Summary

Intramedullary screw fixation is superior to conservative management as it leads to a higher rate of return to play, shorter time to return, higher rate of union, shorter time to union, and improved functional outcomes.

Abstract

Background

Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. Management of this injury can be challenging due to delayed union and refracture. Intramedullary screw fixation rather than conservative management has been recommended in the athletic population.

Aim

This meta-analysis aims to provide an updated summary of return to play (RTP) rate and time with regard to the management, whether operative or non-operative, after Jones fractures in athletes only. We also explore the characteristic of the union such as time and rate, and complications such as refracture.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members searched several databases including PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov throughout November 2019 to identify studies reporting on Jones fractures of the 5th metatarsal, exclusively in athletes. The primary outcomes were return to play rate and time to return to play, whereas the secondary outcomes were union rate, time to union, and refracture

Results

Out of 168 studies identified, 22 studies where eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (97.3%- 99.4%) in 626 out of 646. The RTP rate in IM screw only was 98.8% (97.8%-99.7%), in other surgical fixations methods (plate, mini fix) was 98.4% (95.8%-100%) whereas in conservative management was 71.6% (45.6%-97.6%). There were three studies directly comparing the RTP in surgical versus conservative management, which showed significant superiority in favor of the surgical group OR: 0.033 CI:( 0.005-0.215) P-value <0.001. The RTP according to type of sport was 99% (97.5%-100%) in American football, 91.1%( 82.2%-99.4%)in basketball and 96.6%% (92.6%-100%) in Soccer. The overall time to RTP was 9.6 (8.5-10.7) weeks. The time to RTP in the surgical group (IM screw) was 9.6 (8.3-10.9) weeks, significantly less than conservative groups, which was 13.05 (8.15-17.95) weeks. The pooled union rate in operative group (excluding refracture) was 97.3% (95.1%-99.4%), whereas the pooled union rate in the conservative group was 71.4% (49.1%- 93.7%). The overall time to union was 9.1(7.7-10.4) weeks. Time to union in IM screw group 8.2 (7.5-9) weeks was shorter than conservative group 13.7 (12.7-14.6). The rate of delayed union was 2.5% (1.2%-3.7%), and the overall refracture rate was 10.2% (5.9%-14.5%).

Conclusion

Return to play following surgical management of Jones fractures in athletes is excellent regardless of the implant used and sport. Intramedullary screw fixation is superior to conservative management as it leads to a higher rate of return to play, shorter time to return, higher rate of union, shorter time to union, and improved functional outcomes. The authors recommend surgical fixation for all Jones fractures in athletes.