Cannulated Screw Fixation of Jones Fifth Metatarsal Fractures: A Comparison of Titanium and Stainless Steel Screw Fixation

J. George DeVries, DPM, AACFAS 1, Daniel J. Cuttica, DO 2, Christopher F. Hyer, DPM, FACFAS 3

The Journal of Foot & Ankle Surgery: 50 (2011) 207–212

The classic Jones fracture involves the fifth metatarsal at the level of the proximal diaphyseal-metaphyseal junction. The mainstay of surgical treatment for the Jones fracture is intramedullary screw fixation. There is no consensus of the type or material of screw that should be used. The purpose of this retrospective cohort study was to test the hypothesis that there is no clinical difference in the incidence of healing, or complica- tions, when comparing stainless steel to titanium cannulated screws used in Jones fracture open-reduction internal fixation (ORIF). Data were collected on a total of 53 patients (fractures) that were fixed with either cannulated titanium screws (Ti group) or cannulated stainless steel screws (SS group). The postoperative protocol was standardized. The mean time to radiographic union was 11.7 ` 5.1 weeks in the Ti group and 13.4 ` 5.7 weeks in the SS group (P 1⁄4 .333). The overall union rate for the Ti group was 36/37 (97%) and 14/16 (88%) in the SS group (P 1⁄4 .213). Complications were rare in both groups, and the prevalence was not statistically significantly different (P > .05). There was 1 patient with an asymptomatic radiographic nonunion in the Ti group, and this patient elected not to undergo revision. There were 2 nonunions in the SS group. One was revised and went on to heal and the other is awaiting revision. Our study has demonstrated the decision to use stainless steel or titanium can be left to patient constraints, such as allergies, or physician preference without compromising the clinical result.

Level of Clinical Evidence: 3 

Keywords: biomechanics injury ORIF nonunion surgery trauma

1 Staff Surgical Podiatrist, Ripon Medical Center, Ripon, WI 

2 Orthopaedic Surgeon, Center for Orthopaedic Surgery and Sports Medicine, Indianapolis, IN 

3 Fellowship Co-director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center, Westerville, OH

Early Clinical and Radiographic Outcomes after Treatment of Displaced Intra-articular Calcaneal Fractures Using Delta-Frame External Fixator Construct

Charles G. Kissel, DPM, FACFAS 1, Zeeshan S. Husain, DPM, FACFAS 2, James M. Cottom, DPM, FACFAS 3, Ryan T. Scott, DPM 4, Joshua Vest, DPM 5

The Journal of Foot & Ankle Surgery: 50 (2011) 135–140

Intra-articular calcaneal fractures are associated with high morbidity, persistent pain, and long-term disability. This retrospective study assesses early clinical and radiographic postoperative findings of intra-articular calcaneal fractures following treatment by ligamentotaxis using a delta frame construct with a large frag- ment external fixator. Minimally invasive percutaneous reduction of calcaneal fractures is an alternative treatment for Sanders type II, III, and IV fractures. Ten patients from the Detroit Medical Center were followed between January 2002 and December 2004 for follow-up over a mean of 353.5 ` 85.45 days postoperatively. The mean age of the patients was 45.8 ` 12.3 years. There were 2 patients with Sanders type IIA, 3 patients with type IIIAB, 1 patient with type IIIAC, and 4 patients with type IV fracture patterns. The results demon- strated that the mean calcaneal width decreased, the calcaneal height increased, and the calcaneal length increased when comparing preoperative to postoperative measurements. Bo€hler’s angle increased from 20.8 ` 8.27 preoperatively to 25.7 ` 5.21 postoperatively, and Gissane’s angle decreased from 127.4 ` 45.22 preoperatively to 111.2 ` 39.38 postoperatively. The posterior facet step-off on CT examination reduced from 2.6 ` 0.82 mm preoperatively to 0.4 ` 0.26 mm postoperatively. The mean postoperative total subtalar joint range of motion was 19.0 ` 4.5 on the affected side and 34.4 ` 4.58 on the contralateral foot. The mean Maryland Foot score was 85.8 ` 6.41 in the 10 patients. With the exception of the change from preoperative to postoperative Bo€hler’s angle, and the comparison of the ipsilateral (side of the fracture) to contralateral resting calcaneal stance position, all of the comparisons revealed statistically significant (P .05) differences. The authors conclude that the delta frame construct is a viable alternative method to open reduction and internal fixation for treating intra-articular calcaneal fractures.

Level of Clinical Evidence: 4 

Keywords: distraction frame heel ligamentotaxis trauma

1 Detroit Medical Center PM&S-36 Residency Program Director, Detroit, MI 

2 Detroit Medical Center PM&S-36 Assistant Residency Director, Detroit, MI 

3 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI 

4 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI 

5 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI

Medial Column Rodding Facilitated by Transitional Osteochondral Graft

Jeremy Cook, DPM, MPH, Emily Cook DPM, MPH, Philip Basile, DPM

Foot and Ankle Specialist: Foot Ankle Spec April 2011 vol. 4 no. 2, 106-111

This is a case report using a new technique designed to allow passage of a screw through a joint while simultaneously preserving the joint cartilage. A 58-year-old woman with diabetes with midfoot Charcot neuro-arthropathy underwent reconstruction, which included a medial column rodding. A headless 8.0-mm screw was inserted into the first metatarsal head coursing along the entire medial column after temporary removal of a portion of the osteochondral surface. This allowed the screw to be positioned perpendicular to the medial column joints. Serial radiographs were collected to evaluate alignment, stability, and osteochondral graft incorporation. The patient showed preservation of joint motion and function with complete osteochondral graft incorporation without evidence of joint degeneration or pain after 45 months of follow-up. This is the first study to present the use of a local osteochondral graft to allow passage of a large diameter screw in the foot. Although graft incorporation was complete, the situation regarding joint preservation remains unclear, but midterm follow-up shows promise.

Levels of Evidence: Therapeutic, Level IV, retrospective case study

Stability of Locking and Non-Locking Plates in an Osteoporotic Calcaneal Fracture Model

Till Illert, MD; Stefan Rammelt, MD, PhD; Tim Drewes, MD; Rene Grass, MD

Foot & Ankle International: March 2011 (Vol.32 #3)

Background: The aim of this biomechanical cadaver study of calcaneal

fractures was to investigate whether a locking calcaneal plate provides

more stiffness in osteoporotic bone compared to a non-locking plate.

Materials and Methods: Sixteen fresh frozen bone mineral density

(BMD)-matched cadaver feet were tested in a four-part model of a

Sanders Type IIB calcaneal fracture. The fractures were fixed either

with a non-locking AO (Sanders) plate or an interlocking AO plate

(Synthes, Paoli, PA) to the lateral calcaneal wall with six screws.

Specimens were subjected to cyclic loading which was increased stepwise

to full body weight. Displacement of the posterior facet fragment was

measured with an optical tracking system in the sagittal and transverse

planes. Results: No statistically significant differences were observed

between the non-locking and the locking plates with respect to number

of cycles to failure or 1-mm displacement of the posterior facet. The

initial stiffness was significantly higher for non-locking plates.

Conclusion: In osteoporotic bone, the greater stiffness of the

screw-locking plate construct was offset by the smaller diameter of the

screw threads and the lower friction between the plate and bone when a

locking plate was used. In clinical practice, the plate should first be

compressed to osteoporotic bone with cancellous screws and at least two

screws should be placed in the anterior process and in the tuberosity

of the calcaneus.

Key Words: Calcaneus; Fracture; Locking Plate; Non-Locking Plate;

Biomechanical Properties

Outcomes of Suture Button Repair of the Distal Tibiofibular Syndesmosis

Henry DeGroot, MD, FAAOS; Ali A. Al-Omari, MD; Sherif Ahmed El Ghazaly, MD, FRCS, PhD

Foot & Ankle International: March 2011 (Vol.32 #3) March 1, 2011 

Background: Recently, a suture button device has been advocated as a simple and effective method of repairing the syndesmosis. Proponents of the device have cited earlier weightbearing and elimination of the need for device removal as potential advantages over metallic screws. However, the available reports generally have short followup. With longer followup, some concerns about the suture button device have surfaced. Materials and Methods: We reviewed the clinical and radiographic results of 24 patients with acute injuries to the distal tibiofibular syndesmosis who were treated with suture button fixation. Average followup was 20 months. The primary outcomes measure was the AOFAS ankle hindfoot score. Secondary outcomes measures included a calibrated measurement of the tibiofibular clear space and tibiofibular overlap. Results: The average AOFAS score was 94 points. Syndesmotic parameters returned to normal after surgery and remained normal throughout the followup period. One in four patients required removal of the suture endobutton device due to local irritation or lack of motion. Osteolysis of the bone and subsidence of the device into the bone was observed in four patients. Three patients developed heterotopic ossification within the syndesmotic ligament, one mild, one moderate, and one who had a nearly complete syndesmotic fusion. Conclusion: The suture button device is an effective way to repair the syndesmosis. In our series, the reduction of the syndesmosis was maintained throughout the followup period. However, reoperation for device removal was more common than anticipated. Osteolysis of the bone near the implant and subsidence of the device may occur. 

Level of Evidence: IV, Intervention Case Series

Key Words: Ankle; Syndesmosis; Surgical Treatment