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The American Journal of Sports Medicine Oct 2021Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population.
PURPOSE
To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures.
STUDY DESIGN
Meta-analysis.
METHODS
Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures.
RESULTS
Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%).
CONCLUSION
The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.
Topics: Athletes; Fractures, Bone; Humans; Metatarsal Bones; Retrospective Studies; Return to Sport
PubMed: 33740393
DOI: 10.1177/0363546521990020 -
The Journal of Foot and Ankle Surgery :... 2021The optimal method of fixation of acute Lisfranc injuries is yet to be established. We aim to systematically review the literature to identify the impact of fixation... (Meta-Analysis)
Meta-Analysis Review
The optimal method of fixation of acute Lisfranc injuries is yet to be established. We aim to systematically review the literature to identify the impact of fixation method on postoperative functional outcomes. A systematic review was undertaken using the PRISMA framework to identify all studies reporting postoperative functional outcomes in patients who underwent open-reduction internal fixation of acute Lisfranc injuries. Studies reporting outcomes of numerous fixation methods were divided into fixation subcohorts. Studies comparing bridge plate with transarticular screw fixation were included for meta-analysis, conducted using a random-effects model. Seventeen studies (20 subcohorts) with 462 patients were included. Mean patient age was 29.6 (rang, 15-81) years. Mean follow-up was 38.7 (range 11 to 287) months. American Academy of Orthopaedic Surgeons midfoot score (AOFAS-MF) was the most frequently reported functional outcome (16/20 subcohorts). Overall weighted mean AOFAS-MF was 76.3 ± 9.4 for all cases, with 74.2 ± 9.4 for transarticular screws and 79.2 ± 8.3 for bridge plates. The mean difference between screw and plate was not statistically significant (mean difference = 5.0, 95% confidence interval, -4.8 - 14.8, p = .3). A single study reported AOFAS-MF mean of 92 using suture button fixation. Meta-analysis of the 2 available comparative studies revealed higher postoperative AOFAS-MF with bridge plate fixation (pooled standardized mean difference, 0.51; 95% confidence interval, 0.15-0.87, p = .006). There is scarcity of literature examining the impact of fixation method on postoperative functional outcomes in acute Lisfranc injuries. A small number of studies have reported superior functional outcomes with use of bridge plate fixation. Further evidence is needed to ascertain which injuries are best managed with each fixation method or whether 1 fixation construct is universally superior.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bone Plates; Bone Screws; Fracture Fixation, Internal; Humans; Metatarsal Bones; Middle Aged; Open Fracture Reduction; Young Adult
PubMed: 33039319
DOI: 10.1053/j.jfas.2020.04.005 -
Foot (Edinburgh, Scotland) Mar 2023Historically, most Lisfranc injuries have been considered to be unstable and treated with surgical intervention. However, with better access to cross-sectional imaging,... (Review)
Review
BACKGROUND
Historically, most Lisfranc injuries have been considered to be unstable and treated with surgical intervention. However, with better access to cross-sectional imaging, stable injury patterns are starting to be recognised. The aims of the current study were to perform a systematic review of outcomes of Lisfranc injuries treated non-operatively.
METHODS
A literature review was performed of studies reporting nonoperative management of Lisfranc injuries (PROSPERO registered and following PRISMA guidelines). Following exclusions, 8 papers were identified: 1 prospective and 7 retrospective studies. A total of 220 patients were studied with a mean age of 39.8 years and a mean follow-up of 4.3 years. Outcomes included function, displacement, and rates of surgery.
RESULTS
High heterogeneity was observed with variable outcomes. Four papers reported good outcomes, with adjusted functional scores ranging from 82.6 to 100 (out of 100). However, one study reported late displacement in 54 % of patients. Rates of secondary osteoarthritis ranged from 5 % to 38 %. Rates of surgical intervention were as high as 56 %. Several studies compared operative to non-operative treatment, reporting superior outcomes with surgery. Those injuries with no displacement on CT, measured at the medial cuneiform-second metatarsal had the best outcomes.
CONCLUSION
Reported outcomes following nonoperative treatment of Lisfranc injuries vary widely, including high rates of conversion to surgery. In contrast, some studies have reported excellent functional outcomes. CT seems to be an important diagnostic tool in defining a stable injury. Due to limited data and lack of a clear definition of a stable injury or treatment protocol, prospective research is needed to determine which Lisfranc injuries can be safely treated nonoperatively.
Topics: Adult; Humans; Foot Injuries; Fracture Fixation, Internal; Fractures, Bone; Metatarsal Bones; Prospective Studies; Retrospective Studies; Conservative Treatment; Foot Joints; Joint Dislocations; Tomography, X-Ray Computed
PubMed: 36841140
DOI: 10.1016/j.foot.2023.101977 -
Foot and Ankle Surgery : Official... Aug 2021We reviewed the rates of and reasons for hallux valgus (HV) recurrence and the rates of avascular necrosis following Scarf osteotomy. (Review)
Review
BACKGROUND
We reviewed the rates of and reasons for hallux valgus (HV) recurrence and the rates of avascular necrosis following Scarf osteotomy.
METHODS
We searched the Cochrane Library, PubMed, and Embase databases for studies reporting operative management of HV using Scarf osteotomy. The primary endpoints were reasons for and rates of HV recurrence. The secondary endpoint was the rate of avascular necrosis.
RESULTS
We included 15 studies with 946 operations for HV. Seven studies reported no recurrence, six reported recurrence rates of 3.6-11.3%, one reported a recurrence rate of 30%, and one reported a recurrence rate of 78%. Thirteen studies (678 feet) reported other complications from Scarf osteotomy without avascular necrosis.
CONCLUSIONS
Although HV recurrence is not uncommon following Scarf osteotomy, patient-related factors, surgical competence, and longer follow-up are more likely to be associated with recurrence. Avascular necrosis is an infrequent complication in HV patients treated using Scarf osteotomy.
Topics: Bunion; Foot; Hallux Valgus; Humans; Metatarsal Bones; Osteonecrosis; Osteotomy; Treatment Outcome
PubMed: 32891491
DOI: 10.1016/j.fas.2020.08.009 -
Strategies in Trauma and Limb... 2023Juvenile hallux valgus (JHV) is a forefoot deformity that causes pain and functional limitation. Treatment poses a challenge in terms of the optimal technique and timing... (Review)
Review
BACKGROUND
Juvenile hallux valgus (JHV) is a forefoot deformity that causes pain and functional limitation. Treatment poses a challenge in terms of the optimal technique and timing of intervention. A systematic review of the literature on the use of growth modulation in treating JHV was conducted.
MATERIALS AND METHODS
The literature review was performed using PubMed and EMBASE searches for articles investigating growth modulation in the treatment of JHV published before December 1st, 2021. Seven articles were included in the final review that matched the inclusion and exclusion criteria. The primary outcomes included the degree of correction of hallux valgus angle and intermetatarsal angle. A qualitative assessment of the articles was done due to the heterogeneity of the growth modulation methods used in these articles.
RESULTS
A total of 135 feet from 78 patients were included from the reviewed articles. Growth modulation methods included temporary screw lateral hemiepiphysiodesis of the first metatarsal, lateral drilling hemiepiphysiodesis of the first metatarsal, and a trephine plug removal of the lateral epiphysis followed by cancellous bone graft insertion. The degree of correction of the hallux valgus and intermetatarsal angles were found to be statistically significant in all studies, regardless of the technique.
CONCLUSION
Growth modulation for JHV by lateral hemiepiphysiodesis using minimally invasive techniques produced favourable radiologic outcomes with some evidence of clinical improvement. Larger, prospective and comparative studies with objective clinical outcome measures may further consolidate this surgical approach as a mean to treating this deformity.
HOW TO CITE THIS ARTICLE
AlZeedi M, Park JP, Marwan Y, . Growth Modulation for the Treatment of Juvenile Hallux Valgus: A Systematic Review of Literature. Strategies Trauma Limb Reconstr 2023;18(1):51-55.
PubMed: 38033921
DOI: 10.5005/jp-journals-10080-1579 -
The Journal of Foot and Ankle Surgery :... Mar 2019This study aims to compare outcomes of open reduction and internal fixation (ORIF) and primary arthrodesis in management of Lisfranc injuries. In accordance with... (Comparative Study)
Comparative Study Meta-Analysis
This study aims to compare outcomes of open reduction and internal fixation (ORIF) and primary arthrodesis in management of Lisfranc injuries. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, a systematic review was carried out. MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched to identify both randomised controlled trials (RCTs) and nonrandomised studies comparing the outcomes of ORIF and primary arthrodesis for Lisfranc injuries. Random- and fixed-effect statistical models were applied to calculate the pooled outcome data. Two RCTs and 3 observational studies were identified, compiling a total of 187 subjects with acute Lisfranc injuries and a mean follow-up duration of 62.3 months. Our results demonstrate that ORIF is associated with a significantly higher need for revision surgery (odds ratio [OR] 6.37, 95% confidence interval [CI] 2.68 to 15.11, p < .0001) and a significantly higher rate of persistent pain (OR 6.29, 95% CI 1.07 to 36.89, p = .04) compared with primary arthrodesis. However, we found no significant difference between the groups in terms of visual analogue scale pain score, American Orthopaedic Foot & Ankle Society functional score, or rates of infection. Separate analysis of RCTs showed that ORIF was associated with a more frequent need for revision surgery (OR 17.56, 95% CI 5.47 to 56.38, p < .00001), higher visual analogue scale pain score (mean difference 2.90, 95% CI 2.84 to 2.96, p < .00001), and lower American Orthopaedic Foot & Ankle Society score (mean difference -29.80, 95% CI -39.82 to -19.78, p < .00001). The results of the current study suggest that primary arthrodesis may be associated with better pain and functional outcomes and lower need for revision surgery compared with ORIF. The available evidence is limited and is not adequately robust to make explicit conclusions. The current literature requires high-quality and adequately powered RCTs.
Topics: Arthrodesis; Female; Foot Injuries; Fracture Fixation, Internal; Fracture Healing; Humans; Injury Severity Score; Male; Metatarsal Bones; Open Fracture Reduction; Postoperative Complications; Prognosis; Randomized Controlled Trials as Topic; Reoperation; Risk Assessment; Tarsal Bones
PubMed: 30850102
DOI: 10.1053/j.jfas.2018.08.061 -
The Journal of Foot and Ankle Surgery :... 2010Isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus due to the perceived ability to "decompress" the first... (Review)
Review
Isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus due to the perceived ability to "decompress" the first metatarsophalangeal joint through axial shortening, as well as plantar displacement of the first metatarsal head to correct purported elevation. Additionally, isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus because of the perceived safety and efficacy. Furthermore, it has been proposed that undergoing isolated periarticular osteotomy of the first metatarsal does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the clinical outcomes and need for surgical revision after isolated periarticular osteotomy of the first metatarsal for hallux rigidus. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated periarticular osteotomy of the first metatarsal for hallux rigidus, involved a prospective study design, included some form of objective and subjective data analysis, evaluated patients at a mean follow-up ≥12 months' duration, and included details of complications requiring surgical intervention. Four studies involving 93 isolated periarticular osteotomies of the first metatarsal followed up for a weighted mean of 18.6 months were identified that met the inclusion criteria. Peak dorsiflexion range of motion of the first metatarsophalangeal joint for the entire cohort of 93 patients increased 10.4°. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scoring Scale for the entire cohort of 93 patients increased 39 points from a weighted mean of 47.2 preoperatively to 86.2 postoperatively. For the two studies that included it, complete satisfaction or satisfaction with reservations was reported in only 55/75 (73.3%) patients, with the remainder being dissatisfied. A total of 21 (22.6%) procedures underwent surgical revision in the form of hardware removal (n = 8), lesser metatarsal surgery for intractable postoperative metatarsalgia (n = 7), no mention of revision procedure (n = 3), Keller resection arthroplasty (n = 2), and treatment of infection with revision of non-union (n = 1). Two studies specified the grade of hallux rigidus that underwent revision surgery after isolated periarticular osteotomy of the first metatarsal as follows: grade I, 16.7% (n = 3/18) and grade II, 30.5% (n = 18/59). Finally, a total of 30.5% (n = 18/59) of patients developed postoperative metatarsalgia or stress fracture. Additional prospective studies involving validated subjective and objective outcome measurement tools with computerized gait analysis and long-term follow-up after isolated periarticular osteotomy of the first metatarsal for the various grades of hallux rigidus, as well as with comparison with isolated cheilectomy and Valenti arthroplasty, would be beneficial. Based on the high incidence of complications until these studies can be completed, routine use of isolated periarticular osteotomy of the first metatarsal for hallux rigidus should be performed with caution or not at all.
Topics: Hallux Rigidus; Humans; Metatarsal Bones; Osteotomy; Outcome Assessment, Health Care; Patient Satisfaction; Postoperative Complications; Range of Motion, Articular; Reoperation
PubMed: 21035041
DOI: 10.1053/j.jfas.2010.08.014 -
Journal of Foot and Ankle Research 2018Metatarsus adductus is the most common congenital foot deformity in newborns. It involves adduction of the metatarsals at the Lisfranc joint. A systematic literature... (Review)
Review
BACKGROUND
Metatarsus adductus is the most common congenital foot deformity in newborns. It involves adduction of the metatarsals at the Lisfranc joint. A systematic literature review was conducted to investigate the following question: What tools are used to identify and quantify metatarsus adductus and how reliable, valid and responsive are they?
METHODS
The following electronic databases were searched for studies describing tools for the identification and quantification of metatarsus adductus in adults and children published from inception to June 2016: Ovid MEDLINE, Embase, CINAHL, Scopus, Web of Science and AMED. Two researchers initially searched all articles by screening titles and abstracts. If there was any doubt as to an article's eligibility, the full text paper was retrieved. Reference lists and citations of all retained studies were examined in an attempt to locate further studies. Articles were excluded if they were not in English or described other congenital foot conditions that did not include metatarsus adductus. Studies included in the review reporting measurement properties of measurement tools were critically appraised using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) critical appraisal tool.
RESULTS
There were 282 articles screened by title and abstract and 28 articles screened from full text. Fifteen articles were included and nine had data that were extractable for appraisal using the COSMIN critical appraisal tool. Techniques to measure metatarsus adductus included the heel bisector method, photocopies, ultrasound, footprints, dynamic foot pressure and radiographs. There was a paucity of quality data reporting the reliability, validity or responsiveness for measuring metatarsus adductus. Several radiographic angles showed good reliability (intraclass correlation (ICC) - 0.84, 0.97) in adults during pre-operative planning.
CONCLUSION
There have been multiple assessment techniques proposed for quantification of metatarsus adductus, but there is paucity of reliability, validity or responsiveness to measurement data about these techniques, especially in relation to the paediatric population. Further consideration of measurement testing is required to determine if the most common non-radiographic measures of metatarsus adductus are acceptable for clinical use.
Topics: Foot Deformities, Congenital; Humans; Metatarsal Bones; Metatarsus Varus; Observer Variation; Radiography; Reproducibility of Results
PubMed: 29881466
DOI: 10.1186/s13047-018-0268-z -
The Journal of Orthopaedic and Sports... Oct 2009Systematic review of case control studies. (Review)
Review
STUDY DESIGN
Systematic review of case control studies.
OBJECTIVES
To identify and analyze demographic and structural factors associated with hallux limitus/rigidus.
METHODS
A literature search was conducted across several electronic databases (Medline, EMBASE, CINAHL, and PubMed) using the following terms: hallux limitus, hallux rigidus, metatarsophalangeal joint, and big toe. Methodological quality of included studies was evaluated using the Quality Index. To evaluate the magnitude of differences between cases and controls, odds ratios were calculated for dichotomous variables and effect sizes (Cohen d) were calculated for continuous variables.
RESULTS
The methodological quality of the 7 included studies was moderate, with Quality Index scores ranging from 6 to 11 out of a possible score of 14. The overall mean age for the case group was 44.8 years (mean range, 23.4-54.9 years) and for the control group was 39.6 years (mean range, 23.4-58.8 years). There was a similar distribution of males and females across case and control groups. All studies used plain film radiography to assess foot structure. Cases were found to have a dorsiflexed first metatarsal relative to the second metatarsal, a plantar flexed forefoot on the rearfoot, reduced first metatarsophalangeal joint range of motion, a longer proximal phalanx, distal phalanx, medial sesamoid, and lateral sesamoid, and a wider first metatarsal and proximal phalanx. Measures of foot posture and arch height were not found to substantially differ between cases and controls.
CONCLUSIONS
This review of case control studies indicates that several variables pertaining to the structure of the first metatarsophalangeal joint may be associated with hallux limitus/rigidus. These findings have implications for the conservative and surgical treatment of the condition.
Topics: Foot Bones; Hallux Limitus; Hallux Rigidus; Humans; Metatarsophalangeal Joint; Radiography; Range of Motion, Articular
PubMed: 19801816
DOI: 10.2519/jospt.2009.3003 -
Foot and Ankle Surgery : Official... Dec 2011This study assessed the clinical and radiological outcomes of different non-surgical interventions, surgical versus non-surgical interventions, and different surgical... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This study assessed the clinical and radiological outcomes of different non-surgical interventions, surgical versus non-surgical interventions, and different surgical interventions used in the management of proximal fifth metatarsal fractures.
METHODS
A systematic review of published and unpublished literature was undertaken.
RESULTS
Six studies, assessing 330 patients and 333 fractures of the proximal fifth metatarsal were reviewed. Four studies assessed outcomes following tuberosity fractures, whilst 2 studies recruited patients following proximal diaphyseal or Jones fractures. The findings suggested that bandage is superior to below knee cast immobilisation for patient-reported functional and pain scores, with no difference in fracture union or re-fracture, and a shorter duration to return to work. There was no significant difference in complication rates or functional outcomes for patients managed in a plaster slipper compared to a bandage post-injury. When comparing surgical and non-surgical management, intramedullary screw fixation results in a shorter time to fracture union, reduced complication rates and earlier return to pre-injury activities compared to non-surgical cast immobilisation. However, the evidence-base is limited in it size and presented with a number of methodological limitations.
CONCLUSIONS
Further well-conducted randomised controlled trials are required to determine the optimal management strategy for the different types of proximal fifth metatarsal fractures.
Topics: Evidence-Based Medicine; Fractures, Bone; Humans; Metatarsal Bones
PubMed: 22017907
DOI: 10.1016/j.fas.2010.12.005