Advertisement

Biomechanical Comparison of Cannulated Screw Osteosynthesis With Tension-Band Wiring for Proximal Fractures of the Fifth Metatarsal (Jones Fracture)

Open AccessPublished:August 15, 2022DOI:https://doi.org/10.1053/j.jfas.2022.08.004

      Abstract

      Jones fractures, which lie at the junction of the diaphysis to the metaphysis of the fifth metatarsal, are a well-described clinical issue. There are various surgical approaches, including the commonly performed cannulated screw osteosyntheses, and the less frequently used tension-band approach. The aim is to compare the biomechanical stability of these osteosyntheses. We performed an osteotomy on 16 fresh frozen fifth metatarsal bones from body donors representing a Jones fracture. The fractures were treated pairwise with screw osteosynthesis or tension-band wiring. This was followed by cyclic axial bending until osteosynthesis failure. Stability under axial bending force was higher in the screw osteosynthesis (mean: 70.0 ± 66.5 N) compared to the tension-band wiring (mean: 35.7 ± 23.3 N) group although not reaching statistical significance (p = .116). The study shows no statistically significant difference in biomechanical stability under axial loading between screw osteosynthesis and tension band wiring. Based on the data obtained, no differences can be observed from a biomechanical point of view. The study supports the established method of treating Jones fractures primarily with screw osteosynthesis. In addition, the data suggest that tension band wiring may be a good alternative osteosynthesis, for example, after failed casting treatment or failure of primary osteosynthesis.

      Level of Clinical Evidence

      Keywords

      Metatarsal fractures are common in adults, consisting of 3.2% to 6.8% of all fractures (
      • Cakir H
      • van Vliet-Koppert ST
      • van Lieshout EMM
      • Vries MR de, van der Elst M
      • Schepers T.
      Demographics and outcome of metatarsal fractures.
      ). Of the metatarsal bones, the fifth is the most commonly affected with 56% to 68% of all metatarsal injuries (
      • Cakir H
      • van Vliet-Koppert ST
      • van Lieshout EMM
      • Vries MR de, van der Elst M
      • Schepers T.
      Demographics and outcome of metatarsal fractures.
      ,
      • Petrisor BA
      • Ekrol I
      • Court-Brown C.
      The epidemiology of metatarsal fractures.
      ). Jones fractures occur at the metaphyseal-diaphyseal junction at the base of the fifth metatarsal.
      Poor blood supply as shown by Smith et al. (
      • Smith JW
      • Arnoczky SP
      • Hersh A.
      The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing.
      ) is a reason for prolonged healing time in nonoperative treatment of this fracture type leading to delayed union or non-union. Furthermore, activation of the peroneal tendons inserting proximally to the fracture site during gait contribute to dislocation of Jones fractures (
      • Willegger M
      • Benca E
      • Hirtler L
      • et al.
      Peroneus brevis as source of instability in Jones fracture fixation.
      ). Therefore, surgical treatment was recommended to avoid this complication and the associated more complicated course of treatment.
      In a literature review by Dean et al., it was shown, that the acute Jones fractures, that are located approximately 1.5 cm distal to the proximal tuberosity (Dameron & Quill type II) are related to an incidence of non-union of 20%, showing radiographic union mean times of 15.9 weeks under nonsurgical treatment (
      • Dean BJF
      • Kothari A
      • Uppal H
      • Kankate R.
      The jones fracture classification, management, outcome, and complications: a systematic review.
      ). Surgical treatment showed decreased time for radiographic union of 7.1 weeks accompanied by a surgical complication rate of 22.6%, mostly screw related complications and rarely non-unions.
      There is consensus that displaced type II fractures require operative treatment (
      • Portland G
      • Kelikian A
      • Kodros S.
      Acute surgical management of Jones' fractures.
      ,
      • Bowes J
      • Buckley R.
      Fifth metatarsal fractures and current treatment.
      ,
      • Zwitser EW
      • Breederveld RS.
      Fractures of the fifth metatarsal; diagnosis and treatment.
      ,
      • Ruta DJ
      • Parker D.
      Jones Fracture Management in Athletes.
      ). But the management of non-displaced type II fractures is debatable. Many studies have shown a benefit of early fixation when compared to conservative cast therapy, resulting in earlier radiographic union, weightbearing, and return to normal activity, including sports (
      • Mindrebo N
      • Shelbourne KD
      • van Meter CD
      • Rettig AC.
      Outpatient percutaneous screw fixation of the acute Jones fracture.
      ,
      • Mologne TS
      • Lundeen JM
      • Clapper MF
      • O'Brien TJ
      Early screw fixation versus casting in the treatment of acute Jones fractures.
      ).
      There are several surgical procedures to treat type II fifth metatarsal fractures. The most used is that of cannulated screw osteosynthesis. Nevertheless, refracture following surgical treatment occurs by rates of 10% to 15% (
      • Dean BJF
      • Kothari A
      • Uppal H
      • Kankate R.
      The jones fracture classification, management, outcome, and complications: a systematic review.
      ,
      • Bowes J
      • Buckley R.
      Fifth metatarsal fractures and current treatment.
      ,
      • Scott RT
      • Hyer CF
      • DeMill SL.
      Screw fixation diameter for fifth metatarsal jones fracture: a cadaveric study. The Journal of foot and ankle surgery official publication of the American College of Foot and.
      ,
      • Reese K
      • Litsky A
      • Kaeding C
      • Pedroza A
      • Shah N.
      Cannulated screw fixation of Jones fractures: a clinical and biomechanical study.
      ,
      • Nayak R
      • Barrett J
      • Patel MS
      • Barbosa MP
      • Kadakia AR.
      Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures.
      ). As recently suggested, the use of headless compression screw may add a greater amount of stiffness than conventional, partially threaded screws (
      • Lam K
      • Bui R
      • Morris R
      • Panchbhavi V.
      Biomechanical analysis of conventional partially threaded screws versus headless compression screws in proximal fifth metatarsal (Jones) fracture fixation.
      ). Plate osteosynthesis, that provides higher biomechanical stability compared to screw osteosynthesis is a viable proposition (
      • Duplantier NL
      • Mitchell RJ
      • Zambrano S
      • et al.
      A biomechanical comparison of fifth metatarsal Jones fracture fixation methods.
      ). A shorter time to fracture zone union was described for the plate in a clinical study (
      • Kim J-B
      • Song I-S
      • Park B-S
      • Ahn C-H
      • Kim C-U.
      Comparison of the outcomes between headless cannulated screw fixation and fixation using a locking compression distal ulna hook plate in fracture of fifth metatarsal base.
      ). An alternative to this osteosynthesis, is tension-band wiring as suggested by Sarimo et al. (
      • Sarimo J
      • Rantanen J
      • Orava S
      • Alanen J.
      Tension-band wiring for fractures of the fifth metatarsal located in the junction of the proximal metaphysis and diaphysis.
      ). They treated delayed or non-union Jones fractures under cast therapy and described a postoperative radiographic union rate of around 12.8 weeks and a return to activity in about 14.7 weeks.
      To the best of our knowledge there is no study evaluating the biomechanical stability of tension-band wiring in Jones fractures.
      In our study we compare the biomechanical stability of tension-band wiring to that of cannulated screw osteosynthesis in fifth using a bending-stress cadaver bone model.

      Materials and Methods

      Specimens

      Sixteen fresh frozen human fifth metatarsal (8 pairs) were isolated from body donors while obtaining the insertion of the peroneus brevis tendon. Bone mineral density (BMD) of all cadavers was determined in the associated calcanei (QDR 4500 Elite Densitometer,). The specimens were thawed at room temperature. The study was approved by the local ethics committee.

      Fracture Model

      Osteotomy was performed 1.5 cm distal to the styloid process in the metaphyseal zone involving the joint of the fourth/fifth metatarsal. The distance was measured with a ruler aligned with the shaft axis of the bone.

      Osteosynthesis

      Following the osteotomies, a screw osteosynthesis was performed on the right metatarsal bone and tension-band wiring on the left. The screw osteosynthesis was performed using a 4.5 mm cannulated titanium partial thread screw (Stryker GmbH & Co. KG) as suggested in the user manual. After measuring the possible screw length, the longest possible screw was used shown in Fig. 1A. The tension-band wiring was performed as described by Sarimo et al. using 1.25 mm K-wires and 1.0 mm cerclage wire shown in Fig. 1B. All osteosynthesis were performed by 2 experienced traumatological foot consultants. One clinically experienced surgeon performed screw osteosynthesis and the other performed tension band wiring to standardize the procedure.
      Fig 1
      Fig. 1Radiographic image of a fracture of the proximal junction of the metaphysis and diaphysis of the fifth metatarsal treated with A- cannulated screw osteosynthesis B- tension-band wiring.
      Prior to embedding the osteotomy gap, all segments of K-wires and screws were capped with modeling clay to avoid contact with the embedment liquids (Fig. 2). Both ends of the specimen were embedded in liquid methymethacrylate (Technovit 3040) in a cylindrical form, matching the size of the mounting device of the test machine.
      Fig 2
      Fig. 2Cadaver bone with tension-band wiring osteosynthesis capped with modelling clay, embedded distal and proximal.

      Test Design and Procedure

      Biomechanical testing was performed using a universal material testing machine (TC-FR 1.0TH.D09, Zwick Z1.0). During the measurement the distal enclosing cylinder could slide freely in the longitudinal direction of the specimen axis using a 2-dimensional free-swinging table (Fig. 3).
      The sufficiency of the osteosynthesis was plotted by using an ultrasound measurement system (ZEBRIS, CMS 70PV5, ZEBRIS Medical) applied to the specimen. One ultrasound sensor each was attached to the metatarsal base and the metatarsal diaphysis. The ultrasound measurement registers movement in a 3-dimensional space. Any movement of each attached button respectively to the sensing camera is registered every 33 ms. This results in a change in the coordinates system with a sensitivity of 0.1 mm. The distance of displacement is calculated afterwards. The protocol of axial loading force was determined by preliminary tests using a fifth metatarsal bone (SYNBONE). After 5 setting cycles, axial bending force was determined in 10 measuring cycles. Each specimen then underwent 10 cycles of a 10 N dorsally directed bending force at a rate of 1 mm/s and unloading to a tensile force of −5 N simulating unloading. After each cycle the force was increased by 10 N until osteosynthesis failure. As the definition of failed osteosynthesis is widely discussed and not conclusively defined, we assume a widening fracture gap larger than 2 mm as osteosynthesis failure. This threshold is commonly accepted describing foot and ankles fractures as displaced (
      • Bowes J
      • Buckley R.
      Fifth metatarsal fractures and current treatment.
      ,
      • Klos K
      • Randt T
      • Simons P
      • Knobe M.
      Vor- und Mittelfußfrakturen beim Erwachsenen.
      ).
      Shown is a prepared specimen with the added markers for ultrasound measurement (green and yellow). The proximal end of the fifth metatarsal bone undergoes 10 cycles per measurement of dorsal bending starting at 10 N and unloading of 5 N. The dorsally bending force is increased by 10 N per measurement until osteosynthesis failure.

      Statistical Analysis

      Statistical analysis was performed using the Wilcoxon test for comparison of median and rank sums of the two study groups. BMD values between groups were analyzed using the Wilcoxon test. The relation between BMD and osteosynthesis failure was analyzed by Spearman correlation coefficient. A p ≤ .05 was considered statistically significant for all tests. The SPSS Statistics (version 21, IBM, Armonk) and graph pad PRISM (version 6, graph pad, San Diego) were used for all calculations.

      Results

      There were no significant differences in bone density between the two groups using the osteosyntheses cannulated screw osteosynthesis 154.9 ± 45.3 g/cm2 and tension-band wiring 156 ± 43.3 g/cm2 (p = .779).
      There was no statistically significant correlation between the BMD and the axial bending force which led to osteosynthesis failure (r = 0.566, p = .148).
      The group, that underwent cannulated screw osteosynthesis shows higher means (mean: 70.0 ± 66.5 N, minimum-maximum 10-170 N) at the point of osteosynthesis failure than the group that underwent tension-band wiring (mean: 35.0 ± 23.3 N, minimum-maximum 10-70 N) not reaching statistical significance (p = .116) (Fig. 4).
      Fig 4
      Fig. 4Comparison between maximum forces before onset of osteosynthesis failure of the tension band wiring and screw osteosynthesis.

      Discussion

      In this study, we show that there is no difference in maximum failure load between the osteosynthesis with cannulated screws or tension-band wiring. Furthermore, no influence of bone density values could be seen.
      For the test, the force was introduced via a dorsally directed vector, the existing rotational impulses through the tendon of the m. peroneus brevis were under-estimated (
      • Willegger M
      • Benca E
      • Hirtler L
      • et al.
      Peroneus brevis as source of instability in Jones fracture fixation.
      ,
      • Morris PM
      • Francois AG
      • Marcus RE
      • Farrow LD.
      The effect of peroneus brevis tendon anatomy on the stability of fractures at the fifth metatarsal base.
      ). The value of rotational forces in Jones fractures has not been clearly proven, as the natural joint surfaces and surrounding soft tissue can only allow slight rotational movements. A possible higher stability against these rotational movements could not be considered with our test set-up. Improving rotational stability and compression of the fracture site may favor tension-band wiring. The displaced avulsion fracture is a more recognized site for tension-band wiring with respect to the slightly oblique fracture line (
      • Bowes J
      • Buckley R.
      Fifth metatarsal fractures and current treatment.
      ). The strictly transverse fracture line is not ideal for tension-band wiring and requires an orthogonal entry for the K-wires.
      To ensure the best possible stiffness of the screw osteosynthesis, conventional partially threaded screws were used. In biomechanical tests, these showed superiority to variable-pitch fully threaded headless compression screws (
      • Orr JD
      • Glisson RR
      • Nunley JA.
      Jones fracture fixation: a biomechanical comparison of partially threaded screws versus tapered variable pitch screws.
      ). Screws of the same size were used for all cadavers with diameter 4.5 mm. A superiority of 5.5 mm could not be demonstrated in other studies (
      • Sides SD
      • Fetter NL
      • Glisson R
      • Nunley JA.
      Bending stiffness and pull-out strength of tapered, variable pitch screws, and 6.5-mm cancellous screws in acute Jones fractures.
      ,
      • Shah SN
      • Knoblich GO
      • Lindsey DP
      • Kreshak J
      • Yerby SA
      • Chou LB.
      Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study.
      ). Due to the anatomical curvature of the fifth metatarsal correct screw length should be taken into consideration to avoid fracture gapping (
      • Cates NK
      • Gulati AR
      • Tenley JD
      • O'Hara NN
      • Wynes J
      • Brandão RA.
      Screw length associated with fracture gapping of fifth metatarsal base fracture with intramedullary screw fixation: a cadaveric study.
      ,
      • van Dijk PA
      • Breuking S
      • Guss D
      • Johnson H
      • DiGiovanni CW
      • Vopat B.
      Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures.
      ).
      Twenty-five N load was estimated as physiologic load on the fifth metatarsal head during ambulation (
      • Hayafune N
      • Hayafune Y
      • Jacob H.
      Pressure and force distribution characteristics under the normal foot during the push-off phase in gait.
      ), this load could be provided in fractured bones treated with cannulated screws (mean: 70.0 ± 66.5 N) and almost with the tension band wiring (mean: 35.0 ± 23.3 N). Thus, a complete avoidance of weight bearing can be avoided and at least a partial weight bearing after surgical treatment can be considered.
      Even though the outcomes with screw osteosynthesis have been satisfactory, there are 10% to 15% of the cases osteosynthesis failed and refractures occurred (
      • Dean BJF
      • Kothari A
      • Uppal H
      • Kankate R.
      The jones fracture classification, management, outcome, and complications: a systematic review.
      ,
      • Wright RW
      • Fischer DA
      • Shively RA
      • Heidt RS
      • Nuber GW.
      Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes.
      ). In such cases revisional osteosynthesis may be indicated. Due to lack of alternatives, re-osteosynthesis is mostly performed using a larger screw (
      • Wright RW
      • Fischer DA
      • Shively RA
      • Heidt RS
      • Nuber GW.
      Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes.
      ). Tension-band wiring could be considered as an alternative. Taking into consideration that screw osteosynthesis is minimally invasive related to satisfactory clinical outcome as shown by early return to normal activity, there should be no change in the primary management of treating acute Jones fractures. This is supported by the experience of Sarimo et al., using tension-band wiring, that resulted in early weight bearing and an early return to activity after screw osteosynthesis (
      • Sarimo J
      • Rantanen J
      • Orava S
      • Alanen J.
      Tension-band wiring for fractures of the fifth metatarsal located in the junction of the proximal metaphysis and diaphysis.
      ).
      The main clinical advantage of the tension-band wiring is more stability against torsional stability. The impact of the torsional impact on fifth metatarsal fracture has to be solidly proven with a further study.
      We cannot make a statement about the maximum stability of the osteosyntheses in patients with surgically treated fifth metatarsal fractures because we did not test the specimens to failure. Additional cyclic testing would be useful. In addition, it is difficult to extrapolate the in vivo load to ex vivo fracture models. The biomechanical setup tries to adapt the in vivo forces as close as possible to the clinical setting. A recommendation on weight-bearing after osteosynthetic treatment of a fracture of the fifth metatarsal cannot be made on basis of biomechanical results alone. Further clinical studies are necessary to verify the statements made.
      The study shows no statistically significant difference in biomechanical stability under axial loading between screw osteosynthesis and tension band wiring. Therefore, the data tend to support the use of the established method of treating Jones fractures with screw osteosynthesis. However, not from a biomechanical point of view, because in this respect the osteosynthesis methods are equivalent, but because of the minimally invasive surgical technique and the complications that can be minimized.
      We believe that tension-band wiring is a viable proposition in stabilizing acute Jones fractures especially when rotational stability is considered or in cases of operative revisions. We, therefore, aim to challenge our hypothesis with a future study.

      Statement of Consent

      Informed consent was obtained during lifetime from all human subjects for experimentation involved in the study. Approval was granted by the Ethic Committee of the Friedrich-Schiller-University (University Hospital Jena, 2020-2016-Material).

      Assessors

      The first author (MU) and senior author (FK) were involved in planning the study, performing the experiments, data analysis and interpretation, writing the manuscript, and revising the manuscript. The coauthors were involved in planning the study (IG, JH, RL), performing the experiments (IG, JH), supervision (GH), and revising the manuscript (IG, JH, RL, GH).

      Acknowledgments

      For providing the specimen we thank Dr. U. Biedermann and the Institute of Anatomy, University Jena. A special thanks to Dr. Steffen Derlien and the Institute of Physiotherapy, University Hospital Jena, for providing the ZEBRIS system.

      References

        • Cakir H
        • van Vliet-Koppert ST
        • van Lieshout EMM
        • Vries MR de, van der Elst M
        • Schepers T.
        Demographics and outcome of metatarsal fractures.
        Arch Orthop Trauma Surg. 2011; 131: 241-245
        • Petrisor BA
        • Ekrol I
        • Court-Brown C.
        The epidemiology of metatarsal fractures.
        Foot Ankle Int. 2006; 27: 172-174
        • Smith JW
        • Arnoczky SP
        • Hersh A.
        The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing.
        Foot Ankle. 1992; 13: 143-152
        • Willegger M
        • Benca E
        • Hirtler L
        • et al.
        Peroneus brevis as source of instability in Jones fracture fixation.
        Int Orthop. 2020; 44: 1409-1416
        • Dean BJF
        • Kothari A
        • Uppal H
        • Kankate R.
        The jones fracture classification, management, outcome, and complications: a systematic review.
        Foot Ankle Specialist. 2012; 5: 256-259
        • Portland G
        • Kelikian A
        • Kodros S.
        Acute surgical management of Jones' fractures.
        Foot Ankle Int. 2003; 24: 829-833
        • Bowes J
        • Buckley R.
        Fifth metatarsal fractures and current treatment.
        World J Orthoped. 2016; 7: 793-800
        • Zwitser EW
        • Breederveld RS.
        Fractures of the fifth metatarsal; diagnosis and treatment.
        Injury. 2010; 41: 555-562
        • Ruta DJ
        • Parker D.
        Jones Fracture Management in Athletes.
        Orthop Clin North Am. 2020; 51: 541-553
        • Mindrebo N
        • Shelbourne KD
        • van Meter CD
        • Rettig AC.
        Outpatient percutaneous screw fixation of the acute Jones fracture.
        Am J Sports Med. 1993; 21: 720-723
        • Mologne TS
        • Lundeen JM
        • Clapper MF
        • O'Brien TJ
        Early screw fixation versus casting in the treatment of acute Jones fractures.
        Am J Sports Med. 2005; 33: 970-975
        • Scott RT
        • Hyer CF
        • DeMill SL.
        Screw fixation diameter for fifth metatarsal jones fracture: a cadaveric study. The Journal of foot and ankle surgery official publication of the American College of Foot and.
        Ankle Surg. 2015; 54: 227-229
        • 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: 1736-1742
        • Nayak R
        • Barrett J
        • Patel MS
        • Barbosa MP
        • Kadakia AR.
        Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures.
        J Orthopaed Surg Res. 2021; 16: 209
        • Lam K
        • Bui R
        • Morris R
        • Panchbhavi V.
        Biomechanical analysis of conventional partially threaded screws versus headless compression screws in proximal fifth metatarsal (Jones) fracture fixation.
        Foot Ankle Specialist. 2021; 14: 509-514
        • Duplantier NL
        • Mitchell RJ
        • Zambrano S
        • et al.
        A biomechanical comparison of fifth metatarsal Jones fracture fixation methods.
        Am J Sports Med. 2018; 46: 1220-1227
        • Kim J-B
        • Song I-S
        • Park B-S
        • Ahn C-H
        • Kim C-U.
        Comparison of the outcomes between headless cannulated screw fixation and fixation using a locking compression distal ulna hook plate in fracture of fifth metatarsal base.
        J Foot Ankle Surg Offic Publication Am College Foot Ankle Surg. 2017; 56: 713-717
        • Sarimo J
        • Rantanen J
        • Orava S
        • Alanen J.
        Tension-band wiring for fractures of the fifth metatarsal located in the junction of the proximal metaphysis and diaphysis.
        Am J Sports Med. 2006; 34: 476-480
        • Klos K
        • Randt T
        • Simons P
        • Knobe M.
        Vor- und Mittelfußfrakturen beim Erwachsenen.
        Orthopädie und Unfallchirurgie Update. 2019; 14: 63-89
        • Morris PM
        • Francois AG
        • Marcus RE
        • Farrow LD.
        The effect of peroneus brevis tendon anatomy on the stability of fractures at the fifth metatarsal base.
        Foot Ankle Int. 2015; 36: 579-584
        • Orr JD
        • Glisson RR
        • Nunley JA.
        Jones fracture fixation: a biomechanical comparison of partially threaded screws versus tapered variable pitch screws.
        Am J Sports Med. 2012; 40: 691-698
        • Sides SD
        • Fetter NL
        • Glisson R
        • Nunley JA.
        Bending stiffness and pull-out strength of tapered, variable pitch screws, and 6.5-mm cancellous screws in acute Jones fractures.
        Foot Ankle Int. 2006; 27: 821-825
        • 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: 581-584
        • Cates NK
        • Gulati AR
        • Tenley JD
        • O'Hara NN
        • Wynes J
        • Brandão RA.
        Screw length associated with fracture gapping of fifth metatarsal base fracture with intramedullary screw fixation: a cadaveric study.
        J Foot Ankle Surg Offic Publ Am Coll Foot Ankle Surg. 2021;
        • van Dijk PA
        • Breuking S
        • Guss D
        • Johnson H
        • DiGiovanni CW
        • Vopat B.
        Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures.
        Injury. 2020; 51: 2887-2892
        • Hayafune N
        • Hayafune Y
        • Jacob H.
        Pressure and force distribution characteristics under the normal foot during the push-off phase in gait.
        Foot. 1999; 9: 88-92
        • Wright RW
        • Fischer DA
        • Shively RA
        • Heidt RS
        • Nuber GW.
        Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes.
        Am J Sports Med. 2000; 28: 732-736