The October 2024 Foot & Ankle Roundup. 360. looks at: Hemiarthroplasty for hallux rigidus; Fixed or mobile-bearing ankle arthroplasty? A meta-analysis; Bone grafting for periprosthetic bone cysts following total ankle arthroplasty; Diabetic foot ulcer after first-ray amputation; Early motion after ankle surgery: the path to faster recovery?; Are podiatrists and orthopaedic surgeons approaching zone 2 fifth metatarsal fractures in the same way?

Aims. This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures. Methods. This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m. 2. (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64). Results. Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003). Conclusion. Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists. Cite this article: Bone Joint J 2024;106-B(9):942–948

The August 2024 Foot & Ankle Roundup³⁶⁰ looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.

Introduction

Treatment pathways of 5^th metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management.

Fifth metatarsal fractures in sport are known to be associated with acceleration and cross cutting movements when running. It is also established that playing surface has an impact on the ground reaction forces through the foot, increasing the strain through the fifth metatarsal. But what impact does boot design have on these forces? Current thought is that boots that utilise a blade stud design resist sideways slipping of the planted foot more than boots with a rounded stud. This study aims to compare ground reaction forces through the fifth metatarsal in 2 two different designs of rugby boot to assess what impact stud design might have. The forces across the foot were measured using Tekscan in-shoe pressure plates in 24 rugby players. Each player was asked to complete an agility course to measure acceleration, cutting and cross-cutting in the two different designs of rugby boot, reproducing true playing conditions. The boots used were the Canterbury Phoenix Club 8 Stud boot and the Canterbury Speed Club Blade boot. The trial was conducted on an 4G artificial pitch at the Cardiff Arms Park rugby ground. Ethical approval was obtained from Bath University and a research grant was provided by British Orthopaedic Foot and Ankle Society. The blade boot had significantly higher contact pressures than the stud boot on the fifth metatarsal in the combined movements (17.909 ± 10.442 N/cm2 Blade Vs 16.888 ± 9.992 N/cm2 Boot; P < .0125; n= 864 steps in each boot group). The blade boot also produced higher pressure during cross-cutting (32.331 ± 13.568 N/cm2 Vs 27.651 ± 15.194 N/cm2 p < 0.007). Pressures were also higher in both acceleration and cutting, although not significantly so. These results will guide clinicians advising athletes in shoe design, especially those predisposed to or rehabilitating from a fifth metatarsal fracture

Aims

Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.

Aims

The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC.

Background. Fractures of the metatarsal bones are the most frequent fracture of the foot. Up to 70% involve the fifth metatarsal bone, of which approximately eighty percent are located proximally. Low-intensity pulsed ultrasound (LIPUS) has been shown to be a useful adjunct in the treatment of delayed fractures and non unions. However, there is no study looking at the success rate of LIPUS in fifth metatarsal fracture delayed unions. Objectives. The aim of our study was to investigate the use of LIPUS treatment for delayed union of fifth metatarsal fractures. Study Design & Methods. A retrospective review of patients who were treated with LIPUS following a delayed union of fifth metatarsal fracture was conducted over a three-year period (2013 – 2015). Delayed union was defined as lack of clinical and radiological evidence of union, bony continuity or bone reaction at the fracture site if 3 months has elapsed from the initial injury. Results. There were thirty patients (9 males, 21 females) in our cohort. The average age was 39.3 years. Type 2 fractures made up 43% of our cohort. Twenty-seven (90%) patients went on to progress to union clinically and radiologically following LIPUS treatment. Smoking (p=0.014) and size of fracture gap (p=0.045) were predictive of non-union. Conclusions. This is the first study looking at the use of LIPUS in the treatment of delayed union of fifth metatarsal fractures. We report a success rate of 90%. There is a role in the use of LIPUS in delayed union of fifth metatarsal fractures and can serve as an adjunct prior to consideration of surgery

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.

Aims

The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast.

Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior.

The February 2014 Foot & Ankle Roundup³⁶⁰ looks at: optimal medial malleolar fixation; resurfacing in the talus; predicting outcome in mobility ankles; whether mal-aligned ankles can be successfully replaced; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; recalcitrant Achilles tendinopathy; and recurrent fifth metatarsal stress fractures.

Fifth metatarsal fractures are common and the majority unite regardless of treatment. A sub-type of these fractures carries a risk of non-union and for this reason many centres follow up all 5. th. metatarsal fractures. In 2011, a standardised protocol was introduced to promote weight-bearing as pain allowed with a tubigrip or Velcro boot according to symptoms. No routine fracture clinic appointments were made from A&E but patients were provided with information and a help-line number to access care if required. Some patients still attended fracture clinics, but only after review of their notes/X-rays by an Orthopaedic Consultant, or after self-reported “failure to progress” using the special help-line number. Audit of a year prior to the introduction of the protocol and the year following it was performed. All x-rays taken at presentation in A&E were reviewed and classified independently (KBF/JM) for validation. During 2009/2010, 279 patients presented to A&E with a 5. th. metatarsal fracture and were referred to a fracture clinic. 106(38%) attended 1 appointment, 130(47%) attended 2 appointments and 31 (11%) attended 3 or more appointments – 491 appointments in total. 3% failed to attend the clinic. Operative fixation was performed in 3 patients (1.07%). In 2011/2012, of 339 A&E fractures, only 63 (19%) attended fracture clinic. 37 (11%) attended 1 appointment, 12 (4%) 2 and 9 (3%) 3 or more appointments – 96 appointments in total. Four patients (1.17%) required operative fixation. Our study did not demonstrate any added value for routine outpatient follow-up of 5. th. metatarsal fractures. Patients can be safely allowed to weight bear and discharged at the time of initial presentation in the A&E department if they are provided with appropriate information and access to a “help line” run by experienced fracture clinic staff. The result is a more efficient, patient-centred service

Introduction. Fifth metatarsal fracture is a common injury. Current practice supports conservative management, with surgery in the event of non-union. Early fracture clinic review is not perceived to improve patient experience or increased detection of non-union. A new protocol standardises treatment to symptom level and discharges patients from ED with advice but without any routine follow-up arranged. A leaflet advises on management, prognosis and helpline details and there is an open-access policy for those whose symptoms persist to investigate potential non-union. Method. A prospective audit evaluated the protocol, surveying patients at 8-weeks and 6-months post-injury. A minor injuries unit continued to refer to fracture clinic and was the control group. During 6-months 46 acute fractures were recorded in the new protocol(group 1) and 47 in the control(group 2). 1 patient in each group was known to experience non-union. 31 of group 1 and 22 of group 2 responded to at least one survey. Results. Satisfaction with information provided at initial presentation was high for both protocols. 87%(27/31) satisfied in group 1 and 90%(20/22) group 2(p=1.0000). At 8-weeks 82%(19/23) were satisfied with their progress following the new protocol compared to 89%(17/19) in the control(p=0.6729). At 6-months 88%(22/25) were satisfied compared to 76%(13/17) respectively(p=0.4133). The new protocol is not associated with a significant symptoms increase. At 8 weeks 22%(5/23) described their pain severity as >5/10 reducing to 8%(2/25) by 6-months. Compared to 10%(2/19) of the control at 8-weeks and 6%(1/17) at 6-months. Patients rating fracture management overall as ‘good or excellent’ were comparable between both new, 67%(21/31) and traditional, 77%(17/22) protocols(p=0.5441). Conclusion. No significant difference in patient satisfaction and symptom levels between the old and new protocol was found. The new protocol reduces unnecessary patient appointments. This reduces demands on fracture clinic while maintaining a safe, resource efficient service

The April 2013 Trauma Roundup³⁶⁰ looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction.

Introduction. Fifth metatarsal fractures are a common injury suffered by professional footballers. It is frequently reported in the media that such an injury will result in a 6-week absence from play. The purpose of this study was to assess frequency of media reporting of fifth metatarsal fractures, the time that is predicted by the media before the player will return to soccer and the actual time taken for the player to return to play. Methods. Internet search engines identified 40 professional footballers that suffered 49 fifth metatarsal fractures between 2001 and 2011. Information was collected from various media and team websites, match reports, photography and video evidence to provide data regarding the mechanism of injury, playing surface conditions, frequency of fractures per season, fracture treatment, estimated amount of time to be missed due to the injury and time taken to return to play. Results. 49 fractures were identified in the 40 players. 6 players suffered a recurrence of a previous fifth metatarsal fracture. 3 players sustained 5. th. metatarsal fractures in their contralateral foot. There was a trend of increased reporting of fifth metatarsal fractures over the course of the decade. 43% of fractures were sustained without contact with another player, 24% were suffered in a tackle. 77% of fractures were sustained in dry conditions. 90% of fractures were treated surgically. Mean return to play time was 14.6 weeks (range 5 to 34 weeks). The mean estimated absence in the media was 7.8 weeks (range 2 to 16 weeks), median 6 weeks. Conclusions. Fifth metatarsal fractures are being commonly reported in professional footballers with an increasing trend. Most are treated surgically. It appears that the commonly quoted period of 6 weeks before return to play is unrealistic. It should be expected that a player would be unavailable for 3 months