problems, nerve injury, and hardware intolerance. Further investigations with larger sample size should be conducted in order to confirm the present conclusions. LEVEL OF EVIDENCE Level II, therapeutic, pilot randomized controlled trial.
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Affiliation(s)
- Silvia Ramon
- Department of Physical Medicine and Rehabilitation, Hospital Quirónsalud Barcelona, Spain
- Fundación García-Cugat, Barcelona, Spain
| | - Giacomo Lucenteforte
- Policlinico Vittorio Emanuele, Università degli Studi di Catania, Catania, Italy
- Isokinetic Medical Group, FIFA Medical Centre of Excellence, Education & Research Department, Bologna, Italy
| | - Eduard Alentorn-Geli
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Gilbert Steinbacher
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
| | - Rocío Unzurrunzaga
- Department of Physical Medicine and Rehabilitation, Hospital Quirónsalud Barcelona, Spain
- Fundación García-Cugat, Barcelona, Spain
- Department of Physical Medicine and Rehabilitation, MC Mutual, Barcelona, Spain
| | - Pedro Álvarez-Díaz
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - David Barastegui
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Sebastián Grossi
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
| | - Esther Sala
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Escola Universitària Gimbernat, Universitat Autònoma de Barcelona, Sant Cugat del Vallès, Barcelona, Spain
| | - Adrián Martinez-De la Torre
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | | | - Xavier Cuscó
- Fundación García-Cugat, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Marta Rius
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
| | - Alfred Ferré-Aniorte
- Fundación García-Cugat, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
| | - Ramón Cugat
- Fundación García-Cugat, Barcelona, Spain
- Mutualidad de Futbolistas Españoles-Delegación Catalana, Federación Española de Fútbol, Barcelona, Spain
- Instituto Cugat, Hospital Quirónsalud Barcelona, Barcelona, Spain
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3
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Rizzi AM, Baker HP, Lee CS, Athiviraham A. Lower Extremity Stress Fractures in the National Basketball Association, 2013-2014 Through 2018-2019. Orthop J Sports Med 2022; 10:23259671221126485. [PMID: 36225389 PMCID: PMC9549108 DOI: 10.1177/23259671221126485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Players in the National Basketball Association (NBA) are at risk for lower extremity stress fractures, partly because of the sport's high-intensity demand on the lower body. PURPOSE To provide insight on the identification and management of potential risk factors associated with lower extremity stress fractures in NBA athletes. STUDY DESIGN Case series; Level of evidence, 4. METHODS A retrospective study was conducted using the NBA electronic medical record database for all players who were on an NBA roster for ≥1 game from the 2013-2014 through 2018-2019 seasons. Player characteristics, games missed, and treatment methodology were independently analyzed. Results were presented as incidence per 1000 player-games. RESULTS There were 22 stress fractures identified in 20 NBA players over the course of 6 years, with an average of 3.67 stress fractures per year and an incidence of 0.12 stress fractures per 1000 player-games. Most stress fractures occurred in the foot (17/22), and 45% (10/22) of stress fractures were treated surgically, with the most common site of operation being the navicular. On average, approximately 37 games and 243 days were missed per stress fracture injury. There was no significant difference in time to return to play between high-risk stress fractures treated operatively versus nonoperatively (269.2 vs 243.8 days; P = .82). CONCLUSION The overall incidence of stress fractures in NBA players was 0.12 per 1000 player-games, and a high percentage of players returned to NBA activity after the injury. There was a relatively even distribution between high-risk stress fractures treated operatively and nonoperatively. When comparing high-risk stress fractures treated operatively to ones treated nonoperatively, no significant difference in average time to return to play in the NBA was found.
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Affiliation(s)
- Andrew M. Rizzi
- Department of Orthopaedic Surgery, University of Chicago Medicine,
Chicago, Illinois, USA.,Andrew M. Rizzi, MD, Department of Orthopaedic Surgery,
University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
()
| | - Hayden P. Baker
- Department of Orthopaedic Surgery, University of Chicago Medicine,
Chicago, Illinois, USA
| | - Cody S. Lee
- Department of Orthopaedic Surgery, University of Chicago Medicine,
Chicago, Illinois, USA
| | - Aravind Athiviraham
- Department of Orthopaedic Surgery, University of Chicago Medicine,
Chicago, Illinois, USA
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4
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Bezuglov E, Zholinsky A, Chernov G, Khaitin V, Goncharov E, Waśkiewicz Z, Barskova E, Lazarev A. Conservative Treatment of the Fifth Metatarsal Bone Fractures in Professional Football Players Using Platelet-Rich Plasma. Foot Ankle Spec 2022; 15:62-66. [PMID: 34142576 DOI: 10.1177/19386400211017368] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Injuries of the metatarsal bones in football are relatively rare and in most cases are localized in the fifth metatarsal. The gold standard of the diagnosis of fractures in this area can be X-rays, which in most cases allows verifying the diagnosis. The treatment tactics depend on the localization of the fracture according to Lawrence and Botte's classification: 3 zones of localization are distinguished. Fractures located in zones 2 and 3 belong to a high-risk group due to delayed consolidation and nonunion and therefore athletes are most often treated with osteosynthesis using intramedullary screws. The minimal recovery time for this type of treatment is at least 8 weeks. This report describes 7 cases of the fifth metatarsal bone fractures, located in zones 2 and 3 in professional football players who were treated with an immobilization boot, cryotherapy, nutritional supplements of calcium and vitamin D, and local injections of platelet-rich plasma, which contains numerous growth factors. The deadline for returning to regular training activities was 43 to 50 days, and there was no relapse of damage within 6 months of follow-up.Levels of Evidence: Level of evidence 4: case report study.
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Affiliation(s)
- Eduard Bezuglov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation.,Russian Football Union, Moscow, Russian Federation.,Federal Research and Clinical Center of Sports Medicine and Rehabilitation, Federal Medical Biological Agency, Moscow, Russian Federation
| | - Andrey Zholinsky
- Federal Research and Clinical Center of Sports Medicine and Rehabilitation, Federal Medical Biological Agency, Moscow, Russian Federation
| | | | | | - Evgeniy Goncharov
- Russian Medical Academy of Continuous Professional, Moscow, Russian Federation.,Traumatology and Orthopedics Center, Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russian Federation
| | - Zbigniew Waśkiewicz
- Institute of Sport Science, Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - Ekaterina Barskova
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation.,High Performance Sports Laboratory, Moscow Witte University
| | - Artemii Lazarev
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation.,High Performance Sports Laboratory, Moscow Witte University.,A.I. Burnazyan Federal Medical and Biophysical Center, Federal Biomedical Agency of Russia, Moscow, Russian Federation
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5
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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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6
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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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7
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Baumfeld T, Fernandes Rezende R, Nery C, Batista JP, Baumfeld D. Fifth Metatarsal Fractures in Professional Soccer Players: Case Series. Foot Ankle Spec 2021; 14:213-218. [PMID: 32172591 DOI: 10.1177/1938640020911223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Fifth metatarsal fractures occur mainly in young athletes, with an estimated incidence of 1.8 per 1000 individuals per year. This study aims to evaluate the functional outcome of professional soccer players undergoing surgical treatment of fifth metatarsal base fractures. METHODS We appraised 34 soccer players operated on from July 2001 to June 2016. All individuals were assessed by the American Orthopedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) before and after surgery, with a mean 23-month follow-up. The need for grafting, fracture healing, Torg classification, and return to sports were also evaluated. RESULTS There were 10 attackers, 7 offensive-defensive midfielders, 6 side defenders, 5 central defensive midfielders, 3 defenders, 2 goalkeepers, and 1 defensive midfielder, at an average age of 19 years. Preoperative and postoperative AOFAS averaged 42 and 99 points, respectively, whereas VAS scores were 6 and 0. The longer the time to get operated on, the greater was the need for grafting (P = .011). In our study, all fractures have consolidated. Return to sports occurred, on average, 73 days after surgical treatment, and it was not influenced by the time to get operated on, fracture healing, Torg classification, and grafting. CONCLUSION Surgical treatment of the fifth metatarsal base fracture in professional soccer players presents good clinical results. Getting back to activities after surgery is not influenced by surgery time, fracture healing, Torg classification, and grafting.Levels of Evidence: Level IV: Therapeutic studies, Case series.
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Affiliation(s)
- Tiago Baumfeld
- Universidade Federal de Minas Gerais (UFMG), MG, Brasil (TB, DB).,Hospital Felício Rocho, Belo Horizonte, MG, Brasil (RFR).,Escola Paulista de Medicina, UNIFESP, São Paulo, SP, Brasil (CN).,Centro Artroscópico Jorge Batista AS (CAJB AS), Buenos Aires, CABA, Argentina (JPB)
| | - Ricardo Fernandes Rezende
- Universidade Federal de Minas Gerais (UFMG), MG, Brasil (TB, DB).,Hospital Felício Rocho, Belo Horizonte, MG, Brasil (RFR).,Escola Paulista de Medicina, UNIFESP, São Paulo, SP, Brasil (CN).,Centro Artroscópico Jorge Batista AS (CAJB AS), Buenos Aires, CABA, Argentina (JPB)
| | - Caio Nery
- Universidade Federal de Minas Gerais (UFMG), MG, Brasil (TB, DB).,Hospital Felício Rocho, Belo Horizonte, MG, Brasil (RFR).,Escola Paulista de Medicina, UNIFESP, São Paulo, SP, Brasil (CN).,Centro Artroscópico Jorge Batista AS (CAJB AS), Buenos Aires, CABA, Argentina (JPB)
| | - Jorge P Batista
- Universidade Federal de Minas Gerais (UFMG), MG, Brasil (TB, DB).,Hospital Felício Rocho, Belo Horizonte, MG, Brasil (RFR).,Escola Paulista de Medicina, UNIFESP, São Paulo, SP, Brasil (CN).,Centro Artroscópico Jorge Batista AS (CAJB AS), Buenos Aires, CABA, Argentina (JPB)
| | - Daniel Baumfeld
- Universidade Federal de Minas Gerais (UFMG), MG, Brasil (TB, DB).,Hospital Felício Rocho, Belo Horizonte, MG, Brasil (RFR).,Escola Paulista de Medicina, UNIFESP, São Paulo, SP, Brasil (CN).,Centro Artroscópico Jorge Batista AS (CAJB AS), Buenos Aires, CABA, Argentina (JPB)
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8
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Lee KT, Kim KC, Young KW, Jegal H, Park YU, Lee HS, Roh Y. Conservative treatment of refractures after modified tension band wiring of fifth metatarsal base stress fractures in athletes. J Orthop Surg (Hong Kong) 2021; 28:2309499020926282. [PMID: 32539561 DOI: 10.1177/2309499020926282] [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] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Recurrent fifth metatarsal base stress fractures (MT5-BSF) in athletes present a challenging problem. The aim of this study was to evaluate the result of conservative treatment for the refracture of MT5-BSF after modified tension band wiring (MTBW). MATERIALS AND METHODS The outcomes of 15 elite athletes undergoing conservative treatment for refracture of MT5-BSF after MTBW were retrospectively reviewed. They were instructed to avoid weight-bearing with short leg cast for 6 weeks. After that, they started partial weight with a postop shoe. Stepwise exercise followed bone union by radiographs. RESULTS Thirteen cases (86.6%) had a complete bone union after a mean of 18.9 ± 8.6 weeks. Twelve cases (80%) returned to their previous activity level and maintained for at least two consecutive seasons. CONCLUSION Eighty percent of all athletic patients with the conservative treatment for refractures with healed MT5-BSF after MTBW on the plantar-lateral side could maintain and return to their previous sports activity for at least 2 years.
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Affiliation(s)
- Kyung Tai Lee
- Foot and Ankle Service, KT Lee's Orthopedic Hospital, Seoul, Republic of Korea
| | - Ki Chun Kim
- Seoul Medical Center, Seoul, Republic of Korea
| | | | - Hyuk Jegal
- BonBone Orthopedic Clinic, Bucheon, Republic of Korea
| | | | | | - Youngju Roh
- Seoul Medical Center, Seoul, Republic of Korea
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9
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van Dijk PA, Breuking S, Guss D, Johnson H, DiGiovanni CW, Vopat B. 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. Injury 2020; 51:2887-2892. [PMID: 32998823 DOI: 10.1016/j.injury.2020.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- P A van Dijk
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Academic Center for Evidence-based Sports Medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands; Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA.
| | - S Breuking
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - D Guss
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - H Johnson
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - C W DiGiovanni
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - B Vopat
- Department of Sports Medicine and Orthopedics, University of Kansas Medical Center, Kansas City, KS, USA
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10
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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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11
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Bucknam RB, Scanaliato JP, Kusnezov NA, Heida KA, Dunn JC, Orr JD. Return to Weightbearing and High-Impact Activities Following Jones Fracture Intramedullary Screw Fixation. Foot Ankle Int 2020; 41:379-386. [PMID: 31904264 DOI: 10.1177/1071100719898278] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the benefit of primary intramedullary (IM) screw fixation of fifth metatarsal Jones fractures in athletes is clear, limited data support its use in conventional patient populations. This study evaluated radiographic and functional outcomes following primary IM screw fixation in a series of Jones fractures to determine if similar excellent outcomes were achievable. METHODS We reviewed the data of 32 consecutive patients who underwent Jones fracture primary IM screw fixation by a single surgeon. Demographic risk factors of interest (age, gender, tobacco use, pertinent medical comorbidities, military service status, and prior nonoperative management) were collected prospectively. Primary outcomes included times to return to full weightbearing, radiographic union, and resumption of high-impact or restriction-free activities. Complications including reoperations were recorded. Categorical data are reported as frequencies, and statistical means with P values are reported for continuous variables. Mean age for the 32 patients was 33.4 years. RESULTS All 32 fractures healed uneventfully, and at mean follow-up time of 24.2 months, overall patient-reported satisfaction was 100%. Overall mean postoperative outcomes are as follows: 3.7 weeks return to full weightbearing, 10.8 weeks to radiographic union, and 13.0 weeks to resumption of restriction-free activities. Among the risk factors assessed, only preoperative peripheral vascular disease (PVD) and/or diabetes mellitus (DM) and active duty military service resulted in significantly increased and decreased time to resumption of restriction-free activities, respectively, but did not impact overall weightbearing or union times. Patient age, gender, and tobacco use had no effects on radiographic or functional outcomes. CONCLUSION Primary IM screw fixation was a safe, reliable option for all appropriate operative candidates with Jones fractures and may result in similar early weightbearing, osseous healing, and expeditious return to full activities consistently reported in high-level athletes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Ryan B Bucknam
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - John P Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Nicholas A Kusnezov
- Department of Orthopaedic Surgery, Blanchfield Army Community Hospital, Ft. Campbell, KY, USA
| | - Kenneth A Heida
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - John C Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Justin D Orr
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
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12
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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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13
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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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14
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Roberts L, Bernasconi A, Netto CDC, Elliott A, Hamilton W, O'Malley M. Cuboid Edema Syndrome Following Fixation of Proximal Fifth Metatarsal Fractures in Professional Athletes. Foot Ankle Spec 2019; 12:373-379. [PMID: 31248285 DOI: 10.1177/1938640019857798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Stress fractures of the proximal fifth metatarsal are common injuries in elite athletes. Fixation using an intramedullary screw represents the most popular surgery performed for treating these injuries, with excellent results in most cases. However, multiple reports in the literature highlight the possibility of painful hardware, usually related to the presence of the screw head, following intramedullary fixation In this case report, we outline 4 cases of professional athletes who developed lateral-based foot symptoms following complete healing of their surgically treated proximal fifth metatarsal fractures and were found to have significant cuboid edema on magnetic resonance images. We also outline recommendations regarding specific surgical technique considerations aiming to minimize this possible complication. Level of Evidence: Level V: Case report.
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Affiliation(s)
- Lauren Roberts
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York
| | - Alessio Bernasconi
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, London, Stanmore, Middlesex, UK
- Orthopaedics and Traumatology Unit, Department of Public Health, "Federico II" University of Naples, Napoli, Italy
| | - Cesar de Cesar Netto
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York
| | - Andrew Elliott
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York
| | - William Hamilton
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York
| | - Martin O'Malley
- Foot and Ankle Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York
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15
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Shaner AC, Spiker AM, Goolsby MA, Kelly BT, Helfet DL. Case report: ischial stress fracture non-union in a college football player. J Hip Preserv Surg 2018; 5:312-318. [PMID: 30393560 PMCID: PMC6206699 DOI: 10.1093/jhps/hny019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/19/2018] [Indexed: 12/31/2022] Open
Abstract
Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.
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Affiliation(s)
- Adam C Shaner
- Department of Orthopaedic Surgery, Trauma Surgery, Westchester Medical Center, New York Medical College, NY, USA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, Sports Medicine and Hip Preservation, University of Wisconsin – Madison, Madison, WI, USA
| | | | - Bryan T Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David L Helfet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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16
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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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17
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High-Risk Stress Fractures: Diagnosis and Management. PM R 2017; 8:S113-24. [PMID: 26972260 DOI: 10.1016/j.pmrj.2015.09.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 09/22/2015] [Accepted: 09/25/2015] [Indexed: 12/11/2022]
Abstract
Stress fractures are common overuse injuries in athletes. They occur during periods of increased training without adequate rest, disrupting normal bone reparative mechanisms. There are a host of intrinsic and extrinsic factors, including biochemical and biomechanical, that put athletes at risk. In most stress fractures, the diagnosis is primarily clinical, with imaging indicated at times, and management focused on symptom-free relative rest with advancement of activity as tolerated. Overall, stress fractures in athletes have an excellent prognosis for return to sport, with little risk of complication. There is a subset of injuries that have a greater risk of fracture progression, delayed healing, and nonunion and are generally more challenging to treat with nonoperative care. Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites share a characteristic region of high tensile load and low blood flow. High-risk stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment. Treatment consists of nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity. These stress fractures may require surgical intervention. A high index of suspicion is essential to avoid delayed diagnosis and optimize outcomes in this subset of stress fractures.
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18
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Yates J, Feeley I, Sasikumar S, Rattan G, Hannigan A, Sheehan E. Jones fracture of the fifth metatarsal: Is operative intervention justified? A systematic review of the literature and meta-analysis of results. Foot (Edinb) 2015; 25:251-7. [PMID: 26481787 DOI: 10.1016/j.foot.2015.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/30/2015] [Accepted: 08/03/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study assesses the outcomes of surgical vs. conservative management in the treatment of the Jones fracture. MATERIALS AND METHODS A systematic review using four databases from their inception until September 2014 was undertaken. Six studies were found evaluating operative therapy compared to conservative treatment. RESULTS Six relevant studies were included, with a total of 237 patients. Of these, 51% were treated non-operatively, and 49% had surgical intervention. Those in the non-operative group were found to have a significantly higher odds ratio (OR) of fracture non-union (OR 5.74, 95% confidence interval (CI) 2.65-12.40, P<0.001). Studies also reported a prolonged healing time and a longer time to return to sports. Of the trials with time to union as an outcome measure, 3 of 4 trials found favourable results in the operative cohort. CONCLUSIONS Surgical intervention is recommended for patients presenting with a Jones fracture as it is found to result in a lesser non-union rate and an improved time to union.
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Affiliation(s)
- Jeffrey Yates
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Iain Feeley
- Midlands Regional Hospital, Tullamore, Co Offaly, Ireland.
| | | | - Gurender Rattan
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Ailish Hannigan
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Eoin Sheehan
- Midlands Regional Hospital, Tullamore, Co Offaly, Ireland
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19
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Hoffman DF, Nazarian LN, Smith J. Enthesopathy of the lateral cord of the plantar fascia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1711-1716. [PMID: 25154957 DOI: 10.7863/ultra.33.9.1711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The objective of this study was to raise awareness of the diagnosis of enthesopathy of the lateral cord of the plantar fascia (LCPF) and describe its sonographic findings. We conducted a retrospective case series of 13 sonographic examinations with the diagnosis of LCPF enthesopathy. Two cadaver dissections of the plantar foot were performed for anatomic correlation. Sonographic findings of LCPF enthesopathy included generalized or focal hypoechoic thickening, loss of the normal fibrillar echo texture, cortical irregularity of the fifth metatarsal tuberosity, and vascularity on color Doppler imaging. Anatomic dissections of the plantar foot detailed the course of the LCPF and served as a guide for optimal sonographic imaging. Enthesopathy of the LCPF is an important etiology of nontraumatic pain at the base of the fifth metatarsal. Sonographic evaluation can readily show the characteristic findings of LCPF enthesopathy.
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Affiliation(s)
- Douglas F Hoffman
- Department of Orthopedics and Radiology, Essentia Health, Duluth, Minnesota USA (D.F.H.); Department of Radiology, Thomas Jefferson University Hospital; Philadelphia, Pennsylvania USA (L.N.N.); and Departments of Physical Medicine and Rehabilitation and Radiology, Mayo Clinic College of Medicine and Mayo Clinic Sports Medicine Center, Rochester, Minnesota USA (J.S.).
| | - Levon N Nazarian
- Department of Orthopedics and Radiology, Essentia Health, Duluth, Minnesota USA (D.F.H.); Department of Radiology, Thomas Jefferson University Hospital; Philadelphia, Pennsylvania USA (L.N.N.); and Departments of Physical Medicine and Rehabilitation and Radiology, Mayo Clinic College of Medicine and Mayo Clinic Sports Medicine Center, Rochester, Minnesota USA (J.S.)
| | - Jay Smith
- Department of Orthopedics and Radiology, Essentia Health, Duluth, Minnesota USA (D.F.H.); Department of Radiology, Thomas Jefferson University Hospital; Philadelphia, Pennsylvania USA (L.N.N.); and Departments of Physical Medicine and Rehabilitation and Radiology, Mayo Clinic College of Medicine and Mayo Clinic Sports Medicine Center, Rochester, Minnesota USA (J.S.)
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20
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Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CWC. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med 2014; 49:370-6. [PMID: 25138980 DOI: 10.1136/bjsports-2013-093246] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. METHODS Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective studies. Two reviewers independently extracted data and assessed methodological quality. Main outcomes were return to sport and complication rate. RESULTS 18 studies were included (2 anterior tibia (N=31), 8 navicular (N=200) and 8 fifth metatarsal (N=246)). For anterior tibial fracture, no studies on initial surgery were eligible. Conservative treatment resulted in high complication rates and few cases returned to sport. For navicular fracture, a weighted mean return to sport of 22 for conservative and 16 weeks for surgical treatment was found. Six weeks of non-weightbearing cast was mostly used as conservative treatment. Surgical procedures varied widely. For the fifth metatarsal fracture, weighted mean return to sport was 19 for conservative and 14 weeks for surgical treatment. Surgery consisted of intramedullary screw fixation or tension band wiring. For conservative methods, insufficient details were reported. Overall, there was a high risk of bias; sample sizes were small and GRADE level of evidence was low. CONCLUSIONS Strong conclusions for surgical or conservative therapy for these high-risk stress fractures cannot be drawn; quality of evidence is low and subjected to a high risk of bias. However, there are unsatisfying outcomes of conservative therapy in the anterior tibia. The role of initial surgery is unknown. For the navicular, surgery provided an earlier return to sport; and when treated conservatively, weightbearing should be avoided. For the fifth metatarsal, surgery provided the best results. Treatment decision-making would greatly benefit from further prospective research. STUDY REGISTRATION NUMBER PROSPERO database of systematic reviews: CRD42013004201.
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Affiliation(s)
- Wouter H Mallee
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke Weel
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department Health Sciences, EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Gino M Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Chung-Wei Christine Lin
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
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