592836 research-articleXXXX

FASXXX10.1177/1938640015592836Foot & Ankle SpecialistFoot & Ankle Specialist

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〈 Clinical Research 〉 Failed Surgical Management of Acute Proximal Fifth Metatarsal (Jones) Fractures

Jaymes D. Granata, MD, Gregory C. Berlet, MD, Terrence M. Philbin, DO, Grant Jones, MD, Christopher C. Kaeding, MD, and Kyle S. Peterson, DPM

A Retrospective Case Series and Literature Review Abstract: Nonunion, delayed union, and refracture after operative treatment of acute proximal fifth metatarsal fractures in athletes is uncommon. This study was a failure analysis of operatively managed acute proximal fifth metatarsal fractures in healthy athletes. We identified 149 patients who underwent operative treatment for fifth metatarsal fractures. Inclusion criteria isolated skeletally mature, athletic patients under the age of 40 with a minimum of 1-year follow-up. Patients were excluded with tuberosity fractures, fractures distal to the proximal metaphyseal-diaphyseal region of the fifth metatarsal, multiple fractures or operative procedures, fractures initially treated conservatively, and medical comorbidities/risk factors for nonunion. Fifty-five patients met the inclusion/exclusion criteria. Four

associated with early postoperative (7.3%) patients required a secondary weight-bearing protocol. Maximizing operative procedure due to refracture. initial fixation stiffness may decrease The average time to refracture the late failure rate in competitive was 8 months. All refractures were associated with bent screws and occurred in male patients The proximal fifth metatarsal is the who participated in professional basketball, most commonly fractured bone in the professional volleyball, foot . . .” and college football. The average time for release to progressive weight-bearing was 6 weeks. Three athletes. More clinical studies are patients were revised to a bigger size needed to better understand risk screw and went on to union. One factors for failure after screw fixation patient was revised to the same-sized in the competitive, athletic population. screw and required a second revision Levels of Evidence: Prognostic Level surgery for nonunion. All failures IV, Case series were refractures in competitive athletes who were initially treated with small Keywords: Jones fracture; proximal diameter solid or cannulated stainless fifth metatarsal; nonunion; delayed steel screws. The failures were not union; revision surgery



DOI: 10.1177/1938640015592836. From the Desert Orthopaedic Center, Las Vegas, Nevada (JDG); Orthopedic Foot and Ankle Center, Westerville, Ohio (GCB, TMP); Department of Orthopaedics, The OSU Sports Medicine Center, The Ohio State University Medical Center, Columbus, Ohio (GJ); Department of Orthopaedics and The OSU Athletic Department, Columbus, Ohio (CCK); and Suburban Orthopaedics, Bartlett, Illinois (KSP). Address correspondence to Terrence M. Philbin, DO, Orthopedic Foot and Ankle Center, 300 Polaris Pkwy, Suite 2000, Westerville, OH 43082; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)

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T

he diagnosis and treatment of proximal fifth metatarsal fractures has been a topic of much debate over the last century. Discrepancies in fracture classifications, natural history, and optimal treatment methods have led to some controversy in the published literature. The proximal fifth metatarsal is the most commonly fractured bone in the foot and a clear understanding of the different fracture characteristics is important for proper management.1 In 1902, Robert Jones described a small case series of 4 patients with proximal fifth metatarsal metaphyseal-diaphyseal fractures.2 He included himself as a patient in the series after sustaining a proximal fifth metatarsal fracture while dancing. Since that original report, the eponym “Jones” has become synonymous with proximal fifth metatarsal fractures. The definition of a “Jones” fracture has not been consistent in the literature. A Jones fracture is most often described as occurring in the metaphyseal-diaphyseal region of the proximal fifth metatarsal, distal to the tuberosity, and exiting toward or through the fourth to fifth intermetatarsal joint. Differentiating between the Jones fracture and proximal diaphyseal fractures may be difficult in some cases. The sometimes subtle differences may not be important from a prognostic standpoint, as both fracture types are associated with delayed healing and nonunion.3 For the purpose of this study, all proximal metaphyseal-diaphyseal fractures distal to the tuberosity were considered to be Jones fractures. This may be the most pure definition of a Jones fracture, as the original reported series depicted both fracture types.2,3 The inherent healing difficulties of the Jones fracture was described in 1927 by Carp, who reported a 24% delayed union rate.4 The proximal metaphysealdiaphyseal region of the fifth metatarsal was thought to be a watershed area with poor blood supply. Subsequent anatomical studies have confirmed the tenuous blood supply in this region.5,6 The inherent healing difficulties associated with Jones fractures have led many surgeons to recommend surgery as

the initial treatment of choice, especially in the athletic population. Operative treatment with intramedullary screw fixation has become a well-accepted treatment method. There is little published literature on failed operative management of acutely treated Jones fractures in athletes. The purpose of this study was to review the results of operative management of acute proximal fifth metatarsal (Jones) fractures in a competitive athletic population, with particular attention to implant selection.

Materials and Methods Institutional review board approval was obtained for this study. Current procedural terminology codes were used to identify all patients who underwent operative treatment for fifth metatarsal fractures at our sports clinic over a 19-year period. A retrospective chart review was performed to select for patients who failed operative management. Information regarding the activity level (elite vs recreational athlete), presence of prodromal symptoms, postoperative weight-bearing status, return to play, screw size, screw type (solid vs cannulated; titanium vs steel), and complications (nonunion, delayed union, and refracture) were collected and reviewed. Inclusion criteria were used to select for skeletally mature, athletic patients under the age of 40 with a minimum of 1-year follow-up. The following exclusion criteria were applied to select for acute “Jones”-type fractures: tuberosity fractures, fractures distal to the proximal metaphyseal-diaphyseal region of the fifth metatarsal, multiple fractures or operative procedures, fractures initially treated conservatively up to 4 weeks from acute injury, and medical comorbidities and risk factors for nonunion, including diabetes and smoking.

Results One hundred and forty-nine patients with fifth metatarsal fractures were

identified in the initial chart review. Fiftyfive patients met the inclusion/exclusion criteria with an acutely treated Jones fracture. Four (7.3%; 4/55) patients were identified based on clinical review as failures requiring a secondary operative procedure. All 4 failures were due to refracture. This was determined based on patient complaints of pain and radiographs confirming a refracture through a previously healed fifth metatarsal. The average time to refracture was 8 months (range = 2.5-15). All refractures were associated with bent small diameter solid or cannulated screws, ranging from 3.5 to 5.0 mm in diameter. All the refractures occurred in male patients, average age of 23, who participated in the following elite competitive sports: professional basketball, professional volleyball, Division I college football, and high school football (Table 1). There were no nonunions or delayed unions in the initial cohort of patients. Average follow-up for all patients was 30 months (range = 16-38), with none lost to follow-up. The average time for release to progressive weight-bearing for all patients was 6 weeks. In the 4 patients who sustained a refracture, 3 were revised to a bigger size screw, while orthobiologics and external bone stimulators were also used to augment healing. The fourth patient was revised to the same-sized screw, but also required a second revision surgery for nonunion. One revision case required a Dwyer osteotomy to correct a varus heel, which was thought to be a biomechanical force contributing to the refracture. Figures 1A,B through 4A,B are representative radiographs for the initial injury (Figure 1A and B), initial postoperative fixation (Figure 2A and B), failure films (Figure 3A and B), and successful revision (Figure 4A and B).

Discussion The delayed and nonunion rates for conservatively treated acute Jones fractures range from 7% to 67%.7-11 Conservative management is also

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Table 1. Patient Demographics and Failure Analysis. Fixation

Weeks to Full Weight-Bearing

Age

Sport

Male

21

College football

4.5-mm cannulated stainless steel screw

8

Refracture, bent screw

 6

Male

17

College football

5.0-mm cannulated stainless steel screw

6

Refracture, bent screw

 7

Male

31

Professional basketball

5.0-mm cannulated stainless steel screw

6

Refracture, bent screw

2.5

Male

23

Professional volleyball

3.5-mm solid stainless steel screw

6

Refracture, bent screw

15

Figure 1. Initial injury radiographs: (A) anteroposterior and (B) oblique views.

associated with longer healing times. For some patients, the nonunion rates and prolonged immobilization required for conservative management are undesirable. This is especially true in many athletes, who are interested in getting the best results in the shortest amount of time possible. Kavanaugh

et al9 emphasized the importance of acute operative management of athletes using intramedullary screw fixation. They reported a series of 22 patients, with 21 injuries related to athletic activities. Twelve of the 18 patients (67%) initially treated conservatively had delayed unions. Five of the athletes

Failure Mode

Failure Date (Months)

Gender

required prolonged immobilization, potentially compromising a future athletic career in professional sports. They concluded that the Jones fracture in an athlete can be tremendously disabling and recommended initial operative management with intramedullary screw fixation to increase healing rates and avoid prolonged immobilization. Primary operative fixation in athletes has been subsequently advocated in the literature and is considered to be the preferred treatment method by many surgeons. Because of the success of intramedullary screw fixation, there is a limited amount of literature regarding failed operative management of Jones fractures. Portland et al12 reported a 100% healing rate of acutely treated Jones fractures, including proximal diaphyseal stress fractures, in 22 patients over a 5-year period. Their patient population consisted of both athletes and nonathletes; all treated successfully with either 4.5-mm stainless steel or 5.0-mm titanium cannulated screws. There was an overall complication rate of 9% due to painful hardware. The authors concluded that acute operative management with intramedullary screw fixation produces predictable outcomes and rapid recovery and is the treatment of choice for both athletes and nonathletes alike.

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Figure 2. First postoperative radiographs: (A) anteroposterior and (B) oblique views.

Figure 3. Six months postoperative radiographs demonstrating refracture: (A) anteroposterior and (B) oblique views.

In a prospective randomized trial by Mologne et al,13 patients were randomized to either cast treatment or acute operative fixation with an intramedullary screw. Cast treatment resulted in a 44% complication rate related to delayed healing, refracture, or nonunion. In the operatively treated group, 1 of 19 (5.2%) patients failed operative management. Glasgow et al14 analyzed the failed operative management of Jones fractures after intramedullary screw fixation or corticocancellous grafting. With intramedullary screw fixation, 3 delayed unions and 3 refractures were reported. This was attributed to early postoperative weight-bearing and the use of screws smaller than 4.5 mm. Corticocancellous grafting resulted in 1 nonunion and 4 refractures, 1 through the graft and 3 through the original fracture site. Failure in the grafting group was attributed to undersized grafts and incomplete debridement of the intramedullary sclerosis. Six cases of refracture in athletes after intramedullary screw fixation were reported by Wright et al.15 All refractures occurred in athletes who returned to sport after clinical and radiographic evidence of complete healing. To treat the refracture, the authors reported both operative and conservative management techniques, including revision screw fixation, bone grafting, and immobilization. All patients healed regardless of the treatment method. The athletes who underwent revision screw fixation with a larger diameter screw were able to return to sport in the same season. Larson et al16 reported an operative failure rate of 40% after acute intramedullary screw fixation of proximal fifth metatarsal fractures. Four patients refractured and 2 patients had symptomatic nonunions. Five of the 6 patients had revision procedures performed, including bone grafting and screw exchange. All patients healed between 8 and 18 weeks after their second operation. The authors concluded that elite athletes who

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Figure 4. Radiographs depicting revision surgery with larger diameter screw: (A) anteroposterior and (B) oblique views.

the high level of activity and the physical demand placed on the foot during competitive sport. The current study suggests that intramedullary screw fixation for Jones-type fifth metatarsal fractures in high-demand athletes may be best achieved by maximizing the screw size and strength. Selecting large screws that resist fatigue bending may be beneficial in reducing the refracture rate for this specific cohort of high-demand patients. Further clinical studies are needed to better understand the risk factors associated with failed intramedullary screw fixation in athletes, including possible associations with foot shape, bracing, orthotics, and footwear.

References returned to play before complete radiographic healing were at increased risk of operative failure. An operatively treated Jones fracture in athletes was also reported in a retrospective, comparison study of 4.5- and 5.5-mm cannulated stainless steel screws.17 The authors reported bent screws in 12.5% (3/24) of patients in the 4.5-mm group without any refracture. They also demonstrated a reinjury rate of 15% (3/20) in the 5.5-mm group without any bent screws. They noted superior bending strength with the larger 5.5-mm screw and recommended to match the screw size with canal size and shape. The outcomes of revision surgery for failed fifth metatarsal fractures in athletes were reported by Hunt and Anderson.18 All failures were revised with solid screws and bone grafting. Twenty-one of the 22 patients healed uneventfully and all patients returned to sport. They concluded that revision surgery with this technique was effective and that, in general, screw fixation for athletes should be achieved with 5.5-mm or 6.5-mm solid screws. Most published studies report low failure rates of acute intramedullary screw fixation of Jones fractures in the healthy, athletic population, consistent with the 7% failure rate in our current

series. There is a substantial variation in the reported success rate, and it is important to identify the variables associated with failure. Our current study supports previously published literature that has identified elite athletes as particularly prone to failure, possibly due to increased physical demands and inadequate fixation.16,18,19 Despite clinical and radiographic evidence of a healed fracture after an early weight-bearing rehabilitation protocol and successful return to play, the athletes in our series were subject to late failure by refracture. This was associated with bending of a small diameter solid screw in 1 case and cannulated screws in 3 cases. Although bent screws were identified in the failure group, the authors cannot conclude this was the primary cause of refracture. Many factors may have contributed to the bending of screws in our athletic patients. Biomechanical issues, such as a varus heel, may have contributed to the refracture in one of our patients. This can cause greater stress on the lateral foot during weight-bearing postoperatively. Additionally, as most competitive athletes are anxious to return to sport, early weight-bearing may have added stress on the operatively repaired fracture sites. Other confounding factors include

1. Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27:172-174. 2. Jones RI. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg. 1902;35:697-700.2. 3. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008;466:1966-1970. 4. Carp L. Fracture of the fifth metatarsal bone: with special reference to delayed union. Ann Surg. 1927;86:308-320. 5. Shereff MJ, Yang QM, Kummer FJ, Frey CC, Greenidge N. Vascular anatomy of the fifth metatarsal. Foot Ankle. 1991;11:350-353. 6. Smith JW, Arnoczky SP, Hersh A. The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing. Foot Ankle. 1992;13: 143-152. 7. Dameron TB Jr. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am. 1975;57:788-792. 8. Fernandez Fairen M, Guillen J, Busto JM, Roura J. Fractures of the fifth metatarsal in basketball players. Knee Surg Sports Traumatol Arthrosc. 1999;7:373-377. 9. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am. 1978;60:776-782. 10. Stewart IM. Jones’s fracture: fracture of base of fifth metatarsal. Clin Orthop. 1960;16:190-198. 11. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of

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the fifth metatarsal distal to the tuberosity. Classification and guidelines for nonsurgical and surgical management. J Bone Joint Surg Am. 1984;66:209-214. 12. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones’ fractures. Foot Ankle Int. 2003;24:829-833. 13. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33: 970-975. 14. Glasgow MT, Naranja RJ Jr, Glasgow SG, Torg JS. Analysis of failed surgical

management of fractures of the base of the fifth metatarsal distal to the tuberosity: the Jones fracture. Foot Ankle Int. 1996;17: 449-457. 15. Wright RW, Fischer DA, Shively RA, Heidt RS Jr, Nuber GW. Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med. 2000;28: 732-736. 16. Larson CM, Almekinders LC, Taft TN, Garrett WE. Intramedullary screw fixation of Jones fractures. Analysis of failure. Am J Sports Med. 2002;30:55-60.

17. Porter DA, Rund AM, Dobslaw R, Duncan M. Comparison of 4.5- and 5.5-mm cannulated stainless steel screws for fifth metatarsal Jones fracture fixation. Foot Ankle Int. 2009;30:27-33. 18. Hunt KJ, Anderson RB. Treatment of Jones fracture nonunions and refractures in the elite athlete: outcomes of intramedullary screw fixation with bone grafting. Am J Sports Med. 2011;39:1948-1954. 19. Nunley JA, Glisson RR. A new option for intramedullary fixation of Jones fractures: the Charlotte Carolina Jones Fracture System. Foot Ankle Int. 2008;29:1216-1221.

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Failed Surgical Management of Acute Proximal Fifth Metatarsal (Jones) Fractures: A Retrospective Case Series and Literature Review.

Nonunion, delayed union, and refracture after operative treatment of acute proximal fifth metatarsal fractures in athletes is uncommon. This study was...
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