SLR - August 2014 - Crystal Sheng-Shan Hsu
Reference: Nery C, Baumfeld D, Raduan F, Macedo B, Filho MA, Esper L, et al. Anterograde Percutaneous Treatment for Lesser Metatarsal Fractures. Techniques in Foot & Ankle Surgery. June 2014; 13(2): 94-7.
Scientific Literature Review
Reviewed By: Crystal Sheng-Shan Hsu, DPM
Residency Program: Montefiore Medical Center
Podiatric Relevance: Metatarsal fractures are common injuries that have a prevalence between 3 percent and 7 percent of all fractures and as high as 35 percent of all foot fractures. In fractures with more than 3 to 4 mm of deviation or more than 10 degrees of angulation, surgical treatment is indicated. Retrograde insertion of K-wires for fixation and exteriorization of wires at the plantar skin is the most common surgical approach. Treatment goals are restoring alignment of the metatarsals, preserving the longitudinal and transverse arch of the forefoot, and establishing a normal weight distribution under the metatarsal heads. This article introduces a new anterograde percutaneous technique to treat lesser metatarsal fractures associated with lower complication rates.
Methods: A prospective study was performed with 14 patients between 2003 and 2008. All patients were treated with distal traction and closed reduction with anterograde percutaneous pinning under fluoroscopy guidance. First, a small incision was made 10 mm distal from the base of the fractured metatarsal. A 1.5- or 2.0-mm K-wire with 15 degrees of angulation was then inserted until it reached the proximal edge of the fracture site. While closed reduction was being performed, the K-wire was inserted to the distal fragment via fluoroscopic guidance.
A questionnaire containing information about the mechanism of injury, comorbidities, and lifestyle was given to all patients to complete. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot functional score was obtained 6 months postoperatively. Fracture healing was confirmed by x-rays 8 weeks after surgery.
Results: Simple torsion was the most common mechanism of injury. By anatomic distribution, the highest frequency of metatarsal fractures occur in the neck (77 percent), and most commonly in the second (43 percent) and the third metatarsals (43 percent). Multiple metatarsal fractures are more common (57 percent) than isolated ones. The average AOFAS functional score at six months postoperatively was 98 points. No soft tissue complications were encountered. Factors that may worsen postoperative results are obesity, female sex, diabetes mellitus, and degree of deviation. Smoking was not shown to affect outcome in this study, however.
Conclusions: In this prospective study, surgical treatment of metatarsal fractures with an anterograde percutaneous pinning technique led to a high functional AOFAS score at six months postoperatively. Due to the minimal dissection required in this alternative technique, the vascularity and the soft tissue envelope are not disturbed. This technique can properly treat metatarsal fractures while avoiding common postoperative complications with other treatments. The study is limited by the small sample size and short follow-up period.