Metatarsal Fractures Research Articles

What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?

Fractures of the proximal fifth metatarsal are common, and often they are classified using a three-part scale first proposed by Lawrence and Botte. A clear consensus on prognosis and treatment for these fractures is lacking, particularly for fractures in the middle classification, Zone 2; the reliability of the classification scheme itself may be partly at fault for this. The intra- and interrater reliability of the classification itself has never been established, and it remains unclear whether the three-part classification of fifth metatarsal fractures can be applied consistently enough to guide treatment. When used by experienced orthopaedic surgeons, (1) What is the overall interrater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (2) What is the overall intrarater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (3) What are these same metrics for the individual transitions within the classification (Zone 1-2 and Zone 2-3)? Thirty sets of initial presentation radiographs representing an equal number of fractures originally diagnosed by treating clinicians as Zone 1, Zone 2, and Zone 3 were evaluated and classified by three orthopaedic surgeons specializing in foot and ankle surgery and eight foot and ankle fellows to determine interrater reliability. Two weeks later, the same set of radiographs were reevaluated in random order to determine intrarater reliability. Kappa values for interrater and intrarater reliability were calculated. Additionally, the individual transitions between zones were separately analyzed by calculating kappa values for a hypothetical two-part classification based on each transition. The three-part Lawrence and Botte classification of fifth metatarsal fractures demonstrated an overall interrater agreement of κ = 0.66 (observed agreement 77% versus chance agreement 33%). Intrarater reliability for the 11 surgeons ranged from κ = 0.60 to κ = 0.90. A two-part scheme divided by the transition between Zone 1 and Zone 2 demonstrated an interrater agreement of κ = 0.83, and a two-part scheme divided by the transition between Zone 2 and Zone 3 demonstrated a much lower interrater reliability of κ = 0.66. The three-part Lawrence and Botte classification system demonstrated a concerningly low level of interrater reliability with an observed agreement of 77% compared with a chance agreement of 33%. The primary source of concern is the assessment of the interface between Zone 2 and Zone 3, which proved much less reliable than that between Zone 1 and Zone 2. This suggests that previous studies of isolated Zone 1 fractures likely contain a homogeneous fracture cohort, whereas studies of Zone 2 or Zone 3 fractures are likely to include a mixture of fracture types. In practice, the consensus treatment of fifth metatarsal fractures differs based on whether they represent a more proximal, avulsive injury or a more distal injury from indirect trauma. Our data suggest that the Lawrence and Botte classification should be abandoned. Further work should focus on developing a new classification scheme that demonstrates improved interobserver reliability and more directly corresponds to this treatment paradigm. Level III, diagnostic study.

Therapy strategies of fifth metatarsal base fracture with lateral collateral ligament injury

BackgroundFifth metatarsal base fracture (fifth MBF) and lateral collateral ankle ligament (LCAL) injury are mainly caused by plantar flexion and inversion of the foot. However, there is no relevant report on the incidence, injury type and treatment principle of the fifth MBF combined with an LCAL injury.Materials and methodsWe retrospectively analyzed 61 patients with fifth MBF. After admission, patients were given the symptomatic treatment and underwent standard anteroposterior (AP), 30-degree oblique foot radiographs, ankle MR and/or ultrasonic examination. The type of surgery varied base on the individual patients (type of fracture with/without lateral collateral ankle ligament injury).ResultsIn 61 patients, there were 39 patients with LCAL injury. Among the 39 patients with LCAL injury, 24 patients with Grade I–II injury, 6 patients with Grade III injury, and 9 patients with avulsion fractures. There was no significant difference between the patients without LCAL injury and the patients with LCAL injury in terms of age (p = 0.67) and gender (p = 0.575). The incidence of fifth MBF with LCAL injury accounted for 63.93% of fifth metatarsal base fracture; the most common causes of injury included sprains and falls. The average fracture healing time was 8.3 (range, 6–12) weeks. For fifth MBF with displaced more than 2 mm, hook plate or lag screw was used for fixation; for complete rupture of LCAL, suture anchor was used to repairing the ligament; for partial LCAL injury, plaster was used for fixation after surgery; for avulsion fractures, cannulated screw or suture anchor was used for repair. None of the patients had complications such as delayed union, nonunion, and incision infection.ConclusionEarly diagnosis and appropriate treatment can obtain good therapeutic results in fifth MBF patients combined with LCAL injury. Moreover, defining a treatment plan for ligament injury is essential for reducing postoperative complications. This study provides a basis for epidemiology, diagnosis, and treatment of fifth MBF with LCAL injury.

Fifth metatarsal fractures: an update on management, complications, and outcomes

Even though fifth metatarsal fractures represent one of the most common injuries of the lower limb, there is no consensus regarding their classification and treatment, while the term ‘Jones’ fracture has been used inconsistently in the literature.In the vast majority of patients, Zone 1 fractures are treated non-operatively with good outcomes.Treatment of Zone 2 and 3 fractures remains controversial and should be individualized according to the patient’s needs and the ‘personality’ of the fracture.If treated operatively, anatomic reduction and intramedullary fixation with a single screw, with or without biologic augmentation, remains the ‘gold standard’ of management; recent reports however report good outcomes with open reduction and internal fixation with specifically designed plating systems.Common surgical complications include hardware failure or irritation of the soft tissues, refracture, non-union, sural nerve injury, and chronic pain.Patients should be informed of the different treatment options and be part of the decision process, especially where time for recovery and returning to previous activities is of essence, such as in the case of high-performance, elite athletes.

Fifth Metatarsal Injuries in NCAA Division I Athletes: Management and Return to Play

Category:Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Optimal management of metadiaphyseal fifth metatarsal fractures (Jones fractures) in athletes remains controversial. In high-level athletes, surgical treatment with intramedullary screw fixation is commonly recommended to minimize the risk of nonunion and to allow for faster return to sport. The purpose of this study was to report the rate and time to return to sport in collegiate athletes who sustained an isolated fracture to the fifth metatarsal bone.Methods:From 2003 to 2020, we retrospectively reviewed the clinical notes and imaging studies of all athletes participating in NCAA Division I sports at a single college and who sustained a fracture of the fifth metatarsal bone. Athletes with a diagnosis of 5th metatarsal bone fracture were included. Athletes were excluded if they had a fracture in any of the other metatarsal bones (1st-4th). Data collected were: demographic information (age, gender), type of sport, date of injury and/or surgery, diagnosis of Jones fracture, type of treatment received (operative with intramedullary screw fixation versus non operative with the application of boot or cast of the lower extremity and non- weightbearing activity), rate of return to sport, and time to return to sport. The rate and time to return to sport were reported as percentage and mean-standard deviation, respectively. The level of statistical significance was set at <0.05.Results:From 2003 to 2020, we retrospectively reviewed the clinical notes and imaging studies of all athletes participating in NCAA Division I sports at a single college and who sustained a fracture of the fifth metatarsal bone. Athletes with a diagnosis of 5th metatarsal bone fracture were included. Athletes were excluded if they had a fracture in any of the other metatarsal bones (1st-4th). Data collected were: demographic information (age, gender), type of sport, date of injury and/or surgery, diagnosis of Jones fracture, type of treatment received (operative with intramedullary screw fixation versus non operative with the application of boot or cast of the lower extremity and non- weightbearing activity), rate of return to sport, and time to return to sport. The rate and time to return to sport were reported as percentage and mean-standard deviation, respectively. The level of statistical significance was set at <0.05.Conclusion:Jones fractures of the 5th metatarsal bone are a relatively rare injury in collegiate athletes at our institution occurring mostly in male football and basketball players at a rate of about one fracture per year for 21 intercollegiate teams. These fractures are treated with a high level of success with intramedullary screw fixation. Given that postoperative recovery may last for approximately 3 months, return to play following surgical fixation of a Jones fracture is highly dependent on the timing of injury; an athlete who sustains the injury in-season is unlikely to return to play that same season.

Outcomes and Cost Analysis of Virtual Fracture Clinic Management of 5th Metatarsal Base Fractures

Category:Midfoot/Forefoot; TraumaIntroduction/Purpose:Overwhelming demand for trauma services with increasing emergency department (ED) attendances, has increased pressure on fracture clinics in many units, with this demand exceeding capacity. Virtual fracture clinics (VFCs) have been shown to be safe and cost-effective in many specialties. Optimal treatment of 5th metatarsal base fractures remains controversial. Complications of base of 5th metatarsal fractures include delayed union and painful mal/non-union. Surgical fixation has been shown to enable faster return to sport, with lower faster union times and lower non-union rates than conservative management. The aims of this study were to assess whether the management of 5th metatarsal base fractures using a VFC model is safe, cost-effective and accceptable to the patients, whilst avoiding undesirable outcomes.Methods:All patients presenting to the VFC at our major trauma centre, with a 5th metatarsal base fracture between January 2019 and December 2019 were included in the study. One hundred and thirty six patients were identified. All patients had a standardised VFC treatment protocol including full weight bearing in a walker boot, rehabilitation planning to wean out of the boot and advice to contact the unit for follow-up if ongoing pain after 4 months. Minimum follow-up was one year. Patient records were retrospectively reviewed for baseline demographic data, including co-morbidities and smoking history. Overall complication rates, including mal and non-union as well as operative intervention rates were noted. Patients from the cohort who required face to face appointments were identified and the cause for return was identified. A cost analysis was also performed to evaluate the financial implications of the service.Results:Mean age was 41,6 years (18-92). Average time from ED attendance to VFC review was 2 days (1 - 5). Fractures were classified according to the Torg Classification with 106 (78%) Type 1 fractures, 15 (11%) Type 2 fractures and 15 (11%) Type 3 fractures. At VFC, 135/136 (99.2%) were discharged with the appropriate 5th metatarsal base fracture protocol. Twelve patients (8.8%) arranged further follow-up after initial discharge. The most common reason for return was ongoing pain (6/8 - 75.0%). This subgroup of the patients required an average of 3 (1-6) further appointments. There was 1 non-union during the study period. Based on 2 face to face visits on a traditional pathway, 248 clinic visits were saved with an approximate cost saving of nearly £40,000 ($55,500).Conclusion:Our study supports the management of 5th metatarsal base fractures in the VFC setting. We have shown that the VFC model, with well a defined protocol is both safe and cost effective. Fifth metatarsal base fractures have good outcomes with conservative management, removing the traditional need to have in-person clinic visits to confirm the diagnosis, management and prognosis.

Early Results of a Novel Intramedullary Fixation Device for Proximal Fifth Metatarsal Fractures

Category:Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Proximal fifth metatarsal fractures are commonly treated surgically due to their poor healing capacity. While intramedullary screws may be the most popular operative treatment choice, newer fixation methods continue to develop that offer fracture compression in addition to maintenance of length, alignment and rotation. We present a case-series utilizing a novel intramedullary fixation device for proximal fifth metatarsal fractures. To our knowledge, no other study in the literature has assessed the safety and efficacy of this novel fixation methodMethods:A retrospective analysis was performed for 16 patients with proximal fifth metatarsal fractures who underwent fixation with the same novel intramedullary device. Patient charts were reviewed for fracture union, plantar fracture gapping, time to weightbearing, refracture, perioperative complications, and secondary surgeries.Results:Sixteen patients with an average age of 43.3 years old underwent fixation with this novel device from 2015 to 2020. Mean follow-up was 32.4 weeks. Fifteen of the 16 patients achieved radiographic union at a mean of 8.9 weeks. One patient suffered a non-union. Mean time to full weight-bearing in, and out of, a walking boot was 6.4 and 9.8 weeks, respectively, for healed fractures. Mean plantar fracture gap improved from 1.22 mm to 0.88 mm following surgery. There were zero infections, refractures or hardware complications. Three patients suffered iatrogenic distal diaphyseal fracture during implant insertion, however postoperative progression to weightbearing was not altered in these patients relative to the remainder of the cohort.Conclusion:To our knowledge, this is the first report of early results for this novel intramedullary device. Excellent union rates, acceptable time to weight bearing, and a low complication profile can be achieved. Additionally, plantar fracture gapping, which has been shown to delay time to union, was improved using this novel implant. Based on our early findings, we propose a viable treatment option that is safe and effective for proximal fifth metatarsal fracture stabilization.

Proximal Fifth Metatarsal Fracture Treated with Plantar Plating: Retrospective Multi-Surgeon Case Series

Category:Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Proximal fifth metatarsal fractures are a common foot injury. Previous surgical treatments have consisted of intramedullary screw fixation and a newer technique of plantar plating due to non-union and refractures seen with screw fixation. Purpose of this multi-surgeon case series study is to evaluate clinical and radiographic outcomes and complication rates after fifth metatarsal plating for proximal fifth metatarsal fractures in recreational and elite athletes.Methods:Retrospective multiple surgeon case series involving patients who underwent fifth metatarsal plantar plating for proximal fifth metatarsal fractures with a mean follow-up of 33.1 months (range, 12-52). Elite and recreational athletes were included. Demographic data, radiographic evaluation, and clinical notes were analyzed. Patient phone conversations were made to document complications outside of our electronic medical record.Results:Forty-four patients (45 fractures) were treated with plantar plating technique with a mean age of 37.3 years (range 14- 80). Five patients sustained refractures (11.1% of patients), 2 at previous fracture site, 1 through a screw hole, 1 proximal to plate, and 1 distal to plate. All refractures were treated non-operatively. No wound complications were seen. No secondary revision surgery was needed and union rate was 100% at final follow up.Conclusion:With a one year minimum follow up, plantar plating of proximal fifth metatarsal fractures is a viable option for treatment of both acute and chronic fractures as well as after failed intramedullary screw fixation with low refracture rates and without non-unions. Plantar plating allows the surgeon to have direct visualization of fracture reduction and ease of access for bone grafting. Both elite and recreational athletes can benefit from the plating technique.

Return to Play and Fracture Union after Surgical Management of Jones Fracture in Athletes: A Systematic Review and Meta-Analysis

Category:Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. Management of this injury can be challenging due to delayed union and refracture. Intramedullary screw fixation rather than conservative management has been recommended in the athletic population. This meta-analysis aims to provide an updated summary of return to play (RTP) rate and time with regard to the management, whether operative or non-operative, after Jones fractures in athletes only. We also explore the characteristics of the union such as time and rate, and complications such as refracture.Methods:Following PRISMA guidelines, relevant studies in English literature were identified between databases inceptions to November 2019. Electronic based search on MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases using the following keywords with their synonyms: ('fifth metatarsal fracture' AND 'athlete' AND 'return to play'). In addition, the reference lists from previous review articles were searched manually to check for eligible studies. Two investigators independently reviewed all titles, abstracts, and the full text of articles that were potentially eligible based on the abstract review. Any disagreement was resolved by the senior author. The primary outcomes were (1) return to play rate and (2) time to return to play, whereas the secondary outcomes were (1) games missed, (2) time to union and union rate (3) non-union, delayed union and refracture. The current study accepted the definitions of included studies for non-union, delayed union, and refracture for practicality purposes.Results:Out of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (97.3%- 99.4%) in 626 out of 646. The RTP rate in IM screw only was 98.8% (97.8%-99.7%), in other surgical fixations methods (plate, mini fix) was 98.4% (95.8%-100%) whereas in conservative management was 71.6% (45.6%-97.6%). There were three studies directly comparing the RTP in surgical versus conservative management, which showed significant superiority in favor of the surgical group OR: 0.033 CI:( 0.005-0.215) P-value <0.001. The overall time to RTP was 9.6 (8.5-10.7) weeks. The time to RTP in the surgical group (IM screw) was 9.6 (8.3-10.9) weeks, significantly less than the conservative group, which was 13.05 (8.15-17.95) weeks. The pooled union rate in the operative group (excluding refracture) was 97.3% (95.1%-99.4%), whereas the pooled union rate in the conservative group was 71.4% (49.1%- 93.7%).Conclusion:Return to play following surgical management of Jones fractures in athletes is excellent regardless of the implant used and sport. Intramedullary screw fixation is superior to conservative management as it leads to a higher rate of return to play, shorter time to return, higher union rate, shorter time to union, and improved functional outcomes. The authors recommend surgical fixation for all Jones fractures in athletes.

EXOGEN Mitigates Risk of Fifth Metatarsal Fracture Nonunion: Results of a Novel Real-World Clinical Study.

Category:Midfoot/ForefootIntroduction/Purpose:Fifth metatarsal fractures are the most commonly fractured metatarsal in adults and are associated with high rates of nonunion. This study compared the 9-month incidence of nonunion in fifth metatarsal fracture patients using EXOGEN (Bioventus LLC), low-intensity pulsed ultrasound, versus a control cohort of patients receiving standard of care.Methods:Adults (21-80 years) prescribed EXOGEN for any acute or delayed fifth metatarsal fracture and initiated treatment within 91 days of the fracture were enrolled via prescription record abstraction and direct-to-patient outreach. Open, closed, surgically repaired and conservatively managed fractures were eligible. Jones' fractures consisted of 31.2% of the overall EXOGEN population. EXOGEN treatment compliance was assessed using patient self-report and the device's software. A control cohort of patients with the same eligible fractures were extracted from the MarketScanTM national insurance database (IBM Watson Health). Propensity score (PS) modeling accounting for demographics, comorbidities, concomitant medication, and type of fracture/fracture treatment was used to address potential selection bias via three methods: subclassification, 1:1 matching on individual covariates, and PS weighting. Effectiveness was compared for 1,943 EXOGEN and 10,259 controls. Study endpoint was based on presence or absence of an ICD-10-CM nonunion diagnosis code in the medical billing records for both groups.Results:Matched MarketScan controls had a clinically and statistically significant increase in risk of nonunion compared to patients who used EXOGEN for at least 90 total once-daily treatments (McNemar's OR = 1.67; p=0.048). Results improved with more treatments; the nonunion risk was 2.44 times (p=0.0239) and 5.00 times (p=0.008) for the control patients than EXOGEN patients with at least 120 and 140 total treatments, respectively. The nonunion rate was reduced by over half in Jones' fracture patients treated with at least 90 total once-daily EXOGEN treatments (n=269; 3.3%) as compared to those not reaching this minimum threshold (n=337, 6.8%); such results approached statistical significance (p=0.057). Analyses of the treatment effect by nonunion risk factors showed EXOGEN attenuated the effect of many of these factors on nonunion rates. Early treatment was found beneficial; treatment delay was associated with increased nonunion risk of ~20% for every 15 days of latency 45 days post- fracture.Conclusion:In this large external comparator study, EXOGEN was found to be effective in mitigating the risk of nonunion in fifth metatarsal fracture patients when used for a minimum of 90 total treatments, even in the presence of many nonunion risk factors. Treatment should be initiated as soon as possible following fracture (at least by 45 days post-fracture) to further reduce the risk of nonunion.

Percutaneous Fixation of Metatarsals Fractures with Kirchner’s Wire, Comparison of Antegrade and Retrograde Technique

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:The antegrade intramedullary nailing technique with Kirchner’s wire (K-wire) (EAK) for the management of metatarsal fractures (MTT) is recent and with few reports. Our objective was to evaluate and compare the clinical results among patients operated on in our center for MTT fractures using the EAK technique versus the traditional retrograde technique (ERK).Methods:Retrospective, analytical study. We reviewed the cases of patients with a diagnosis of MTT fracture and surgical indication operated with EAK or ERK between February 2010 and January 2016. First and fifth metatarsal fractures were excluded from the analysis, as well as patients in which a fixation method other than K-wire was used. Demographic data, clinical and radiological results were recorded. A total of 34 patients (34 feet, 70 metatarsals) were analyzed and were divided into two groups: Group 1, operated with EAK (15 feet, 22 metatarsals), and Group 2, operated with ERK (19 feet, 48 metatarsals). Statistical analysis was carried out with Fisher's exact test and Mann-Whitney U test for non-parametric variables, with fixed statistical significance at p <0.05.Results:The median age was 37 years [IQR = 51-25.25], p = 0.128. Both groups presented similar soft tissue involvement (p = 1,000), similar associated injury rate (20.0% vs 42.1%, p = 0.271), and similar proportions of diaphyseal and neck fractures (p = 0.659 and p = 0.733 respectively). The group operated with the EAK technique presented a lower report of metatarsalgia (6.7% (1) vs 47.3% (9), p = 0.020), shorter rest time since injury (94 days [IQR = 129-82] vs 144 days [IQR = 210-122], p = 0.002) and shorter time to full load (7 weeks [IQR = 9-6] vs 10 weeks [IQR 12.5-8.5], p = 0.002). EAK and ERK did not show differences in criteria for poor reduction (p = 1.00), number of re-interventions (p = 0.560), infections (p = 0.492), or metatarsophalangeal stiffness (p = 0.451).Conclusion:Metatarsal fracture fixation with EAK presented a lower rate of metatarsalgia and shorter rest time compared to ERK, demonstrating similarity in terms of quality of reduction and complication rate.

Inter-Rater Reliability of Classifications for Fifth Metatarsal Base Fractures

Category:Trauma; Midfoot/Forefoot; SportsIntroduction/Purpose:Fractures of the fifth metatarsal base have been a source of confusion since their original description by Jones in 1902. The term Jones' fracture has been used indiscriminately leading to further confusion. Zone classifications have been described but never evaluated for their reliability. The most recent classification, metaphyseal versus metaphyseal-diaphyseal is unknown to most surgeons. The purpose of this study was to evaluate the inter-rater reliability of American Orthopaedic Foot & Ankle Society (AOFAS) members classifying fractures of the base of the fifth metatarsal.Methods:A survey was emailed to members of the AOFAS including radiographs of 18 fifth metatarsal base fractures. Demographic information was collected in addition to evaluation of the 18 sets of radiographs using three classification systems. Surgeons were asked if the fracture is a Jones' fracture, zone of the fracture and if the fracture was metaphyseal or metaphyseal- diaphyseal. A total of 223 surgeons with an average experience of 14 years in practice (range: fellow - 50 years) completed the initial survey for inter-rater reliability. Additionally, each surgeon was asked which zones or zone junctions they consider a Jones' fracture. Reliability was tested using Fleiss' Kappa scores.Results:Inter-rater agreement for use of the term Jones' fracture was moderate (kappa 0.533, 95% confidence interval (CI) [0.530, 0.535]). The zone classification had an inter-rater agreement was moderate (kappa 0.537, 95% CI [0.535, 0.539]). Inter- rater agreement for metaphyseal versus metaphyseal-diaphyseal was substantial (kappa 0.705, 95% CI [0.702, 0.708]). Results of surgeon definition of a Jones' fracture is seen in Figure 1.Conclusion:This is the largest study of its kind looking at inter-rater reliability of an orthopaedic classification with 223 raters. The terminology regarding the classification of fifth metatarsal base fractures remains confusing and inconsistent. The term Jones' fracture has little meaning in terms of communicating these injuries as there is only moderate agreement when surveying surgeons and it is defined differently by most. The zone classification has similar reliability as the Jones' fracture. The terms metaphyseal and metaphyseal-diaphyseal was the most reliable means to describe these fractures.

The Metatarsal Cortical Index as an Indicator of Insufficiency Fracture of the Foot

Category:Basic Sciences/Biologics; Midfoot/ForefootIntroduction/Purpose:The diagnosis of metatarsal stress fractures is challenging. Standard imaging often shows false negative results. The aim of this study was to create reliable radiologic outcome parameters to predict insufficiency fractures of the metatarsalsMethods:We performed an age- and sex-matched case-control study of patients with (n = 18) and without insufficiency fracture (n = 18) of the foot. To measure the ratio between the outer cortical border and the endosteal diameter, the MCI was developed as a novel radiographic measurement on dorsoplantar images. The MT was divided into thirds, and the width from the outer cortical border to the endosteal diameter was measured at the junction of the proximal to the middle third (proximal), at the midshaft (middle), and at the junction of the middle to the distal third (distal). The metatarsal cortical index (MCI) for each metatarsal was developed to predict an insufficiency fracture. The MTs were sequentially numbered as MT I-V. To correct for potential bias due to MT length, the Coughlin index and Maestro method were used in all patients.Results:The MCI of each metatarsal was significantly decreased in the insufficiency fracture group compared with the control group (p <.01). The MCI of the fourth ray yielded the highest area under the curve among the analyzed MCI values (area under the curve, 0.79; 95% confidence interval, 0.61-0.90). A cut-off value of 1.62 for the MCI of the fourth ray yielded a sensitivity of 78% and a specificity of 78% to predict insufficiency fracture of the foot (odds ratio, 12.25; 95% confidence interval, 2.54-58.97), and enabled accurate allocation to the insufficiency fracture group versus the control group in 74% of cases.Conclusion:A decreased MCI is associated with metatarsal insufficiency fractures and enables an accurate diagnosis in three out of four cases. Despite the highly variable anatomy and morphology of the MTs, we were able to show that the MCI is a reliable tool to determine insufficiency fracture of the MT on plain radiography. The MCI might aid clinicians in identifying insufficiency fracture, and raise the suspicion of the diagnosis without additional imaging studies.

Inter-Rater and Intra-Rater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:Fractures of the proximal fifth metatarsal are common injuries with a unique history. Treatment of these fractures is controversial, in part due to confusion regarding the nomenclature of the fracture subtypes. The most commonly utilized classification system is the Lawrence and Botte classification, which separates fractures into zones 1, 2, and 3 based on their relationship to the tuberosity and the 4th-5th intermetatarsal articulation. The purpose of this study was to evaluate the inter-rater and intra-rater reliability of the Lawrence and Botte classification of fifth metatarsal base fractures.Methods:Thirty sets of x-rays representing an equal number of zone 1, zone 2 and zone 3 fractures of varying chronicity were sent to eleven fellowship trained orthopedic foot and ankle surgeons. Surgeons were asked to classify each fracture according to the Lawrence and Botte classification system (round 1). No review of the classification system or visual aids were provided. Two weeks later, the same set of x-rays were reordered and renumbered in a random fashion. The surgeons then re-classified each fracture in a blinded fashion under the same conditions (round 2). Inter-rater and intra-rater reliability was summarized using the kappa statistic. To determine the source of variability between the zones, additional analyses were performed to determine the kappa statistic for a) combined zone 1 and 2 fractures versus zone 3 fractures and b) combined zone 2 and 3 fractures versus zone 1 fractures.Results:The Lawrence and Botte classification demonstrated substantial overall inter-rater agreement for both rounds 1 and 2 (kappa = 0.66 and 0.65, respectively). Zone 1 fractures demonstrated the highest inter-rater reliability (kappa = 0.83 and 0.83). There was moderate agreement for zone 2 fractures (kappa = 0.51 and 0.50). There was substantial agreement for zone 3 fractures (kappa = 0.64 and 0.65). Dichotomous evaluation of the zone 1 vs. combined zones 2-3 boundary yielded excellent agreement (kappa = 0.83, 0.83). The combined zones 1-2 vs. zone 3 boundary yielded a much lower agreement (kappa = 0.66, 0.65). Intra-rater reliability varied by individual, with kappa values ranging from 0.60 to 0.90, corresponding to modest to almost perfect agreement.Conclusion:The Lawrence and Botte classification system has overall substantial inter-rater and intra-rater reliability, but assessment of the interface between zone 2 and zone 3 fractures is much less reliable than that between zone 1 and zone 2. Previous studies of isolated zone 1 fractures most likely contain a homogenous fracture cohort, while studies of zone 2 or zone 3 fractures are likely to include a mixture of fracture types. Future studies may utilize supplemental imaging or modify the classification to best determine treatment of these more distal fractures.

Anatomy of the Intermetatarsal Facets of the Fourth and Fifth Metatarsals

Category:Basic Sciences/BiologicsIntroduction/Purpose:The intermetatarsal joint between the fourth and fifth metatarsals (4-5 IM) is important in defining fifth metatarsal fractures. The purpose of the current study was to quantify this joint in order to determine the mean cartilage area, the percentage of the articulation that is cartilage, and to give the clinician data to help understand the joint anatomy as it relates to fifth metatarsal fracture classification.Methods:Twenty cadaver 4-5 IM joints were dissected. Digital images were taken and the articular cartilage was quantified by calibrated digital imaging software.Results:For the lateral fourth proximal intermetatarsal articulation, the mean area of articulation was 188 + 49 mm, with 49% of the area composed of articular cartilage. The shape of the articular cartilage had 3 variations: triangular, oval, and square. A triangular variant was the most common (80%, 16 of 20 specimens). For the medial fifth proximal intermetatarsal articulation, the mean area of articulation was 143 + 30 mm, with 48% of the joint surface being composed of articular cartilage. The shape of the articular surface was oval or triangular. An oval variant was the most common (75%, 15 of 20 specimens).Conclusion:This study supports the notion that the 4-5 IM joint is not completely articular and has both fibrous and cartilaginous components.

Correction of hallux abducto valgus by scarf osteotomy. A ten-year retrospective multicentre review of patient reported outcomes shows high satisfaction rates with podiatric surgery

BackgroundCorrective surgery for hallux abducto valgus is one of the most performed elective procedures in foot and ankle practice. Numerous methods of surgical correction have been reported within the literature, with varying clinical and patient reported outcomes. This study reviews the patient experience and outcomes in five podiatric surgery centres using the scarf diaphyseal osteotomy.MethodPatient reported outcome measures (PROMs) were captured using the Patient Satisfaction Questionnaire 10 (PSQ-10), part of the PASCOM-10 podiatric surgery audit tool. PROMs were collated across five hospital sites over a 10-year period.ResultsOf 1351 patients reported during the period, 1189 had complete retrospective data. The most common patient aim of surgery was ‘no/less pain’ reported in 70% of patients. 96.8% of patients reported their original foot complaint as ‘better’ or ‘much better’ after surgery. 92.8% of patients reported their expectations had been met with 96.6% reporting they would have surgery again under the same conditions. 98.5% of patients noted that the risks, complications, and expectations had been discussed prior to surgery. The most common complication was metatarsal fracture (4.6%).ConclusionThe scarf osteotomy (with or without an Akin phalangeal osteotomy) consistently showed high patient satisfaction with low complication rates using PSQ-10 and this information can be used as part of the pre-operative consenting process. Patient expectations for surgery were often achieved, which may be attributed to the pre-operative work up of the patient. Further investigation into this correlation is suggested.Level of clinical evidenceIV (retrospective review).

Morton’s neuroma after metatarsal neck fracture: A case report

Morton’s neuroma after metatarsal neck fracture: A case report

Cavovarus Foot: Conservative Management Techniques/Case Studies

Category:OtherIntroduction/Purpose:The cavovarus foot is a true challenge for both the patient and the surgeon. This complex deformity can be a result of many different causal factors including genetics, Charcot-Marie-Tooth disease, diabetes and spina bifida. It may also be caused or worsened by trauma or surgical procedures. The cavovarus foot is difficult to manage conservatively as it tends to be rigid, is not a good shock absorber and causes the joints of the foot to process abnormal stresses. The mechanical construct of a cavus foot makes it susceptible to a multitude of complications and injuries like inversion ankle sprains and metatarsal stress fractures.Methods:While foot orthoses would likely be the most commonly considered conservative treatment option for the symptomatic cavus foot, other modalities like shoe modification, bespoke and/or therapeutic footwear and bracing have also proven effective. Oftentimes, a combination of the aforementioned options is employed. Given the individual complexities of each cavus foot, the conservative treatment plan is typically custom tailored to fit a particular patient's foot structure, biomechanical and corrective needs, and occupational or recreational demands. A so-called 'cookie cutter' approach is not appropriate for management of the cavovarus foot.Results:A review of published research demonstrates that foot orthoses - and other conservative modalities - are effective in the treatment of the cavus foot. These devices work by correcting the varus foot alignment (when applicable), offloading painful areas such as ball of the foot or the base of the fifth metatarsal, providing shock absorption and replacing lost motion. These applications work together to provide a more normal, safer and energy-efficient gait.Conclusion:Conservative management, specifically pedorthics, is not only a viable treatment option for the cavovarus foot but should be considered integral to the overall management of the cavus foot patient. Pedorthic modalities are successfully used post-operatively or in lieu of surgical intervention. Modern pedorthics (technological advances in shoe and orthotic design, construction and materials) allows for cosmetically pleasing, affordable and comfortable management allowing patients to return to a healthy and active lifestyle in many cases.

Fourth metatarsal basis stress fracture after steroid use secondary to COVID-19

Joint Diseases and Related Surgery (JDRS), the official journal of the Turkish Joint Diseases Foundation, is an international, peer-reviewed, immediate open access journal. All published articles in JDRS has been free for everyone, without embargo, since 1990.

The Influence of Metatarsus Adductus Angle on Fifth Metatarsal Jones Fractures

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:Previous studies have reported increasing metatarsus adductus angle (MAA) to be associated with delayed union and refracture following intramedullary screw fixation of fifth metatarsal Jones fractures. The purpose of this study was to determine the influence of MAA on postoperative course following intramedullary screw fixation of Jones fractures. We also sought to identify associations between elevated MAA and both fracture and patient characteristics.Methods:We performed a retrospective review of all Jones fractures treated with primary intramedullary screw fixation by 4 foot and ankle fellowship-trained orthopaedic surgeons at a single institution from 1995 through 2015. Exclusion criteria included concomitant foot/ankle procedures and revision surgery. Charts were reviewed for patient and injury characteristics, implant, and postoperative course. Radiographs were examined for fracture classification, radiographic union, and MAA. MAA calculations were performed on standard weight-bearing digital radiographs using the traditional method, with the 5th metarso-cuboid joint as a reference. Based on severity of MAA, comparative and correlation analyses were performed. Primary outcomes were the number of surgical failures (defined as delayed union, nonunion, or refracture) and time to radiographic union, weight bearing, and pain resolution. Data was analysed using independent T test, one-way ANOVA, chi-square, and correlation analyses with significance defined as p<0.05.Results:59 feet in 58 patients were identified with a mean age of 30 years and average follow-up of 9.6 months. The pooled union rate was 96.6%. The mean MAA was 20.9 (SD 6.7). Eleven feet had MAA<15, 18 mild (MAA 15-20), 12 moderate (MAA 20- 25), 18 severe (MAA>25), and 1 unknown. 11 patients had failures (18.6%), which consisted of 7 delayed unions (11.9%), 2 delayed unions (3.4%), and 3 refractures (5.1%). Compared to the uncomplicated unions, there was no significant difference in mean MAA (24.3 vs. 20.1, p=0.16). Three of the 4 non-union or refracture patients had MAA>25. MAA was correlated with time to weight bearing (r=0.365, p=0.005), weight (r=0.503, p<0.001), BMI (r=0.280, p=0.03), and approached significance with age (r=0.230, p=0.082). No significant correlation was found with time to radiographic union.Conclusion:To our knowledge, this is the largest series investigating MAA in fifth metatarsal Jones fracture patients treated with intramedullary screw fixation. Our mean MAA is consistent with previous reports. We found an association between increased MAA and postoperative recovery time, given increased time to initiate weight bearing. We did not find significant associations with prolonged radiographic healing, age, nor failure. The prolonged time to weight bearing may reflect surgeon preference in patients with higher MAA. These results suggest that reported associations with MAA may not be as strong as previously thought.

Consideration of cause and epidemiology of metatarsal fractures

Consideration of cause and epidemiology of metatarsal fractures