Background: Jones fractures of the proximal fifth metatarsal are predisposed to delayed union and nonunion due to a tenuous blood supply. Solid intramedullary (IM) screw fixation is recommended to improve healing, traditionally followed by delayed weightbearing (DWB). However, early weightbearing (EWB) postoperatively may facilitate functional recovery. The purpose of this study was to compare union rates and time to union after solid IM screw fixation of Jones fractures in patients treated with an EWB protocol to those treated with a DWB protocol, as well as to identify any factors that may be predictive of delayed or nonunion. Methods: True Jones (zone 2 fifth metatarsal base) fractures treated from April 2012 through January 2018 with IM screw fixation and 6 months follow-up were identified (41 fractures in 40 patients; mean ± SD age, 45.3 ± 17.9 years). Patients were divided into EWB and DWB cohorts (within or beyond 2 weeks, respectively). Delayed union (12.5 weeks) was statistically derived from established literature. Union times were compared between cohorts. Regression analyses were conducted to investigate possible confounders contributing to delayed union. There were 20 fractures in the EWB cohort and 21 fractures in the DWB cohort. Results: There was no significant difference in healing times (EWB: 25% by 6th week, 55% by the 12th week, 20% delayed; DWB: 33% by 6th week, 43% by 12th week, 24% delayed; P = .819) or delayed unions (EWB, 20% vs DWB, 24%; P > .999). There were no nonunions. No significant confounding risk factors were identified. Conclusion: Postoperative protocols using early weightbearing following solid IM screw fixation of Jones fractures appear to be safe and do not delay fracture healing or increase the risk of delayed union. Older age may be a risk for delayed union, but larger studies are needed to evaluate this with appropriate power in light of possible confounders. EWB protocols may allow better functional recovery without compromising outcomes by increasing the risk of delayed union. Level of Evidence: Therapeutic level III, retrospective comparative study.
Introduction We hypothesize that respiratory variation in the pulmonary artery tracing predicts fluid responsiveness (primary hypothesis) and that inclusion of multiple physiologic waveforms as well as ventilator settings in a predictive model of fluid responsiveness would lead to improvements in the clinical utility of this class of metrics (secondary hypothesis). Methods Blood pressure tracings were prospectively recorded in 35 patients immediately following cardiac surgery. Fluid bolus administration data, ventilator settings, and cardiac output were recorded prospectively before and after fluid boluses given at the discretion of the treating physician. Results We observed statistically significant but limited relationships between pulmonic (r(2) = .26, P = .0052) and systemic (r(2) = .13, P = .011) pulse pressure variation and changes in cardiac index. A multiparameter estimate of fluid responsiveness, which included respiratory variation in central venous pressure and pulmonary artery pressure, indexed tidal volumes, positive end-expiratory pressure, and mean airway pressure, was also correlated with change in cardiac index (r(2) = .42, P = .0056). Using the area under the curve (AUC) technique to compare specificity and sensitivity, dynamic indicators (AUC = 0.74, 0.67, and 0.81 for systemic arterial respiratory [pulse pressure] variation, pulmonic arterial respiratory [pulse pressure] variation, and the multiparameter estimate, respectively) outperformed static estimates (0.49 and 0.48 for central venous pressure and pulmonary artery diastolic pressure, respectively). Conclusion While integration of multiple physiologic waveforms as well as ventilator parameters improves the predictability of fluid responsive metrics in the setting of lung-protective ventilation, the composite index may still be of limited predictive value.
Although there are a number of techniques to address osseous deformity in hallux valgus surgery, the lateral soft tissue release and medial capsulorrhaphy are also important to a successful correction. Rebalancing the deforming forces is integral to a durable correction. We describe a new technique of multidirectional medial capsulorrhaphy that allows the surgeon to balance the soft tissue reliably in the coronal, sagittal, and axial planes. This described technique utilizes a Y-V flap configuration with multiple anchor points that can be tailored to the optimal tension and rotation to suit the individual deformity. Proper tensioning of the flap produces soft tissue balance and reduction of the sesamoids that is readily apparent with fluoroscopy. The technique is simple to perform and reproduce, and can be easily adopted and applied to any open hallux valgus procedure. Level of Evidence: Diagnostic Level V.
Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: The Jones fracture of the proximal fifth metatarsal metadiaphysis is predisposed to delayed union and nonunion due to a tenuous blood supply. Surgical fixation followed by delayed weightbearing is commonly recommended, though the optimal period of nonweightbearing after surgery is not well defined. In response to more recent literature and in an effort to facilitate functional recovery, the trend in our practice has begun to shift toward earlier weightbearing for all patients after Jones fracture fixation. The purpose of this study is to investigate the effect of earlier weightbearing after surgical fixation of Jones fractures. Methods: All Jones fractures treated with an intramedullary (IM) screw in a large, urban practice from 2012-2018 were identified. We excluded fractures that were chronic in nature and patients with underlying metabolic disease. We defined a delayed union as longer than 12.5 weeks based on published data. Time to weightbearing and early weightbearing (within 1 week of surgery) were investigated as risk factors for delayed union using logistic regression and Fisher exact tests, respectively. The relationship between time to weightbearing and time to union was assessed with Spearman correlation. Additional variables were explored in bivariate analysis: time to surgery from initial presentation; age, sex, chronicity, tobacco use, weight, BMI, screw size; preoperative NSAID use, and postoperative VTE prophylaxis. Multivariate regression analyses were then performed to identify variables independently predictive of delayed union. Results: Forty-one cases were included (17 males, 24 females), all treated with IM fixation. Median age in the sample was 45 years ( IQR, 32-62 years). Overall mean time to union was 10.9 +- 7.0 weeks (range, 4.9-41.4 weeks). There were nine (22.0%) delayed unions. Earlier weightbearing was not significantly predictive of delayed union (OR 1.02; 95% CI, 0.99-1.05; P = 0.211), and the incidence of nonunion was not significantly different between early and delayed weightbearing groups (OR, 1.20; 95% CI, 0.02- 17.54; P > .999). In bivariate analysis, increasing age was associated with increasing risk of delayed union (OR, 1.06; 95% CI, 1.01- 1.12; P = 0.031), and was correlated with time to union (ρ = 0.327, P = 0.037). Mutivariate analaysis demonstarted no significant variables. Conclusion: Our results suggest that earlier weightbearing after internal fixation of Jones fractures is not a risk factor for delayed union and does not significantly alter healing time. These findings are consistent with previously published data, but go further by assessing the effects of time to weightbearing in continuous regression models.
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