524399

research-article2014
FASXXX10.1177/1938640014524399Foot and Ankle SpecialistFoot and Ankle Specialist

vol. 7 / no. 2 Foot & Ankle Specialist 127

〈 Roundtable Discussion 〉
Fifth Metatarsal Fractures Fracture of the fifth metatarsal is one
of the most common injuries present-
ing to a foot and ankle specialist, yet
there is little consensus as to the opti-
mal treatment. Philosophies range
from benign neglect to operative
This is a 27-year-old marathoner optional but rarely needed. The patient
intervention. This symposium
who sustained a twisting injury would place 20 kg of partial weight
explores the spectrum of fifth metatar-
bearing in a surgical shoe for 3 to 4
to the left foot 3 days prior. How weeks and then gradually increase
sal fractures.
would you manage this fifth weight bearing until week 6. At that CONTRIBUTORS
metatarsal fracture? time full, weight bearing is begun. I
would use enoxaparin until the patient Gregory C Berlet MD
Figure 1. is full weight bearing.
Orthopedic Foot and Ankle Center
Saxena: Let me start by a quote from Fellowship Director
George Sheehan, MD: “Everyone is an Westerville, OH
athlete, some just don’t know it yet.” I
think that if a treatment is safe and Kai Olms, MD
shortens the healing and return to Private practice, Founding President of GFFC
activity (RTA), it should be an option (Association for Foot & Ankle Surgery)
regardless whether you are a Bad Schwartau, Germany
professional or recreational or high Helios Agnes Karll Krankenhaus, Bad
school athlete, an industrial worker, or Schwartau, Germany Affiliate
a grandmother having to care for active Atlanta, GA
grandkids. I would fix this with either
screws or K-wires (could be absorbable Amol Saxena, DPM, FACFAS, FAAPSM
pins), put a cast on for 2 to 3 weeks,
Fellowship Director, Palo Alto Division, Dept.
allow no weight bearing for 3 weeks,
of Sports Medicine in Sports Medicine Foot &
let the patient ride a stationary bike
Ankle Surgery
with the heel on the pedal, take an
Palo Alto Foundation Medical Group.
x-ray to make sure there is no
Berlet: This fracture will likely heal Palo Alto, CA USA
displacement or avascular necrosis
uneventfully with protection in a boot developing at the metatarsal heads,
walker. This is assuming that there is SECTION EDITOR
switch to a boot for another 2 to 3
not a spike directed plantarward that weeks (the patient could run in the
the AP image does not reveal. I have on John M. Schuberth, DPM
deep end of the pool at this time if
occasion placed percutaneous Chief, Foot and Ankle Surgery
fixation is stable), and if the patient is
cannulated screws to facilitate a more Department of Orthopedic Surgery
pain-free let him or her start running
anatomic repair and would discuss both Kaiser Foundation Hospital
on an antigravity treadmill at 60% to
options with the patient. San Francisco, CA
70% body weight between 6 and 8
Olms: I would use two or three 2.0- weeks. Running on a regular treadmill
mm lag screws for fixation. A plate is usually would begin around 8 to 12

DOI: 10.1177/1938640014524399.
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128 Foot & Ankle Specialist April 2014

weeks because of the metatarsal head likely to fix the fifth metatarsal as How would you manage
fractures, and the patient could run described above with closed reduction this fracture in a 50-year-
outside thereafter as soon as he or she and percutaneous cannulated
felt stable. compression screw fixation. old female nurse?
Schuberth: Early in my career I Olms: No, even if I would fix the Figure 2.
would have operated on this patient fractures of the second, third, and fourth
without hesitation as I believed in the metatarsals.
so-called AO doctrine. I would have
kept this patient non–weight bearing Saxena: Not really, because the patient
(NWB) for 4 to 6 weeks would be NWB for 3 weeks and I would
postoperatively for fear of disruption likely just pin that, again possibly with
of the fixation (small caliber screws). something bioabsorbable, but in essence
As time went on, I observed a number it is close to a distal lesser metatarsal
of patients who were treated by other osteotomy and I let people use a
providers in a walking boot. The stationary bike with a boot (heel on the
interesting thing is that these patients pedal) all the time without issues.
all seemed to do well. In fact, I cannot Schuberth: Yes, because I would not
ever recall seeing a patient who had allow weight bearing with open
weight transfer problems because of reduction and internal fixation (ORIF) of
medial overload as a consequence of the intra-articular injury on the second
the distal fragment elevation. I think metatarsal head. I still would not fix the
we tend to assume that the distal fracture of the fifth metatarsal. Figure 3.
fragment will elevate an inordinate
amount that would compel operative
reduction. Yet, after observing many Would your treatment
of these patients, I have noticed that change if this were a
the distal fragment doesn’t seem to 74-year-old community
angulate even though it almost
universally translates in a dorsal
ambulator? If so, how?
direction. The mobility of the fourth Berlet: I would tend to support in a
and fifth rays seems to mitigate any Berlet: With shortening and
boot walker and expect to heal without
slight deflections in the sagittal plane. significant displacement I would
surgery.
The distinction between angulation perform ORIF. I would anticipate that
and translation is really the key in my Olms: Yes. I would rather treat soft tissue is interposed between these
mind, and since the former is so conservatively in a surgical shoe or cast fracture fragments, making closed
uncommon, I typically let these with 2 weeks of NWB and then partial reduction and percutaneous screws
patients ambulate in a boot weight bearing for 2 weeks with gradual impossible. My internal fixation would
immediately. Although unequivocal increase of weight bearing until week 6. be cannulated screws. On occasion I
radiographic consolidation can Full weight bearing is allowed at 6 weeks. have defaulted to ORIF with a plate,
take 3 to 4 months, the fracture is Again I would use enoxaparin until the but the problem is that plates almost
usually stable enough to permit patient is bearing at least 20 kg of weight. always need to be removed later due to
full activity to tolerance at prominence.
Saxena: I would consider nonsurgical
approximately 6 weeks.
treatment if health and home status are Olms: I would use 2 or 3 lag screws
not ideal. However, if surgery makes the with an optional plate and the same
Would your treatment change at patient better faster, then I would still postoperative care as above.
all if you decided to fix the intra- recommend surgery for at least for the
Saxena: I would perform ORIF with 2
fifth metatarsal. The patient may need a
articular injury to the second walker as opposed to crutches.
screws and possible augmentation with
metatarsal head? If so, how? cerclage wire. The patient would be
Schuberth: Other than consideration NWB for 3 weeks in a boot or cast and
Berlet: If the patient is under of a postoperative shoe in lieu of a cast, then full weight bearing for an additional
anesthesia for another injury I would be no. 2 to 3 weeks in boot.
vol. 7 / no. 2 Foot & Ankle Specialist 129

Schuberth: Although tempting, I ie, in a patient with a men’s shoe size stainless, and cannulated titanium. There
would still manage this nonoperatively greater than 11). Interestingly, research is some biomechanical research to
in the same manner as the first has shown no real difference between support increased strength of solid
example. I would tell the patient that stress fractures versus acute Jones stainless but no convincing clinical
radiographic union will take many fractures in this region and they should evidence. My choice of fixation is usually
months, but nonunion is extremely rare be treated the same. a cannulated titanium screw, although I
and fourth metatarsalgia is almost would consider solid screw options in
nonexistent. select cases. For technique I would set a
What do you believe to be
screw length adequate for the threads to
the mechanism of injury in be distal to the fracture, but the recent
The enigmatic “true” Jones
a true Jones fracture? trend has been for shorter screws.
fracture has been applied to
many injury patterns of the Berlet: I subscribe to the Olms: Intramedullary screw fixation
with a 4.5- or 5.5-mm screw. Usually a
proximal fifth metatarsal. biomechanical theory of repetitive
4.0-mm screw is too small. The patient
bending loads resulting in a stress
This lends to the confusion, fracture. These occur at a higher rate in would begin immediate partial weight
which in turn confounds the the cavus and adductus foot, both of bearing (20 kg) with full weight bearing
ability to achieve consensus. which load more on the lateral border of after 3 weeks.
How would you define a the foot. Saxena: Intramedullary screw typically
4.5 to 5.5 cancellous and usually solid.
true Jones fracture? Olms: Inversion force to plantar flexed
NWB 2 weeks in a below-knee cast and
foot or direct force to the fifth metatarsal
then weight bearing in a boot for an
from plantar to dorsal in adduction.
additional 4 weeks. Usually the patient
Figure 4. Saxena: Inversion with the forefoot can get out of the boot pending the x-ray
loaded (heel off), as in a lateral shift at 6 to 8 weeks with full RTA at 8+ weeks.
away from the foot involved.
Schuberth: Although I treat the vast
Schuberth: I think one only has to majority of Jones fractures nonoperatively,
make the distinction between the I believe that the fracture does heal more
repetitive load from a cavovarus foot quickly when operated. The fundamental
type and the acute inversion episode. I question is how much more quickly and
would not necessarily change the does it matter to the patient. Yet, I would
treatment plan. It is surprising that there lean toward operative treatment.
is not much agreement or bench studies Accordingly, I select an intramedullary
to universally support a particular screw based on the diameter of the canal
mechanism. at the point of suspected screw thread
contact and the morphology of the
proximal fifth metatarsal. The screw
How would you manage the should be slightly wider than the
above fracture in a competitive endosteal canal to gain purchase. Some
Berlet: A true Jones is a fracture at the recreational tennis player? patients have a more curved proximal
metaphyseal/diaphyseal junction of the Please be specific, including metaphysic, which would favor the use of
fifth metatarsal. a shorter screw. I use a fully threaded
fixation construct and noncannulated titanium screw. I believe
Olms: These fractures have been postoperative management that the modulus of titanium is more
defined as occurring in zone 2
according to Quill’s classification and (if you choose to operate). compatible with bone, lessening the need
to retrieve the screw after healing.
occur at the fourth to fifth Berlet: I would recommend Postoperatively, I keep patients NWB for 6
intermetatarsal articulation at the percutaneous placement of an weeks, but this is probably overkill.
diaphyseal-metaphyseal junction of the intramedullary screw in the fifth
fifth metatarsal. They have a transverse metatarsal. If the fracture has a degree of
fracture pattern and are sometimes chronicity, I will occasionally add a Would your protocol be
close to the “avascular zone.” biologic stimulant at the site of the any different in a 70-year-
Saxena: They occur approximately 1.5 fracture. I do not open the fracture. old obese patient?
cm distal to fifth metatarsal tuberosity, There is considerable controversy
which is in the region of the shaft-base regarding the choice of fixation, with Berlet: I would discuss the risk of
junction (could be further in longer feet; options being solid stainless, cannulated nonunion with nonoperative care. I
130 Foot & Ankle Specialist April 2014

would consider intramedullary screw to do this is with a longitudinal slot burred

fixation in the compromised 70-year- Figure 5. across the nonunion site with the graft
old. The likelihood of this patient being packed into the slot such that it bridges the
able to heal nonoperatively is low. interface. A small, low-profile, nonlocking
Fixation would be done with a plate is then placed over the slot. The
cannulated titanium compression screw. success rate is actually very high and
patients can weight bear in about 6 weeks.
Olms: No.
Saxena: NWB 6 weeks if possible but This next series of x-rays
at least a walker for that period. Again,
I would look for x-ray signs of healing, represent a healthy 45-year-
not just clinical healing, because often male with progressive pain
with an intramedullary screw the over the lateral aspect of the
patients do not have pain but can still foot. The x-rays were taken
have lack of consolidation in the
plantar aspect and that is where at 2-week intervals, while the
refractures occur. I could consider patient was allowed to ambulate
plating as well. I prefer to not open these fractures but in a postoperative shoe. Six
Schuberth: This is a tough situation rather use an intramedullary screw weeks after the last x-ray, there
because the patient’s capacity to remain where the reamings are the internal bone is no appreciable change in the
NWB is suspect. Yet, I am not graft. If additional graft if desired I would
compelled to operate on the acute add an injectable demineralized bone appearance of the film, and the
fracture. I do my best to convince matrix material soaked with bone patient is still quite symptomatic.
patients not to walk on the cast, and I marrow aspirate to inject around the He has a cavo-varus foot type
see them back early to see how fracture site percutaneously. I would use with an otherwise normal
compliant they are. The literature shows a cannulated titanium screw with threads
a 50% union rate with weight bearing, just distal to the fracture site and avoid neuromuscular examination.
so I am hopeful that the fracture will distracting the fracture by placing an
consolidate even if they cheat. If it goes excessively long screw. What would you have done
to nonunion, I would operate. differently in the initial
Olms: The fracture may heal; however,
it usually refractures after some months management of this patient?
This next x-ray is from a 40-year- depending on the patient’s activity. I
Berlet: I think this patient has a high
old female athlete who is 4 would treat it the same, with an
risk of nonunion because of his cavus
intramedullary screw with the same
months post fracture. She was foot. I would have likely offered him
postoperative course.
initially treated with 8 weeks of surgery on the first consultation. The
Saxena: Medullary sclerosis is a bad challenge here is the shape of his fifth
NWB in a short leg cast. She is
sign and incompatible with healing. This metatarsal, in that it has developed an
anxious to return to her athletic needs to be curetted out, bone grafted adductus posture through the fracture.
endeavors. Can this fracture heal (autograft, don’t put dead bone in dead When the intramedullary screw is placed,
without surgical intervention? bone!), and usually plated. This is one this bone will straighten, which may
area in which level II research has shown complete the fracture of the medial cortex.
If yes, what would you do? How
a benefit of mixing platelet-rich plasma I do not correct the shape of the cavus
would you manage this surgically? (PRP) with the ORIF of fractures in the foot on the primary fifth metatarsal
Jones region. This can be done using a fracture but rather leave periarticular
Berlet: These fractures can heal without
trephine technique I learned from Rich osteotomies for cases of nonunion or
surgery although it has been my
Bouché, DPM: taking the nonunion out refracture.
experience that few athletes are patient
and then inserting an autograft from the
enough to work through the long healing Olms: Intramedullary screw fixation.
heel and plating over it.
process. I believe that the risk of refracture
Saxena: I would have placed a NWB
is higher in these patients. I would obtain Schuberth: I don’t think this will heal
below-knee cast/boot for at least 4
a computed tomography (CT) scan to without an operation. I would do ORIF
weeks.
assess the amount of healing that has with autologous graft from heel or distal
occurred prior to recommending a return tibia. The medullary sclerosis needs to be Schuberth: I would have treated this
to sporting activity. eliminated. I have found that the best way exactly like an acute Jones fracture by
vol. 7 / no. 2 Foot & Ankle Specialist 131

Figure 6.

placing the patient in a short leg, NWB For the varus, I would like to see a Schuberth: Fixing the nonunion
cast for 6 to 8 weeks, recognizing that Saltzman view and do a lateral calcaneal is straightforward with essentially
the refracture rate is high after the slide or Dwyer. I would need more details the same technique for the nonunion
commencement of weight bearing and before deciding to do a Cole osteotomy. It of the Jones fracture. However, it
activity. sounds crazy to do rearfoot reconstruction is very tempting to realign the foot
for a fifth metatarsal fracture; however, it because of the insidious change in the
What would you do now? is sometimes necessary. posture of the foot. I believe that the
Please be specific including posture of the foot was developmental
Saxena: I would still just treat the frac- due to an occult or subclinical muscle
how you would address the
ture, again using autograft. A short imbalance. Furthermore, choosing the
cavovarus foot type (if at all). threaded intramedullary screw would be realigning procedures that will prevent
my first choice, but I could also use the refracture is not so straightforward,
Berlet: I would place an intramedullary
plating technique. With some of these because the deformity is at or distal to
screw in the fifth metatarsal. I do not
fifth metatarsal fractures, we are able to the midtarsal joint. Accordingly, I would
recommend realignment osteotomies for a
get bone stimulators approved. My per- probably do a cuboid osteotomy with
first-time fracture of the fifth metatarsal. If
sonal experience has been that the pulsed lateral transfer of the anterior tibialis
the patient gets a nonunion with good
electromagnetic field type work better, tendon and a peroneal switch. This
surgery and has cavus, then I will add
especially if there is hardware present. I sounds aggressive but there is no
periarticular osteotomies to the treatment
have had to address the adducto-varus in credible literature that defines the
algorithm.
very few cases but it can be an issue. refracture rate after reconstructive
Olms: I would use intramedullary John Grady, DPM, used to say that stress surgery. So it does not make sense to
screw fixation. The intramedullary fractures are mother nature’s way of doing ignore the muscle imbalance. Although
reaming should be enough for the surgery, and certainly with this type of osteotomies may align the foot for a
sclerosis. Another option would be an fracture, the tension has created it. In a while, over time the muscle imbalance
autogenous bone graft from the lateral very few select revision cases, I will resect will prevail and the morbid shape of the
heel with an intramedullary guide wire the fracture nonunion and create realign- foot will return.
for the screw. I would trephine the ment osteotomy within the fracture to Nonetheless, I would not do any
nonunion site, leaving the medial cortex address this. There could be a consider- reconstructive surgery in an older patient
intact. Postoperatively, the patient would ation for doing a gastrocnemius slide, when fixing the nonunion, and I would
be NWB for 2 weeks and then partial cuboid closing osteotomy, and even a be selective in recommending this
weight bearing for 4 weeks in a surgical lateral calcaneal slide in this situation, but strategy to a younger patient at the same
shoe or cast depending on compliance. it would be rarely necessary. time as well.
132 Foot & Ankle Specialist April 2014

This is a very athletic 30-year- on the pedal. Nonsurgically, I would

keep her NWB in a short leg cast 3 Figure 8.
old female who sustained
weeks and an additional 3 weeks in a
an inversion injury to the boot.
right foot. How would you Schuberth: Almost all of these fractures
manage this fracture? heal well with a short leg walking cast for
6 weeks. I don’t like removable boots
Figure 7. because when the patient takes the boot
off even for short periods of weight
bearing, the fracture has a tendency to
displace with repetitive pull of the
peroneus brevis. I probably would not
intervene even with slight displacement
even though it is intra-articular unless
there is a step-off. With frank
displacement I would use a single 2.0- or
2.4- or 2.7-mm screw placed across the
fracture to capture the medial cortex. I
would let the patient walk after the first
postoperative visit in a short leg cast.

Would your treatment insertion. In the active 30-year-old I

would recommend reduction (closed if
protocol change in 70-year-
possible) and a single small-caliber (4.0)
old obese person who is oblique compression screw
household ambulatory and has
In the compromised 70-year-old I
marked chronic obstructive would manage this in a boot walker and
Berlet: A tuberosity avulsion fracture is pulmonary disease (COPD)? accept the displacement, and if there is
managed nonoperatively in a boot unless residual pain I would advocate an
Berlet: I am likely to accept more excision of the tuberosity.
there is progressive displacement, at
residual displacement in the
which point I will add a cannulated Olms: Tension band fixation.
compromised patient you describe and
compression screw applied Postoperative care as above.
would manage nonoperatively.
percutaneously.
The screw is placed obliquely to Olms: I would treat conservatively in a Saxena: I would treat the same as the
capture the medial cortex and does not surgical shoe and enoxaparin. last patient (ie, options of surgery, boot,
go intramedullary like traditional Jones etc) but could consider excising the
screws. These screws are often Saxena: I would be less likely to do fragment and using a bone anchor. It
symptomatic after union and have a ORIF, but she may get benefit from a would not require bone healing, but for
higher rate of hardware removal than bone stimulator and use of a walker. the active patient the time for tenodesis
intramedullary screws. It is important to Plan on taking it much longer to heal. could actually be longer. This shouldn’t
avoid splitting the tuberosity piece as this make a difference with the COPD
Schuberth: No, other than allowing
small, 4.0 cannulated, screw is placed. patient.
immediate postoperative weight bearing
Olms: Lag screw fixation with purchase of in a cast. Schuberth: I would probably fixate
medial cortex or tension band. this in the young active patient with a
Postoperative protocol would be 2 weeks small-caliber solid screw. A tension band
NWB, 2 weeks partial weight bearing, and a If this were the fracture may be necessary due to the small size
gradual increase in weight bearing until full. pattern, how would you of the fragment, but I would really try to
Again, we would use enoxaparin. manage both scenarios (active avoid its use because hardware removal
is commonly needed.
Saxena: ORIF with 4.0 cancellous 30-year-old vs 70-year-old
screw since it is intra-articular; weight obese patient with COPD)? In the older patient, I would advise
bearing within a week postoperatively immediate full weight bearing in a
in a below-knee boot, to be worn for 5 Berlet: The displaced tuberosity is short leg walking cast for 4 to 6 weeks
to 6 weeks. Again, she can use a being pulled by the lateral band of the to protect the peroneus brevis
stationary bike with the boot and heel plantar fascia and the peroneus brevis insertion. I think without
vol. 7 / no. 2 Foot & Ankle Specialist 133

immobilization, the fragment will more communition, gapping, or Olms: I would try to determine
displace further, which indicates further displacement), some newer plates are etiology. RSO for rheumatoid patients.
loss of the insertion and consequent made specifically for this type of fracture. Pain radiation if bone scan is negative/
functional compromise. Prongs go into the fifth base near the inactive. Diagnostic injection/infiltration
tendon and work as a tension band with with local and steroid to find out
the drill holes distal to the fracture being whether fifth metatarsal cuboid joint is
What about this fracture in the
eccentrically drilled. the reason for pain. Nonoperatively, I
same set of circumstances? would try some insoles. I would also
Schuberth: It looks like the articular
obtain a CT scan and would avoid fusion
surface is comminuted with some
Figure 9. if possible. However, it can be successful
implosion, but it is hard to tell. I would
even though there will be some residual
get a CT scan and would be inclined to
pain. Arthroplasty is preferred with soft
fix this with a tension band if highly
tissue interposition.
comminuted in either of these patient
scenarios. If it was not comminuted, I Saxena: I remember fusing these
would treat with 6 weeks of early in my career, and after seeing
immobilization. them break down even with rigid fixa-
tion and autograft, I asked Ted Hansen
One of the most vexing problems and Rich Bouché what they do. They
both do a “Keller” of the fourth meta-
in foot and ankle surgery is fifth tarsal base and interpositional arthro-
metatarsal-cuboid arthritis. How plasty. Operatively, I resect a small
would you manage this healthy portion of the bases and then inter-
45-year-old nonathletic patient? pose either local tissue like peroneus
tertius or muscle from extensor digito-
rum brevis. Alternatively, in my opin-
Figure 10. ion, this would be an indication for a
soft tissue collagen-type supplement to
Berlet: In the active athlete, this is not interpose. I did a few of the ceramic
an acceptable position as the tuberosity interposition arthroplasties a while
will create impingement on the calcaneal back but their cost is high and I’m not
cuboid joint. I would try to reduce sure this route is any better than the
closed and hold reduced with a other options I mentioned above. I
percutaneous screw. went to school in Missouri, the “Show
In the older compromised patient, I Me State,” so I need to see proof that
would immobilize in a boot walker and these options are unbiased by financial
accept some malunion. If the patient has incentives. I keep patients NWB in a
unacceptable pain with malunion, I cast or boot for 3 weeks or longer
would excision the fragment. (depends on other procedures such as
the rest of Lisfranc’s being fused, etc).
Olms: Conservative. Surgery if Nonsurgically, a lace-up ankle brace
secondary dislocation should occur. and sometimes a shoe with a midfoot
Berlet: I would maximize what I could
rocker built-in would be recommended
Saxena: For the active patient, NWB 3 achieve with ultrasound-guided
as well as glucosamine and/or nonste-
weeks with boot and weight bearing for fluoroscopic injections. An orthotic can
roidal anti-inflammatory medications
an additional 3 weeks. Could do a PRP be helpful in this patient population.
and activity modification. Some type of
injection or bone stimulator. (We charge If surgery is the only option, I would do
foot orthoses can be tried, but I usu-
a minimal amount to cover the syringes an interposition arthroplasty using either
ally find that stiffening up this area too
for our PRP injections in our setting, an allograft skin matrix or peroneus
much underneath (like a rocker-bot-
nothing close to the exorbitant amounts I tertius as the interposition material. The
tom foot) can aggravate it. It is a tough
hear are used around the country.) Same results with interposition are good but
problem and deserves more detailed
for the older patient but wouldn’t be able not great, meaning that significant pain
attention.
to be NWB. In terms of surgery relief is possible but it is not likely to
(although I don’t think it is needed at resolve all of the patient’s symptoms. I Schuberth: These patients have a
this point but would be if there were avoid fusing the lateral column. difficult problem and I really try to
134 Foot & Ankle Specialist April 2014

avoid surgery because of the uncertain both of the metatarsal cuboid joints, arthroplasty. Since this procedure is not
outcomes. I try to convince the patient then I will operate. To date, I have not that common, it is hard to gather
to learn to manage the symptoms fused this joint in a sensate patient. enough experience to determine the
indefinitely. Rocker bottom type shoes When I do operate I tell the patient that optimal amount of bone taken from the
are helpful, as are fluoroscopically there is 50% to 60% chance of proximal metatarsal.
assisted injections. Naturally, anti- significant functional improvement. I Placing ceramic or other foreign
inflammatories can be of benefit as like the so-called anchovy procedure, materials is not logical in my view,
well. If the patient can convince me which involves interposition of one of although the literature is no less
that she is significantly disabled and I the expendable tendons of the foot into available than it is for soft tissue
can isolate the pain to the either or the space created by resection interposition.