Autogenous Calcaneal Dowel Grafting Jones Fractures: Technique and Case Study Edward G. Blahous JR, DPM, FACFAS, Richard T. Bouché, DPM, FACFAS, Amol Saxena, DPM, FACFAS, FAAPSM, Chad Seidenstricker, DPM, PGY-3

A trephine is now used to obtain a bone graft plug, which will be used as an inlay graft to be placed into reamed hole. To assure a tight custom fit trephine diameter should be Introduction 1 mm greater than the reamer size. The authors’ prefer use of bone graft procured Many foot and ankle surgeons elect to treat the proximal fifth metatarsal base from the lateral calcaneal wall (Fig 6). The bone plug graft is then gently aligned and fractures near the metaphyseal-diaphyseal junction by surgical repair due to tamped into place (Fig 8). unpredictable outcomes with nonoperative management. Intramedullary fixation (IM) is the current “gold standard” and has high union rate [1]. However, there are several reports of complications with the IM technique. Notably, refracture, prominent hardware, and slow time to fracture healing [2-5]. This publication aims to describe a novel technique to treat the problematic Jones fracture.

Figure 10. Intraoperative anteroposterior fluoroscopic Figure 11. Intraoperative lateral fluoroscopic view Figure 6. Incision placement with trephine in Figure 5. Visualization of recipient hole view of fracture site with graft and fixation in place. of fracture site with graft and fixation in place. Surgical Technique [6] place for safe exposure of lateral calcaneal through fracture site. The patient is placed in a lateral decubitus position with ipsilateral side facing wall. superiorly. A dorsolateral incision is made centered over the fifth metatarsal base Discussion fracture site. After the skin incision is completed, careful subcutaneous dissection The current “gold standard” for surgical treatment of Jones fractures is intramedullary is performed to allow identification, and subsequent isolation, of the lateral dorsal screw fixation [1]. A recent literature review demonstrated 96% union rate with IM cutaneous nerve and its respective branches. After completing subcutaneous fixation [1]. However, complication rates with intramedullary screw fixation are in the dissection, the fracture site is explored and extent of fracture line is visualized range of 0-46% [7,8,9]. The screw insertion is percutaneous, placing the sural nerve (Fig 1.). and its branches at risk. Other complications include screw breakage, screw malalignment (missing the intramedullary canal), and painful prominent screw head, delayed union, nonunion, and refracture [2,8]. Figure 7. Dowel graft plug obtained from the Figure 8. Dowel graft plug in fracture site after being calcaneus. gently tapped into the recipient fracture site. Critical steps to this procedure include: evacuation of poor quality bone (e.g., sclerotic, A small plate is then be used to stabilize the fracture. Compression screws, utilizing dysvascular, scarified, etc.) at fracture site; inlaying or packing the evacuated site with a eccentric drilling, are placed first on either side of graft. Subsequently the locking compact, structural cancellous dowel (bone plug); providing rigid internal fixation (small screws can be placed (Fig 9,10&11). Screw sizes in the range of 2.0 to 3.0 mm are low profile compression and locking plate construct with low profile screw heads); and preferred with low profile design to avoid skin irritation. Postoperatively, patients are appropriate post-operative protection (4-6 weeks NWB followed by 2-4 weeks in a short non-weight bearing (NWB) in removable posterior splint with use of crutches and/or leg-walking boot). The benefit of this technique is underscored by fracture healing that roller aid for 4-6 weeks followed by 2-4 weeks in a cast-boot. appears to be predictable with faster times to radiographic and clinical union. Pending validation, this procedure could be the favored procedure for all Jones fractures.

Figure 2. Intraoperative fluoroscopy demonstrating Figure 1. Surgical exposure of a Jones fracture. guide wire placement through the fracture. References 1. Roche A, Calder JDF. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a A guide pin is then placed for the cannulated reamer (Fig 2.).An appropriate systematic review. Knee Surg Sports Traumatol Arthrosc 21:1307-1315, 2013. 2. Larson CM, Almekinders LC, Taft TN, Garrett WE: Intramedullary screw fixation of Jones fractures: sized bone reamer is then chosen and placed over the guide pin (Fig 3.). The analysis of failure. Am J Sports Med 30:55-60, 2002. reamer head “cores through” the fracture and extends to, but not through, 3. Wright, RW; Fischer, DA; Shively, RA; Heidt, RS, Jr, Nuber, GW: Refracture of proximal fifth metatarsal opposite cortex. (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med 28(5):732-736, 2000. 4. Glasgow MT, Naranja RJ, Glasgow SG, Torg JS. Analysis of failed surgical management of fractures of Figure 9. Dowel grafted plug in place with completed fixation. the base of the fifth metatarsal distal to the tuberosity: the Jones fracture. Foot Ankle Int 17(8):449-457, 1996. 5. Hunt KJ, Anderson RB. Treatment of Jones fracture non-unions and refractures in the elite athlete: Case Study outcomes of intramedullary screw fixation with bone grafting. Am J Sports Med 39:1948-1954, 2011. A 19 year-old soccer player sustained a true Jones fracture and underwent open 6. Blahous E. Rethinking our approach to jones fracture to facilitate shorter post-op recovery. Podiatry reduction with internal fixation (ORIF) with an intramedullary screw (4.0 mm today. 2011;24(12). Available at http://www.podiatrytoday.com/rethinking-our-approach-jones-fractures-facilitate-shorter-post-op- cannulated partially threaded). He was NWB in a cast for 6 weeks, and then recovery. Accessed August 10, 2016. progressed to a walking cast-boot for an additional 4 weeks. He also utilized a non- 7. Sarimo J, Rantanen J, Orava S, Alanen J. Tension-band wiring for fractures of the fifth metatarsal invasive ultrasonic bone-stimulator during this time. He did physical therapy and located in the junction of the proximal metaphysis and diaphysis. Am J Sports Med 34:476-480, 2006. 8. Kavanaugh, JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg 60-A:776-782, attempted return to soccer. Five months post-surgery, he had persistent pain and his 1978. X-ray demonstrated sclerosis at the fracture margins. At this time, hardware removal 9. Murawski CD, Kennedy JG. Percutaneous internal fixation of proximal fifth metatarsal Jones fractures was performed followed by ORIF with autogenous calcaneal dowel bone graftand a (Zones II and III) with Charlotte Carolina screw and bone marrow aspirate concentrate: an outcome study in athletes. Am J Sports Med 39:1295-1301, 2011. locking plate. He remained NWB for 4 weeks in a short-leg cast and then wore a cast boot for an additional 4 weeks. Radiographic and clinical healing of the fracture was Figure 3. Drill placed over the guide pin Figure 4. Intraoperative fluoroscopy demonstrating the preparing to make the dowel recipient hole. recipient hole at the fracture site following drilling. noted at eight weeks post-op. He returned to soccer at four months post-surgery. At five years post-index procedure, he remains active in sports with his hardware in place.