As his team battle to stay in contention with Premiership champions Chelsea, the Arsenal coach, Arsene Wenger has had to improvise his team plans following more bad news on the injury front. After already losing Thierry Henry, Sol Campbell and Alexander Hleb to injury while on duty for their national teams, Wenger has now lost left back Gael Clichy after he fractured his right foot whilst playing for the French under 21 team.
Wenger confirmed on the club's website. "The story is that Gael will need surgery. The injury is in the same place where he had a screw put in before. The quite remarkable thing, in a negative way, is that he has the same problem as Ashley Cole. It is terrible for the boy, we feel really bad for him. In my opinion Gael is three to four months away. We'll just have to be patient and wish him well."
Twenty year old Clichy had been deputising for the injured Ashley Cole for the past six games after Cole had suffered exactly the same injury - a Metatarsal fracture in his right foot.
Clichy's latest injury is a recurrence of a similar injury that originally affected him in April and, following surgery, ruled him out for the remainder of 2004/2005 season. The French youngster revealed, "I'm really disappointed, it's a real shame, because I felt I was in good form. It was a bad time to get injured. Now I just have to look after myself and come back as soon as possible. But I'm sure that mentally I'll come back stronger in the future."
Fractures of the Metatarsal bones account for over a third of all foot fractures and were, of course, made famous when England Captain David Beckham suffered a Metatarsal fracture prior to the 2002 World Cup. The shaft of the Fifth Metatarsal on the outer border of the foot is the most commonly injured. Injuries where the fracture is within 1.5cm of the 'tuberosity' (the most prominent part of the Fifth Metatarsal) were first described by Sir Robert Jones, who had injured his own foot in 1896. For this reason these fractures are often called 'Jones fractures'.
Jones fractures are widely believed to begin as 'micro fractures' (where there is an accumulation of microscopic damage to bone cells), which then progress to complete fractures due to repetitive loading during sporting activities. There is often an 'intermediate' stage where the athlete has a 'bone stress reaction' or stress fracture, which is typically accompanied by an aching pain during and following activity.
These fractures are notoriously difficult to treat. There is a high incidence of non-union (where the fracture fragments don't heal) and delayed union (where fracture fragment healing takes much longer than normal). This poor healing is due to a disruption of the blood supply to the Fifth Metatarsal which often corresponds with the fracture site. For this reason surgical fixation is the preferred treatment method of Jones fractures.
Surgical fixation involves inserting an intramedullary screw through the middle of the Fifth Metatarsal, followed by a period of restricted weight bearing using a removable plastic cast. The success rate following this surgery is excellent, with a return to sports possible after eight to twelve weeks. However, several complications have recently been reported after use of these techniques. Some studies have described several failures after screw fixation in athletes.
Experts believe that an early return to intense weight bearing activity is believed to be instrumental in delayed union and refracture of the Fifth Metatarsal. For this reason, it is very difficult to define an appropriate time for a safe return to sporting activity. Imaging methods such as CT scans may be helpful when considering a return to activity.
There are several treatment options if a refracture does occur. A non-operative approach using a removable plastic cast with no running or jogging activities often produces healing in 6 to 8 weeks. However, there is still a theoretical risk that the forces which lead to the refracture could lead to a second recurrence. For this reason, a more aggressive surgical approach is often undertaken with elite athletes. The surgeon usually inserts a larger intramedullary screw. This is followed by a period of non weight bearing then partial weight bearing using a removable plastic cast and healing is confirmed around three months later.