Rethinking Our Approach To Jones Fractures To Facilitate Shorter Post-Op Recovery
- Volume 24 - Issue 12 - December 2011
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If there was a surgical technique that could abbreviate the time it took to achieve clinical and radiographic healing of first metatarsal base osteotomies by three weeks, podiatric physicians would be obligated to investigate. Further, if this new technique afforded superior outcomes in comparison to the existing surgical standard, word would spread quickly to foot surgeons everywhere. Imagine how much more rapidly athletes could bear weight, exercise, go to work or return to their sport.
Alas, I am not aware of any “new technique” that affords us this luxury in the instance of first metatarsal osteotomies. However, in the case of Jones fractures of the fifth metatarsal, there appears to be a novel and perhaps better method to address this enigmatic fracture. In fact, this method does appear to facilitate accelerated radiographic and clinical healing in comparison to the more commonly employed surgical practices.
Like so many other surgical improvements, this new technique is not revolutionary. Rather, it is evolutionary, taking some of the desirable attributes from existing techniques and combining them in an effort to improve outcomes. It employs the idea presented by Torg and colleagues, who advocated using autogenous bone graft, especially in cases with medullary sclerosis.1 This technique also implements rigid internal fixation as advocated by many authors but primarily credited to Delee and co-authors.2 By combining these two fundamental concepts, this technique appears to have significantly accelerated the time to union of these fractures.
Weighing Surgical Versus Conservative Treatment For Jones Fractures
Before delving into a unilateral surgical discussion, it is important to acknowledge the persistent debate about conservative and surgical care of these fractures. Many true Jones fractures do heal with conservative management. In instances in which patients are poor surgical candidates due to comorbidities, certainly non-invasive treatment is justified. Even in healthy populations, many practitioners anecdotally maintain that non-weightbearing with or without external bone stimulators has facilitated consistent healing.
However, even the most ardent supporters of conservative management must agree that healing is slow, unpredictable and re-fractures are relatively common. Clapper and colleagues found that even in cases with no medullary sclerosis, the average time to union was 21.2 weeks with a 28 percent failure rate with conservative treatment.3 Suffice it to say, this is an eternity for an active patient even if he or she is lucky enough to heal. In my practice, I encourage early surgical intervention. I believe a thorough inspection of the literature validates this contention.
Before examining this technique, it is critical to establish the terminology of proximal fifth metatarsal fractures. As a general rule, there are three types of fifth metatarsal base fractures: the tuberosity avulsion fracture, the true Jones fracture and the diaphyseal stress fracture.4