Return to Play and Fracture Union after Surgical Management of Jones Fracture in Athletes: A Systematic Review and Meta-Analysis

Abstract

Category: Midfoot/Forefoot; Sports; Trauma Introduction/Purpose: 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. 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 characteristics of the union such as time and rate, and complications such as refracture. Methods: Following PRISMA guidelines, relevant studies in English literature were identified between databases inceptions to November 2019. Electronic based search on MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases using the following keywords with their synonyms: ('fifth metatarsal fracture' AND 'athlete' AND 'return to play'). In addition, the reference lists from previous review articles were searched manually to check for eligible studies. Two investigators independently reviewed all titles, abstracts, and the full text of articles that were potentially eligible based on the abstract review. Any disagreement was resolved by the senior author. The primary outcomes were (1) return to play rate and (2) time to return to play, whereas the secondary outcomes were (1) games missed, (2) time to union and union rate (3) non-union, delayed union and refracture. The current study accepted the definitions of included studies for non-union, delayed union, and refracture for practicality purposes. Results: Out of 168 studies identified, 22 studies were 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 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 the conservative group, which was 13.05 (8.15-17.95) weeks. The pooled union rate in the 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%). 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 union rate, shorter time to union, and improved functional outcomes. The authors recommend surgical fixation for all Jones fractures in athletes.