A New Look at Fifth Metatarsal Base Fractures

 

 

Fifth metatarsal fractures are traditionally divided into three zones: Zone I (tuberosity avulsions), Zone II (Jones fractures) and Zone III (diaphyseal stress fractures). 

 

Based on a recent diagnostic study, a new two-part system refines Zone 1 injuries by splitting them into two distinct patterns:

 

• Avulsion – stable, pulled off by the peroneus brevis tendon

• Indirect – unstable, caused by a bending force that extends beyond the tendon's footprint

 

Reading the x-rays

 

The dividing line between the two patterns sits 15 mm from the tuberosity, at the articular surface‘s inflection point. 

 

What this means for practice

 

The system scored near-perfect reliability (κ = 0.92) among surgeons using the system. Critically, all four indirect fractures managed without surgery resulted in nonunion – underscoring the system's real clinical stakes. 

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Surgical Treatment of Insertional Achilles Tendinopathy: An Open Surgeon's Crisis of Faith

by Vince Vacketta, DPM

 

My Gospel: Open debridement of diseased tendon, resection of the osseous deformity, and reanchoring of the Achilles with tendon transfer when needed.

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The heterodoxy

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More developing literature refutes the significance of the Achilles tendon and instead treats insertional disease as little more than “bump pain”:

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• Open vs. MIS repair: Minimally invasive tendon debridement and reinsertion achieves excellent outcomes comparable to open surgery, with less morbidity.

• Arthroscopic debridement + calcaneoplasty vs. percutaneous calcaneoplasty alone: Both techniques significantly improved outcomes with zero complications, while isolated calcaneoplasty actually produced lower postoperative pain.

• The Zadek osteotomy: Don't touch the tendon at all. MIS Zadek produced pain and functional outcomes comparable to open debridement/reattachment, but patients walked independently sooner and had fewer wound complications. 

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Meanwhile, flexor hallucis longus tendons can finally breathe easy in this new world of insertional Achilles repair.

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Losing my religion

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Perhaps the key to treating insertional Achilles tendinopathy isn't removing the abnormal tendon, but changing the mechanical environment that made the tendon symptomatic in the first place.

 

The Zadek and percutaneous calcaneoplasty data make the strongest case: If we can achieve comparable outcomes without debriding or repairing the Achilles, how much of the tendon pathology actually needs to be treated at all?

 

The evidence is still retrospective, and the samples are relatively small, but it’s increasingly challenging to defend the assumption that abnormal tendon must come out for patients to get better.

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​Is it an Ortho Foot and Ankle Problem, or a Problem of Fellowships in General?

 

Is it an Ortho Foot and Ankle Problem, or a Problem of Fellowships in General?

 

From 2012 to 2023, overall U.S. applicants to American Orthopaedic Foot & Anke Society fellowship slots declined, with the steepest drop among male MD applicants; female applicants remained stable.

 

In the 2026 SF Match, 88 applicants competed for 79 positions – 46 matched, with one additional position filled post-match, for fellowship match rate of 59%.

 

The hard reality: Most orthopaedic fellowships don't pay off financially

 

A 2025 career-long financial model finds that for most orthopaedic surgeons, fellowship training costs more than it returns. Spine surgery is the lone exception – the only subspecialty with a positive lifetime return, breaking even six years post-fellowship. If your decision is purely economic, other paths to avoid include military funded education, academic practice, and trauma surgery. 

 

Follow the interest, not the spreadsheet

 

The real ROI for orthopedic surgeons: Choose a fellowship for clinical interest and lifestyle, not financial return.