A clinical and radiographic comparison of two hardware systems used to treat jones fracture of the fifth metatarsal.

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.

Fifth Metatarsal Jones Fractures: Diagnosis and Treatment.

A Jones fracture, located at the metaphyseal-diaphyseal junction of the fifth metatarsal, is at an increased risk for nonunion and continued pain. Even with excellent surgical technique and postoperative management, a delayed union and refracture can occur. These complications in athletes can have deleterious effects on performance and delay return to sport. This article reviews the classification, diagnosis, and treatment considerations for Jones fractures. Treatment options including nonsurgical management, intramedullary screw, and plate fixation will be covered. The authors preferred technique using intramedullary screw fixation will be discussed in depth. Emerging considerations including biologic augmentation, primary bone grafting, and refracture will be examined as well. Ideal rehabilitation protocols, orthoses, and shoe wear suggestions will be given to optimize patient outcomes.

Noninvasive Soft Tissue Expansion Strips and Wound Complications After Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty through the anterior approach (TAR-AA) is an increasingly popular treatment for ankle arthritis, but it carries a known risk for wound complications. Several products have been investigated to mitigate this risk; however, most are either costly or invasive. Noninvasive skin expansion strips (NSESs) were designed to transfer tension away from the incision and induce new skin growth at the edges of the strips. We hypothesize that postoperative application of NSESs will decrease unplanned clinic visits and wound complications after TAR-AA. METHODS: This is a prospective cohort study of 41 patients at a single institution (3 surgeons) treated with NSESs after undergoing TAR-AA. An additional 41 consecutive historical patients treated without NSESs were retrospectively included as a control group. Patients received application of NSESs in the operating room after routine wound closure and again 2 weeks postoperatively. No other changes were made to the surgeons' wound closure technique, immobilization, follow-up timing, or rehabilitation protocols. Primary outcomes included (1) additional clinic visit required for wound assessment or suture removal, (2) superficial wound complication, and (3) deep infection. RESULTS: Baseline demographics did not differ significantly from our 41 consecutively treated historical controls. Additional clinic visits for suture removal or wound evaluation were significantly lower for patients treated with NSESs (15%, 6 of 41) compared to the control group (49%, 20 of 41) (P = .001). There was also a significant difference in the superficial wound complication rate in the treatment group vs control group, 2% and 12%, respectively (P = .04). There were no deep infections in either group. CONCLUSION: Noninvasive skin expansion strips placed after TAR-AA with an anterior approach have the potential to decrease wound complications and unplanned clinic visits. Further high-volume or randomized studies are needed to clarify their cost effectiveness and effect on long-term outcomes. LEVEL OF EVIDENCE: Level II, prospective cohort study.

High-Energy Achilles Tendon Rupture With Associated Medial Malleolus Fracture and Traumatic Peroneal Dislocation: A Case Report.

Fracture, Achilles tendon rupture, or traumatic dislocation of the peroneal tendons are often seen in isolation after a trauma or sports-related injury. However, in rare circumstances, a combination of these injuries can occur simultaneously. Multiple previous case reports describe a combination of 2 of these injuries. Missed or delayed diagnosis is common in these combination injuries and can lead to significant patient morbidity and result in long-term consequences. We report a case of a 35-year-old man who sustained an Achilles tendon rupture with an associated medial malleolus fracture and traumatic peroneal dislocation after a snowboarding injury. These injuries were treated surgically, and at 9 months postoperatively, the patient had returned to all activities. Clinicians should have a high index of suspicion for concomitant injuries with higher-energy trauma to the ankle and should perform a thorough history, physical examination, and plain radiographs at a minimum.Levels of Evidence: LEVEL 5.

Outcomes Following Ankle Fracture Fixation With or Without Ankle Arthroscopy.

BACKGROUND: Ankle fractures are one of the most common orthopedic injuries, and although most patients have a satisfactory outcome following operative fixation, there are patients that have persistent pain despite anatomic reduction. Intra-articular injuries have been suggested as one potential cause of these suboptimal outcomes. Our study assesses the clinical impact of performing an ankle arthroscopy during ankle fracture open reduction and internal fixation (ORIF). METHODS: This was a retrospective chart review of all patients who underwent operative fixation of a bimalleolar or trimalleolar ankle fracture at our institution from 2014 through 2018. We extracted all demographic data, fracture pattern, operative procedures performed, tourniquet times, arthroscopic findings and any arthroscopic interventions. We then conducted a phone and e-mail survey. Our study included 213 total patients (142 traditional ORIF, 71 ORIF plus arthroscopy) with an average age of 40 years. The average follow-up was 32.4 months with a survey follow-up rate of 50.7% (110/213). RESULTS: The average tourniquet time for the arthroscopy cohort was 10 minutes longer (89 minutes vs 79 minutes). During the arthroscopy, there was a 28% (20/71) rate of full-thickness osteochondral lesions, 33% (24/71) rate of loose bodies, and a 49% (35/71) rate of partial-thickness cartilage injury. The mean Patient Reported Outcome Information System (PROMIS) physical function score among Weber B fibula fractures was 45.8 and 42.3 in the arthroscopy and nonarthroscopy groups, respectively (P = .012). In addition, the patient satisfaction rate in Weber B fibula fractures was higher in those patients who underwent arthroscopy compared with ORIF alone (93% vs 75%, P = .05). Patients who had a tibiotalar joint dislocation at the time of the ankle fracture had a significantly higher PROMIS physical function score (46.6 vs 40.2, P = .005) when their surgery included arthroscopy. CONCLUSION: Ankle arthroscopy at the time of ORIF led to statistically significant improvements in patient-reported outcomes for Weber B fibula fractures and ankle dislocations. There was no increase in complication rates and the arthroscopy took 10 minutes longer on average. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Naviculocuneiform Sag in the Acquired Flatfoot: What to Do.

Sag at the naviculocuneiform (NC) joint represents an important aspect of the flatfoot deformity. Failure to address medial column instability could lead to continued deformity and poor patient outcomes. No single procedure is enough to address the complexity of the adult acquired flatfoot deformity. Whether in combination with other procedures or in isolation, NC fusion and Cotton osteotomy are important pieces of the armamentarium to address all aspects of the flatfoot deformity.

Clinical and Radiographic Outcomes of Total Shoulder Arthroplasty With a Hybrid Dual-Radii Glenoid Component.

In total shoulder arthroplasty (TSA), glenoid prostheses have conforming or nonconforming designs. A hybrid glenoid was designed with dual radii of curvature: a central conforming region surrounded by an outer nonconforming region. We retrospectively reviewed the cases of 169 patients who underwent 196 hybrid glenoid prosthesis TSAs for primary glenohumeral arthritis. Clinical data, retrieved for 178 shoulders at a mean follow-up of 4.8 years, included physical examination, 36-Item Short Form Health Survey (SF-36), American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), subjective Neer criteria, and postoperative complication data. Radiographic data were retrieved for 136 shoulders at a mean of 3.7 years. Kaplan-Meier survivorship analysis was performed with glenoid or humeral revision as the endpoint. All range of motion and survey measures improved in a statistically significant manner (P < .001). Of 139 respondents, 130 (93.5%) stated they were satisfied or very satisfied with their TSA. Of 178 patients, only 3 (1.7%) required revision for component loosening: 2 glenoid and 1 humeral. Of 136 shoulders, 86 (63.2%) had no glenoid lucencies, and 91 (66.9%) had no humeral stem lucencies. Use of a hybrid-congruency glenoid prosthesis had excellent intermediate clinical and radiographic outcomes in the treatment of primary glenohumeral osteoarthritis.

A novel arthroscopic technique utilizing bone morphogenetic protein in the treatment of Kienböck disease.

Kienböck disease, first described in 1910, is osteonecrosis of the carpal lunate and has been associated with ulnar minus variance. Numerous joint leveling procedures have been developed for patients with ulnar-negative variance to decrease forces transmitted across the lunate. The basis of operative treatment is the presence or absence of advanced osteoarthritis associated with fragmentation of the carpal lunate and capitate descent. Bone morphogenetic proteins (BMPs) have been utilized successfully as adjunctive treatment in fracture healing and recently in the surgical treatment of a patient with Lichtman stage IIIA Kienböck disease. Arthroscopy is an available tool in assessing cartilage injury and coupled with the use of BMP may be of benefit in patients with ulnar-neutral or ulnar-negative wrists who have not progressed to severe arthritis and capitate descent. We report a novel arthroscopic technique in which a stage IIIA and IIIB carpal lunate osteonecrosis is treated by curettage and grafting with an admixture of autologous radial cancellous bone marrow graft and BMP-2.

The ruptured Achilles tendon: operative and non-operative treatment options.

The Achilles tendon is the strongest and thickest tendon in the human body. Like any other tendon in the body, however, it is susceptible to rupture. Many surgeons advocate early operative repair of the ruptured Achilles tendon, citing decreased re-rupture rates and improved functional outcome. Waiting for surgical repair for longer than one month may lead to inferior functional results postoperatively. Non-operative treatment has higher re-rupture rates as compared to surgically repaired tendons, but may be the treatment of choice in some patients. While for many years, patients were rigidly immobilized in a non-weightbearing cast for 6-8 weeks postoperatively, newer studies have shown excellent results with early weightbearing, and this is quickly becoming the standard of care amongst many physicians.

Alendronate inhibits spine fusion in a rat model.

STUDY DESIGN: A posterolateral lumbar fusion model in rats. OBJECTIVE: To study the effects of alendronate on posterolateral lumbar fusion in rats. SUMMARY OF BACKGROUND DATA: To our knowledge, there are no studies that show a significant inhibition of manual palpation-assessed spine fusion by alendronate. METHODS: A total of 75 Sprague-Dawley rats underwent intertransverse fusion with 7-tailbone autograft at L4-L5. Animals received saline (control), alendronate equivalent to human dose (dose1, 5 microg/kg/day), or 10 times the human dose (dose10, 50 microg/kg/day) via subcutaneous osmotic pumps starting the day of surgery. Eight weeks after surgery, animals were euthanized, and fusion was assessed by manual palpation. Radiographic area and optical density of fusion masses were calculated. Histomorphometry was used to assess the percentage area of fusion masses occupied by bone or marrow tissues. RESULTS: Manual palpation fusion rates were lower in alendronate groups (50% and 40%, respectively) than in the control group (95%, P = 0.002). Interobserver and intraobserver kappa values were high (0.97-1.00). There were dose-dependent and statistically significant (P < 0.001) increases in fusion mass area and optical density with increasing alendronate dose. Fusion masses in dose10 animals had significantly higher percent area of bone tissue (P = 0.01) and lower percent area of marrow elements (P < 0.001) when compared to control animals. CONCLUSIONS: Alendronate inhibits spine fusion in rats. Fusion masses in alendronate-treated animals appeared radiographically larger and denser than those in control animals despite lower fusion rates. Quantitative histomorphometry confirmed that alendronate inhibited bone graft resorption and incorporation. We recommend that patients undergoing spine arthrodesis should not take alendronate until fusion is achieved.