Foot & Ankle International

http://fai.sagepub.com/ A Clinical and Radiographic Comparison of Two Hardware Systems Used to Treat Jones Fracture of the Fifth Metatarsal
Joshua Metzl, Kirstina Olson, W. Hodges Davis, Carroll Jones, Bruce Cohen and Robert Anderson Foot Ankle Int 2013 34: 956 DOI: 10.1177/1071100713483100 The online version of this article can be found at: http://fai.sagepub.com/content/34/7/956

Published by:
http://www.sagepublications.com

On behalf of:

American Orthopaedic Foot & Ankle Society

Additional services and information for Foot & Ankle International can be found at: Email Alerts: http://fai.sagepub.com/cgi/alerts Subscriptions: http://fai.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Jul 2, 2013 What is This?

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

483100
3100Foot & Ankle InternationalMetzl et al 2013

FAIXXX10.1177/107110071348

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

Foot & Ankle International 34(7) 956961 The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100713483100 fai.sagepub.com

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 Torgs 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 Fishers 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 A Jones fracture, located at the metaphyseal-diaphyseal junction of the fifth metatarsal, is at increased risk for nonunion and continued pain. First described by Sir Robert Jones in 1902,6 these fractures represent a challenging clinical 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 immobilization 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
1 2

Steadman Hawkins Clinic Denver, Greenwood Village, CO, USA UCSF Orthopaedic Institute, San Francisco, CA, USA 3 OrthoCarolina 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

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

Metzl et al
Table 1. Torgs Classification System for Fractures of the Proximal Fifth Metatarsal. Torg Classification Type I (early) Radiographic Appearance No intramedullary sclerosis Fracture line with sharp margins and no widening Minimal cortical hypertrophy Minimal evidence of periosteal reaction to chronic stress Fracture line that involves both cortices with associated periosteal bone union Widened fracture line with adjacent radiolucency related to bone resorption Evidence of intramedullary sclerosis Wide fracture line Periosteal new bone and radiolucency Complete obliteration of the medullary canal at the fracture site by sclerotic bone

957
Table 2. Size and Type of Screw Used in Both Patient Groups. Indication Specific Screw (group I) Screw Type Indication Specific Indication Specific Indication Specific Traditional Screw (group II) Screw Type DePuy Ace Cancellous Synthes ASIF Malleolar Synthes ASIF Malleolar Screw Size 4.0mm 4.5mm 6.5mm Number of Patients 1 17 3 Screw Size 4.5mm 5.5mm 6.5mm Number of Patients 15 10 1

Type II (delayed)

Type III (nonunion)

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

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 Specifically in athletic patients, Kavanaugh et al found evidence 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.

Methods
Forty-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 identified by a retrospective chart review of appropriate CPT codes. Any patient having undergone percutaneous internal 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 traditional 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 tissue 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 Torgs classifications system 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 examined by 2 independent orthopaedic surgeons that were not part of the operative or postoperative care of any of the subjects in this study. Any disagreement in grade among the reviewers was discussed and a mutual conclusion was reached. Additional procedures (bone grafting), complications, and adverse events were recorded as well.

Demographics
Twenty-six patients (26 feet) were treated with the indicationspecific 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 average patient age was 43.8 years of age. One patient in the

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

958 indication-specific screw group and 5 patients in the traditional 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 traditional 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 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 was diabetic), 1 patient had iliac crest bone graft placed at the fracture site, and 1 patient had isolated bone marrow aspirate injected at the fracture.

Foot & Ankle International 34(7)

20 18 16 14 Frequency 12 10 8 6 4 2 0 I II Torg Class Indication specific screw Traditional screw III

Operative Technique
Using 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 transitioned into running shoes with an orthotic insert, which was usually 4-6 weeks (range, 4-8 weeks) postoperatively. Recreational activities were resumed thereafter.

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.

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 difficulty 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 statistically significant.

Radiographic
There 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 traditional group (II), both of which went on to hardware failure. 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

Statistical Analysis
The results were analyzed using Fishers exact tests and independent t test with a significance level of .05.

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

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

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

959 Larson et al retrospectively reviewed 6 treatment failures in 15 patients with Jones fractures treated with intramedullary 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 complete radiographic union was predictive of failure.8 Wright et al retrospectively reviewed 6 cases of refracture of clinically 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 marrow aspirate to the fracture site may add additional biological 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 subsequently 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 difference in time to radiographic healing or return to sport compared 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 precise indications for the addition of bone marrow aspirate,

Complications
All adverse events occurred in the traditional screw group. The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 case of symptomatic hardware, 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 indication-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 sustained 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 nondiabetic patients.

Discussion
Sir Robert Jones first described an acute fracture of the fifth metatarsal base in 1902 after he sustained the injury dancing 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 metaphysis of the fifth metatarsal without distal extension beyond the fourth to fifth intermetatarsal articulation.1,9 The difficulty for some patients to heal Jones fractures may be due to the precarious blood supply of the proximal fifth metatarsal. 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 fractures 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 consecutive 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.

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

960 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 retrospective 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 literature that intramedullary screw fixation of fifth metatarsal fractures yields excellent clinical results with a low complication rate. Although both the indication-specific and traditional screw groups in this study had statistically similar

Foot & Ankle International 34(7) clinical and radiographic results, there was a higher refracture 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 Interests
The 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.

Funding
The 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, OBrien 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 metatarsal. 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. Intramedullary screw fixation of Jones fractures. Analysis of failure. 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 Fracture System. Foot Ankle Int. 2008;29(12):1216-1221. 12. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture 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):726733. 13. Porter DA, Rund AM, Dobslaw R, Duncan M. Comparison of 4.5- and 5.5-mm cannulated stainless steel screws for fifth metatarsal Jones fracture fixation. Foot Ankle Int. 2009;30(1):27-33.

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

Metzl et al
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 fractures 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 fracture healing. Foot Ankle. 1992;13(3):143-152.

961
18. Strayer SM, Reece SG, Petrizzi MJ. Fractures of the Proximal Fifth Metatarsal Virginia. Am Fam Physician. 1999;59(9):25162522. 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):209214. 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.

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