SLR - July 2022 - Katarina Perri, DPM
Reference: Al-Ashhab, M. G., El-Hammady, A. A., & Awad-Allah, M. E. (2021). Comparison between conservative and surgical treatment of base of fifth metatarsal fracture. Benha Journal of Applied Sciences (BJAS) . Vol (6), Issue (5), Part (1) (2021)Level of Evidence: Level 1 - Meta-analysis
Scientific Literature Review
Reviewed by: Katarina Perri, DPM
Residency Program: James H. Quillen / Mountain Home VA in Johnson City, TN
Podiatric Relevance:
5th metatarsal base fractures, most commonly associated with Jones fractures, are routinely seen in the Podiatry realm. This article is a meta-analysis comparing conservative vs surgical intervention of Jones fractures and which is more ideal overall for patients.
Methods:
Study Design: A meta-analysis of 8 trials for a total of 137 surgically treated patients and 270 non-surgically (or conservatively) treated patients. The inclusion criteria was: human studies, RCTs, English only literature, and Jones fracture (type II) of the 5th metatarsal base. The exclusion criteria: cadaver, animal studies, open/pathological fractures, in vitro studies, case control/case series/case reports, and Types I and III 5th metatarsal base fractures. Outcome Measures: The outcomes, overall, were to measure which is more effective, non-surgical vs surgical intervention, with regards to 5th metatarsal base fractures (Jones). This study utilized statistical analysis and odds ratios with regards to complications, non-union, and time of union. This study also included odds ratio with regards to study bias (the author’s judgments about each risk).
Results:
- Complications showed no significant difference between non-surgical and surgical (33/243 surgical patients vs 16/146 non-surgical patients; Odds Ratio (OR) 0.37, 95 percent CI, [0.08, 1.65], P<0.19, I2=70 percent).
- Non-union was higher in non-surgical patients compared to surgical patients (30/173 surgical patients vs 5/245 non-surgical patients; OR 0.16, 95 percent CI [0.07, 0.40], P < 0.001, I2=0 percent)
- Time to union was faster in surgical patients compared to non-surgical patients (OR 0.56, 95 percent CI [0.27, 0.85], P<0.001, I2=98 percent)
- Risk of Bias: Patients in the study were not blinded, they were aware of which treatment option they would receive (surgical vs non), therefore this was felt to have the highest risk of bias among the authors (performance bias). There was also felt to be selection bias with most of the studies with regards to random sequence generation and allocation concealment – meaning these were not performed in the RCTs reviewed.
Conclusion:
In this meta-analysis study, it was found that surgical intervention may provide more benefits for patients, especially if they are athletic. There were less non-unions and faster unions (time to union) surgical patients compared to the non-surgical. While this meta-analysis did not find a significant difference between the two groups when comparing complication risks, a few studies within this paper did show less healing issues with surgical patients. Individual RCT studies within this meta-analysis also showed athletic patients can return to their sport earlier/faster due to recovery/healing time with surgical intervention. I believe elective surgery will always be a patient-to-patient basis. While surgical intervention is not ideal for some patients who have limited mobility/activity or serious health issue, I do feel most patients would benefit from surgical intervention for this fracture type. It is important to take into account the peroneal brevis and its insertion, which was not directly mentioned in this article, but I feel may have caused some difficulty in healing with the non-surgical patients. Regardless, I will use this article to further assist me in my decision on the appropriate treatment course for my patients.