The Cavovarus Foot and It's Association with Fractures of the Fifth Metatarsal

Transcription

1 The Cavovarus Foot and It's Association with Fractures of the Fifth Metatarsal Daniel Fuchs, Aamir Bhimani, James Brodsky, Christian Royer, Veerabhadra Reddy, Jacob Zide, Yahya Daoud, Justin Kane

2 Disclosure No conflict to disclose Daniel Fuchs, Aamir Bhimani, James Brodsky, Christian Royer, Veerabhadra Reddy, Jacob Zide, Yahya Daoud, Justin Kane Our disclosures are in the Final AOFAS Mobile App. We have no potential conflicts with this presentation. 1

3 5 th Metatarsal Fracture and Cavovarus Commonly accepted association Limited evidence Prior research Zone 2 and Zone 3 3,4 Fractures in elite athletes 3,5 Association with proximal stress fractures most widely accepted 3. Carreira DS, Sandilands SM. Radiographic factors and effect of fifth metatarsal Jones and diaphyseal stress fractures on participation in the NFL. Foot & ankle international Raikin SM, Slenker N, Ratigan B. The association of a varus hindfoot and fracture of the fifth metatarsal metaphysealdiaphyseal junction: the Jones fracture. The American journal of sports medicine Lee KT, Park YU, Jegal H, et al. Factors associated with recurrent fifth metatarsal stress fracture. Foot & ankle international

4 5 th Metatarsal Fracture and Cavovarus Implications for diagnosis and treatment Identify other cavovarus-related conditions Chronic ankle instability Peroneal tendon tears Additional stress fractures of foot Association of cavovarus with nonunion and refracture 3

5 5 th Metatarsal Fracture and Cavovarus In this study we aim to evaluate the association between fifth metatarsal fractures and cavovarus alignment using measurements of multiple standardized radiographic angles that indicate the degree of cavovarus. We hypothesize that cavovarus foot alignment is positively correlated with incidence of fifth metatarsal fractures. 4

6 Methods Central data warehouse used to identify patients treated for isolated 5 th metatarsal fracture from Inclusion criteria Follow-up until radiographic union Complete weight bearing AP and lateral radiographs Complete office notes Exclusion criteria Multiple metatarsal fractures Previous surgery which altered the foot alignment Surgery to address 5 th metatarsal fracture which included alteration of the foot alignment Control group patients presenting for pathology unrelated to foot alignment Phalanx fractures Interdigital neuroma Plantar fasciitis Radiographic review Classify fracture by location (study group) Measure radiographic angles (study and control groups) For study group, angles were measured from weight-bearing radiographs at final follow up. Statistical analysis ANOVA fractures vs. controls Tukey-Kramer compare 5 th metatarsal fracture types 5

7 Methods Radiographic Parameters Lateral radiograph A. Calcaneal pitch B. Calcaneal-first metatarsal angle C. Talo-metatarsal angle D. Talo-calcaneal angle Anteroposterior radiograph A. Talo-second metatarsal angle B. Talonavicular coverage angle C. Talo-calcaneal angle 6

8 Results Distribution of 5th Metatarsal Fractures by Type Type Number of Fractures Incidence Zone % Zone % Zone % Dancer s % Metatarsal Neck % Total Fractures 238 Controls 104 Proximal fractures Zone 1 Zone 2 Zone 3 Dancer s fracture distal spiral diaphyseal Metatarsal neck fracture Den Hartog BD. Fracture of the proximal fifth metatarsal. Journal of the American Academy of Orthopaedic Surgeons. 2009;17(7):

9 Results Measurement Calcaneal Pitch (Lateral) Calcaneal 1st Metatarsal Angle (Lateral) Meary's Angle (Lateral) Talocalcaneal Angle (Lateral) Talo-Second Metatarsal Angle (AP) Talonavicular Coverage Angle (AP) Talocalcaneal Angle (AP) Radiographic Parameters Control (n=104) 18.8 (±5.3) [ ] (±8.61) [ ] 1.21 (±7.12) [ ] (±5.31) [ ] (±8.06) [ ] (±8.97) [ ] (±6.40) [ ] 5th Metatarsal Fracture (n=298) 22.5 (±5.34) [ ] (±8.04) [ ] 2.35 (±7.06) [ ] (±5.91) [ ] (±8.62) [ ] (±8.62) [ ] (±6.71) [ ] p-value < < < Bold values indicate a significant difference between fracture group and controls. For all measurements with a significant difference, the fracture group had values which indicated a greater degree of cavovarus. 8

10 Results Tukey-Cramer Subgroup Analysis Comparative Analysis Between Specific Fracture Type and Controls Calcaneal Pitch (Lateral) Talo-Calcaneal (Lateral) Talo-Metatarsal (Anteroposterior) Talo-navicular Coverage (Anteroposterior) Talo-calcaneal (Anteroposterior) Control vs Dancer (p<0.01) (p<0.01) (p=0.90) (p=0.58) (p<0.01) Control vs MT Neck (p=0.90) (p<0.01) (p=0.90) (p=0.90) (p<0.01) Control vs Zone 1 (p<0.01) (p<0.01) (p=0.66) (p=0.30) (p<0.01) Control vs Zone 2 (p=0.03) (p<0.01) (p<0.01) (p<0.01) (p<0.01) Control vs Zone 3 (p<0.01) (p<0.01) (p<0.01) (p=0.09) (p<0.01) Dancer vs MT Neck (p=0.07) (p=0.60) (p=0.90) (p=0.67) (p=0.90) Dancer vs Zone 1 (p=0.90) (p=0.90) (p=0.90) (p=0.90) (p=0.90) Dancer vs Zone 2 (p=0.90) (p=0.90) (p=0.08) (p=0.23) (p=0.58) Dancer vs Zone 3 (p=0.73) (p=0.90) (p=0.03) (p=0.81) (p=0.90) MT Neck vs Zone 1 (p=0.29) (p=0.57) (p=0.90) (p=0.62) (p=0.90) MT Neck vs Zone 2 (p=0.10) (p=0.49) (p=0.23) (p=0.07) (p=0.90) MT Neck vs Zone 3 (p=0.90) (p=0.90) (p=0.12) (p=0.27) (p=0.83) Zone 1 vs Zone 2 (p=0.90) (p=0.90) (p=0.04) (p=0.13) (p=0.87) Zone 1 vs Zone 3 (p=0.90) (p=0.90) (p=0.01) (p=0.75) (p=0.74) Zone 2 vs Zone 3 (p=0.90) (p=0.90) (p=0.90) (p=0.90) (p=0.37) Numerous significant differences (indicated by bold) seen between each fracture subgroup and the controls (blue zone) for various parameters. Very few significant differences across all parameters when comparing one fracture subgroup to another. (red zone) 9

11 Conclusions Individuals that sustain zone 1, zone 2, zone 3, distal spiral diaphyseal, and metatarsal neck fractures have evidence of cavovarus foot alignment. Cavovarus foot alignment is a risk factor for all fifth metatarsal fractures. Future study correlate radiographic parameters of cavovarus with Risk of nonunion following nonoperative treatment Risk of nonunion following operative treatment of fracture without foot realignment Risk of refracture What degree of cavovarus justifies surgical treatment and what degree of cavovarus warrants concomitant realignment surgery? 10

12 References 1. Carreira DS, Sandilands SM. Radiographic factors and effect of fifth metatarsal Jones and diaphyseal stress fractures on participation in the NFL. Foot & ankle international. 2013;34(4): doi: / Hunt KJ, Anderson RB. Fifth Metatarsal Fractures and Refractures. Operative Techniques in Sports Medicine. 2014;22(4): Jones R. I. Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence. Annals of surgery. 1902;35(6): Kane JM, Sandrowski K, Saffel H, et al. The Epidemiology of Fifth Metatarsal Fracture. Foot & ankle specialist. 2015;8(5): doi: / Ledoux WR, Shofer JB, Ahroni JH, et al. Biomechanical Differences Among Pes Cavus, Neutrally Aligned, and Pes Planus Feet in Subjects with Diabetes. Foot & ankle international. 2003;24(11): doi: / Lee KT, Kim KC, Park YU, Kim TW, Lee YK. Radiographic evaluation of foot structure following fifth metatarsal stress fracture. Foot & ankle international. 2011;32(8): Lee KT, Park YU, Jegal H, et al. Factors associated with recurrent fifth metatarsal stress fracture. Foot & ankle international. 2013;34(12): doi: / Manoli A, 2nd, Graham B. The subtle cavus foot, "the underpronator". Foot & ankle international. 2005;26(3): Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot & ankle international. 2006;27(3): Raikin SM, Slenker N, Ratigan B. The association of a varus hindfoot and fracture of the fifth metatarsal metaphysealdiaphyseal junction: the Jones fracture. The American journal of sports medicine. 2008;36(7): doi: /