scholarly journals Predictors of Malreduction in Zone II and III 5th Metatarsal Fractures Fixed with an Intramedullary Screw: A Retrospective Analysis

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0028
Author(s):  
Ankit Khurana ◽  
Charles C. Pitts ◽  
Bradley Alexander ◽  
Akshar Patel ◽  
Charles R. Sutherland ◽  
...  
Keyword(s):  
Delayed Union ◽  
Fracture Site ◽  
Entry Point ◽  
Entry Length ◽  
Increased Risk ◽  
Screw Length ◽  
Metatarsal Fractures ◽  
Screw Diameter ◽  
Zone Ii ◽  
Intramedullary Screw

Category: Midfoot/Forefoot; Sports Introduction/Purpose: Percutaneous fixation of 5th metatarsal fractures may lead to malreduction due to improper implant selection and placement. Our aim was to test the effects of screw entry, length, and diameter on malreduction, delayed union, non-union, or refracture. Methods: We retrospectively reviewed zone II and proximal zone III 5th metatarsal fractures managed with intramedullary screw fixation. Comparisons were made between plantar cortex distraction/lateral cortex distraction and ratios of screw length, diameter, and entry point using multiple regression analysis. A further analysis was carried out between time to union and distraction in the lateral and plantar cortices. Results: Plantar and lateral gap were both correlated with entry point ratio on lateral and AP view respectively (p<0.001 for both views). We did not see an association between plantar and lateral gap with screw diameter ratio (p=0.393 for AP and p=0.981 for lateral) or screw length ratio (p=0.966 for AP and p=0.740 for Lateral). Ratio of postop/preop apex height on AP and lateral showed correlation to presence of lateral and plantar fracture gap respectively (p<0.0001). Presence of a plantar gap did have a slight influence on time to union (p=0.044). Most fractures showed radiographic union at 12 weeks (38/44 that were followed until union). There were no refractures or nonunions as per available records. Conclusion: Our study shows that screw length and diameter did not lead to significant plantar or lateral fracture site distraction. However, entry point had a significant effect on plantar and lateral gap on post-operative x-ray. Patients with a plantar gap did have an increased risk of delayed union. Entry point should be given more significance rather than screw diameter and length in managing zone 2/3 fifth metatarsal base fractures. This is contradictory to existing radiologic studies. [Table: see text]

Predictors of Malreduction in Zone II and III Fifth Metatarsal Fractures Fixed With an Intramedullary Screw

2020 ◽  
Vol 41 (12) ◽  
pp. 1537-1545
Author(s):  
Ankit Khurana ◽  
Bradley Alexander ◽  
Charles Pitts ◽  
Ashish Brahmbhatt ◽  
Benjamin Cage ◽  
...  
Keyword(s):  
Delayed Union ◽  
Fracture Site ◽  
Diameter Ratio ◽  
Entry Point ◽  
Screw Length ◽  
Metatarsal Fractures ◽  
Screw Diameter ◽  
Zone Ii ◽  
Intramedullary Screw ◽  
Lateral Gaps

Background: Proper implant selection and placement is crucial during fixation of zone II and III fifth metatarsal fractures to avoid postoperative complications. This study examined the effects of screw parameters and placement on malreduction, delayed union, nonunion, and refracture rate. Methods: A retrospective review of zone II and proximal zone III fifth metatarsal fractures managed with intramedullary screw fixation was conducted. Comparisons were made between cortex distraction (gap) and ratios of screw length, diameter, and entry point. Further analysis was carried out between time to union and distraction in the lateral and plantar cortices. Results: The plantar and lateral gaps were both associated with the mean entry point ratio on the lateral and anteroposterior (AP) views ( P < .001 for both views). No association between the plantar and lateral gaps and the screw diameter ratio ( P = .393 for AP and P = .981 for lateral) or the screw length ratio ( P = .966 for AP and P = .740 for lateral) was identified. The ratio of postoperative to preoperative apex height on AP and lateral views was correlated with the presence of lateral and plantar fracture gaps ( P < .001). The presence of a plantar gap was associated with increased time to union ( P = .022). A majority of fractures showed radiographic union at 12 weeks (38/43). Only 5 of 38 patients had delayed union. There were no refractures or nonunions as per available records. Conclusion: Plantar or lateral fracture site distraction (gap) was not influenced by screw diameter ratio or screw length ratio. The entry point ratio had a significant effect on plantar and lateral gaps on postoperative radiographs, with lateral and inferior placement leading to fracture site distraction. Patients with a plantar gap did have an increased risk of delayed union. The results of this study emphasize the significance of the entry point when managing zone II and III fifth metatarsal base fractures. Level of Evidence: Level IV, case series.

Fifth Metatarsal Jones Fractures in the Athlete

2017 ◽  
Vol 39 (2) ◽  
pp. 250-258 ◽  
Author(s):  
David A. Porter
Keyword(s):  
Screw Fixation ◽  
Nonoperative Treatment ◽  
Fracture Site ◽  
Medullary Canal ◽  
Return To Sports ◽  
Stress Reactions ◽  
Current Standard ◽  
Level Of Evidence ◽  
Metatarsal Fractures ◽  
Intramedullary Screw

Fifth metatarsal fractures, otherwise known as “Jones” fractures, occur commonly in athletes and nonathletes alike. While recent occurrence in the popular elite athlete has increased public knowledge and interest in the fracture, this injury is common at all levels of sport. This review will focus on all three types of Jones fractures. The current standard for treatment is operative intervention with intramedullary screw fixation. Athletes typically report an acute episode of lateral foot pain, described as an ache. Radiographic imaging with multiple views of the weightbearing injured foot are needed to confirm diagnosis. If these images are inconclusive, further magnetic resonance imaging (MRI) or computed tomography (CT) is used. Nonoperative treatment is not commonly used as the sole treatment, except when following reinjury of a stable screw fixation. While screw selection is still controversial, operative treatment with intramedullary screw fixation is the standard approach. Technical tips on screw displacement are provided for Torg (types I, II, III) fractures, cavovarus foot fractures, recurrent fractures, revision surgery, occult fractures/high-grade stress reactions, and Jones’ variants. Excellent clinical outcomes can be expected in 80% to 100% of patients when using the intramedullary screw fixation to “fit and fill” the medullary canal with threads across the fracture site. Most studies show the timing for return to sports with optimal healing to be seven to twelve weeks after fixation. Level of Evidence: Level V, expert opinion.

scholarly journals Comparison of Contact and Damage to Anatomic Structures in the Fixation of Zone II Fifth Metatarsal Fractures with an Intramedullary Screw or an Intramedullary Nail

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
David Garras ◽  
Samuel Adams ◽  
Brian Burgess
Keyword(s):  
Intramedullary Nail ◽  
Injury Rate ◽  
Plantar Fascia ◽  
Safe Zone ◽  
Starting Point ◽  
Metatarsal Fractures ◽  
Zone Ii ◽  
Potential Damage ◽  
To Receive ◽  
Intramedullary Screw

Category: Sports, Trauma Introduction/Purpose: Percutaneous intramedullary screw fixation of Zone II fifth metatarsal fractures has become commonplace. The potential for injury to the important surrounding anatomy has not been well documented, though some authors have reported unexplained postoperative pain and paresthesia over the lateral aspect of the foot despite hardware removal. The purpose of this study was to determine the contact and injury rate of surrounding anatomic structures with either the use of the traditional intramedullary screw (IMS) inserted “high and inside” or a novel intramedullary nail (IMN) inserted “low and outside” through a relative “safe-zone.” Methods: Zone II fifth metatarsal fractures were created in ten cadaver matched-pairs using a 1 mm thick saw through a small incision. Fractures were randomized to receive either an IMS or an IMN. The surgical technique was performed in accordance with the manufacturer’s instructions. For the IMS group, the guide pin was inserted percutaneously according to the “high and inside” starting point on the base of the fifth metatarsal using fluoroscopy; followed by insertion of the 3.5 mm drill, tissue protector, tap, and screw. For the IMN group, the guide pin was inserted percutaneously “low and outside,” positioned slightly medial and dorsal to the tip of the tuberosity of the fifth metatarsal; followed by the 5.2 mm reamer, tissue protector, and IMN. Dissection was performed to identify damage or contact to the peroneus brevis tendon (PB), peroneus longus tendon (PL), sural nerve (SN), lateral insertion of the plantar fascia (PF) and cuboid-fifth metatarsal jointspace. Results: There were significantly more episodes of PB injury, PL contact, SN contact, and presence in the cuboid-fifth metatarsal jointspace for the IMS group. There were significantly more episodes of contact of the PF with the IMN group but no episodes of damage. The results are summarized in Table 1. Images of contact and damage are shown in Figure 1. Fluoroscopic images of the IMN inserted through the “low and outside” position are shown in Figure 2. Conclusion: We have demonstrated significant contact and injury to surrounding structures with the placement of a “high and inside” IMS for the fixation of Zone II fifth metatarsal fractures. We believe there is a relative safe zone at the “low and outside” position that affords less potential damage to the important surrounding structures. Consideration should be given to the development of implants inserted through the relative safe zone.

scholarly journals Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Rusheel Nayak ◽  
Joshua Barrett ◽  
Milap S. Patel ◽  
Mauricio P. Barbosa ◽  
Anish R. Kadakia
Keyword(s):  
Patient Reported Outcomes ◽  
Correlation Coefficients ◽  
Metatarsal Angle ◽  
Medial Cuneiform ◽  
Hardware Complications ◽  
Increased Risk ◽  
Screw Length ◽  
Patient Reported ◽  
Metatarsal Fractures ◽  
Metatarsus Adductus

Abstract Background Zones 2 and 3 fifth metatarsal fractures are often treated with intramedullary fixation due to an increased risk of nonunion. A previous 3-dimensional (3D) computerized tomography (CT) imaging study by our group determined that the screw should stop short of the bow of the metatarsal and be larger than the commonly used 4.5 millimeter (mm) screw. This study determines how these guidelines translate to operative outcomes, measured using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Radiographic variables measuring the height of the medial longitudinal arch and degree of metatarsus adductus were also obtained to determine if these measurements had any effect on outcomes. And lastly, this study aimed to determine if morphologic differences between males and females affected surgical outcomes. Methods We retrospectively identified 23 patients (14 male, 9 female) who met inclusion criteria. Eighteen patients completed PROMIS surveys. Preoperative PROMIS surveys were completed prior to surgery, rather than retroactively. Weightbearing radiographs were also obtained preoperatively to assist with surgical planning and postoperatively to assess interval healing. Correlation coefficients were calculated between PROMIS scores and repair characteristics (hardware characteristics [screw length and diameter] and radiographic measurements of specific morphometric features). T tests determined the relationship between repair characteristics, PROMIS scores, and incidence of operative complications. PROMIS scores and correlation coefficients were also stratified by gender. Results The average screw length and diameter adhered to guidelines from our previous study. Preoperatively, mean PROMIS PI = 57.26±11.03 and PROMIS PF = 42.27±15.45 after injury. Postoperatively, PROMIS PI = 44.15±7.36 and PROMIS PF = 57.22±10.93. Patients with complications had significantly worse postoperative PROMIS PF scores (p=0.0151) and PROMIS PI scores (p=0.003) compared to patients without complications. Females had non-significantly worse preoperative and postoperative PROMIS scores compared to males and had a higher complication rate (33 percent versus 21 percent, respectively). Metatarsus adductus angle was shown to exhibit a significant moderate inverse relationship with postoperative PROMIS PF scores in the overall cohort (r=−0.478; p=0.045). Metatarsus adductus angle (r=−0.606; p=0.008), lateral talo-1st metatarsal angle (r=−0.592; p=0.01), and medial cuneiform height (r=−0.529; p=0.024) demonstrated significant inverse relationships with change in PROMIS PF scores for the overall cohort. Within the male subcohort, significant relationships were found between the change in PROMIS PF and metatarsus adductus angle (r=−0.7526; p=0.005), lateral talo-1st metatarsal angle (r=−0.7539; p=0.005), and medial cuneiform height (r=−0.627; p=0.029). Conclusion Patients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. Screws larger than 4.5mm did not lead to hardware complications, including screw failure, iatrogenic fractures, or cortical blowouts. Females had non-significantly lower preoperative and postoperative PROMIS scores and were more likely to suffer complications compared to males. Patients with complications, higher arched feet, or greater metatarsus adductus angles had worse functional outcomes. Future studies should better characterize whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.

Optimal Starting Point for Fifth Metatarsal Zone II Fractures: A Cadaveric Study

2017 ◽  
Vol 38 (7) ◽  
pp. 802-807 ◽  
Author(s):  
Geoffrey I. Watson ◽  
Sydney C. Karnovsky ◽  
Gabrielle Konin ◽  
Mark C. Drakos
Keyword(s):  
Average Distance ◽  
Entry Point ◽  
Intramedullary Fixation ◽  
Starting Position ◽  
Femur Fractures ◽  
Starting Point ◽  
Intramedullary Canal ◽  
Metatarsal Fractures ◽  
Zone Ii ◽  
The Ideal

Background: Identifying the optimal starting point for intramedullary fixation of tibia and femur fractures is well described in the literature using a retrograde or anterograde technique. This technique has not been applied to the fifth metatarsal, where screw trajectory can cause iatrogenic malreduction. The generally accepted starting point for the fifth metatarsal is “high and inside” to accommodate the fifth metatarsal’s dorsal apex and medial curvature. We used a retrograde technique to identify the optimal starting position for intramedullary fixation of fifth metatarsal fractures. Methods: Five matched cadaveric lower extremity pairs were dissected to the fifth metatarsal neck. An osteotomy was made to access the intramedullary canal. A retrograde reamer was passed to the base of the fifth metatarsal to ascertain the ideal entry point. Distances from each major structure on the lateral aspect of the foot were measured. Computed tomography scans helped assess base edge measurements. Results: In 6 of 10 specimens, the retrograde reamer hit the cuboid with a cuboid invasion averaging 0.7 mm. The peroneus brevis and longus were closest to the starting position with an average distance of 5.1 mm and 5.7 mm, respectively. Distances from the entry point to the dorsal, plantar, medial, and lateral edges of the metatarsal base were 8.3 mm, 6.9 mm, 9.7 mm, and 9.7 mm, respectively. Conclusion: Optimal starting position was found to be essentially at the center of the base of the fifth metatarsal at the lateral margin of the cartilage. Osteoplasty of the cuboid or forefoot adduction may be required to gain access to this site. Clinical Relevance: This study evaluated the ideal starting position for screw placement of zone II base of the fifth metatarsal fractures, which should be considered when performing internal fixation for these fractures.

Design analysis of a standard injection screw for plasticising polycarbonate resins

2016 ◽  
Vol 36 (5) ◽  
pp. 537-548 ◽  
Author(s):  
Ming-Shyan Huang
Keyword(s):  
Simulation Analysis ◽  
Melt Temperature ◽  
Factors Affecting ◽  
Control Factors ◽  
Screw Length ◽  
Plastic Injection Moulding ◽  
Screw Diameter ◽  
Grey Relational ◽  
Injection Screw ◽  
Simulation Programme

Abstract The industrial use of plastic injection moulding machines is widespread. However, few studies have examined the injection screw, which is one of the key components of moulding machines. Studies have demonstrated that a properly designed injection screw improves both the moulding quality and the production rate. Factors that affect the plasticisation properties of conventional standard reciprocating screws include the screw geometry, the screw operation settings, and the processed resins. An ideal standard reciprocating screw exhibits a high plasticising capacity and excellent melt temperature homogeneity; however, these properties typically conflict. Through simulation analysis, this study investigated the optimal design of a standard reciprocating injection screw used for plasticising polycarbonate resins. First, the Taguchi method was integrated with a commercial simulation programme to identify the key control factors affecting the plasticising rate of a screw and the temperature uniformity of the melt. Simulation results revealed that the screw diameter, rotation speed, metering channel depth, ratio of the screw length to the screw diameter, and compression ratio substantially influence performance. Consequently, grey relational analysis was adopted to optimise the design of an injection screw that ensures sufficient quality according to the plasticisation rate and the homogeneity of molten plastic.

Screw Length Associated with Fracture Gapping of Fifth Metatarsal Base Fracture with Intramedullary Screw Fixation: A Cadaveric Study

2021 ◽  
Author(s):  
Nicole K. Cates ◽  
Amar R. Gulati ◽  
Jonathan D. Tenley ◽  
Nathan N. O'Hara ◽  
Jacob Wynes ◽  
...  
Keyword(s):  
Screw Fixation ◽  
Cadaveric Study ◽  
Screw Length ◽  
Intramedullary Screw

scholarly journals Radiographic parameters and a novel fluoroscopic control view for posterior screw fixation of coracoid base fractures

SICOT-J ◽  
2020 ◽  
Vol 6 ◽  
pp. 9
Author(s):  
Hatem Galal Said ◽  
Tarek Nabil Fetih ◽  
Hosam Elsayed Abd-Elzaher ◽  
Simon Martin Lambert
Keyword(s):  
Sagittal Plane ◽  
Coracoid Process ◽  
Entry Point ◽  
Coronal Plane ◽  
Screw Placement ◽  
Posterior Fixation ◽  
Screw Insertion ◽  
Screw Length ◽  
Scapular Spine ◽  
The Mean

Introduction: Coracoid fractures have the potential to lead to inadequate shoulder function. Most coracoid base fractures occur with scapular fractures and the posterior approaches would be utilized for surgical treatment. We investigated the possibility of fixing the coracoid through the same approach without an additional anterior approach. Materials and methods: Multi-slice CT scans of 30 shoulders were examined and the following measurements were performed by an independent specialized radiologist: posterior coracoid screw entry point measured form infraglenoid tubercle, screw trajectory in coronal plane in relation to scapular spine and lateral scapular border, screw trajectory in sagittal plane in relation to glenoid face bisector line and screw length. We used the results from the CT study to guide postero-anterior coracoid screw insertion under fluoroscopic guidance on two fresh frozen cadaveric specimens to assess the reproducibility of accurate screw placement based on these parameters. We also developed a novel fluoroscopic projection, the anteroposterior (AP) coracoid view, to guide screw placement in the para-coronal plane. Results: The mean distance between entry point and the infraglenoid tubercle was 10.8 mm (range: 9.2–13.9, SD 1.36). The mean screw length was 52 mm (range: 46.7–58.5, SD 3.3). The mean sagittal inclination angle between was 44.7 degrees (range: 25–59, SD 5.8). The mean angle between screw line and lateral scapular border was 47.9 degrees (range: 34–58, SD 4.3). The mean angle between screw line and scapular spine was 86.2 degrees (range: 75–95, SD 4.9). It was easy to reproduce the screw trajectory in the para-coronal plane; however, multiple attempts were needed to reach the correct angle in the parasagittal plane, requiring several C-arm corrections. Conclusion: This study facilitates posterior fixation of coracoid process fractures and will inform the “virtual visualization” of coracoid process orientation.

Cuboid Edema Syndrome Following Fixation of Proximal Fifth Metatarsal Fractures in Professional Athletes

2019 ◽  
Vol 12 (4) ◽  
pp. 373-379 ◽  
Author(s):  
Lauren Roberts ◽  
Alessio Bernasconi ◽  
Cesar de Cesar Netto ◽  
Andrew Elliott ◽  
William Hamilton ◽  
...  
Keyword(s):  
Case Report ◽  
Elite Athletes ◽  
Magnetic Resonance Images ◽  
Complete Healing ◽  
Professional Athletes ◽  
Screw Head ◽  
Level Of Evidence ◽  
Metatarsal Fractures ◽  
Literature Highlight ◽  
Intramedullary Screw

Stress fractures of the proximal fifth metatarsal are common injuries in elite athletes. Fixation using an intramedullary screw represents the most popular surgery performed for treating these injuries, with excellent results in most cases. However, multiple reports in the literature highlight the possibility of painful hardware, usually related to the presence of the screw head, following intramedullary fixation In this case report, we outline 4 cases of professional athletes who developed lateral-based foot symptoms following complete healing of their surgically treated proximal fifth metatarsal fractures and were found to have significant cuboid edema on magnetic resonance images. We also outline recommendations regarding specific surgical technique considerations aiming to minimize this possible complication. Level of Evidence: Level V: Case report.

scholarly journals Evaluation of C2 pedicle screw placement via the freehand technique by neurosurgical trainees

2018 ◽  
Vol 29 (3) ◽  
pp. 235-240 ◽  
Author(s):  
Martin H. Pham ◽  
Joshua Bakhsheshian ◽  
Patrick C. Reid ◽  
Ian A. Buchanan ◽  
Vance L. Fredrickson ◽  
...  
Keyword(s):  
Pedicle Screw ◽  
Medical Center ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Pedicle Screw Placement ◽  
C2 Pedicle Screw ◽  
Canal Diameter ◽  
Screw Length ◽  
Freehand Technique ◽  
Screw Diameter

OBJECTIVEFreehand placement of C2 instrumentation is technically challenging and has a learning curve due the unique anatomy of the region. This study evaluated the accuracy of C2 pedicle screws placed via the freehand technique by neurosurgical resident trainees.METHODSThe authors retrospectively reviewed all patients treated at the LAC+USC Medical Center undergoing C2 pedicle screw placement in which the freehand technique was used over a 1-year period, from June 2016 to June 2017; all procedures were performed by neurosurgical residents. Measurements of C2 were obtained from preoperative CT scans, and breach rates were determined from coronal reconstructions on postoperative scans. Severity of breaches reflected the percentage of screw diameter beyond the cortical edge (I = < 25%; II = 26%–50%; III = 51%–75%; IV = 76%–100%).RESULTSNeurosurgical residents placed 40 C2 pedicle screws in 24 consecutively treated patients. All screws were placed by or under the guidance of Pham, who is a postgraduate year 7 (PGY-7) neurosurgical resident with attending staff privileges, with a PGY-2 to PGY-4 resident assistant. The authors found an average axial pedicle diameter of 5.8 mm, axial angle of 43.1°, sagittal angle of 23.0°, spinal canal diameter of 25.1 mm, and axial transverse foramen diameter of 5.9 mm. There were 17 screws placed by PGY-2 residents, 7 screws placed by PGY-4 residents, and 16 screws placed by the PGY-7 resident. The average screw length was 26.0 mm, with a screw diameter of 3.5 mm or 4.0 mm. There were 7 total breaches (17.5%), of which 4 were superior (10.0%) and 3 were lateral (7.5%). There were no medial breaches. The breaches were classified as grade I in 3 cases (42.9%), II in 3 cases (42.9%), III in 1 case (14.3%), and IV in no cases. There were 3 breaches that occurred via placement by a PGY-2 resident, 3 breaches by a PGY-4 resident, and 1 breach by the PGY-7 resident. There were no clinical sequelae due to these breaches.CONCLUSIONSFreehand placement of C2 pedicle screws can be done safely by neurosurgical residents in early training. When breaches occurred, they tended to be superior in location and related to screw length choice, and no breaches were found to be clinically significant. Controlled exposure to this unique anatomy is especially pertinent in the era of work-hour restrictions.

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