The return to play rate was higher, and the time to return to play shorter after intramedullary screw fixation of Jones fracture in athletes compared with nonsurgical management, according to a new study.
Return to Sport More Likely With Surgery vs. Non-Surgery
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Secondary#jonesfracture#intramedullaryscrewfixation#nonsurgicalmanagement
While proximal fifth metatarsal fractures are common forefoot injuries in athletes, management of them can be challenging because of delayed union and re-fractures.
The researchers of “Return to Play and Fracture Union After the Surgical Management of Jones Fracture in Athletes: A Systematic Review and Meta-analysis,” published on March 19, 2020 in The American Journal of Sports Medicine set out to compare return to play outcomes of surgical fixation compared with nonoperative management.
They also collected data on the union rate, time to union and rate of complications such as re-fractures. The meta-analysis included studies through November 2019.
Primary outcomes of the studies were return to play rate and time to return to play. Secondary outcomes were the number of games missed, time to union, union rate as well as the rates of nonunion, delayed union and re-fractures.
The final analysis included 22 studies with 646 Jones fractures. The overall return to play rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The return to play rate with intramedullary screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) it was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management 71.6% (95% CI, 45.6%-97.6%).
The researchers noted that there were three studies that directly compared return to play rates with surgical versus nonoperative management and they showed surgery to be superior (odds ratio, 0.033 [95% CI, 0.005-0.215]; p < .001).
The return to play rate according to sport was 99.0% in football; 91.1% in basketball; and 96.6% in soccer. Overall, time to return to play was 9.6 weeks. The time to return to play in the surgical group was 9.6 weeks and 13.1 weeks in the nonoperative group.
The pooled union rate in the operative group (excluding re-fractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with intramedullary screw fixation was shorter than that with nonoperative treatment. The rate of delayed union was 2.5% and the overall re-fracture rate was 10.2%.
“The return to play rate and time to return to play after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. Intramedullary screw fixation was superior to nonoperative management, as it led to a higher rate of return to play, shorter time to return to play, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes,” the researchers wrote.
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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