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A Novel Method for Internal Fixation of Basal Fifth Metatarsal Fracture in Athletes: a Cadaveric Study of the F.E.R.I

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A Novel Method for Internal Fixation of Basal Fifth Metatarsal Fracture in Athletes: a Cadaveric Study of the F.E.R.I D’Hooghe et al. Journal of Experimental Orthopaedics (2019) 6:45 Journal of https://doi.org/10.1186/s40634-019-0213-5 Experimental Orthopaedics RESEARCH Open Access A novel method for internal fixation of basal fifth metatarsal fracture in athletes: a cadaveric study of the F.E.R.I. technique (Fifth metatarsal, Extra-portal, Rigid, Innovative) Pieter D’Hooghe1, Silvio Caravelli2* , Simone Massimi2, James Calder3,4, Peter Dzendrowskyj1 and Stefano Zaffagnini2 Abstract Purpose: One of the main problems of Kirschner wire fixation of fifth metatarsal base fractures (in combination with a tension band wiring technique) seems to be hardware intolerance and several studies in athletes also report failure after isolated fixation with a screw only. These reports prompted us to look at new materials and a novel technique through fixation with an intramedullary screw combined with a high-resistance suture via the presented F.E.R.I. (Fifth metatarsal, Extra-portal, Rigid, Innovative) technique. Methods: This cadaveric study describes F.E.R.I. technique. On a cadaver, through two mini portals, a full reduction and solid internal fixation with an intramedullary screw and suture cerclage with Fiberwire of a fifth metatarsal base fracture is achieved. In this article, the cadaveric study and proposed surgical technique are explained and illustrated step by step. Results: The presented internal fixation F.E.R.I. technique is indicated in acute proximal fractures, stress fractures or non-union of metatarsal 5 (Zone 2–3 by Lawrence and Botte) and it resulted feasible and stable during manual stress test. The authors intend to study this technique in the clinical setting in the near future. Conclusions: Fifth metatarsal base fractures gain specific interest when occurring in athletes. In this group of patients, internal fixation is often required to obtain a satisfactory outcome and time to return to play. The aim of the presented cadaveric study is to illustrate an innovative concept of internal fixation, named F.E.R.I. Keywords: Fifth metatarsal, Fracture, Internal fixation, Athlete Introduction interesting review, Spang RC et al (Spang et al. 2018) Sir Robert Jones (Jones 1902), in 1902, first described have found that the overall percentage of fifth metatarsal fractures at the metaphyseal/diaphyseal junction of the base fractures in NFL players was 3.2%. Fifth metatarsal fifth metatarsal (MT-5). These make up approximately fractures are an increasing problem, particularly in ath- 70% of all metatarsal fractures (Petrisor et al. 2006), both letes. Surgical treatment strategies and outcomes are, in the general population and also in athletes. In an therefore, of particular interest among those involved in their care. Orendurff et al.(Orendurff et al. 2009) demonstrated * Correspondence: [email protected] Investigations have been performed at Aspetar Orthopaedic and Sports that during sport activities, bending moments and peak Medicine Hospital – Doha (Qatar) pressure are considerable through the fifth metatarsal. 22nd Clinic of Ortopaedics and Traumatology, IRCCS Istituto Ortopedico They highlighted how different athletic gestures, such as Rizzoli, Bologna, Italy Full list of author information is available at the end of the article jump-off, landing and cutting movements can produce © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. D’Hooghe et al. Journal of Experimental Orthopaedics (2019) 6:45 Page 2 of 7 high tensile stress on bone structures - a forceful push- treatment (Clapper et al. 1995; Kavanaugh et al. 1978; off of acceleration generates a high load on the forefoot, Raikin et al. 2008). particularly on the fifth metatarsal (Orendurff et al. Several studies, however, report failure after fixation 2009). This can lead to either acute fractures of the base with screw, in particular, in athletes. Wright R. et al. of the fifth metatarsal or, during high periods of activity, (Wright et al. 2000) found that failure seemed to be cor- to stress fractures. related with the dimension rather than the type of screw Pre-disposing factors include: cavo-varus foot, promin- (cannulated, cancellous or malleolar screws). He re- ence of the fifth metatarsus, high body mass index (BMI), ported a 5% failure rate – a combination of refracture and the use of narrow-width shoes (Jastifer et al. 2017; and nonunion. Granata JD. et al. (Granata et al. 2015) McBryde Jr. 2009). An indirect force secondary to foot reported a 7.3% failure rate in patients with primary sur- plantar-flexion and inversion - transmitted to the MT-5 gical treatment - mainly due to refracture. Because of by the peroneus brevis and plantar fascia traction (Mayer this, other fixation methods have been developed aiming et al. 2014; Glasgow and Naranja Jr 1997)-istheusual for better primary stability and a lower rate of complica- mechanism of injury leading to this proximal fracture. In- tions and refractures. Internal fixation by tension band creased forces during physical activity make it easy to wiring has been used with similar outcomes (Delee et al. understand how athletes, in particular are predisposed to 1983; Lee et al. 2011). There have been many publica- this type of injury. tions regarding fractures of the base of fifth metatarsal, MT-5 fractures have been classified by Lawrence and however disagreement and controversy remain around Botte (Lawrence and Botte 1993) according to the ana- the most appropriate surgical treatment. tomical area affected, and also the mechanism of injury, This report describes and discusses an innovative con- in Zone 1 (tuberosity area), Zone 2 (tuberosity – meta- cept for surgical fixation via a combination of screw and physeal area) and Zone 3 (metaphyseal – diaphyseal suture cerclage of MT-5 fractures in athletes, named area). Fractures in Zones 2 and 3 are commonly referred F.E.R.I. “Fifth metatarsal, Extra-portal, Rigid, Innovative”. to as Jones’ fractures, due to their similarity in symp- toms, treatment and possible complications. Zones 2 Materials and methods and 3 are predisposed to delayed healing due to a vascu- The “two portal technique” (TPT), or “F.E.R.I. technique”,is lar watershed zone (Smith et al. 1992; Le and Anderson indicated for internal fixation of acute proximal fractures - or 2017) between the insertion of peroneus brevis and the stress fractures of MT-5 - (Zone 2–3 by Lawrence and Botte) diaphyseal blood supply. Fractures interrupt the vascular (Fig. 1). A further indication is chronic delayed union or channels in this area, leading to hypo-vascularisation non-unionofproximalMT-5fractures. and difficulty in complete healing. The feasibility of the technique has been tested on a Fractures of the proximal MT-5 can be treated ei- cadaveric specimen. After creating a fifth metatarsal base ther conservatively or surgically; Josefsson (Josefsson fracture with a 10 mm osteotome, reduction and fixation et al. 1994) demonstrated good functional outcomes has been performed under direct visual control. with non-operative treatment. However, in athletes, treatment is usually surgical, because of the long re- Surgical technique covery time, the higher risk of non-union and high A 1 cm longitudinal stab incision (“proximal portal”)is rates of re-fracture associated with conservative made 15 mm proximal to the base of the fifth metatarsal. Fig. 1 Proximal fractures or stress fractures of MT-5 (Zone 2–3 by Lawrence and Botte) can be treated with the F.E.R.I. technique D’Hooghe et al. Journal of Experimental Orthopaedics (2019) 6:45 Page 3 of 7 This reveals the insertion of the peroneus brevis tendon. medullary canal to across the fracture line (Fig. 3). Dissection identifies the lateral dorsal cutaneous nerve Aftermarkingthedorsalendthesuturewirewitha and its distal branches. marking pen, the Fiberwire® is then pulled subcutane- A second 15 mm incision (“distal portal”) is made ob- ously from the distal incision to the proximal one in liquely, at the same level as the fracture site, following a figure-of-eight pattern and looped around the neck Langer’s skin folds, from dorsal to plantar and from of the screw (Fig. 5). The screw is then tightened and proximal to distal (Fig. 2). Blunt subcutaneous dissection the Fiberwire® cerclage properly tensioned and se- identifies the fracture line, which is then inspected and curely knotted (Fig. 6 and Fig. 7). Manual tests and minimally debrided. maneuvers have been performed and fracture stability Under X-ray C-arm guidance, any displaced fracture is was achieved with success. reduced. If a cannulated screw is used, a guide wire is then introduced through the proximal portal into the Additional procedures fifth metatarsal medullary cavity in a dorso-medial entry In cases of delayed union, or to improve fracture con- angle, medial to the tip of the base. This maximises solidation, a small amount of autogenous cancellous screw length whilst protecting the insertion point of per- bone can be harvested from superolateral aspect of the oneus brevis (Fig. 3). A through-hole is drilled vertically calcaneus. through the distal port, 10 mm distal to the fracture line. A10mm“extra-portal” is made posteriorily and An Arthrex Fiberwire® (Arthrex, Naples, FL USA) no. 2 slightly distal to the Sural nerve and peroneal tendon. is passed through the hole (Fig. 2 and Fig. 4). Subcutaneous blunt dissection is performed to reveal A 5.5 mm partially threaded screw is placed along periosteum, which is then reflected back with a perios- the guide wire, if cannulated, and inserted into the teum elevator. The bone graft borders are visualised, and Fig. 2 Creation of two portals allows for a minimally invasive technique, minimising soft tissue damage, when compared to classic tension band techniques or fixation with plate and screws D’Hooghe et al.
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