Metatarsal Fractures Research Articles

Feline Skeletal Reference Guide: A Cadaveric Radiographic Measurement on Lower Limb Extremities.

The aim of this study was to create a feline reference database for the length, width and slenderness (length to width ratio) of metacarpal and metatarsal bones, radius and tibia. Radiographs of the radius, tibia, metacarpus and metatarsus were performed in domestic short hair cat cadavers (n = 40). Length and width of the aforementioned bones were measured in mature domestic shorthair cats and bone slenderness (length/width) and index ratios calculated. A significant skeletal sex dimorphism exists in cats, with bones of the metacarpus, metatarsus, radius and tibia generally longer and wider in male cats compared with female cats, with differences frequently significant. The most significant difference was identified for the width of Mc5 (p = 0.0008) and the length and width of Mt5 (p = 0.0005). Index ratios for length and width of radius to metacarpal bones, and tibia to metatarsal bones, were not significantly different between male and female cats, except for Mc5. The index ratio for Mc5 was significantly higher in male cats (p = 0.002). The present study provides insights into the normal length and width of distal forelimb and hind limb bones as well as bone index ratios in mature domestic shorthair cats. Using this information, it is now possible to quantitatively assess the relationship between these bones in domestic cats using radiography. This will assist not only with the diagnosis and categorization of skeletal abnormalities but can also guide surgical interventions of metacarpal and metatarsal bone fractures.

Surgical Management of Proximal Fifth Metatarsal Fractures in Elite Athletes: A Systematic Review.

Background:As a result of the high physical demand in sport, elite athletes are particularly prone to fifth metatarsal fractures. These injuries are typically managed surgically to avoid high rates of delayed union and allow for quicker return to play (RTP).Purpose:To review studies showing clinical and radiographic outcomes, RTP rates, and complication rates after different surgical treatment modalities for fifth metatarsal fractures exclusively in elite-level athletes.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic search was conducted within the PubMed, Scopus, and Cochrane databases from January 2000 to January 2020. Inclusion criteria consisted of clinical outcome studies after operative management of fifth metatarsal fractures in elite athletes. Exclusion criteria consisted of nonoperative management, high school or recreational-level athletic participation, nonclinical studies, expert opinions, and case series with <5 patients.Results:A total of 12 studies met inclusion and exclusion criteria, comprising 280 fifth metatarsal fractures treated surgically. Intramedullary screw fixation was the most common fixation construct (47.9%), and some form of intraoperative adjunctive treatment (calcaneal autograft, iliac crest bone graft, bone marrow aspirate concentrate, demineralized bone matrix) was used in 67% of cases. Radiographic union was achieved in 96.7% of fractures regardless of surgical construct used. The overall mean time to union was 9.19 weeks, with RTP at a mean of 11.15 weeks. The overall reported complication rate was 22.5%, with varying severity of complications. Refracture rates were comparable between the different surgical constructs used, and the overall refracture rate was 8.6%.Conclusion:Elite athletes appeared to have a high rate of union and reliably returned to the same level of competition after surgical management of fifth metatarsal fractures, irrespective of surgical construct used. Despite this, the overall complication rate was >20%. Specific recommendations for optimal surgical management could not be made based on the heterogeneity of the included studies.

Association between Bone Mineral Density and Fracture Characteristics in the 5th Metatarsal Bone Base Fracture in Elderly for Prediction of Osteoporotic Fracture.

BackgroundThis study aimed to analyze the correlation between bone mineral density (BMD) and the type of 5th metatarsal fracture, as well as to demonstrate whether there is a difference in radiological findings (heel alignment angle [HAA], heel moment arm [HMA], and metatarsus angle) between fracture types.MethodsA total of 87 patients were enrolled in the study and allocated into 3 groups: the Zone 1 group (N=36), the Zone 2 group (N=33), and the Zone 3 group (N=18). The participants’ demographic data, T-scores, existing fracture or osteoporosis medications, and radiologic parameters including HAA, HMA, and metatarsus adductus angle were analyzed and compared.ResultsThere was a significant difference between the mean age of the participants, with the highest age in the Zone 1 group and the lowest in the Zone 3 group. Regarding the history of concurrent fracture or osteoporosis medications, there was no significant difference between the 3 groups. Similarly, no significant difference was observed between the 3 groups about the BMD values. In contrast, the HAA was statistically significant in all groups with a positive correlation of −8.9 in the Zone 1 group, a negative correlation of 3.55 in the Zone 2 group, and an inverse relationship of 6.1 in the Zone 3 group. The metatarsus adductus angle was significantly higher in the Zone 3 group than the Zone 1 and Zone 2 groups.ConclusionsThe location of a 5th metatarsal bone fracture is not significantly associated with BMD. However, mechanical influences, such as hindfoot varus or forefoot adductus, have a significant correlation with fracture types.

Stress Fractures of the Foot and Ankle

Stress fractures are relatively unique to the athletic population with up to 98.5% of all stress fractures occurring in the athletic population. However, stress fractures are a rare entity even in the athletic population, yet they can have a high morbidity. Stress fractures are the result of repeated submaximal loads without adequate recovery time or inadequate biologic repair. Multiple factors contribute to the etiology of these injuries including type and frequency of activity, shoe wear, playing surface, vascular supply, osseous anatomy and alignment, and endocrine abnormalities. Most stress fractures of the foot and ankle can successfully be treated nonoperatively with nonweightbearing for 4-6 weeks with provisions for early range of motion and progressive return to weightbearing in a fracture boot. Base of the fifth metatarsal, navicular and medial malleolus stress fractures have a higher risk of displacement, malunion, nonunion or delayed union and should be considered for early surgical fixation in the athlete to limit time away from play and ensure timely healing. Adjuvants to treatment including vitamin D and calcium supplementation, daily bone stimulator, and biweekly shockwave therapy should be used liberally in the athletic population if feasible. Early diagnosis and treatment can decrease the time away from activity, thus a high index of suspicion is critical in this population. Advanced diagnostic imaging should be used liberally in athletes to identify these injuries early. The following chapter will discuss the etiology, epidemiology, presentation, and management of specific stress fractures of the foot and ankle as they pertain to the athlete.

Can low-intensity pulsed ultrasound (LIPUS) accelerate bone healing after intramedullary screw fixation for proximal fifth metatarsal stress fractures? A retrospective study

BackgroundIntramedullary screw fixation is considered the standard treatment for proximal fifth metatarsal stress fractures. Low-intensity pulsed ultrasound (LIPUS) is a well-known bone-healing enhancement device. However, to the best of our knowledge, no clinical study has focused on the effect of LIPUS for postoperative bone union in proximal fifth metatarsal stress fractures. This study aimed to investigate the effect of LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures.MethodsBetween January 2015 and March 2020, patients who underwent intramedullary screw fixation for proximal fifth metatarsal stress fractures were investigated retrospectively. All patients underwent intramedullary screw fixation using a headless compression screw with autologous bone grafts from the base of the fifth metatarsal. The time to restart running and return to sports, as well as that for radiographic bone union, were compared between groups with or without LIPUS treatment. LIPUS treatment was initiated within 3 weeks of surgery in all cases.ResultsOf the 101 ft analyzed, 57 ft were assigned to the LIPUS treatment group, and 44 ft were assigned to the non-LIPUS treatment group. The mean time to restart running and return to sports was 6.8 and 13.7 weeks in the LIPUS treatment group and was 6.2 and 13.2 weeks in the non-LIPUS treatment group, respectively. There were no significant differences in these parameters between groups. In addition, the mean time to radiographic bone union was not significantly different between the LIPUS treatment group (11.9 weeks) and the non-LIPUS treatment group (12.0 weeks). The rate of postoperative nonunion in the LIPUS treatment group was 0% (0/57), while that in the non-LIPUS treatment group was 4.5% (2/44). However, this difference was not statistically significant.ConclusionsThere were no statistically significant differences regarding the time to start running, return to sports, and radiographic bone union in patients with or without LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures. Therefore, we cannot recommend the routine use of LIPUS to shorten the time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures.

Outcomes of Surgically Treated Fifth Metatarsal Fractures in Major League Soccer Athletes

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.

Functional Outcomes of Surgical Treatment of the Fifth Diaphyseal Metatarsal Fractures (Dancer’s Fractures). A Case-Series and a Literature Review

Functional Outcomes of Surgical Treatment of the Fifth Diaphyseal Metatarsal Fractures (Dancer’s Fractures). A Case-Series and a Literature Review

Acute Fixation Vs Casting in Treatment of Fracture Base of Fifth Metatarsal Comparative Study

Background: The understanding of the anatomy of the proximal portion of the fifth metatarsal is essential as it explains the injury process and cures of various kinds of fifth metatarsal fractures that influence the appropriate treatment decision. Work objective: Comparison of clinical and radiographic outcomes among conservation therapy and acute surgical therapy of the fifth-metatarsal fracture base. Methods and patients: Twenty patients have been treated with percutaneous fixation with a 4,0 mm cannula screw and 20 have been conservatively treated with a lower knee cast. The length of the injury to hospital admission varied from 1 to 3 days with an average of 2 days between September 2020 and May 2021. The average follow-up time was six months (range from 5 to 7 months). Findings: Our results revealed that for zone 2 and zone 3 the acute fixation is superior than casting with respect to the union time and the AOFAS score. Conclusion: Early screw fixing is a safe and efficient therapeutic technique for acute fifth metatarsal base fractures, particularly zones 2 and 3. Early operational therapy leads to before clinical union and enables patients to return to regular daily activities rather than to cast therapy, leading to a high delayed union rate.

Pediatric Foot Pain

HISTORY: A 14-year-old male presented with left foot pain for 1 week. He was playing wiffleball over the weekend and noticed severe pain the next day; he went on to develop foot swelling. He reported similar symptoms 3 months prior and was treated with a CAM boot for 2 weeks. He also had 2 previous episodes of right knee pain and swelling, and underwent joint aspiration during one of these episodes, which was negative for infection. Labs were significant for mildly elevated CRP 3.4 and ESR 39. RF, ANA, and lyme PCR were all negative. During the second episode of right knee swelling, MRI showed a 2 mm full-thickness chondral defect in the medial femoral condyle and diffuse myositis. The patient underwent arthroscopic chondroplasty. PHYSICAL EXAMINATION: Examination of the left foot revealed diffuse edema over the dorsal aspect of the foot to the level of the ankle, no erythema or warmth, tender to palpation over the 2nd and 3rd metatarsal heads, limited flexion and extension of digits 2-5 secondary to pain and swelling, normal sensation, brisk capillary refill; left ankle was normal. DIFFERENTIAL DIAGNOSIS: Metatarsal fracture; Metatarsal stress fracture or stress reaction; Freiberg’s infarction; Plantar plate rupture; Synovitis TEST AND RESULTS: X-ray of left foot: No osseous abnormalitiesNo substantial soft tissue swelling or joint effusion MRI of left foot: Increased bone marrow signal in distal aspect of second and third metatarsals and metatarsal heads, effusions of 2nd and 3rd MTP joints; No underlying fracture; Plantar plate intact; Tendons intact and normal FINAL WORKING DIAGNOSIS: Stress reaction; extraintestinal manifestation of inflammatory bowel disease TREATMENT AND OUTCOMES: Immobilization with CAM boot for 3 weeks. On repeat exam foot pain and swelling had resolved, patient was transitioned out of CAM boot successfully. One month later began having polyarthritis (swelling of right knee and right elbow), abdominal pain and low grade fevers; eventually diagnosed with Crohns’ disease.

Percutaneous Fixation of a Fifth Metatarsal Base Fracture.

Owing to a vascular watershed, zone II and III fifth metatarsal base fractures commonly progress to nonunion without operative intervention. This article and the accompanying video demonstrate the use of intramedullary screw fixation for a fifth metatarsal base fracture and review treatment decisions involved with management of these injuries.

Flight Crash During COVID-19: Lessons Learnt.

PurposeThe survival rate of a Flight crash is quite low and this makes the Calicut incident unique. Management of flight crash victims is itself a herculean task and during COVID-19 pandemic it poses another challenge to the treating team since all the patients are under quarantine and the treatment protocols are not well defined.MethodsOn 7/8/2020 at around 7.41 pm, Air India Express aircraft from Dubai to Calicut, while landing on the runway lost its control and skidded off the runway and broke into three parts. We report a detailed analysis of orthopaedic injury patterns and difficulties encountered in the management of these patients with full personal protective equipment (PPE) kit during COVID-19 pandemic.Results47 patients from the crash site were brought to our hospital and 38 of them were admitted under the orthopaedic department. 74 doctors and 76 trained nurses along with 58 supporting staff were involved in the management of the mass casualty during that night. Most of the patients suffered injuries to lower extremity and spine which included 11 femur, 13 tibial and 12 spine fractures. Average union time was around 3 months for fractures. Delayed union of fracture femur, avascular necrosis of talus and nonunion of 5th metatarsal base fracture were the reported complications. Surgical site infection was observed in two patients.ConclusionTrauma management team should be prepared to manage difficulties encountered during identification, communication, and treatment of the disaster victims during this COVID-19 era.

The Fifth Metatarsal Bone Fracture in Athletes - Modalities of Treatment Related to Agility in Soccer Players.

The 5th metatarsal fracture is a common foot fracture which could exclude a player from competition for several months and significantly affect his or her career. This manuscript presents the treatment and rehabilitation of professional soccer players who had acute fractures of the 5th metatarsal bone and a cannulated screw fixation. The main purpose of the analysis was to determine the minimum time necessary for a permanent return to the sport after a 5th metatarsal fracture among professional soccer players. We followed the surgical and rehabilitation path of 21 professional soccer players from the Polish League (Ist and IInd divisions) who suffered from the 5th metatarsal bone fracture. All players underwent standard percutaneous internal fixation with the use of cannulated screws. The total inability to play lasted for 9.2 (± 1.86) weeks among players treated only surgically (n = 10), 17.5 (± 2.5) weeks in the conservative and later surgery group, excluding players with nonunion (n = 6), and 24.5 (± 10.5) weeks for nonunion and switch treatment (n = 4) players. Prompt fracture stabilization surgery is recommended for athletes, enabling the implementation of an aggressive rehabilitation protocol as soon as possible. Early limb loading after surgery (from week 2) does not delay fracture healing or hinder the bone union, thus rehabilitation plays a crucial role in shortening the time of RTP (return to play) and is obligatory for each athlete who undergoes surgical treatment.

Factors influencing postoperative residual diastasis after the operative treatment of acute Lisfranc fracture dislocation.

Clinically, surgeons may frequently encounter residual diastasis between the medial cuneiform and 2nd metatarsal base after the operative treatment of acute Lisfranc fracture dislocations. The purpose of this study was to identify factors influencing postoperative residual diastasis. We specifically focused on the preoperative fracture pattern using 3-dimensional computed tomography (3D-CT). Radiographic and clinical findings of 66 patients who underwent operative treatment for acute Lisfranc fracture dislocation were reviewed. Patients were grouped according to residual diastasis evaluated by weight-bearing anteroposterior radiograph of the foot at the final follow-up. Residual diastasis was defined as distance between the medial cuneiform and 2nd metatarsal base greater than the distance on the contralateral side by 2mm or more. Demographic parameters and fracture patterns based on preoperative foot 3D-CT were compared. A paired t test was used to compare continuous numeric parameters, while a Chi-square test was used for the proportional parameters. Statistical significance was set at P value less than 0.05 for all analyses. The mean age at operation, sex, body mass index, and the rate of underlying diabetes were not significantly different between the two groups (P > 0.05 each). Preoperative foot 3D-CT evaluation showed that the rate of large (> 25% of 2nd tarsometatarsal joint involvement), displaced (> 2mm) fracture fragments on the plantar side of the 2nd metatarsal base was more pronounced in the group with residual diastasis (P = 0.001), while medial wall avulsion of the 2nd metatarsal base was more frequent in the group without residual diastasis (P = 0.001). While treating acute Lisfranc injuries, surgeons should be aware of the presence of a 2nd metatarsal base plantar fracture. A dorsoplantar inter-fragmentary fixation can be considered if the fragment is large and displaced.

Comparative Study between Operative versus Non-operative Treatment for Base of Fifth Metatarsal Fractures in Young Adults

Background The treatment of displaced base of fifth metatarsal fracture remains controversial regarding the conservative and operative treatment.&#x0D; Objective To investigate the therapeutic effect of operative and non-operative treatment for base of fifth metatarsal fractures.&#x0D; Method This was retrospective comparative study performed in Civil Service Hospital, Kathmandu, Nepal from December 2014 to November 2019. Patients were randomly divided into two groups by computer generated technique. Group1 included 17 patients who underwent open reduction and internal fixation using tension band wiring, whereas group 2 included 17 patients who underwent non-operative treatment with boot cast.&#x0D; Result The AOFAS and VAS-FA scores at 3 months in operative and non-operative groups were 89.34±2.14 versus 86.94±2.22 (p &lt; 0.05) and 5.58±0.87 versus 3.58±0.93 (p &lt; 0.05). Similarly, AOFAS and VAS-FA at 12 months after treatment were 90.94±2.43 versus 90.17±1.55 (p &gt; 0.05) and 0.64±0.280.94±0.39 (p &gt; 0.05) in operative and non-operative groups respectively. The average time to bear full weight and return to work were 6.82±1.13 versus 7.08±1.24 weeks (p &gt; 0.05) and 8.76±1.20 versus 10.35±1.41 weeks ( p &lt; 0.05) respectively. The mean of VAS score at 3months of treatment is 5.58±0.87 for non-operative group and 3.58±0.93 for operative group (p &lt;0.05).&#x0D; Conclusion Operative intervention has been preferred over the non-operative treatment in young adults or athletes with more than 3 mm displaced fifth metatarsal base fracture to achieve anatomical reduction of fracture, hasten the recovery and rehabilitation and to decrease the complications associated with non-operative treatment.

Polymorphic variants of alkaline phosphatase gene correlate with clinical signs of adult hypophosphatasia?

SummaryWe analyzed polymorphism of the ALPL gene in patients with low serum levels of tissue-nonspecific alkaline phosphatase (TNAP). The presence of three or more of the less frequent alleles of ALPL polymorphisms was associated with significantly lower TNAP serum level and higher frequencies of metatarsal fractures, which may help confirm a clinical suspicion of adult hypophosphatasia.IntroductionAlkaline phosphatases (ALPs) are membrane-bound enzymes that hydrolyze monophosphate esters at a high pH (pH 8–10). Inorganic pyrophosphate, pyridoxal 5-phosphate, the activated form of vitamin B6 (PLP), and phosphoethanolamine (PEA), are natural substrates of ALPs. Hypophosphatasia (HPP, OMIM 146300, 241500, 241510) is a heterogeneous rare metabolic bone disease caused by loss-of-function mutations in the tissue-nonspecific alkaline phosphatase gene (ALPL; MIM 171760) with a deficiency of TNAP. Clinical presentation of HPP in adults demonstrated a wide range of manifestations, many of which are nonspecific. In the present study, we screened the polymorphic genetic variants of ALPL in 56 subjects presenting low serum levels of TNAP and/or other clinical signs of adult HPP in order to evaluate a possible role of polymorphic variants in the diagnosis and management of HPP in adults.MethodsGenomic DNA was extracted from peripheral blood and ALPL gene was sequenced by PCR-based Sanger technique.ResultsFourteen different polymorphic variants were found in the study population. A lower serum level of TNAP and higher frequencies of metatarsal fractures were observed in patients bearing three or more of the minor frequency alleles (MFAs) of the ALPL polymorphic variants. The presence of some MFAs, mostly as a contemporary presence of three or more of them, was found to be mainly represented in patients having both a significantly lower level of TNAP and a higher level of vitamin B6.ConclusionThe genetic analysis and presence of some polymorphic variants may be an instrument to confirm clinical and biochemical data, consider adult HPP, and help clinicians be cautious in the administration of anti-reabsorption drugs.

EVALUATION OF EFFICACY OF DIFFERENT MODALITIES IN TREATMENT OF FRACTURE METATARSAL

Objectives: This study mainly aims to evaluate the efficacy of three different modalities in treatment of fracture metatarsal.&#x0D; Methods: A hospital-based prospective comparative study was conducted in Mahatma Gandhi Medical College, Jaipur, from December 2018 to June 2020, involving 50 patients above 16 years of age presented with isolated metatarsal fractures and grade I open fractures were included in the study. Patients fulfilling the inclusion criteria were then allocated to one of three groups. Group A – Conservative management, Group B – K-wire fixation, and Group C – external Fixator. Outcome measurement was done using AOFAS MID FOOT SCALE (100 points total).&#x0D; Results: Majority of 29 patients belong to 35–60 years of age group followed by 18 patients in 26–35 years. Maximum number of cases is reported in male category that was 45 cases. Majority of the cases falls under the category of road traffic accidents that are 28 cases which is about 56% of the total cases. In 37 cases right foot was involved, whereas 13 cases are on the left side, suggesting the right was the dominant side. About 48% of the second metatarsal and 30% of the third metatarsal showed the maximum involvement. Maximum number of cases were designated as excellent having score between 90 and 100 that was about 38 cases which are 76% of total cases suggesting every treatment modality was good in its own right. There was a significant difference between the different treatment modalities at final follow-up p&lt;0.05.&#x0D; Conclusion: All treatment modalities equally good, achieving good fracture union, decreased incidence of pain, and achieve a good range of movements, but complications rate was more in the conservative group as compared to other groups.

An Uncommon Case of Hypophophatasia Presenting With Galactorrhea, Diagnosed at a Later Age Than Expected

Hypophosphatasia is a rare genetic disorder which causes accumulation of inorganic pyrophosphate that in turn inhibits mineralization. It is caused by a mutation in the non-specific alkaline phosphatase gene (TNSALP). We will review the diagnosis during adulthood when the presentation is characterized by poor healing, recurrent metatarsal stress fractures and bone pain. We are reporting the case of a 38-year-old white female with history of Melanoma referred to the Pituitary Clinic due to galactorrhea. During the encounter it was noted that she had history of disseminated joint pain, myalgias, periodontal complications as well as biochemical evidence of low alkaline phosphatase. At age three she had premature teeth loss, and clumsy gait, which later resolved. She was evaluated for this and diagnosed with odontohypophophatasia at which time no treatment was initiated. As an adult patient had two non-traumatic ankle fractures with associated frail teeth, chipping, and cracking without significant trauma. At around 36 years of age, patient started developing worsening joint pain, stiffness, myalgias and 35 pounds weight gain. Family History is remarkable for her father, having history of low alkaline phosphate and odontogenic infections with no joint or muscle pain. Paternal grandmother had history of dental infections and frail teeth. The patient has four sons; her oldest son has low alkaline phosphate with no clinical symptoms. Patient’s biochemical analysis was unremarkable except for low alkaline phosphate range between 25–38 U/L (40–125 U/L) and elevated Vitamin B6 69.5 ng/mL (2.1–21.7 ng/mL). The physical exam was unremarkable. Brain MRI showed a 3 mm microadenoma with normal pituitary hormonal workup, including diluted prolactin. Mammogram did not show any abnormalities. It was determined that the pituitary microadenoma was non-functioning, and galactorrhea was not hormonal mediated. The patient was referred to a genetic specialist for evaluation of Hypophosphatasia. Testing for TNSALP mutation was done which showed an ALP Mutation variant c.1172G>A (p. Arg391His). She was started on asfotase alfa (Strensiq) an enzyme replacement for Hypophosphatasia, in November 2019. Hypophosphatasia is a rare condition often diagnosed during early life. Due to wide number of possible mutations in the TNSALP gene, the clinical presentation can vary between patients and diagnosis can be elusive. In our patient, despite being diagnosed with odontohypophophatasia at an early age, and having many periodontal complications, hypophosphatasia was not confirmed until more than 30 years after the initiation of symptoms. In the management of Hypophosphatasia, having an accurate timely diagnosis can provide patients with early intervention of advanced treatment modalities such as Strensiq that can improve symptoms.

Clinical evaluation of minimally invasive plate osteosynthesis in tibial and metatarsal fracture repair in goats

In this study Minimally Invasive Plate Osteosynthesis (MIPO) technique using Locking Compression Plates (LCP) was employed in the stabilization of 2 tibial and 4 metatarsal fractures in goats. Immediate postoperative radiographs revealed good alignment and apposition of the fracture fragments in all the goats. All the goats showed partial weight bearing from the 1st post-operative day. Full weight bearing was observed between 7th to 30th post-operative days with a mean of 13.6 ±4.11 days. Postoperative radiographs on 60thday revealed complete radiological union in five out of six goats. The MIPO techniue using LCPs in tibial and metatarsal fracture repair, showed remarkable improvement with normal limb function and maintaining good implant stability throughout the treatment period without any complications.

Metatarsal Stress Fracture: Different Imaging Aspects, a Case Report

Metatarsal Stress Fracture: Different Imaging Aspects, a Case Report

Diagnosis of Hypophosphatasia in Adults Presenting With Metatarsal Stress Fracture: Proof-of-Concept for a Case-Finding Strategy.

ABSTRACTHypophosphatasia (HPP) is caused by loss‐of‐function mutations in ALPL resulting in decreased alkaline phosphatase (ALP) activity. Metatarsal stress fracture (MSF) is a common clinical feature of hypophosphatasia in adults. In this study, the primary objectives were to determine whether new cases of ALPL variants could be identified in patients with MSF and who also had serum ALP concentration below the reference range and to phenotype their clinical course. Electronic health records were queried for adult patients with MSF using International Classification of Disease codes (ICD‐9, ICD‐10CM) and ALP measurements. Patients with ALP levels below the normal limit were invited to receive mutational analysis of ALPL and to complete the following surveys: the Short Form 36 version 2 (SF36v2), the Brief Pain Inventory‐Short Form (BPI), and the Health Assessment Questionnaire Disability Index (HAQ‐DI). Cases with and controls without ALPL pathogenic variants were compared by survey scores and clinical variables relevant to fracture. In 1611 patients with MSF presenting to a podiatry clinic (10/1/2011–10/1/2017), 937 had ALP measurement, of whom 13 (1.4%) had ALP levels below the lower normal limit. In eight patients consenting to participate, two had heterozygous pathogenic ALPL variants. ALPL variants were found in 2 of 1611 patients (0.12%) with MSF, 2 patients of 937 (0.21%) in those with MSF and any ALP measurement, and 2 of 13 patients (15%) in MSF and decreased ALP level. Cases versus controls rated lower scores on eight of eight SF36v2 scales (range, 0–100); higher scores for worst pain (8.0 vs. 0.8) and average pain (6.0 vs. 0.7) on the BPI (range, 0–10); and higher standard disability score (1.4 vs. 0) on the HAQ‐DI (range, 0–3). These data provide proof‐of‐concept for HPP case identification in patients presenting to a podiatry clinic with MSF, suggesting a search for historically low ALP levels may be a useful step for consideration of HPP diagnosis, and supports a prospective study to determine an optimal case‐finding strategy. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.