Thursday, January 9, 2014

Brook Lopez's foot surgery


Brook Lopez of the Brooklyn Nets suffered a broken 5th metatarsal in his right foot during a December 20 game against the Philadelphia Sixers.  He underwent season ending surgery on his foot last weekend and is expected to miss the rest of the season.  An additional procedure was done in addition to the repair of the fracture to help "unload and protect the injured area".  The theory is that it would redistribute the pressure sustained in that area more evenly.  This additional procedure was reportedly done to the first metatarsal.  Lopez has had issues with the 5th metatarsal before - injuring it in back in the 2011-12 season twice on the same right foot.

What does Brook Lopez have? 

Brook Lopez likely has a Jones fracture of the 5th metatarsal.  The 5th metatarsal is a long bone on the outside of the foot that consists of a head, neck, shaft and base.  Many nutrient arteries supply the long bone of the 5th metatarsal but there is one area where the shaft of the 5th metatarsal meets the base of the 5th metatarsal where there is poor vascular supply to the area.  Fractures that occur in this area of the 5th metatarsal - Jones fractures - are notoriously slow and difficult to heal due to this.

What is the procedure used to fix the Jones fracture?  

Jones fractures can be treated conservatively with casting and strict non-weightbearing if the bone is well aligned.  However, most will often require surgery to increase the probability of the bone healing.  Athletes in particular will often require surgery to speed up the healing process so that they can return to play quickly.  The surgery involves making sure that the fracture edges are fresh and bleeding so that new bone can form at the fracture site.  After this, a large screw is placed down the shaft of the 5th metatarsal to compress the fracture, giving it an ideal environment to mend and heal.  During this procedure, bone graft may added to the fracture site to help augment repair and promote healing.  After the surgery, the bone will often take 8 to 12 weeks to heal.  During that time, the patient is in a cast, non-weightbearing.

What is the additional procedure done to Brook Lopez? 

In addition to the fracture repair, reports have indicated that Lopez also underwent a separate procedure on the foot on the first metatarsal to help unload the injured area.  Jones fractures often will occur with increased stress to the fifth metatarsal.  Often, this is either due to "metatarsus adductus" or "pes cavus".  "Metatarsus adductus" is when the long bones in the foot point towards the midline of the body, creating a prominent 5th metatarsal and increased stress on the bone.  "Pes cavus" is when a high arch is present and this is often due to a dropped, or plantarflexed, first metatarsal.  When a plantarflexed first
metatarsal is present, the first metatarsal will often strike the ground first and the heel is unable evert/move to provide shock absorption.   This will often result in increased pressure on the outside of the foot where the 5th metatarsal is present.

The procedure that was likely done on Brook Lopez is an elevational first metatarsal osteotomy.  With the first metatarsal dropped causing increased pressure on the 5th metatarsal, elevating the first metatarsal in line with the other metatarsals should theoretically distribute the weight evenly across the foot and reduce the likelihood of another injury to that bone.  This procedure helps to correct "pes cavus".

Is this the right procedure? 

Brook Lopez has now had this injury several times and his foot type may be predisposing him to this injury.  Without examining him or seeing radiographs, it is hard to say whether or not it is the right procedure for him.  However, in theory, the additional procedure should offload the 5th metatarsal by allowing the heel to evert and put less pressure on the 5th metatarsal.  Less pressure means less stress on the bone and a lower probability of the bone breaking.  This procedure involves cutting a wedge in the bone and elevating the first metatarsal.  Screws are placed across the osteotomy site in order to hold the bone cut in place.

Since this is a recurrent injury and not an isolated one, it is valid to think that his foot type may be predisposing him to this injury.  If done correctly, I do believe that this procedure will effectively offload the 5th metatarsal and reduce his chance of injury in that same area.

1 comment:

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