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Since the first publication on proximal metatarsal V fractures by Jones in 1902,1 there has been a lot of controversy about the classification and ideal treatment of the proximal metatarsal V fracture. The controversy includes mainly the different anatomical,2,–,4 radiological5 and aetiological aspects.6,–,9 A proper understanding of these different aspects of the proximal metatarsal V fracture is essential, because a right interpretation of fracture type and the appropriate treatment strategy may greatly diminish the time to return to competitive sports or activities of daily living (ADL).
The purpose of this study was to evaluate the treatment strategies of the different proximal metatarsal V fractures (avulsion, Jones and stress fractures, figure 1) and their outcomes in athletes and non-athletes.
This evaluation is based on a critical overview of the current literature combined with the opinion of a group of international experts.
The hypothesis of this study is that operative treatment is the most effective treatment strategy for all proximal metatarsal V fractures, besides the non-displaced avulsion fracture.
Materials and methods
A literature search was performed covering the period between 1994 and 2010 using the MEDLINE and EMBASE databases. The following search items were used: Jones and fracture and stress fracture and avulsion and fifth and fifth and metatarsus and metatarsal and fracture.
The therapeutic level of evidence was determined according to the following criteria.
Level I studies were defined as high-quality randomised controlled trials (RCTs) with statistically significant difference or no statistical significance but with narrow CI, or a review of level 1 RCTs. Level II studies were defined as RCTs of lesser quality (<80% follow-up, no blinding or improper randomisation), prospective comparative studies, systematic review of level II or level I studies with inconsistent results. Level III studies were defined as case-control studies, retrospective comparative studies or systematic reviews of level III studies. Level IV studies were defined as case series. Level V studies were defined as expert opinions.
Healing tendency (% delayed union and/or non-union), time to union and time to light and full athletic activity were noted for non-operative and operative treatment.
X-rays of 10 different patients, treated in our department between 2000 and 2010, were selected. Radiographs of avulsion fractures (n=2), Jones fractures (n=2), stress fractures (n=4, two in athletes and two in non-athletes) and delayed union or non-unions or both (n=2) were used. The radiographs were placed anonymously in a questionnaire, accompanied with information on age, gender and aetiology (attachment 1). The questionnaire was published online and experts were invited by e-mail to participate.
Weighted averages for time to union and the weighted average percentages for healing tendency, delayed union and non-union were calculated from the literature search. If not presented in the articles, ranges were calculated by adding and subtracting 2×SD from the given mean.
Literature consisted mostly of retrospective case series and showed a large heterogeneity of populations and a lack of reporting of ranges for the outcomes; thus it was not possible to perform a meta-analysis to prevent the occurrence of type I and II errors.
The results of the online questionnaire were analysed using SPSS 15.0. Agreement in diagnosis between respondents was determined using the unweighted multirater fixed marginal κ.
Dichotomous variables were analysed using a univariate χ2 test. To differentiate between treatment strategies (operative vs non-operative) in athletes versus non-athletes, OR were calculated using logistic regression analysis. Continuous variables (eg, time to full activity) were analysed non-parametrically (Mann–Whitney U test). A p value of less than 0.05 was regarded as statistically significant.
A total of 177 potentially relevant articles were selected using our search strategy. Original articles published from 1994 until 2010 that presented treatment results in adult patients with a metatarsal V fracture were included; of these, 21 articles were selected (figure 2 and table 1).9,–,29 Only five studies9 ,14 ,15 ,17 ,28 described their own therapeutic level of evidence. The level of evidence of these 21 articles was as follows: 1 therapeutic level I study, 6 therapeutic level III studies and 14 therapeutic level IV studies (table 1).
From these 21 articles, we can conclude the following:
▶ Non-displaced avulsion fractures are always treated non-operatively (table 2).
▶ Jones fractures in non-athletes are often treated non-operatively. Non-operative treatment of Jones fractures results in a longer time to union than operative treatment (table 2). Non-operative treatment of Jones fractures results in a higher number of delayed union or non-unions compared with operative treatment (table 3).
▶ Stress fractures in non-athletes are usually treated non-operatively. Non-operative treatment of stress fractures results in longer time to union than operative treatment (table 2). Non-operative treatment of stress fractures results in higher number of delayed union or non-unions compared with operative treatment (table 3).
Nineteen orthopaedic experts (response rate: 29%) with a mean experience of 13.7 years (SD: 8.7) filled out the online questionnaire. Two experts did not complete the survey, as they logged out before they reached the last case. Because we saved data for each single case, instead of each completed survey, we were still able to use the completed cases of these authors in our analysis.
An absolute agreement in diagnosis noted was 50% of the cases in the questionnaire. This resulted in a non-weighted multirater κ of 36%. This is within the range of a fair agreement (0.21–0.40)30 in diagnosis by the experts.
Among the experts, the treatment of choice for non-displaced avulsion fractures also was non-operatively (95%).
Treatment of Jones and stress fractures was not uniform among the panel of experts, although there was a definite preference if the patient was an ‘athlete’. Athletes were operated on four times as often (OR=4, p<0.01) as opposed to non-athletes. The choice for operative treatment was not significantly dependent on the type of fracture (Jones or stress; p=0.89).
Treatment of choice for the non-union cases was operative for most experts in athletes and non-athletes (80–100%).
Regarding the advice on after-treatment (non-weightbearing (NWB), weightbearing (WB) or a combination of NWB and WB), no significant difference was found for time to full activity between operative and non-operative treatment of Jones (p=0.81) or stress fractures (p=0.33). Among the experts, the duration of immobilisation varied from 4 to 12 weeks (NWB: 4 to 6 weeks; WB: 4 to 8 weeks; NWB+WB: 4+4 to 4+8 weeks).
The most important findings of the present study are the consensus noted in the pertinent literature and that given by experts on non-operative treatment for non-displaced avulsion fractures. We also found consensus in the literature and experts that operative treatment of Jones and stress fractures of the proximal fifth metatarsal will lead to a higher healing rate and faster time to recovery.
This study admittedly has few shortcomings. First, this research consisted from 1 therapeutic level I study, 6 therapeutic level III studies and 14 therapeutic level IV studies. Therefore, the studies may not be perfectly comparable. To create a global view of the current treatment of proximal metatarsal V fractures, we chose to present the weighted averages and weighted percentages of the results. Some studies presented means and SD having skewed distributions. As a result, ranges presented in the results section exceed zero (negatively) when not clinically possible, and results can be biased because of this effect.
Second, the definition of the different types of metatarsal V fractures is problematic. A different interpretation is given to the terms proximal, Jones and stress fracture in numerous articles. Therefore, we identified four different groups (avulsion, Jones, stress, delayed union/non-union) and differentiated these and the athletic involvement, athlete or non-athlete, in the articles.
Third, the above-described problem emerged for the online questionnaire. Different experts can judge the same fracture differently. To minimise the influence of these impurities, we chose clearly distinguishable cases and had experts choose their own diagnosis. Nonetheless, there was only a fair overall agreement (κ: 0.36) for diagnosis in this questionnaire. But in the case of agreement in diagnosis, there was good agreement (κ 0.80) for the preferred treatment.
Last, although 19 international experts present a large group for such a study, a higher number of experts might have yielded more power.
An RCT28 in which early screw fixation of Jones fractures in active military personnel was compared with an NWB plaster cast for 8 weeks was published in 2005. The authors concluded that long periods of NWB immobilisation were needed to accomplish full healing in the cast group, while operative treatment presented as a safe and effective alternative. Non-operative treatment also resulted in a high incidence (44%) of treatment failure, refractures and delayed unions or non-unions. Early operative treatment resulted in a shorter time to clinical healing and provided an earlier return to sports and daily activities when compared with non-operative treatment. This concept now seems to be the standard of care for athletes. It should be noted, however, that this RCT did not perform a power analysis.
Several authors4 ,16 ,28 ,31 ,32 have suggested that primary surgical treatment of Jones and stress fractures is a good option for the young and active patient, and not merely the high-profile athlete.
Chuckpaiwong et al9 claimed that there was no need to distinguish between the Jones and the proximal diaphysis fracture, including stress fractures, as there were similar outcomes for non-surgical and surgical treatment for both types of fracture. Analysis of our questionnaire filled out by 19 experts showed that not the type of fracture (Jones or stress), but rather the involvement in competitive sports was the determining factor to decide for operative treatment or not. In contrast to this expert opinion, our literature review clearly shows a poor tendency to heal and a prolonged time to return to sports for stress fractures regardless of the chosen treatment. Until better data are available, we think it is important to differentiate between the different types of fractures not for choosing the (operative) treatment but in order to adequately inform the patient on prognosis. An international multicentre RCT comparing different types of (after) treatment in the different fracture types would add significant input to this dilemma.
Our current advice is to treat all non-displaced avulsion fractures non-surgically, regardless of whether the patient is an athlete or not. On rare occasions, displaced avulsion fractures may need operative fixation. Jones and stress fractures can be adequately treated surgically and non-surgically. Surgical treatment is more sought in athletes, and it will likely result in a higher healing rate, faster time to union and a faster return to sports. Given these advantages, operative treatment of Jones and stress fractures in non-athletes can be considered. We acknowledge that access to surgical treatment may be an issue in some parts of the world.
All non-displaced avulsion fractures can be treated non-operatively.
Jones and stress fractures in non-athletes can be treated non-operatively and operatively. For this decision-making, a lower rate of complications needs to be weighed against a superior tendency to heal, lower percentage of delayed union or non-union and a quicker return to full activity.
Jones and stress fractures in athletes are preferably treated surgically given the better tendency to heal and a quicker return to sports.
Non-unions of Jones and stress fractures are preferably treated operatively, in which bone-grafting can be considered.
The authors thank all 19 orthopaedic surgeons who took the time and made the effort to respond to our online questionnaire.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.