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 DOI: 10.1177/1071100713483100

2013 34: 956Foot Ankle IntJoshua Metzl, Kirstina Olson, W. Hodges Davis, Carroll Jones, Bruce Cohen and Robert Anderson

Fifth MetatarsalA Clinical and Radiographic Comparison of Two Hardware Systems Used to Treat Jones Fracture of the

  

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Foot & Ankle International34(7) 956 –961© The Author(s) 2013Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1071100713483100fai.sagepub.com

A Jones fracture, located at the metaphyseal-diaphyseal junction of the fifth metatarsal, is at increased risk for non-union and continued pain. First described by Sir Robert Jones in 1902,6 these fractures represent a challenging clini-cal problem. Nonoperative treatment typically includes a non-weight-bearing cast, followed by a weight-bearing orthosis. Conservative treatment has been shown to heal a high percentage of fractures in several studies. Torg et al reported on 15 Jones fractures that were treated with immo-bilization and progressive weight-bearing and found a 93%

healing rate at an average of 6.5 weeks.19 However, other authors have shown a risk of delayed union or nonunion as

483100 FAIXXX10.1177/1071100713483100Foot & Ankle InternationalMetzl et al2013

1Steadman Hawkins Clinic Denver, Greenwood Village, CO, USA2UCSF Orthopaedic Institute, San Francisco, CA, USA3OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA

Corresponding Author:Joshua Metzl, MD, Steadman Hawkins Clinic Denver, 8200 East Belleview Ave Suite 615, Greenwood Village, CO 80111. Email: jmetzl@shcdenver.com

A Clinical and Radiographic Comparison of Two Hardware Systems Used to Treat Jones Fracture of the Fifth Metatarsal

Joshua Metzl, MD1, Kirstina Olson, MD2, W. Hodges Davis, MD3, Carroll Jones, MD3, Bruce Cohen, MD3, and Robert Anderson, MD3

Abstract

Background: There is a broad variation in the type and size of screws used for Jones fractures. Therefore, a screw implant specifically designed for the operative treatment of a Jones fracture has been developed. The purpose of this retrospective study was to compare the clinical and radiographic results of patients treated with a screw specifically designed for this fracture to a group treated with a traditional screw.Methods: Forty-seven patients underwent surgery (47 feet) for a Jones fracture between 1999 and 2007, performed by 4 foot and ankle fellowship-trained orthopaedic surgeons at one institution. Twenty-six patients (26 feet) were treated with the indication-specific screw (group I), while 21 patients (21 feet) were operated on with the traditional screw (group II). All patients were retrospectively reviewed for either radiographic signs of union or an adverse event. Radiographic parameters were evaluated by 2 independent observers, which included Torg’s classification system (intramedullary sclerosis, cortical hypertrophy, periosteal reaction), hardware failure, with an endpoint of healing or nonunion. Of 47 patients, 40 were available for clinical follow-up, and functional outcomes with VAS pain scores at final follow-up visit were compared. Additional procedures (bone grafting), complications, and adverse events were recorded. The results were analyzed using Fisher’s exact tests and independent t test with a significance level of .05. The average age of the patients was 43.8 years, with a mean clinical follow-up of 37 months (range of 6 to 105 months).Results: Preoperative films were classified according to the Torg classification system and did not demonstrate any difference between group I and group II, with respect to the type of Jones fracture. There was no significant difference found between the 2 groups as related to fracture union, but there was a higher number of adverse events in group II as compared with group I (P = .03). The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 symptomatic hardware, all requiring further surgical interventions. All adverse events occurred within an average of 2 months after surgery. Clinically, there were no statistically significant differences between the 2 systems in regard to limitations in activity, shoe-wear modifications, recovery time, satisfaction, and willingness to repeat the surgery. The VAS pain scales (0-100) were equivalent; average VAS pain of group II was reported as 9 (range, 0-33), as compared to the VAS pain of patients in group I averaging 11 (range, 0-47).Conclusions: In our retrospective series, comparing 2 differing instrumentation systems in treating Jones fractures, both groups were found to progress to radiographic union above 95%. Although there was a statistically greater number of adverse events in the traditional hardware system (group II), clinically both groups had similar outcomes with good results.Level of Evidence: Level III, retrospective comparative series.

Keywords: Jones fracture, indication-specific screw

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Torg Classification Radiographic Appearance

Type I (early) No intramedullary sclerosisFracture line with sharp margins and no

wideningMinimal cortical hypertrophyMinimal evidence of periosteal reaction

to chronic stressType II (delayed) Fracture line that involves both cortices

with associated periosteal bone unionWidened fracture line with adjacent

radiolucency related to bone resorption

Evidence of intramedullary sclerosisType III (nonunion) Wide fracture line

Periosteal new bone and radiolucencyComplete obliteration of the medullary

canal at the fracture site by sclerotic bone

Source: Data from Strayer et al18 and Torg et al.19

Table 2. Size and Type of Screw Used in Both Patient Groups.

Indication Specific Screw (group I) Screw Type

Screw Size

Number of Patients

Indication Specific 4.5mm 15Indication Specific 5.5mm 10Indication Specific 6.5mm 1

Traditional Screw (group II)

Screw Type

Screw Size

Number of Patients

DePuy Ace Cancellous 4.0mm 1Synthes ASIF Malleolar 4.5mm 17Synthes ASIF Malleolar 6.5mm 3

Table 1. Torg’s Classification System for Fractures of the Proximal Fifth Metatarsal.

high as 25% to 50%.2,5,7,15 Clapper et al found that time to union was 12.1 weeks, as compared to 21.2 weeks for the nonoperatively treated patients with Jones fractures.2 Spe-cifically in athletic patients, Kavanaugh et al found evi-dence of delayed union in 66.7% of patients with Jones fractures.7

Intramedullary screw fixation is a common treatment modality used to expedite healing, return to play, decrease nonunion rates, and prevent refracture.3,12-14,16 There is a broad variation in the type and size of screws used. Therefore, a screw implant specifically designed for the operative treatment of a Jones fracture has been developed. The purpose of this retrospective study was to compare the clinical and radiographic results of patients treated with a screw specifically designed for this fracture to a group treated with a traditional screw.

MethodsForty-seven patients underwent surgery (47 feet) for a Jones fracture between 1999 and 2007, performed by 1 of 4 foot and ankle fellowship-trained orthopaedic surgeons at 1 institution. Patients included in the study were identi-fied by a retrospective chart review of appropriate CPT codes. Any patient having undergone percutaneous inter-nal fixation of an acute fifth metatarsal Jones fracture was included in the study. Twenty-six patients (26 feet) were treated with the Charlotte Carolina Jones Fracture System (Wright Medical Technology, Arlington, TN; group I), while 21 patients (21 feet) were operated on using a tradi-tional solid screw (group II). The Carolina Jones Fracture System utilized a cannulated surgical system to allow for

greater surgical efficiency and reproducibility. Appropriate screw size was determined by measuring directly from the appropriately size tap. The set allowed for insertion of 3 different size solid stainless steel screw diameters (4.5, 5.5, and 6.5 mm) in lengths from 40 to 70 mm with a specially designed low-profile head to minimize soft tis-sue irritation. All screw sizes had the same thread pitch which used the same instrument set for insertion.11 The mean clinical follow-up was 37 months (range, 6 to 105 months). Of 47 patients, 40 were available for clinical follow-up, and functional outcomes with VAS pain scores were compared.

All patients were retrospectively reviewed for either radiographic signs of union or an adverse event. All films were classified by 2 independent observers. Preoperative films were classified according to Torg’s classifications sys-tem as seen in Table 1 (intrameduallary sclerosis, cortical hypertrophy, periosteal reaction).19 Postoperative films were reviewed for the presence of hardware failure with an endpoint of union or nonunion. All radiographs were exam-ined by 2 independent orthopaedic surgeons that were not part of the operative or postoperative care of any of the sub-jects in this study. Any disagreement in grade among the reviewers was discussed and a mutual conclusion was reached. Additional procedures (bone grafting), complica-tions, and adverse events were recorded as well.

DemographicsTwenty-six patients (26 feet) were treated with the indication-specific screw (group I) while 21 patients (21 feet) were treated with the traditional screw (group II). The majority of patients in both groups had a 4.5 mm screw. The sizes and number of patients with each screw are listed in Table 2. No screw in any group was cannulated. The aver-age patient age was 43.8 years of age. One patient in the

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958 Foot & Ankle International 34(7)

indication-specific screw group and 5 patients in the tradi-tional screw group had a preexisting diagnosis of diabetes. Bone graft was added to the fracture in 5 patients in the indication-specific screw group and 4 patients in the tradi-tional screw group.

All patients who received bone graft had a delayed union or non union of 3 months or more based on patient history, physical examination and plain radiographs. Isolated calca-neal bone graft was added to the fracture site in 3 patients in the indication-specific group and BMA/DBM/CaSO4 (Ignite Powermix Injectable Stimulus, Wright Medical Technology, Arlington, TN) was added to the fracture site in 2 patients. In the traditional screw group, 2 patients had cal-caneal bone graft placed at the fracture site (1 patient was diabetic), 1 patient had iliac crest bone graft placed at the fracture site, and 1 patient had isolated bone marrow aspi-rate injected at the fracture.

Operative TechniqueUsing direct palpation, a dorsomedial starting point was obtained in the proximal fifth metatarsal (ie, “high and inside”). A K wire was advanced past the fracture site and the placement was checked on fluoroscopy. The 3.2 mm drill was advanced under image guidance past the fracture site. Successive taps were then used, starting with 4.5 mm, then 5.5 mm, then 6.5 mm if needed, until sufficient torque was felt during tapping. Torque was deemed sufficient when turning of the torque screwdriver caused palpable rotation of the distal fifth metatarsal shaft. The appropriate screw length and size were selected such that the threads of the partially threaded screw were just past the fracture site. The typical screw length was between 40 and 50 mm.

Postoperatively, patients were non-weight-bearing in a splint or cast for 2 weeks. Weight-bearing in a short CAM (controlled ankle motion) walker boot was then initiated. Once patients were minimally tender to palpation, showed radiographic evidence of bone consolidation at the fracture site, and were able ambulate without pain, they were transi-tioned into running shoes with an orthotic insert, which was usually 4-6 weeks (range, 4-8 weeks) postoperatively. Recreational activities were resumed thereafter.

Statistical AnalysisThe results were analyzed using Fisher’s exact tests and independent t test with a significance level of .05.

ResultsClinical

The VAS pain scales (0-100) were equivalent; average VAS pain of group II (indication-specific screw) was reported as

9 (range, 0-33), as compared with the VAS pain of patients in group I (traditional screw) averaging 11 (range, 0-47).

Five patients in both groups were not satisfied with their surgery, but the remainder in both groups were satisfied. Three patients in the indication-specific screw group and 5 patients in the traditional screw group experienced diffi-culty with shoe wear postoperatively. One patient in each group required a modified shoe or brace for ambulation. All other patients were able to wear a fashionable shoe or a comfortable shoe with an insert. The majority of patients in both groups considered themselves recovered in less than 6 months. Three patients in the traditional screw group and 1 patient in the indication-specific screw group required 6 to 12 months for recovery. These differences were not statisti-cally significant.

RadiographicThere was no statistically significant difference between the patients in groups I and II with regard to preoperative radiographic appearance of the fracture (Figure 1). The majority of fractures in both groups were Torg type I (minimal cortical reaction and intramedullary sclerosis with sharp fracture lines).

There were 2 cases of radiographic nonunion in the tra-ditional group (II), both of which went on to hardware fail-ure. There were no cases of hardware failure in the indication-specific group. Group II had a longer follow-up because the surgeries were performed at an earlier time

0

2

4

6

8

10

12

14

16

18

20

I II III

Freq

uenc

y

Torg Class

Indication specific screwTraditional screw

Figure 1. There was no statistically significant difference between the patients in groups I and II with regard to preoperative radiographic appearance of the fracture.

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Metzl et al 959

point, but all adverse events occurred within an average of 2 months after surgery.

ComplicationsAll adverse events occurred in the traditional screw group. The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 case of symptomatic hard-ware, all requiring further surgical interventions. Three of the adverse events were in patients with 4.5 mm screws and 1 occurred in a patient with a 6.5 mm screw. There were no adverse events in any patient in the indi-cation-specific screw group (group I) that had calcaneal bone graft or bone marrow aspirate with Ignite (WMT) added to the fracture site. One patient in the traditional screw group (group II) that had calcaneal bone graft added to the fracture with a 4.5 mm malleolar screw sus-tained a refracture 33 months after surgery. There was not an increased complication rate among the diabetic patients in either study group as compared to the nondia-betic patients.

DiscussionSir Robert Jones first described an acute fracture of the fifth metatarsal base in 1902 after he sustained the injury danc-ing around a military pole.6 Current literature defines a Jones fracture as an acute fracture of the fifth metatarsal at the junction between the proximal diaphysis and metaphy-sis of the fifth metatarsal without distal extension beyond the fourth to fifth intermetatarsal articulation.1,9 The diffi-culty for some patients to heal Jones fractures may be due to the precarious blood supply of the proximal fifth meta-tarsal. Using cadaver specimens, Smith et al showed that the arterial supply to the tuberosity joined the supply of the proximal diaphysis in the area just distal to the tuberosity, corresponding to the region of poor prognosis for fracture healing.17

The size and type of operative fixation for Jones frac-tures has been a topic of considerable debate as well. DeLee et al used a percutaneous screw in 10 athletes with fifth metatarsal stress fractures and achieved a union rate of 100%. There were no refractures, but 7 out of 10 patients reported hardware irritation at the screw head.4 Porter et al used a 4.5 mm cannulated screw for 24 consecutive feet in 23 athletes with a clinical healing rate of 100%. The mean percentage healing as shown on radiographs was 98.9%, with no refractures.12 Murawski et al reported on 26 con-secutive patients with proximal fifth metatarsal fractures fixed with a Charlotte Carolina screw and bone marrow aspirate concentrate. There was 1 refracture and 1 delayed union that eventually healed.10

Other studies, however, have shown less predictable results with intramedullary fixation.

Larson et al retrospectively reviewed 6 treatment fail-ures in 15 patients with Jones fractures treated with intra-medullary screw fixation. There were no significant differences in age, sex, screw diameter, use of bone graft, or age of fracture between patients with failures and those without complications. Return to full activity before com-plete radiographic union was predictive of failure.8 Wright et al retrospectively reviewed 6 cases of refracture of clini-cally and radiographically healed fractures of the base of the fifth metatarsal after intramedullary screw fixation. A cannulated screw between 4.5 and 5.0 mm was used in 4 out of 6 cases.20

Our study retrospectively compared 26 patients (26 feet) treated with an indication-specific screw (group I) to 21 patients (21 feet) with a traditional screw (group II). Clinically, there were no statistically significant differences between the 2 systems in regard to limitations in activity, shoe-wear modifications, recovery time, satisfaction, and willingness to repeat the surgery. However, there was a higher number of adverse events in group II as compared with group I (P = .03). The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 case of symptomatic hardware, all requiring further operative interventions.

Although the mechanical stability of the Jones fracture is addressed with screw placement, the addition of bone mar-row aspirate to the fracture site may add additional biologi-cal stimulation for union. Murawski et al retrospectively reviewed 27 patients who underwent percutaneous screw placement with bone marrow aspirate injection. One patient experienced a delayed union and another healed but subse-quently refractured. In the series by Hunt and Anderson, 8 patients had DBM with autologus BMA added to Jones refractures and nonunions. They found no significant differ-ence in time to radiographic healing or return to sport com-pared with standard cancellous autograft.10

In our series, isolated calcaneal bone graft was added to the fracture site in 3 patients in the indication-specific group and BMA/DBM/CaSO4 (Ignite Powermix Injectable Stimulus, Wright Medical Technology, Arlington, TN) was added to the fracture site in 2 patients. In the traditional screw group, 2 patients had calcaneal bone graft placed at the fracture site, 1 patient had iliac crest bone graft placed at the fracture site, and 1 patient had isolated bone marrow aspirate injected at the fracture site. There were no adverse events in any patient in the indication-specific screw group that had calcaneal bone graft or BMA/DBM/CaSO4 (Ignite Powermix Injectable Stimulus, Wright Medical Technology, Arlington, TN) added to the fracture site. One patient in the traditional screw group that had calcaneal bone graft added to the fracture with a 4.5 mm malleolar screw sustained a refracture 33 months after surgery. Based on these results, it is difficult to draw definitive conclusions regarding the pre-cise indications for the addition of bone marrow aspirate,

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demineralized bone matrix, or cancellous autograft to Jones fractures. However, given the 100% union rate in the indication-specific screw group using calcaneal autograft (3 patients) or BMA/DBM/CaSO4 (Ignite Powermix Injectable Stimulus, Wright Medical Technology, Arlington, TN; 2 patients), the use of these adjuncts could potentially be justified in the revision, delayed union, or refracture scenario.

The excellent clinical outcome and low complication rate using the Charlotte Carolina screw may be due to the superior biomechanical properties of the screw itself. Nunley et al compared the bending fatigue resistance of the smallest-diameter Wright Medical Technologies Charlotte Carolina screw to that of 3 commonly used contemporary screws.11 The number of load cycles withstood by the Wright Medical Technologies Charlotte Carolina screw greatly exceeded the number of cycles tolerated by Acutrak 4/5 screws, Synthes 4.5 mm malleolar screws, and Synthes 4.5 mm cannulated screws.1 Our study also found similar clinical results to those of a series by Murawski et al, who reported 1 refracture and 1 delayed union that eventually healed using the Charlotte Carolina screw.10

The cost of solid as compared to cannulated screws for the treatment of Jones fractures is also worth consideration. Although several companies produce solid, partially threaded screws, only a few companies provide the 5.5 mm and 6.5 mm sizes that are frequently required. They are also typically more expensive than a standard 4.5 mm solid screw from a “nonspecific” implant set.

In this study, there were 6 patients with a preexisting diagnosis of diabetes: 1 patient in the indication-specific group (I) and 5 patients in the traditional screw group (II). Because none of the diabetic patients in either group of this study experienced postoperative complications related to operative intervention, we are unable to draw conclusions regarding the use of indication-specific or traditional screws for the treatment of Jones fractures in the diabetic patient population.

Limitations of this study are largely related to its retro-spective nature. There was no randomization of the implant size, type, or implantation system. In addition, neither the patients nor the surgeons were blinded to the type of screw used. Also, we did not obtain potential risk factors for adverse outcomes such as smoking history or cavus foot position. Last, multiple bone grafting techniques were used (eg, BMA, calcaneal autograft, Ignite) for patients with delayed unions or nonunions, making it difficult to draw definitive conclusions about which technique was superior, the precise indications for use and any potential influence on long term patient outcomes in this study.

In conclusion, the current study supports previous litera-ture that intramedullary screw fixation of fifth metatarsal fractures yields excellent clinical results with a low compli-cation rate. Although both the indication-specific and tradi-tional screw groups in this study had statistically similar

clinical and radiographic results, there was a higher refrac-ture rate in the traditional group. It is our opinion that one could consider using an indication-specific screw in any patient where postoperative refracture is a concern.

Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Some of the authors of this study receive royalties from Wright Medical.

FundingThe author(s) received no financial support for the research, authorship, and/or publication of this article.

Reference

1. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008;466(8): 1966-1970.

2. Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal. Analysis of a fracture registry. Clin Orthop Relat Res. 1995;315:238-241.

3. Dameron TB Jr. Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg. 1995;3(2):110-114.

4. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth meta-tarsal. Am J Sports Med. 1983;11(5):349-353.

5. Den Hartog BD. Fracture of the proximal fifth metatarsal. J Am Acad Orthop Surg. 2009;17(7):458-464.

6. Jones RI. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg. 1902;35(6):697-700.

7. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am. 1978;60(6):776-782.

8. Larson CM, Almekinders LC, Taft TN, Garrett WE. Intra-medullary screw fixation of Jones fractures. Analysis of fail-ure. Am J Sports Med. 2002;30(1):55-60.

9. Lawrence SJ, Botte MJ. Jones’ fractures and related fractures of the proximal fifth metatarsal. Foot Ankle. 1993;14(6): 358-365.

10. 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. 2011;39(6):1295-1301.

11. Nunley JA, Glisson RR. A new option for intramedullary fixation of Jones fractures: the Charlotte Carolina Jones Frac-ture System. Foot Ankle Int. 2008;29(12):1216-1221.

12. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones frac-ture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and recreational athlete: a clinical and radiographic evaluation. Am J Sports Med. 2005;33(5):726-733.

13. Porter DA, Rund AM, Dobslaw R, Duncan M. Comparison of 4.5- and 5.5-mm cannulated stainless steel screws for fifth meta-tarsal Jones fracture fixation. Foot Ankle Int. 2009;30(1):27-33.

by charles lombardi on August 3, 2013fai.sagepub.comDownloaded from

Metzl et al 961

14. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones’ fractures. Foot Ankle Int. 2003;24(11):829-833.

15. Rosenberg GA, Sferra JJ. Treatment strategies for acute frac-tures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg. 2000;8(5):332-338.

16. 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. 2001;22(7):581-584.

17. Smith JW, Arnoczky SP, Hersh A. The intraosseous blood supply of the fifth metatarsal: implications for proximal frac-ture healing. Foot Ankle. 1992;13(3):143-152.

18. Strayer SM, Reece SG, Petrizzi MJ. Fractures of the Proximal Fifth Metatarsal Virginia. Am Fam Physician. 1999;59(9):2516-2522.

19. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984;66(2):209- 214.

20. Wright RW, Fischer DA, Shively RA, Heidt RS Jr, Nuber GW. Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med. 2000;28(5):732-736.

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