Managing A Problematic Intramedullary Screw In A Patient With A Jones Fracture

These authors describe a cortical window technique for extracting a failed intramedullary screw in a 57-year-old patient with a fifth metatarsal fracture.

Fifth metatarsal base fractures are the most common metatarsal fractures of the foot.¹ Acute fractures of the fifth metatarsal metaphyseal-diaphyseal junction generally present as transverse fractures due to a low energy force when the individual experiences a fall or twisting motion to the foot.^2,3 Although controversial, conservative or surgical management of the fracture is primarily based on the severity of displacement and the patient’s activity level. Non-displaced acute fractures of the fifth metatarsal tend to respond better to conservative treatment whereas authors recommend surgical intervention in athletes and active individuals due to increased failure rates of conservative treatment.^1,2,4,5

When surgical intervention of a fifth metatarsal base fracture is required, authors have described numerous techniques including the use of intramedullary screw fixation, tension band wiring, plating and crossed Kirschner wires.^3,5-8 A concern with utilizing the intramedullary screw technique is the presence of painful hardware once the individual has resumed full activity. This often results in removal of the intramedullary screw after osseous union has occurred. However, when removing a partially threaded intramedullary screw, one should anticipate complications with hardware removal.

The use of a windowing technique has had wide discussion in the orthopedic literature for performing a total hip arthroplasty revision.^9,10 In this technique, a cortical window is created through the anterior aspect of the femur for removal of stem implant followed by impaction with an allograft which is secured using cerclage wire.

Utilizing a similar approach, we present a case and technique for performing an extraction of an intramedullary screw fixation of the fifth metatarsal. To our knowledge, this is the first cortical window technique described for removal of an intramedullary screw of the fifth metatarsal.

What You Should Know About The Patient And The Surgical Technique

A 57-year-old female presented with pain at the base of the fifth metatarsal after she sustained an inversion injury to her foot. The patient had suffered a Jones fracture approximately 15 years prior, resulting in open reduction internal fixation with the use of a cannulated, partially threaded cancellous screw. The significant past medical history included hypertension, hyperlipidemia, anxiety and smoking. Radiographs revealed an avulsion fracture of the fifth metatarsal tuberosity. After failing conservative measures, the patient elected to have surgical removal of the painful hardware and the fractured base of the fifth metatarsal.

Under general anesthesia, the patient was in the lateral decubitus position. Use of a thigh tourniquet facilitated hemostasis. We carried dissection down to the level of the fifth metatarsal tuberosity where we encountered the avulsed fracture fragment and noted it to be partially incorporated into the peroneus brevis tendon. We sharply excised the fractured bone, taking care not to damage the tendon.

Due to an underlying metatarsus adductus deformity, the screw head became more prominent after excision of the fractured fragment. For the intramedullary screw removal, all standard techniques failed including the use of a screwdriver, pliers and a needle driver. In another approach to remove the screw, we burred the bone around the screw head in an attempt to advance the screw forward prior to reversing it out. This technique did not work and resulted in further stripping of the screw head.

At this time, we opted to perform the intramedullary screw extraction through a cortical window technique. After using a mini-power burr to create a small window along the length of the screw at the lateral aspect of the fifth metatarsal, we had adequate visualization of the screw, which we further loosened with an osteotome and mallet. After removing the screw, we were able to determine through direct visualization and intraoperative fluoroscopy that enough bone remained to preserve the viability of the fifth metatarsal. We packed a bone graft substitute mixture of calcium sulfate, calcium phosphate and demineralized bone matrix into the deficit and secured it using 20 and 28 gauge monofilament wires. The overall correction was excellent and we closed the surgical site.

Postoperatively, the patient was in a cast and remained non-weightbearing for three weeks with a subsequent transition to a controlled ankle motion (CAM) boot. At eight weeks postoperatively, the patient was ambulating in regular shoes and was free of her preoperative symptoms.

Further Insights On The Cortical Window Technique

In analyzing the preoperative radiographs, a bend in the partially threaded cannulated screw was present in addition to the patient’s metatarsus adductus deformity. Acknowledging this, screw removal was anticipated to be problematic. By creating a small window in the lateral aspect of the fifth metatarsal, the resulting increased access and direct visualization of the intramedullary allowed for extraction while ensuring no disruption of the peroneal tendons.

The cortical window technique for removal of intramedullary screws provides an alternative approach for the podiatric surgeon encountering hardware removal problems in the fifth metatarsal. Also of importance is the use of either a solid cortical or fully threaded cancellous screw in the fixation of a Jones fracture. Both of these fixation options allow for easier removal than a partially threaded cannulated screw. Further studies should evaluate the validity of the cortical window technique in the fifth metatarsal and examine the postoperative and long-term results of patients having this novel procedure.

Dr. Visser is the Director of the Foot and Ankle Surgery Program at SSM DePaul Health in St. Louis. 

Dr. Malik is a third-year resident at SSM DePaul Health in St. Louis.

Jesse Wolfe is a fourth-year student at the College of Podiatric Medicine and Surgery at Des Moines University.

Joshua Wolfe is a second-year student at the College of Podiatric Medicine and Surgery at Des Moines University.

References

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