TO THE EDlTOR

We read with interest a review article from Albloushi[1], who present an excellent overview of pathoanatomy, classification, and current concepts of fixation modalities for Jones type fifth metatarsal fracture. We thank the authors for this valuable contribution, and we agree with their conclusion that there remains a lack of consensus on the effective management of Jones fractures, especially in the highlevel athlete group. In part, we believe this lack of consensus may be due to unacceptably high complication rates of existing surgical treatments.

Soon the man in black, on the coal-black horse, galloped up to the gate, and the dark fell and the eyes of the skulls began to shine like day; then the ground began to quake, and the trees of the forest began to creak and the dry leaves to rustle, and the Baba Yaga came riding in her iron mortar, driving with her pestle and sweeping away her path with her broom.

Both delayed union and nonunion remain a challenging problem after Jones fracture fixation. The authors note that delayed union in zone 2 and 3 fractures are often the result of choosing screws that are smaller than 4.5 mm in diameter. They recommend utilization of larger screw diameters, especially in the athlete population. While we agree that smaller diameter screws often contribute to nonunion after Jones fixation, we also draw attention to the risk of cortical perforation and subsequent impingement related symptoms, and even potential nerve injury with use of the larger diameter screws[2]. The authors also mention the challenge in adequately appreciating the natural curvature of the fifth metatarsal during fracture fixation. The authors note that failure to maintain the screw within the cortical bone of the 5metatarsal remains a major cause of nerve injury[3], and recommend meticulous choice of proper entry point of the guidewire and screw with the correct trajectory within the medullary canal. Still, achieving proper positioning of a straight screw within a bone with natural curvature is difficult, and the challenge is expounded when attempting to utilize a larger diameter screw in the case of the elite athlete. Moreover, cannulated screws have been shown to lack proper strength to withstand the significant and repetitive forces the fifth metatarsal must sustain and have been shown to be associated with screw breakage[4].

Despite the difficulties encountered with screw fixation of Jones fracture, plate fixation is also associated with substantial complication risk[5]. Nonunion rates have been unacceptably high in some series[6], and calcaneus autograft has become commonplace for the procedure, denoting an additional area of potential patient morbidity[7]. Hardware prominence also presents a unique challenge in the plating of the Jones fracture. Furthermore, soft tissue injury with the dissection required for proper plate placement flush against the cortical bone can be associated with nerve injury and periosteal stripping with destruction of native bone biology potentially impeding bony union.

With the high complication rates associated with the existing fixation modalities (intramedullary screw fixation and plantar plate fixation), there remains area for innovation with regards to treatment modalities for Jones fracture. Our institution has begun use of an intramedullary implant created specifically for Jones fracture fixation which we hope will be effective in reducing some of the listed complications. This implant has an inherent curve which is fabricated to closely aligned to the natural curvature of the fifth metatarsal. Furthermore, the implant has an end cap which serves to both compress across the fracture site and to reduce hardware prominence at the insertion site. To further enhance fixation at the distal end of the metatarsal, the implant has a talon based mechanism which once activated, provides further implant purchase distally to prevent screw pullout. A study at our institution is currently underway to evaluate whether or not these features lead to decreased complication rates and increased return to play and decreased time to bony union after Jones fracture fixation.

United States

We would like to acknowledge the entire staff and support team at Duke University Department of Foot and Ankle and lower extremity Sports Medicine.

Neither author reports any conflicts of interest.

Toward evening, when the sun was very low and its rays were no longer hot, the Tsar s daughter, Helen the Beautiful, went into the garden to walk with her nurse and the ladies-in-waiting of the Court. When she came near, suddenly the Gray Wolf leaped over the railing into the garden, seized her and ran off with her more swiftly than twenty horses. He ran to the open field, to the green oak tree where Tsarevitch Ivan was waiting, and set her down beside him. Helen the Beautiful had been greatly frightened, but dried her tears quickly when she saw the handsome youth.

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And who was my father? That has nothing to do with the good temper; but I will say he was lively, good-looking round, and fat; he was both in appearance and character a complete contradiction to his profession

Parekh SG designed research; Anastasio AT wrote the letter; and Parekh SG revised the letter.

In summary, Jones fracture fixation remains a challenging problem for the foot and ankle surgeon. Existing treatment modalities are associated with high complication rates. Future research should aim to improve upon design elements of existing implants in an effort to effectively manage patients with this condition.

Albert Thomas Anastasio 0000-0001-5817-3826; Selene G Parekh 0000-0002-1308-9038.

23 Who knows what may not happen before that? thought the miller s daughter; and besides, she saw no other way out of it,24 so she promised the manikin what he demanded,25 and he set to work once more and spun the straw into gold

” It was quite early when she kissed her old grandmother, who was still asleep; then she put on her red shoes, and went quite alone out of the town gates toward the river

Wang JL

A

Wang JL