The Journal of Foot & Ankle Surgery 54 (2015) 227–229
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Screw Fixation Diameter for Fifth Metatarsal Jones Fracture: A Cadaveric Study Ryan T. Scott, DPM, FACFAS 1, Christopher F. Hyer, DPM, MS, FACFAS 2, Shyler L. DeMill, DO 3 1
Podiatric Surgeon, The CORE Institute, Phoenix, AZ Fellowship Director, Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center, Westerville, OH 3 Orthopedic Surgeon, Orthopedics Northwest, Yakima, WA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 5
The fifth metatarsal Jones fracture is a well-documented injury occurring at the proximal diaphysealmetaphyseal junction. Conservative versus surgical intervention has been discussed in published studies for the management of Jones fractures. Solid intramedullary fixation relies on accurate matching of the screw diameter to the intraosseous diameter. The purpose of the present cadaveric study was to determine the average intraosseous diameter of the proximal fifth metatarsal as it relates to screw size selection for Jones fracture stabilization. Twenty fresh-frozen cadaver legs were used for examination. The fifth metatarsal was completely dissected. A transverse osteotomy was performed from laterally to medially along the midline of the metatarsal. A digital caliper was used to measure the diameter of the medullary canal of the fifth metatarsal. The measurement was taken at the narrowest portion of the medullary canal just distal to the proximal metaphysis. The mean dorsal to plantar diameter of the fifth metatarsal was 6.475 1.54 (range 4 to 12) mm and the mean medial to lateral diameter was 4.6 0.85 (range 3 to 6) mm. Intramedullary screw fixation has shown beneficial results in the treatment protocol of fifth metatarsal Jones fractures. Our study has demonstrated that a 4.5-mm cannulated screw is the narrowest diameter screw that can be used in the average fifth metatarsal and still obtain adequate intraosseous purchase. When selecting the appropriate screw, the surgeon must be comfortable selecting the largest screw that will achieve the maximal interface with the dense cortical bone in both the medial to lateral and dorsal to plantar plane. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: fracture stabilization metaphysis nonunion open reduction internal fixation screw diameter
The fifth metatarsal Jones fracture is a well-documented injury occurring at the proximal diaphyseal-metaphyseal junction of the fifth metatarsal (Fig. 1). Conservative versus surgical intervention has been debated in published studies for the management of the Jones fracture. Numerous publications have advised surgical management in the young active athlete (1–4). Compared with nonsurgical management, intramedullary screw fixation results in a shorter interval to fracture union, reduced complication rates, and an earlier return to preinjury activities compared with nonsurgical cast immobilization (1–8). Appropriate preoperative planning and proper intraoperative judgment greatly dictates the surgical outcomes for these athletes. Solid intramedullary fixation relies on accurate matching of the screw
Financial Disclosure: DJO Global funded the cadaveric study. Conflict of Interest: None reported. Address correspondence to: Christopher F. Hyer, DPM, MS, FACFAS, Fellowship Director, Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082. E-mail address: [email protected] (C.F. Hyer).
diameter to the intraosseous diameter of the fifth metatarsal. Undersizing of the screw will result in poor thread purchase and a lack of fracture stability, which will greatly increase the risk of adverse events, such as delayed union, nonunion, and hardware failure. In contrast, oversizing of the screw can lead to iatrogenic fracture or cortical blowout, further compromising the integrity of the metatarsal. Fifth metatarsal Jones fractures can be managed with either intramedullary screws or plate fixation. Screw fixation has been the standard of care owing to the ease of percutaneous insertion. Recently, several studies have shown the efficacy of hook plates for the management of fifth metatarsal fractures, most notably avulsion fractures (9,10). Biomechanical studies comparing screw fixation versus plate fixation in midfoot arthrodesis have shown no significant differences in stiffness and pullout strength. However, a slight trend was seen toward a stiffer construct with plate fixation. This supports the use for intramedullary screw fixation in the stabilization of the Jones fracture (11–14). Our goal with the present investigation was to provide a general guideline to screw selection for Jones fracture stabilization. The present cadaveric study was designed to determine the average
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.11.010
228
R.T. Scott et al. / The Journal of Foot & Ankle Surgery 54 (2015) 227–229
Fig. 1. Typical presentation of a Jones fracture at the diaphysis of the fifth metatarsal.
intraosseous diameter of the proximal fifth metatarsal as it relates to screw size. Materials and Methods A cadaveric model was used to determine the average medullary diameter of the fifth metatarsal. Twenty fresh-frozen adult cadaver legs, 15 males (75%) and 5 females (25%), with a mean age of 73.25 9.33 (range 60 to 92) years, were used for examination at the San Diego Cadaver Anatomy Research Symposium. To be included, the cadaver specimens could not display any gross evidence of injury or defect before measurement. The fifth metatarsal was completely dissected from the foot, including removal of all soft tissue (R.T.S., S.L.D.). A transverse osteotomy was performed from laterally to medially along the midline of the metatarsal (R.T.S., S.L.D.). The sectioned metatarsal was then measured in millimeters using a digital caliper (6-in. 3-Mode Digital Caliper 147, General Tools, New York, NY) by 2 of the authors (R.T.S., S.L.D.). The measurements were taken at the narrowest portion of the medullary canal just distal to the proximal metaphysis, giving us our medial to lateral diameter. The dorsal to plantar diameter was measured for each of the respective sectioned specimens. All data were recorded in a spreadsheet for later statistical analysis.
Results The mean dorsal to plantar diameter of the fifth metatarsal measured 6.475 1.54 (range 4 to 12) mm. The mean medial to lateral diameter measured 4.6 0.85 (range 3 to 6) mm. Discussion Intramedullary screw fixation has shown beneficial results in the treatment protocol of fifth metatarsal Jones fractures. Our study has demonstrated that a 4.5-mm cannulated screw is the narrowest diameter screw that should be selected for the average fifth metatarsal. This should be considered a general guideline for obtaining adequate intraosseous purchase and compression across the fracture site. We have typically used a 4.5-, 5.0-, or 5.5-mm screw, depending on the patient’s anatomy. Recently, a computed tomography model was created with 119 fifth metatarsals to measure the metatarsal length, distance from the base to the haft of curvature, and canal diameter (5). The average coronal canal diameter at the isthmus was 5.0 mm. A coronal diameter >4.5 mm at the isthmus was present in 81% of the males and 74% of the females. Kelly et al (6) performed a cadaveric study with 23 paired fifth metatarsals, which were fixed with 5.0- and 6.5-mm screws. They
noted no significant differences in the bending stiffness of the fractures between the 2 different diameter screws. However, the pullout strength of the 6.5-mm screw was greater. Shah et al (7) also tested the initial load to failure with a 4.5- versus 5.5-mm screw. No statistically significant difference was noted in the respective screws (332.4 N versus 335.2 N). They concluded that maximizing the screw diameter did not appear to be critical for fixation rigidity. Porter et al (8) compared the use of a 4.5- and 5.5-mm cannulated stainless steel screw in the fixation of Jones fractures in athletes. Clinical effectiveness was noted with the 5.5-mm screw; however, no statistical significance was noted compared with the 4.5-mm screw. Both stainless steel and titanium screws have been well accepted for the treatment of the Jones fracture. The material selected is truly determined by surgeon preference. However, DeVries et al (2) noted a greater incidence of union in the Jones fracture when a titanium screw (36 of 37) was used for fixation compared with stainless steel (14 of 16). Metzl et al (3) performed a similar retrospective comparative analysis to review the use of an indication-specific screw (solid) versus treatment with traditional screw fixation (cannulated). No significant difference was found between the 2 groups in terms of fracture union; however, a greater number of adverse events occurred in the group treated with traditional screw fixation (p ¼ .03). The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 case of symptomatic hardware, all requiring additional surgical interventions. All adverse events occurred within an average of 2 months after surgery. They concluded that indication-specific screws were superior in the management of the acute Jones fracture. When managing the acute Jones fracture, the ultimate goal is to efficiently return the patient to sport or daily activity. A recent study by Nagao et al (15) reported their athletes were able to return to running activities 6.3 weeks after open reduction and internal fixation of the Jones fracture. They further reported that the mean interval to full activity was 11.2 weeks, with a 0.16% (1 of 60) complication rate. Habbu et al (16) noted union was achieved in 14 patients, with 1 delayed union, when using intramedullary screw fixation for Jones fracture management. The mean interval to union was 13.3 (range 8 to 20) weeks. All patients were able to start unassisted full weightbearing without pain at a mean of 10.2 weeks. Similar findings were reported by Murawski and Kennedy (17) and Choi et al (9) regarding union and a return to full activity with screw fixation. Recent meta-analyses reviewed the most recent 26 studies published on the management of the Jones fracture. The generalization noted was that Jones fractures heal more predictably and more quickly with surgery compared with nonoperative treatment. Roche and Calder (4) reported that acute fractures treated nonoperatively had a union rate of 76% and that fractures treated with a screw had a union rate of 96%. One potential weakness of the present study was the use of the cadaveric model. We were able to construct our recommendation for the 4.5-mm screw according to the medial to lateral intramedullary diameter of the fifth metatarsal. However, the dorsal to plantar diameter of the fifth metatarsal can accommodate a much larger screw, such as a 5.0- or 5.5-mm screw (Fig. 2). Multiple questions have been posed about the use of intramedullary devices for bone fixation. A study by Greksa et al (18) showed that tibial reaming alone caused significant increases in overall blood vessel and capillary densities in the periosteum compared with those of intact tibias. Implantation with a titanium nail resulted in firm embedding of the nail and caused changes in the periosteal vasculature similar to those after reaming alone. However, the endosteal blood flow was reduced overall. When a smaller diameter device was placed, intramedullary revascularization occurred, together with remodeling of the endosteal, primary bone to
R.T. Scott et al. / The Journal of Foot & Ankle Surgery 54 (2015) 227–229
229
References
Fig. 2. Placement of a 5.5-mm intramedullary solid screw for the management of a Jones fracture.
mature lamellar bone in a tibia model (19). This raises the question of plating metatarsal fractures to reduce the endosteal damage. It has been suggested that a locking compression plate can be considered as an alternative treatment of multifragmentary, osteoporotic, and tuberosity avulsion (zone 1 and II) fifth metatarsal base fractures (9,10). In conclusion, intraoperative selection of the appropriate screw diameter is essential to the overall outcome in the management of the acute Jones fracture. The surgeon must be comfortable selecting the largest screw that will achieve maximal purchase with the dense cortical bone in both the medial to lateral and the dorsal to plantar planes to ensure adequate compression across the fracture site.
1. Smith TO, Clark A, Hing CB. Interventions for treating proximal fifth metatarsal fractures in adults: a meta-analysis of the current evidence-base. Foot Ankle Surg 17:300–307, 2011. 2. DeVries JG, Cuttica DJ, Hyer CF. Cannulated screw fixation of Jones fifth metatarsal fractures: a comparison of titanium and stainless steel screw fixation. J Foot Ankle Surg 50:207–212, 2011. 3. Metzl J, Olson K, Davis WH, Jones C, Cohen B, Anderson R. A clinical and radiographic comparison of two hardware systems used to treat Jones fracture of the fifth metatarsal. Foot Ankle Int 34:956–961, 2013. 4. Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc 21:1307–1315, 2013. 5. Ochenjele G, Ho B, Switaj PJ, Fuchs D, Goyal N, Kadakia AR. Radiographic study of the fifth metatarsal for optimal intramedullary screw fixation of Jones fracture. Foot Ankle Int Epub 2014 Sep 24. pii: 1071100714553467. [Epub ahead of print]. 6. Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA. Intramedullary screw fixation of Jones fractures. Foot Ankle Int 22:585–589, 2001. 7. Shah SN, Knoblich GO, Lindsey DP, Kreshak J, Yerby SA, Chou LB. Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int 22:581–584, 2001. 8. 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 30:27–33, 2009. 9. Choi JH, Lee KT, Lee YK, Lee JY, Kim HR. Surgical results of zones I and II fifth metatarsal base fractures using hook plates. Orthopedics 36:e71–e74, 2013. 10. Lee SK, Park JS, Choy WS. Locking compression plate distal ulna hook plate as alternative fixation for fifth metatarsal base fracture. J Foot Ankle Surg 53:522–528, 2014. 11. Cottom JM, Rigby RB. Biomechanical comparison of a locking plate with intraplate compression screw versus locking plate with plantar interfragmentary screw for Lapidus arthrodesis: a cadaveric study. J Foot Ankle Surg 52:339–342, 2013. 12. Gruber F, Sinkov VS, Bae SY, Parks BG, Schon LC. Crossed screws versus dorsomedial locking plate with compression screw for first metatarsocuneiform arthrodesis: a cadaver study. Foot Ankle Int 29:927–930, 2008. 13. Jarrell SE III, Owen JR, Wayne JS, Adelaar RS. Biomechanical comparison of screw versus plate/screw construct for talonavicular fusion. Foot Ankle Int 30:150–156, 2009. 14. Pope EJ, Takemoto RC, Kummer FJ, Mroczek KJ. Midfoot fusion: a biomechanical comparison of plantar planting vs intramedullary screws. Foot Ankle Int 34:409–413, 2013. 15. Nagao M, Saita Y, Kameda S, Seto H, Sadatsuki R, Takazawa Y, Yoshimura M, Aoba Y, Ikeda H, Kaneko K, Nozawa M, Kim SG. Headless compression screw fixation of Jones fractures: an outcomes study in Japanese athletes. Am J Sports Med 40:2578–2582, 2012. 16. Habbu RA, Marsh RS, Anderson JG, Bohay DR. Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture. Foot Ankle Int 32:603–608, 2011. 17. Murawski CD, Kennedy JG. Percutaneous internal fixation of proximal fifth metatarsal Jones fractures (Zones II and III) with Charlotte Carolina screw and bone marrow aspirate concentrate: an outcome study in athletes. Am J Sports Med 39:1295–1301, 2011. 18. Greksa F, Toth K, Boros M, Szabo A. Periosteal microvascular reorganization after tibial reaming and intramedullary nailing in rats. J Orthop Sci 17:477–483, 2012. 19. Pazzaglia UE. Periosteal and endosteal reaction to reaming and nailing: the possible role of revascularization on the endosteal anchorage of cementless stems. Biomaterials 17:1009–1014, 1996.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Screw Fixation Diameter for Fifth Metatarsal Jones Fracture: A Cadaveric Study Ryan T. Scott, DPM, FACFAS 1, Christopher F. Hyer, DPM, MS, FACFAS 2, Shyler L. DeMill, DO 3 1
Podiatric Surgeon, The CORE Institute, Phoenix, AZ Fellowship Director, Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center, Westerville, OH 3 Orthopedic Surgeon, Orthopedics Northwest, Yakima, WA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 5
The fifth metatarsal Jones fracture is a well-documented injury occurring at the proximal diaphysealmetaphyseal junction. Conservative versus surgical intervention has been discussed in published studies for the management of Jones fractures. Solid intramedullary fixation relies on accurate matching of the screw diameter to the intraosseous diameter. The purpose of the present cadaveric study was to determine the average intraosseous diameter of the proximal fifth metatarsal as it relates to screw size selection for Jones fracture stabilization. Twenty fresh-frozen cadaver legs were used for examination. The fifth metatarsal was completely dissected. A transverse osteotomy was performed from laterally to medially along the midline of the metatarsal. A digital caliper was used to measure the diameter of the medullary canal of the fifth metatarsal. The measurement was taken at the narrowest portion of the medullary canal just distal to the proximal metaphysis. The mean dorsal to plantar diameter of the fifth metatarsal was 6.475 1.54 (range 4 to 12) mm and the mean medial to lateral diameter was 4.6 0.85 (range 3 to 6) mm. Intramedullary screw fixation has shown beneficial results in the treatment protocol of fifth metatarsal Jones fractures. Our study has demonstrated that a 4.5-mm cannulated screw is the narrowest diameter screw that can be used in the average fifth metatarsal and still obtain adequate intraosseous purchase. When selecting the appropriate screw, the surgeon must be comfortable selecting the largest screw that will achieve the maximal interface with the dense cortical bone in both the medial to lateral and dorsal to plantar plane. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: fracture stabilization metaphysis nonunion open reduction internal fixation screw diameter
The fifth metatarsal Jones fracture is a well-documented injury occurring at the proximal diaphyseal-metaphyseal junction of the fifth metatarsal (Fig. 1). Conservative versus surgical intervention has been debated in published studies for the management of the Jones fracture. Numerous publications have advised surgical management in the young active athlete (1–4). Compared with nonsurgical management, intramedullary screw fixation results in a shorter interval to fracture union, reduced complication rates, and an earlier return to preinjury activities compared with nonsurgical cast immobilization (1–8). Appropriate preoperative planning and proper intraoperative judgment greatly dictates the surgical outcomes for these athletes. Solid intramedullary fixation relies on accurate matching of the screw
Financial Disclosure: DJO Global funded the cadaveric study. Conflict of Interest: None reported. Address correspondence to: Christopher F. Hyer, DPM, MS, FACFAS, Fellowship Director, Advanced Foot and Ankle Surgical Fellowship, Orthopedic Foot and Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082. E-mail address: [email protected] (C.F. Hyer).
diameter to the intraosseous diameter of the fifth metatarsal. Undersizing of the screw will result in poor thread purchase and a lack of fracture stability, which will greatly increase the risk of adverse events, such as delayed union, nonunion, and hardware failure. In contrast, oversizing of the screw can lead to iatrogenic fracture or cortical blowout, further compromising the integrity of the metatarsal. Fifth metatarsal Jones fractures can be managed with either intramedullary screws or plate fixation. Screw fixation has been the standard of care owing to the ease of percutaneous insertion. Recently, several studies have shown the efficacy of hook plates for the management of fifth metatarsal fractures, most notably avulsion fractures (9,10). Biomechanical studies comparing screw fixation versus plate fixation in midfoot arthrodesis have shown no significant differences in stiffness and pullout strength. However, a slight trend was seen toward a stiffer construct with plate fixation. This supports the use for intramedullary screw fixation in the stabilization of the Jones fracture (11–14). Our goal with the present investigation was to provide a general guideline to screw selection for Jones fracture stabilization. The present cadaveric study was designed to determine the average
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.11.010
228
R.T. Scott et al. / The Journal of Foot & Ankle Surgery 54 (2015) 227–229
Fig. 1. Typical presentation of a Jones fracture at the diaphysis of the fifth metatarsal.
intraosseous diameter of the proximal fifth metatarsal as it relates to screw size. Materials and Methods A cadaveric model was used to determine the average medullary diameter of the fifth metatarsal. Twenty fresh-frozen adult cadaver legs, 15 males (75%) and 5 females (25%), with a mean age of 73.25 9.33 (range 60 to 92) years, were used for examination at the San Diego Cadaver Anatomy Research Symposium. To be included, the cadaver specimens could not display any gross evidence of injury or defect before measurement. The fifth metatarsal was completely dissected from the foot, including removal of all soft tissue (R.T.S., S.L.D.). A transverse osteotomy was performed from laterally to medially along the midline of the metatarsal (R.T.S., S.L.D.). The sectioned metatarsal was then measured in millimeters using a digital caliper (6-in. 3-Mode Digital Caliper 147, General Tools, New York, NY) by 2 of the authors (R.T.S., S.L.D.). The measurements were taken at the narrowest portion of the medullary canal just distal to the proximal metaphysis, giving us our medial to lateral diameter. The dorsal to plantar diameter was measured for each of the respective sectioned specimens. All data were recorded in a spreadsheet for later statistical analysis.
Results The mean dorsal to plantar diameter of the fifth metatarsal measured 6.475 1.54 (range 4 to 12) mm. The mean medial to lateral diameter measured 4.6 0.85 (range 3 to 6) mm. Discussion Intramedullary screw fixation has shown beneficial results in the treatment protocol of fifth metatarsal Jones fractures. Our study has demonstrated that a 4.5-mm cannulated screw is the narrowest diameter screw that should be selected for the average fifth metatarsal. This should be considered a general guideline for obtaining adequate intraosseous purchase and compression across the fracture site. We have typically used a 4.5-, 5.0-, or 5.5-mm screw, depending on the patient’s anatomy. Recently, a computed tomography model was created with 119 fifth metatarsals to measure the metatarsal length, distance from the base to the haft of curvature, and canal diameter (5). The average coronal canal diameter at the isthmus was 5.0 mm. A coronal diameter >4.5 mm at the isthmus was present in 81% of the males and 74% of the females. Kelly et al (6) performed a cadaveric study with 23 paired fifth metatarsals, which were fixed with 5.0- and 6.5-mm screws. They
noted no significant differences in the bending stiffness of the fractures between the 2 different diameter screws. However, the pullout strength of the 6.5-mm screw was greater. Shah et al (7) also tested the initial load to failure with a 4.5- versus 5.5-mm screw. No statistically significant difference was noted in the respective screws (332.4 N versus 335.2 N). They concluded that maximizing the screw diameter did not appear to be critical for fixation rigidity. Porter et al (8) compared the use of a 4.5- and 5.5-mm cannulated stainless steel screw in the fixation of Jones fractures in athletes. Clinical effectiveness was noted with the 5.5-mm screw; however, no statistical significance was noted compared with the 4.5-mm screw. Both stainless steel and titanium screws have been well accepted for the treatment of the Jones fracture. The material selected is truly determined by surgeon preference. However, DeVries et al (2) noted a greater incidence of union in the Jones fracture when a titanium screw (36 of 37) was used for fixation compared with stainless steel (14 of 16). Metzl et al (3) performed a similar retrospective comparative analysis to review the use of an indication-specific screw (solid) versus treatment with traditional screw fixation (cannulated). No significant difference was found between the 2 groups in terms of fracture union; however, a greater number of adverse events occurred in the group treated with traditional screw fixation (p ¼ .03). The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 case of symptomatic hardware, all requiring additional surgical interventions. All adverse events occurred within an average of 2 months after surgery. They concluded that indication-specific screws were superior in the management of the acute Jones fracture. When managing the acute Jones fracture, the ultimate goal is to efficiently return the patient to sport or daily activity. A recent study by Nagao et al (15) reported their athletes were able to return to running activities 6.3 weeks after open reduction and internal fixation of the Jones fracture. They further reported that the mean interval to full activity was 11.2 weeks, with a 0.16% (1 of 60) complication rate. Habbu et al (16) noted union was achieved in 14 patients, with 1 delayed union, when using intramedullary screw fixation for Jones fracture management. The mean interval to union was 13.3 (range 8 to 20) weeks. All patients were able to start unassisted full weightbearing without pain at a mean of 10.2 weeks. Similar findings were reported by Murawski and Kennedy (17) and Choi et al (9) regarding union and a return to full activity with screw fixation. Recent meta-analyses reviewed the most recent 26 studies published on the management of the Jones fracture. The generalization noted was that Jones fractures heal more predictably and more quickly with surgery compared with nonoperative treatment. Roche and Calder (4) reported that acute fractures treated nonoperatively had a union rate of 76% and that fractures treated with a screw had a union rate of 96%. One potential weakness of the present study was the use of the cadaveric model. We were able to construct our recommendation for the 4.5-mm screw according to the medial to lateral intramedullary diameter of the fifth metatarsal. However, the dorsal to plantar diameter of the fifth metatarsal can accommodate a much larger screw, such as a 5.0- or 5.5-mm screw (Fig. 2). Multiple questions have been posed about the use of intramedullary devices for bone fixation. A study by Greksa et al (18) showed that tibial reaming alone caused significant increases in overall blood vessel and capillary densities in the periosteum compared with those of intact tibias. Implantation with a titanium nail resulted in firm embedding of the nail and caused changes in the periosteal vasculature similar to those after reaming alone. However, the endosteal blood flow was reduced overall. When a smaller diameter device was placed, intramedullary revascularization occurred, together with remodeling of the endosteal, primary bone to
R.T. Scott et al. / The Journal of Foot & Ankle Surgery 54 (2015) 227–229
229
References
Fig. 2. Placement of a 5.5-mm intramedullary solid screw for the management of a Jones fracture.
mature lamellar bone in a tibia model (19). This raises the question of plating metatarsal fractures to reduce the endosteal damage. It has been suggested that a locking compression plate can be considered as an alternative treatment of multifragmentary, osteoporotic, and tuberosity avulsion (zone 1 and II) fifth metatarsal base fractures (9,10). In conclusion, intraoperative selection of the appropriate screw diameter is essential to the overall outcome in the management of the acute Jones fracture. The surgeon must be comfortable selecting the largest screw that will achieve maximal purchase with the dense cortical bone in both the medial to lateral and the dorsal to plantar planes to ensure adequate compression across the fracture site.
1. Smith TO, Clark A, Hing CB. Interventions for treating proximal fifth metatarsal fractures in adults: a meta-analysis of the current evidence-base. Foot Ankle Surg 17:300–307, 2011. 2. DeVries JG, Cuttica DJ, Hyer CF. Cannulated screw fixation of Jones fifth metatarsal fractures: a comparison of titanium and stainless steel screw fixation. J Foot Ankle Surg 50:207–212, 2011. 3. Metzl J, Olson K, Davis WH, Jones C, Cohen B, Anderson R. A clinical and radiographic comparison of two hardware systems used to treat Jones fracture of the fifth metatarsal. Foot Ankle Int 34:956–961, 2013. 4. Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc 21:1307–1315, 2013. 5. Ochenjele G, Ho B, Switaj PJ, Fuchs D, Goyal N, Kadakia AR. Radiographic study of the fifth metatarsal for optimal intramedullary screw fixation of Jones fracture. Foot Ankle Int Epub 2014 Sep 24. pii: 1071100714553467. [Epub ahead of print]. 6. Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA. Intramedullary screw fixation of Jones fractures. Foot Ankle Int 22:585–589, 2001. 7. Shah SN, Knoblich GO, Lindsey DP, Kreshak J, Yerby SA, Chou LB. Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int 22:581–584, 2001. 8. 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 30:27–33, 2009. 9. Choi JH, Lee KT, Lee YK, Lee JY, Kim HR. Surgical results of zones I and II fifth metatarsal base fractures using hook plates. Orthopedics 36:e71–e74, 2013. 10. Lee SK, Park JS, Choy WS. Locking compression plate distal ulna hook plate as alternative fixation for fifth metatarsal base fracture. J Foot Ankle Surg 53:522–528, 2014. 11. Cottom JM, Rigby RB. Biomechanical comparison of a locking plate with intraplate compression screw versus locking plate with plantar interfragmentary screw for Lapidus arthrodesis: a cadaveric study. J Foot Ankle Surg 52:339–342, 2013. 12. Gruber F, Sinkov VS, Bae SY, Parks BG, Schon LC. Crossed screws versus dorsomedial locking plate with compression screw for first metatarsocuneiform arthrodesis: a cadaver study. Foot Ankle Int 29:927–930, 2008. 13. Jarrell SE III, Owen JR, Wayne JS, Adelaar RS. Biomechanical comparison of screw versus plate/screw construct for talonavicular fusion. Foot Ankle Int 30:150–156, 2009. 14. Pope EJ, Takemoto RC, Kummer FJ, Mroczek KJ. Midfoot fusion: a biomechanical comparison of plantar planting vs intramedullary screws. Foot Ankle Int 34:409–413, 2013. 15. Nagao M, Saita Y, Kameda S, Seto H, Sadatsuki R, Takazawa Y, Yoshimura M, Aoba Y, Ikeda H, Kaneko K, Nozawa M, Kim SG. Headless compression screw fixation of Jones fractures: an outcomes study in Japanese athletes. Am J Sports Med 40:2578–2582, 2012. 16. Habbu RA, Marsh RS, Anderson JG, Bohay DR. Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture. Foot Ankle Int 32:603–608, 2011. 17. Murawski CD, Kennedy JG. Percutaneous internal fixation of proximal fifth metatarsal Jones fractures (Zones II and III) with Charlotte Carolina screw and bone marrow aspirate concentrate: an outcome study in athletes. Am J Sports Med 39:1295–1301, 2011. 18. Greksa F, Toth K, Boros M, Szabo A. Periosteal microvascular reorganization after tibial reaming and intramedullary nailing in rats. J Orthop Sci 17:477–483, 2012. 19. Pazzaglia UE. Periosteal and endosteal reaction to reaming and nailing: the possible role of revascularization on the endosteal anchorage of cementless stems. Biomaterials 17:1009–1014, 1996.
