Existing fixation modalities for Jones type fifth metatarsal fracture fixation pose high rates of complications and nonunion

Jones type fifth metatarsal fractures pose a challenge to the foot and ankle surgeon, given documented high nonunion rates as well as high complication rates including hardware prominence, nerve injury, and screw breakage for existing treatment modalities including screw and plantar plate fixation. We call for the design of innovative Jones-fracture specific implants which contour to the natural curve of the fifth metatarsal. Future research should aim to expand upon existing literature for Jones fracture fixation and evaluate efficacy of novel implants which are designed to address unacceptably high complication rates for existing treatment modalities.     

续筋接骨方治疗骨折临床观察

目的研究续筋接骨方治疗骨折的临床疗效。方法选取2018年1月—2018年6月在辽宁中医药大学附属第三医院就诊的骨折患者60例,所有患者按照随机数字表法分为对照组与观察组,每组30例。观察组口服续筋接骨方联合正骨后小夹板固定治疗,对照组患者采用正骨后小夹板固定治疗。分析2组患者干预3个月后的血清骨代谢指标、骨密度、生活质量改善情况以及疗效判定。结果干预前,2组的血清Ⅰ型前胶原羧基端肽β特殊序列(β-CTX)、血清Ⅰ型前胶原氨端肽原(PINP)、骨特异性碱性磷酸酶(ALP)水平、钙、磷及骨密度比较,差异无统计学意义(P>0.05);干预后,2组的β-CTX、PINP、骨特异性ALP水平、钙、磷及骨密度较干预前改善,观察组的改善效果优于对照组,差异均有统计学意义(P<0.05)。干预前,2组的物质生活、社会功能、躯体健康以及心理健康评分比较,差异无统计学意义(P>0.05);干预后,2组的物质生活、社会功能、躯体健康以及心理健康评分较干预前升高,观察组的各项生活质量评分高于对照组,差异均有统计学意义(P<0.05)。观察组的治疗恢复率高于对照组,差异有统计学意义(P<0.05)。结论续筋接骨方可以改善骨折患者骨代谢功能及生活质量。     

Jones type fifth metatarsal fracture fixation in athletes: A review and current concept

Jones type fifth metatarsal fracture is a common occurrence among athletes at all levels. These fractures may occur due to several mechanisms, but inversions and twisting injuries are considered some of the leading causes in sports. However, while Jones fracture incidences are frequent in the sporting world, there is still a lack of consensus on how such fractures should be effectively managed. There are numerous treatment options for patients with fifth metatarsal Jones fractures. The role of nonoperative treatment remains controversial, with concerns about delayed union and nonunion. Surgical stabilization of metatarsal Jones fractures is therefore often recommended for athletes, as it is often associated with a low number of complications and a higher rate of union than nonoperative management. This review will focus on literature regarding the prevalence of Jones type fifth metatarsal fracture, alongside the efficacy of both conservative and surgical treatment within this population.     

Support system of Lisfranc joint complex: An anatomical investigation with an evolutionary perspective

BackgroundThe anatomical arrangement of the Lisfranc joint between the midfoot and forefoot is complex and not just critical for bipedal gait but also for prevention, management, and rehabilitation of injuries in this region.Material and methodsIn forty adult cadaveric lower limbs, the Lisfranc mortise, the ligaments and supports were observed and noted.ResultsThe structural arrangement that accords stability to the joint has osseous, ligamentous, and tendinous components. A bony mortise, which is deep medially, disrupts the linearity of the joint line. An extensive Lisfranc ligament with confluent interosseous and plantar parts was observed. Tibialis posterior, peroneus Longus and Lisfranc ligament exhibit a unique anatomical arrangement that supports the joint inferiorly.ConclusionThe study documents a unique lattice of tendons and ligament offering dynamic support to the joint. Demands of assumption of erect posture and bipedal walking in humans like adduction of the first ray of the foot, maintenance of longitudinal and transverse arches of the foot and ability stiffen midfoot for efficient forefoot take-off are well reflected in the joint structure and supports.     

A new classification for Freiberg’s disease

IntroductionFreiberg’s osteochondrosis is an uncommon cause of foot pain. Following a national survey circulated by the British Foot and Ankle Society it was found that no classification is used to guide surgical treatment. This study aimed to create a simple, reproducible CT based classification to preoperatively plan whether an osteotomy is required.MethodsA retrospective review of 24 CT scans of new Freiberg's diseasediagnoses over a 10 year period was conducted. These images were assigned a study number and anonymised. The scans were then reviewed in their entirety by three independent specialists who determined whether an osteotomy would be of benefit. The sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx was identified and divided the articular surface into 2 zones - plantar and dorsal and this formed the basis for our classification. These sagittal slices were then reviewed independently by two surgeons to determine if patients had disease in one or both zones and re-reviewed two weeks later to assess intra-observer reliability.ResultsAll 24 cases involved the second metatarsal. From reviewing the sagittal CT slices, it was felt that 18 patients were suitable for osteotomy and 6 were suitable for debridement +/− arthroplasty alone. The current classification demonstrated that 18 patients had disease confined to zone 1 only and the remaining patients had disease in both zones. Inter-observer reliability assessment had 95.8% agreement (Krippendorff’s Alpha 0.897). Intra-observer reliability was 100%. Correlation of those observed to have isolated zone 1 disease and suitability for osteotomy was absolute (Pearson r = 1).ConclusionDividing the metatarsal head into two zones on the widest sagittal slice of the CT scan offers an easy reproducible way to preoperatively plan surgical treatment for Freiberg’s osteochondrosis. Patients with isolated zone 1 disease should be suitable for an osteotomy.     

A cone beam CT based 3D-assessment of bony forefoot geometry after modified Lapidus arthrodesis

BackgroundModified Lapidus arthrodesis (MLA) is a well-established treatment modality for hallux valgus deformities (HVD) associated with instability of the first ray. Although the three-dimensional (3D) nature of HVD has long been recognized, diagnostics still focus on plain radiographs. The objective of this study was to validate 3D Cone Beam CT (CBCT) in the perioperative assessment of HVD with focus on the alignment of the forefoot.MethodsIn a prospective clinical study, MLA was performed on 30 patients (25 females, 5 males; mean age: 63.2 years). Pre- and postoperatively standard radiographs and CBCT with full weight-bearing were acquired. For the CBCT based assessment, reproducible criteria have been defined, measured, and correlated with established radiological indicators.ResultsEvaluation of standard radiographic parameters (hallux-valgus angle [HVA], intermetatarsal angle 1-2 [IMA 1-2], distal metatarsal articular angle [DMAA], tibial sesamoid position [TSP]) showed significant improvement postoperatively. Comparison of measurements obtained from plain radiographs and CBCT were significantly correlated between both measuring techniques, indicating high reliability. Pronation of the first metatarsal and the sesamoids were significantly reduced by the procedure. Due to this repositioning effect, the second metatarsal head was elevated by 3.1 mm, and the lateral sesamoid was lowered by 3.8 mm. However, there was no correlation between the amount of pronation and conventional radiographic measures.ConclusionsCompared to plain radiographs, CBCT allows a more detailed view of the forefoot alignment in the coronal plain after MLA. MLA was able to recenter the sesamoids under der first metatarsal head and conversely led to elevation of the second metatarsal head.     

Distal Metatarsal Minimally Invasive Osteotomy (DMMO): Surgical technique,variants, indications,and treatment decision-tree

BackgroundMetatarsal osteotomy is a major means of treating mechanical metatarsalgia. Open techniques are widely used, and notably that described by Weil. They have, however, certain drawbacks, and new types of osteotomy have been developed. Percutaneous techniques are presently very much in favor, and Distal Metatarsal Minimally Invasive Osteotomy (DMMO) has emerged as a treatment for metatarsalgia. Although very widely used, it is poorly codified in the literature.MethodThe present study detailed DMMO techniques and their variants (oblique and reverse), with corresponding indications and treatment decision-tree.ResultsInitial findings seem encouraging, with functional results comparable to those of open surgery. Postoperative edema and radiologic bone healing time seem to be longer in DMMO. There is, on the other hand, no difference regarding stiffness.ConclusionDMMO is an effective option to treat metatarsalgia, with variants enabling adaptation to foot morphology, but needing confirmation by studies with higher levels of evidence.