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Purpose To compare the bone healing, clinical, and return to daily activity outcomes after either surgical or conservative management of acute zone 1, 2, and 3 fifth metatarsal fractures. Methods A literature search was performed to identify studies published from the earliest record to January 2019 using EMBASE (Ovid), MEDLINE via PubMed, CINAHL, and Web of Science. All articles assessing clinical outcomes of acute proximal fifth metatarsal fractures were included. Bone healing and clinical outcomes were thereafter calculated using a simplified pooling method. Results Thirty-two articles comprising of a total of 1,239 fractures were included, of which one was a randomized controlled trial, seven were prospective studies, and 24 were retrospective studies. 627 zone 1 fractures demonstrated union rates of 93.2% following conservative treatment and 95.1% following surgical treatment. Conservatively managed zone 1 fractures were displaced 49.5% of the time, compared to a rate of 92.8% for the surgically treated cases. For Jones’ (zone 2) fractures, bone healing outcomes of conservative versus surgical treatment showed union rates of 77.4% versus 96.3%, refracture rates of 2.4% versus 2.1%, and mean time to union of 11.0 weeks versus 9.4 weeks, respectively. Only ten proximal diaphyseal (zone 3) fractures were reported, with a mean return to work of 8.2 weeks. Conclusion Acute zone 1 fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management. In contradistinction, acute zone 2 fractures demonstrate higher union rates and faster time to union when treated surgically. The outcomes of acute zone 3 fractures are rarely reported in the literature, so treatment recommendations remain unclear. Further research of proximal fifth metatarsal fractures is warranted to provide more definitive conclusions, but current findings can aid surgeons during the shared clinical decision making process. Level of evidence IV.

Background Ideal surgical treatment for hallux valgus is still controversial. A traditional distal metatarsal osteotomy with rigid fixation (Scarf procedure) and a more minimally invasive approach to a distal metatarsal osteotomy, termed SERI (Simple, Effective, Rapid, Inexpensive), have proven successful with short-term followup. However, no data are available directly comparing the two procedures. Questions/Purposes We performed a prospective randomized trial to determine which technique (SERI or Scarf) was associated with (1) better functional outcomes, (2) better radiographic correction, and (3) fewer complications at 2 and 7 years followup. Methods Twenty patients, 53 ± 11 years of age, with bilateral hallux valgus, clinically and radiographically similar, underwent bilateral surgery with Scarf on one side and SERI on the other, at random. Clinical (AOFAS score) and radiographic assessments were considered before surgery, and at 7 years followup. Results SERI and Scarf techniques provided correction of the hallux valgus angle, intermetatarsal angle, and distal metatarsal angle in the range of normal. Both led to similar clinically important improvements in the AOFAS. No differences were observed between the groups. All osteotomies healed, and two patients who underwent the Scarf procedure required hardware removal. Reduction of ROM with respect to preoperative was observed in three patients for SERI and three patients for Scarf procedures. Conclusions Scarf and SERI techniques resulted in effective correction of hallux valgus with similar outcomes, however the SERI technique required a shorter skin incision, less surgical time, less expensive fixation device, and was without residual pain attributable to hardware. Level of Evidence Level II, prospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND AND OBJECTIVESAmong the different adjuvants, dexamethasone is one of the most accepted to prolong the effect of local anesthetics. This study aims to determine the superiority of perineural over systemic dexamethasone administration after a single-shot ankle block in metatarsal osteotomy. METHODSWe performed a prospective, double-blind, randomized study. A total of 100 patients presenting for metatarsal osteotomy with an ankle block were randomized into 2 groups30 mL ropivacaine 0.375% + perineural dexamethasone 4 mg (1 mL) + 2.5 mL of systemic saline solution (PNDex group, n = 50) and 30 mL ropivacaine 0.375% + 1 mL of perineural saline solution + intravenous dexamethasone 10 mg (2.5 mL) (IVDex group, n = 50). The primary end point was the duration of analgesia defined as the time between the performance of the ankle block and the first administration of rescue analgesia with tramadol. RESULTSTime period to first rescue analgesia with tramadol was similar in the IVDex group and the PNDex group. Data are expressed as mean (SD) or median (range). Duration of analgesia was 23.2 (9.5) hours in the IVDex group and 19 (8.2) hours in the PNDex group (P = 0.4). Consumption of tramadol during the first 48 hours was 0 mg (0–150 mg) in the IVDex group versus 0 mg (0–250 mg) in the PNDex group (P = 0.59). Four (8%) and 12 (24%) patients reported nausea or vomiting in the IVDex group and the PNDex group, respectively (P = 0.03). CONCLUSIONSIn front-foot surgery, perineural and systemic administrations of dexamethasone are equivalent for postoperative pain relief when used as an adjuvant to ropivacaine ankle block. CLINICAL TRIAL REGISTRATIONThis study was registered at ClinicalTrials.gov, identifier NCT02904538.

Background Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. Methods/Design A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student’s t -test or equivalent. Discussion This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. Trial registration Netherlands Trial Register (reg.nr NTR4377 )

Objective This study aimed to compare the effectiveness of ultrasound-guided closed reduction and fixation versus traditional techniques in managing pediatric phalangeal and metatarsal fractures. Methods This retrospective study included 112 pediatric patients with phalangeal or metatarsal fractures treated between January 2020 and December 2023. The participants were categorized into two groups: the ultrasound-guided group (US-guided; n  = 50, including 37 with phalangeal and 13 with metatarsal fractures) and the conventional fluoroscopy-guided group (C-group; n  = 62, including 32 with phalangeal and 30 with metatarsal fractures). The collected data included surgical time, frequency of X-ray examinations, radiation exposure, closed reduction rate, complication rate, and postoperative function. Postoperative functional outcomes were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. Results Surgical time was significantly shorter in the US-guided group (average 44.36 ± 15.23 min) than in the C-group (average 59.15 ± 18.85 min; p  < 0.001). Additionally, the US-guided group required approximately four fewer X-ray examinations (2.98 ± 0.94 vs. 7.31 ± 1.47, p  < 0.001). Radiation exposure was significantly lower in the US-guided group (1.73 ± 0.54 mGy) than in the C-group (4.24 ± 0.85 mGy, p  < 0.001). In the US-guided group, the surgical time for phalangeal fractures was shorter than that for metatarsal fractures (41.08 ± 14.17 min vs. 53.69 ± 14.74 min, p  = 0.009). However, there were no significant differences in the closed reduction rate (US-guided group vs. C-group; 92% vs. 80.6%, p  = 0.08), AOFAS score (93.6 ± 7.81 vs. 94.16 ± 5.27, p  = 0.65), or complication rate (2% vs. 3.2%, p  = 0.69). Conclusion Ultrasound-guided closed reduction and fixation significantly shortened surgical time, reduced X-ray frequency and radiation exposure versus fluoroscopy-guided treatment. With additional advantages in efficiency, simplicity and reproducibility, this approach appears to be a safe and effective option for pediatric phalangeal and metatarsal fractures.

Backgrounds There has long been a consensus that shortening of the first metatarsal during hallux valgus reconstruction could lead to postoperative transfer metatarsalgia. However, appropriate shortening is sometimes beneficial for correcting severe deformities or relieving stiff joints. This study is to investigate, from the biomechanical perspective, whether and how much shortening of the first metatarsal could be allowed. Methods A finite element model of the human foot simulating the push-off phase of the gait was established. Progressive shortening of the first metatarsal from 2 to 8 mm at an increment of 2 mm were sequentially applied to the model, and the corresponding changes in forefoot loading pattern during push-off phase, especially the loading ratio at the central rays, was calculated. The effect of depressing the first metatarsal head was also investigated. Results With increasing shortening level of the first metatarsal, the plantar pressure of the first ray decreased, while that of the lateral rays continued to rise. When the shortening reaches 6 mm, the load ratio of the central rays exceeds a critical threshold of 55%, which was considered risky; but it could still be manipulated to normal if the distal end of the first metatarsal displaced to the plantar side by 3 mm. Conclusions During the first metatarsal osteotomy, a maximum of 6 mm shortening length is considered to be within the safe range. Whenever a higher level of shortening is necessary, pushing down the distal metatarsal segment could be a compensatory procedure to maintain normal plantar force distributions.

Objective To compare the efficacy of Nice Knot Internal Fixation with Kirschner Wire External Fixation versus conventional Tension Band Wiring for the treatment of Lawrence zone 1 fractures at the base of the fifth metatarsal bone. Methods This study employed a retrospective case-control design, which included 37 patients with Lawrence zone I fractures of the fifth metatarsal base, treated surgically at our department from October 2023 to December 2024. Patients were divided into Group TB, receiving tension band wiring with K-wire internal fixation, and Group NK, undergoing Nice knot internal fixation combined with K-wire external fixation. Foot function was assessed using the Manchester–Oxford Foot Questionnaire (MOXFQ-ch) and the American Orthopedic Foot and Ankle Society (AOFAS) midfoot score at 1, 2, and 3 months post-surgery. Results Group NK included 22 patients (11 males, 11 females; mean age: 39.50 years (range: 18–64)). Group TB comprised 15 patients (6 males, 9 females) with a mean age of 42.33 years (range: 20–62). Both groups exhibited a decline in MOXFQ-ch scores and an improvement in AOFAS midfoot scores. the 2-month postoperative follow-up, Group NK exhibited significantly superior outcomes in the pain domain of the AOFAS score compared to Group TB ( p  < 0.05). However, at 2 months post-surgery, the mean MOXFQ-ch score of Group NK was lower than that of Group TB (16.27 ± 6.95 < 22.19 ± 5.19, P  < 0.05). Conclusion The method combining Nice knot internal fixation with K-wire external fixation is a straightforward and effective approach for treating Lawrence zone I fractures of the fifth metatarsal base, yielding satisfactory clinical results.

Background Synostosis refers to the abnormal fusion of bones, which have varying aetiologies as well as sites which are commonly affected. Existing literature mostly describes the condition arising congenitally, and affecting the radio-ulnar joint. Case presentation A 57-year-old gentleman presented to our department with symptomatic malunion and synostosis of the fourth and fifth metatarsals, two years following non-operative treatment of a closed fifth metatarsal fracture. The patient subsequently underwent surgical excision of the synostosis, but had complications of recurrence at the two-year post-operative date. Repeat surgical excision was performed with eventual good functional outcome and no signs of recurrence. Conclusion Our paper aims to describe the first known case of post-traumatic synostosis affecting the metatarsals, as well as provide a review of the current literature.

Brachymetatarsia is a rare congenital anomaly characterized by the shortening of one or more metatarsals, which can lead to functional impairment, pain, and aesthetic concerns. This case report describes a 17-year-old female patient with brachymetatarsia affecting the third and fourth metatarsals of the right foot, which was unresponsive to conservative treatment and caused persistent pain while standing. To address this condition, a single-stage surgical approach was performed using an autologous calcaneal bone graft to lengthen the affected metatarsals. Additionally, the second and fifth metatarsals were shortened to restore a physiological metatarsal parabola and resolve chronic metatarsalgia. The procedure resulted in complete correction of the metatarsal parabola, full resolution of metatarsal pain, and satisfactory functional recovery. The use of an autologous calcaneal graft proved to be an effective and reliable surgical option due to its cortico-cancellous composition, high osteogenic potential, and low antigenicity. This case highlights the advantages of autologous bone grafting as a valuable technique in the surgical management of brachymetatarsia.

Background Hallux valgus(HV) with an increased distal metatarsal articular angle (DMAA) is one of the most common foot deformities among adults. Double metatarsal osteotomy (DMO) is effective in treating severe HV deformity with an increased DMAA. However, this technique presents the risk of avascular necrosis (AVN) of the metatarsal head and transfer metatarsalgia due to shortening of the first metatarsal. The aim of this study was to introduce a surgical procedure defined as revolving scarf osteotomy (RSO) and compare the clinical and radiological results of RSO and DMO performed for treating severe HV with an increased DMAA. Methods First metatarsal osteotomies and Akin osteotomy were performed in 56 patients (62 ft) with severe HV with an increased DMAA in Honghui Hospital from January 2015 to December 2017. RSO was performed in 32 ft and DMO was performed in 30 ft. The Akin osteotomy was performed in both groups. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, the hallux valgus angle (HVA), intermetatarsal angle (IMA), DMAA, and first metatarsal length (FML) and the rates of complications were compared preoperatively and postoperatively in the two groups. Results The mean AOFAS score, VAS score, HVA, IMA, and DMAA showed significant improvements in both groups after surgery, but with no significant differences between the two groups. The postoperative FML was significantly larger in the RSO group than in the DMO group ( p  < 0.001). One of the 30 ft (3.3%) in the DMO group exhibited transfer metatarsalgia at 12 months postoperatively, while another foot (3.3%) in same group had avascular necrosis of the metatarsal head. One of the 30 ft (3.1%) in the RSO group had hallux varus. Conclusions No differences in the clinical and radiographic results were observed between the two groups with severe HV and an increased DMAA. However, RSO does not cause shortening of the metatarsal and AVN of the metatarsal head. A long-term, randomized, controlled prospective study with a larger sample would provide higher-level evidence for confirming the clinical efficacy and safety of RSO.