New screw (Acutrak®) in the surgical treatment of elite football players with fifth metatarsal

Abstracts

OBJETIVO: Há uma variabilidade considerável na literatura no que tange ao tratamento ideal de fraturas do quinto metatarso. O objetivo deste estudo é apresentar os resultados da fixação cirúrgica de fraturas do quinto metatarso usando o parafuso Acutrak® em jogadores de futebol de elite. MATERIAL E MÉTODOS: Três casos de fratura do quinto metatarso em jogadores de futebol de elite são apresentados. A média de idade dos pacientes era de 24 anos (18-26 anos). Tratamos as três fraturas do quinto metatarso em jogadores de futebol de elite. Os casos em nosso estudo consistiam de uma fratura diafisiária do quinto metatarso e duas fraturas de Jones. As fraturas ocorreram durante a participação nos jogos. Aplicamos fixação interna utilizando um parafuso Acutrak® percutâneo sob anestesia local com o auxílio de um fluoroscópio. Os pacientes foram clinica e radiograficamente avaliados. RESULTADOS: O restabelecimento clínico foi obtido em 10 semanas após a cirurgia. A consolidação radiográfica ocorreu em 8 semanas de pós-operatório, sendo que os pacientes retornaram a seus níveis prévios de atividade em 11 semanas de pós-operatório. Não foi relatada nenhuma complicação pósoperatória. Não se observou nenhuma irritação de pele devido à ausência de cabeça do parafuso Acutrak®. CONCLUSÃO: Os resultados sugerem que Acutrak® pode ser usado em jogadores de futebol com fraturas do quinto metatarso. Apesar de fatores como facilidade de implante, o custo e a resistência a inclinação também devem ser considerados.

Fraturas ósseas; Ossos do metatarso; Fixadores internos; Parafusos ósseos

ORIGINAL ARTICLE

New screw (Acutrak^®) in the surgical treatment of elite football players with fifth metatarsal

Hayati Ozturk^I; Kenan Kaygusuz^II

^IDepartment of Orthopedics and Traumatology, Cumhuriyet University School of Medicine

^IIAnesthesiology and Reanimation, Cumhuriyet University School of Medicine

^{Correspondences to}

ABSTRACT

OBJECTIVE: There is considerable variability in the literature concerning the optimal treatment of fifth metatarsal fracture. The purpose of this study is to report the outcome of surgical fixation of fifth metatarsal fractures using Acutrak^® screw in elite football players.

MATERIAL AND METHOD: Three cases of fifth metatarsal fracture in elite football players. The mean age was 24 years old (18-26 years). We treated three fifth metatarsal fractures in elite football players. The cases in our study consisted of one diaphyseal fifth metatarsal fracture and two Jones fractures. The fractures had been occurred during sports participation. We applied internal fixation using a percutaneous Acutrak^® screw under local anesthesia with the aid of fluoroscopy. The patients were clinically and radiographycally evaluated.

RESULTS: Clinic healing was obtained at 10 weeks postoperatively. Radiographic consolidation occurred at 8 weeks postoperatively and the patients returned to pre-injury activity levels at 11 weeks postoperatively. No postoperative complication was seen. No skin irritation due to a headless screw of Acutrak^® was observed.

CONCLUSION: The result suggested that Acutrak^® may be used in elite football players with fifth metatarsal fractures. In spite of factors such as ease of implementation, cost and resistance to bending also need to be considered.

Keywords: Fractures, bone. Metatarsal bones. Internal fixators. Bone screws.

INTRODUCTION

Fifth metatarsal fractures are most frequently related to chronic stress, especially in athletes. These fractures are treated operatively or nonoperatively.^1,2 Operative treatment is often recommended for athletes.³ But the optimal surgical treatment has not yet been determined.

Intramedullary screw fixation is popular because the return to competitive sports can be faster than with bone grafting without screw fixation. However, refracture has been reported.⁴ The purpose of this study is to report the outcome of surgical fixation of fifth metatarsal fractures using Acutrak screw in elite football players.

PATIENTS AND METHODS

We treated three elite football players with fifth metatarsal. Our cases consisted one diaphyseal fifth metatarsal fracture and two Jones fractures. The fractures had occurred during sports practice. The mean age was 24 years old (18-26 years).

We applied surgical treatment in order to provide an early return to sports and for preventing recurrences.

Under local anesthesia (deep peroneal and posterior tibial nerve blocks) a straight mini incision parallel to the plantar aspect of the foot was used in order to approach the base of the fifth metatarsal.

Careful blunt dissection was performed taking care to not to sever the cutaneous branches of the sural nerve. Then, a guide wire was placed down the shaft of the metatarsal and placement was verified using fluoroscopy at anteroposterior and lateral planes. Acutrak was placed into the intramedullary canal of the fifth metatarsal with the aid of fluoroscopy.

Patients were asked to not to apply load for three weeks. Subsequently, they were allowed to progressively bear weight for three to four weeks while immobilized in cast brace.

We applied rehabilitation including ankle range-of-motion exercises, manual resistive exercise, proprioceptive activities, and cardiovascular workouts using a stationary bicycle.

RESULTS

Clinical healing was achieved within 10 weeks in average (range 9-11 weeks) postoperatively. Radiographic consolidation occurred within 8 weeks in average (range 6-10 weeks), with patients returning to pre injury activity levels at 11 weeks postoperatively. No postoperative complication was reported. (Figures 1 - 4)

Intramedullary screw fixation has become a popular surgical management method for Jones fractures. The screw head problems are found in more traditional AO screw techniques. Acutrak doesn't irritate skin because of its headless screw. Acutrak may be the treatment of choice in elite football player with Jones fractures. In spite of factors such as ease of implementation, the costs and resistance to bending also need to be considered.

DISCUSSION

Nonoperative treatment of these fractures often requires prolonged immobilization and has been associated with a relatively high incidence of delayed union or nonunion. ⁵

Surgical fixation for managing Jones fractures was first described by Kavanaugh et al in 1978. Since then, high success rates have been reported by many studies in minimizing the risk of nonunion, delayed union, and potential recurrences, as well as for reducing the time to return to athletic activity.⁶ Three recurrence cases after intramedullary screw fixation were previously reported by Josefsson et al., but these refractures occurred after the removal of the intramedullary screw.⁷ Surgical treatment is preferred for returning to previous levels of sports activities and for preventing recurrences in elite football players.

The Acutrak (Acumed, Inc., Beaverton, OR) system is made of a titanium alloy and is a fully-threaded, self-tapping, cannulated, and tapered headless screw with varying thread pitches with both the diameter and pitch gradually increasing toward the trailing end.⁸

Four small metallic screws were compared to the Little Grafter (LG) screw, using a bone model made of rigid polyurethane foam. The screws included the Acutrak, Asnis III, Herbert and Herbert-Whipple types. The mean maximum compression forces for the LG screw, Asnis and Acutrak were comparable (LG 32.3 N, Asnis 32.8 N, Acutrak 38.3 N), whereas those using the Herbert and the Herbert-Whipple screw we re significantly lower (Herbert 21.8 N, Herbert-Whipple 19.9 N).⁹

While obvious advantages have been shown to be associated with operative treatment, significant complications have been reported, including hardware failure, wrong positioning of the intramedullary screw and persistent pain at the operative site.¹⁰

We preferred Acutrak for our cases because it has the best compression forces among any other headless screw. In addition, headless screws are commonly used because they minimize interference with joint surfaces and reduce tissue irritation and immobilization.

Acutrak may be used in elite football players with fifth metatarsal fractures. In spite of factors such as ease of implementation, its costs and resistance to bending also needs to be considered.

REFERENCES

Received in: 03/11/08; approved in: 07/06/08

All the authors state no potential conflict of interest concerning this article.

Study conducted at the Department of Orthopedics and Traumatology Cumhuriyet University School of Medicine

• 1. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995;26:353-61.
• 2. Shah SN, Knoblich GO, Lindsey DP, Kreshak J, Yerby SA, Chou LB. Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int. 2001;22:581-4.
• 3. Mindrebo N, Shelbourne KD, Van Meter CD, Rettig AC. Outpatient percutaneous screw fixation of the acute Jones fracture. Am J Sports Med. 1993;21:720-3.
• 4. Wright RW, Fischer DA, Shively RA, Heidt RS Jr, Nuber GW. Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med. 2000;28:732-6.
• 5. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;11:349-53.
• 6. Reese K, Litsky A, Kaeding C, Pedroza A, Shah N. Cannulated screw fixation of Jones fractures: a clinical and biomechanical study. Am J Sports Med. 2004;32:1736-42.
• 7. Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Jones fracture. Surgical versus nonsurgical treatment. Clin Orthop Relat Res 1994;(299):252-5.
• 8. Faran KJ, Ichioka N, Trzeciak MA, Han S, Medige J, Moy OJ. Effect of bone quality on the forces generated by compression screws. J Biomech. 1999;3:861-4.
• 9. Bailey CA, Kuiper JH, Kelly CP. Biomechanical evaluation of a new composite bioresorbable screw. J Hand Surg Br. 2006;31:208-12.
• 10. Glasgow MT, Naranja RJ Jr, Glasgow SG, Torg JS. Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: the Jones fracture. Foot Ankle Int. 1996;17:449-57

Publication Dates

• Publication in this collection
  19 Nov 2009
• Date of issue
  2009

History

• Accepted
  06 July 2008
• Received
  11 Mar 2008