We'll take a look at a topic that's probably deserving of the second-to-last talk in the entire conference. Disclosures are listed here. Just a brief overview. So there's a lot of forefoot pathology that we won't get into. We'll focus primarily on common pathology as well as pathology that requires, or often necessitates, I should say, operative intervention in the high-level athlete. So metatarsal stress injuries, this is probably the most common injury you're going to see in a high-level athlete. Fortunately, most of these are low-risk injuries. We'll talk about the fifth metatarsal separately. Diagnosis in 2023 often is reliant on advanced imaging. Management of these injuries is primarily symptom-based. There are a lot of treatment options that we have today that I think we can use to our advantage. Certainly in recurrent or recalcitrant injuries, I think it's warranted to get a metabolic panel, involve your endocrine colleagues if you have those resources in the high-level population. I do want to point out that strict immobilization and non-weight-bearing protocols, especially prolonged protocols, do have a deleterious effect. And if we think about bone mineral density and Wolf's Law, that's where I think the AlterG and some other gravity-assisted training devices really help us out now because we're able to load these while minimizing pain and hopefully prevent that next stress injury in some of these athletes. In terms of sport, this is predominantly NCAA epidemiological data, it's about 6-12 weeks and varies depending on sport as well as time and season. So now we'll look at fifth metatarsal stress injuries or Jones fractures. So these are metadiaphysial injuries that are high-risk. In the high-level athlete, operative intervention is typically preferred. There's a high rate of non-union or recurrent fracture with non-surgical methods approaching 50%. The literature kind of combines this zone 2 and zone 3 classification. Again, these are metadiaphysial. The TOR classification is based more on chronicity, which we'll touch on briefly with bone grafting. So what are our options in high-level athletes? Classically, it's the intramedullary screw. More recently, plantar lateral plating has come into play. I think both have a role. When you look at pros and cons of both implant choices, they're listed here. My preferred technique still in the primary setting is an intramedullary screw. In some revision scenarios and in some kind of Jones variants where maybe the fracture is getting a bit more distal, especially in large athletes with large feet, I will consider plantar lateral plating. So some tips for intramedullary screws. The high and inside start points have been popularized by Dr. Anderson. Really this just optimizes your intramedullary position and also allows the implant to kind of end on the plantar lateral cortex so you don't get distraction at the fracture site. When picking an implant, I think this is still important to consider. You want a solid, partially threaded screw, 5.5 millimeters or bigger. In a lot of your larger athletes you can easily get to 6'5". Screw length is important. The longest screw isn't always the best and you want to avoid engaging that distal bow and causing distraction. And then proximally at the screw head junction you want to avoid cuboid irritation. There are a few implant designs as well as technical pearls that can help with that. So bone grafting, I think this is an interesting question. These are high-risk stress injuries so a lot of people will say just do the bone grafting. There are a lot of low morbidity techniques now with bone marrow aspirate and allograft carriers that you can do that. Certainly in TORG type 2 or 3 injuries where there's some clear chronicity to these injuries, I will in the primary setting often consider bone grafting as well. Depending on how you do the fixation will dictate whether you need a separate incision or not. So when we look at this in early return to sport, is it really safe? So here's a list of our major sports in the United States. Return to sport, very achievable. There is a notable risk of refracture, however. My postoperative protocol is listed here. I really start a return to sport progression around six weeks. I have gone faster. I have gone slower. It's really based on how the patient is doing clinically. But I think it's an important question to ask. Are we pushing the limits on this? Are we doing an injustice to the athlete? I think there's a lot of conversation that goes back and forth about risk, where they are at in season, where they are at with contracts when you push the limits with these. When you look at radiographs and CT scans, your healing is going to lag behind the clinical performance. I tend to follow the clinical performance. But this is a helpful study for me to look at where early return to sport caused a more prolonged time to union, but ultimately didn't change the nonunion risk at six months. So 3% nonunion at six months is pretty good, even in a population that was pushed pretty aggressively. So what do you do when these fail? You will have failures if you do these, sometimes to no fault of your own. What I look at is the initial surgery, so is there an implant decision or an implant position that I think is suboptimal that I can improve on, either screw size, screw position. Here's a small cannulated screw that's been changed to a larger screw. If it's something that I think has been done well and there are some challenges with either the fracture kind of characteristics, there are some very oblique fractures that I think are tricky with screws, I will do plantar lateral plating as demonstrated here. Other considerations in the revision setting, I always bone graft in the revision setting. Again, my preference is BMAC with an allograft carrier. I really like cortical fibers. It's just a very malleable bone graft that you can soak in BMAC and use. And then address concomitant pathology, so the cavovarous foot with the first metatarsal osteotomy or ankle impingement. I think especially osteous ankle impingement, if you can address that and unload the forefoot a bit, it's very, very helpful and a lot of our high level athletes will have ankle impingement. I think we have a separate talk on that later. So more kind of fifth metatarsal stuff, zone one fractures, tuberosity fractures, a lot of these can be treated non-surgically, almost like a lateral ankle sprain protocol. There is a risk of fibrous union. A lot of times people are not symptomatic from that. If they do become symptomatic, you can perform an excision. Oftentimes this excision can be performed without involving the peroneus brevis and relatively expeditious return to sport around three months can happen. Dancer's fractures or fifth metatarsal kind of oblique, diaphysial injuries also occur. Again, I tend to treat these non-operatively as I think most people still do. And you can get return to sport pretty predictably around 12 weeks. There are some very short or displaced fractures where plating has been discussed. I think this is controversial. And certainly in this area with soft tissue coverage, you have to think about the morbidity of surgery and having a plate there. We'll jump to the first MTP now. We'll start with kind of true turf toe or plantar plate injuries. This typically is an avulsion or an injury of the phalangeal sesamoid ligament. Treatment is dependent on the grade of injury which we'll look at here. Immediate one and two injuries are partial injuries. Return to sport for these can be aided by taping, orthotics. I do like kind of a performance orthotic for some of these. And immediate to six-week return to sport can be achieved. When we get into complete injuries which can be demonstrated here with a diastased bipartite or here where you have more of a phalangeal sesamoid ligament avulsion, really I favor early operative intervention. I would throw acute chondral injuries or loose bodies into that algorithm as well. I just think that you get a much more predictable return to sport in these scenarios. And technically from a surgical perspective there are certainly some advantages to doing these injuries early. So how do you approach it? I think it's really important to understand the pattern of injury. With advanced imaging today I think we've learned a lot more about that. In the chronic scenario I think diagnostic ultrasound, depending on your colleagues, can be very, very helpful. You want to protect with a medial-based incision. The medial plantar halical nerve. You want to identify the flexor hallucis longus. And again you want to take into consideration soft tissue balancing depending on the pattern of injury, especially with these acute kind of hallux valgus variants. That can include an abductor hallucis tendon transfer or an adductor tenotomy. Our colleagues in industry have helped us out a bit too. There are some micro anchors that are very helpful that you can actually use in the sesamoid if you're doing a partial sesamoid excision. That gives you a little bit of an option to get fixation back to bone. There's some innovative suture-passing devices that can allow you to get a lot done from a medial-sided incision instead of having to use a plantar-based incision or a hockey stick-shaped incision. And again the abductor hallucis transfer with sesamoid excision I think can be very, very helpful. Here's my rehab protocol, nothing fancy here. This is going to be pretty typical to what you see in the literature, 12 weeks and beyond start to return to sport progression. And these athletes are often getting back to most things by four months at the latest. So sesamoiditis, this is a challenging one with advanced imaging. I think we're seeing a lot more of this and it's not necessarily symptomatic but causes a lot of confusion. This is a spectrum of injury or pathology that results in pain. If they don't have symptoms you don't have to do anything. If you incidentally catch this you don't have to do anything. Nonsurgical treatment if they're having predominantly plantar pain, short period of immobilization, maybe a performance orthotic and cleat modification. Sometimes a cleat will be right underneath that sesamoid and if you can shorten that cleat a little bit you'll often get some benefit. If they have plantar pain and pain with passive motion that's what I'll consider a steroid or biologic injection and kind of address that metatarsosesamoid arthrosis. So for recalcitrant cases sesamoidectomy is an option. Again soft tissue balancing and avoiding iatrogenic nerve injury is very important. In Coetzee's study of recreational and higher level athletes they noted an 80% return to sport at four and a half months. So it's not a home run and it does take some time, which I think for the athlete is sometimes confusing because you're just cutting out this little bone. Why is it going to take me four to six months to get back? But that's the reality as we understand with soft tissue balancing. Cartilage stuff at the first MTP definitely exists. There are acute injuries that are focal that can be treated like with other joints. You can do a microfracture, a microfracture plus, a cartilage transfer. If there's an acute chondral flap or loose body I'll typically be fairly aggressive. I approach these through an open approach. There are growing arthroscopic techniques that I'm aware of, but especially if you're going to do a bone plug you're going to open the joint up to get exposure. There is more diffuse pathology as well in our high level athletes. I like to treat that as conservatively as I can with injections, orthotic modifications and so forth. If they have focal dorsal pain with extension you can consider a chylectomy. I would say in this population be a little more conservative with your chylectomy. If you do a big chylectomy like you may do in more of your geriatric or older population you can create some instability. And this is a really, really difficult problem to correct once it's happened. Last thing, Freiberg. So this is lesser metatarsal osteochondrosis, typically the second metatarsal. A variety of treatment options. There are really no non-surgical options that are going to change the natural history. So just treat these symptomatically while you can. Surgery ranges from debridement, osteotomy or cartilage resurfacing. Very few comparative studies. The one that is out there has equivalent results at three month return to sport with osteochondral autograft as well as with dorsal closing wedge osteotomy. So hopefully that gives everyone a little bit of perspective on forefoot pathology and thanks for being here on Sunday morning.

metatarsal stress injuries

operative intervention

diagnosis

advanced imaging

symptom-based