Category: Midfoot/Forefoot; Sports; Trauma Introduction/Purpose: Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. Management of this injury can be challenging due to delayed union and refracture. Intramedullary screw fixation rather than conservative management has been recommended in the athletic population. This meta-analysis aims to provide an updated summary of return to play (RTP) rate and time with regard to the management, whether operative or non-operative, after Jones fractures in athletes only. We also explore the characteristics of the union such as time and rate, and complications such as refracture. Methods: Following PRISMA guidelines, relevant studies in English literature were identified between databases inceptions to November 2019. Electronic based search on MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases using the following keywords with their synonyms: ('fifth metatarsal fracture' AND 'athlete' AND 'return to play'). In addition, the reference lists from previous review articles were searched manually to check for eligible studies. Two investigators independently reviewed all titles, abstracts, and the full text of articles that were potentially eligible based on the abstract review. Any disagreement was resolved by the senior author. The primary outcomes were (1) return to play rate and (2) time to return to play, whereas the secondary outcomes were (1) games missed, (2) time to union and union rate (3) non-union, delayed union and refracture. The current study accepted the definitions of included studies for non-union, delayed union, and refracture for practicality purposes. Results: Out 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% (97.3%- 99.4%) in 626 out of 646. The RTP rate in IM screw only was 98.8% (97.8%-99.7%), in other surgical fixations methods (plate, mini fix) was 98.4% (95.8%-100%) whereas in conservative management was 71.6% (45.6%-97.6%). There were three studies directly comparing the RTP in surgical versus conservative management, which showed significant superiority in favor of the surgical group OR: 0.033 CI:( 0.005-0.215) P-value <0.001. The overall time to RTP was 9.6 (8.5-10.7) weeks. The time to RTP in the surgical group (IM screw) was 9.6 (8.3-10.9) weeks, significantly less than the conservative group, which was 13.05 (8.15-17.95) weeks. The pooled union rate in the operative group (excluding refracture) was 97.3% (95.1%-99.4%), whereas the pooled union rate in the conservative group was 71.4% (49.1%- 93.7%). Conclusion: Return to play following surgical management of Jones fractures in athletes is excellent regardless of the implant used and sport. Intramedullary screw fixation is superior to conservative management as it leads to a higher rate of return to play, shorter time to return, higher union rate, shorter time to union, and improved functional outcomes. The authors recommend surgical fixation for all Jones fractures in athletes.

Category: Hindfoot Introduction/Purpose: Posterior tibial tendon insufficiency (PTTI) remains the most important contributor to AAFD. When the deformity becomes rigid, management options are limited to arthrodesis. Triple arthrodesis is considered the gold standard for treating painful, rigid flatfoot deformities with proven long-term reliability of correction and favorable functional outcomes. However, the necessity of fusing an unaffected calcaneocuboid joint has been questioned, and double arthrodesis has been suggested as an alternative to triple arthrodesis. The double arthrodesis has been proven to restore function, provide a plantigrade foot, and protect against postoperative ankle valgus. This study aims to prospectively compare double and triple arthrodesis in terms of functional outcomes and deformity correction. To the best of our knowledge, this is the first prospective comparative study in the literature to date. Methods: This is a prospective comparative cohort study carried out between May 2017 and May 2019. The study was approved by the IRB at Assiut University and done according to the Helsinki declaration. Patients with AAFD stage III aged between 15 and 40 years old were assigned to double arthrodesis or triple arthrodesis. The groups were prospectively followed for one year. Primary outcomes were union rates, AOFAS scores, and radiological parameters of deformity correction plain radiographs. Secondary outcomes were operative time, time to union, and complications. Twenty-three patients matched the inclusion criteria. Thirteen (all males) patients underwent double arthrodesis, while ten (nine males and one female) patients underwent triple arthrodesis. The mean age for double and triple arthrodesis was 20.15+-5.63 and 25.10+-8.36 years, respectively, and the mean follow-up lengths were 12.46 and 12.9 months, respectively, with no statistically significant differences in age, follow-up or gender between both groups. Results: All patients in both groups achieved union by four months. The mean time to union in the double and triple arthrodesis groups was 3.39+-0.65 vs. 3.31 +-0.6 months, respectively, with no statistically significant differences (P=0.77). The mean operative time in the double arthrodesis group than the triple arthrodesis group, 55.77+-15.18 vs. 91.6+-24.14 minutes (P<0.001), respectively. Both double and triple arthrodesis groups had a statistically significant improvement of the mean AOFAS hindfoot score postoperatively (71.46 +-7.77 vs. 88.38 +-3.66, P<0.001) and (66.9 +-7.69 vs. 85 +-5.83, P<0.001), respectively. Both double and triple arthrodesis groups had statistically significant improvement of preoperative Meary’s angle, calcaneal pitch, Cal-MT5 height, calc-MT1 angle, and TN coverage angle postoperatively. There were no statistically significant differences between double vs. triple arthrodesis groups in AOFAS score improvement or the magnitude of deformity correction. Conclusion: Double arthrodesis is an equally reliable surgical option for AAFD stage III for achieving union, improving the functional outcomes, and deformity correction as triple arthrodesis with a significantly shorter operative time in the former. The authors recommend double arthrodesis if the calcaneocuboid joint is unaffected.

Category: Other Introduction/Purpose: Non-union of foot and ankle arthrodesis sites has been associated with revision surgery, morbidity and increased healthcare costs, so many surgeons elect to augment the fusion site with autologous bone grafts to improve union. While iliac crest autografts are considered the historical gold standard, other donor sites distal in the lower extremity such as calcaneus, proximal and distal tibia have been successfully used in foot and ankle surgery. This study aims to report on the safety and donor site morbidity of distal lower extremity (calcaneal, proximal and distal tibial) bone autografts. We summarized the findings in a comprehensive infographic illustration. We are unaware of any similar meta-analyses to date. Methods: Following the PRISMA guidelines, 2 independent investigators searched several databases in December 2020 using the following keywords and their synonyms: ('Bone graft', 'donor site morbidity', 'calcaneal graft', 'Proximal tibia graft', and 'distal tibia graft'). Besides, the reference lists from previous review articles were searched manually for eligible studies. The primary outcomes of interest were (1) Chronic pain, (2) Fracture and (3) infection whereas the secondary outcomes were (1) neurological complications, (2) sensory disturbance and hypertrophic scars, (3) other complications such as shoe-wear difficulties and gait disturbance. Inclusion criteria were: studies on complications and adverse events of lower extremity bone autografts (calcaneal, proximal tibial, and distal tibial bone autografts) reporting at least one desired outcome. Studies not reporting any of the outcomes of interest or if the full text is not available in English were excluded. Studies reporting on bone marrow aspirate or autografts for non-orthopedic indications were also excluded. Results: After removal of duplicates, 5981 studies were identified. After screening, 85 studies remained for full-text assessment, and 15 studies qualified for the meta-analysis with a total of 2296 bone grafts.1557(67.8%) were calcaneal grafts, 625 (27.2%) were proximal tibial grafts, and 114 (5%) were distal tibial grafts. The mean age of all patients was 52.43+-16 [CI=51.77-53.08] years. The mean follow-up duration was 1.86+-1.70[CI=1.79-1.93] years. The primary surgery was reported for 2129 grafts(92.7%).Out of those, foot and ankle procedure represented 97.4% of the procedures. In calcaneal bone grafts, there were 28 cases of chronic pain [1.97%,CI:1.10-2.50%, I2=66%], 5 fractures [0.32%,CI:0.10-0.60%, I2=0%], 20 sural neuritis [1.28%,CI:0.70-1.80%, I2=0%), and no wound infections. In proximal tibial grafts there were 13 cases of chronic pain [2.08%,CI:1.01-3.2%, I2=34.5%], 1 fracture [0.16%,CI:0.10-0.50%, I2= 0%], and 3 superficial wound infections [0.48%,CI:0.10-1.01, I2=0%]. In the distal tibial grafts there were no cases of chronic pain or wound infections, 1 fracture [0.90%,CI:0.80-2.6%,I2=0%], and 5 saphenous neuritis [4.5%,CI: 0.70- 8.40%,I2=65%]. Conclusion: Calcaneal, distal tibial, and proximal tibial bone autografts are safe with a low rate of overall and major complications. We report an overall complication rate of 6.8%, which is less than half of that previously reported for iliac crest grafts. The authors recommend using distal lower extremity grafts for foot and ankle primary surgeries instead of iliac crest grafts when indicated. Clinical trials with large sample sizes are required.