Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review

Abstract

AimTo compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal.MethodsSystematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective studies. Two reviewers independently extracted data and assessed methodological quality. Main outcomes were return to sport and complication rate.Results18 studies were included (2 anterior tibia (N=31), 8 navicular (N=200) and 8 fifth metatarsal (N=246)). For anterior tibial fracture, no studies on initial surgery were eligible. Conservative treatment resulted in high complication rates and few cases returned to sport. For navicular fracture, a weighted mean return to sport of 22 for conservative and 16 weeks for surgical treatment was found. Six weeks of non-weightbearing cast was mostly used as conservative treatment. Surgical procedures varied widely. For the fifth metatarsal fracture, weighted mean return to sport was 19 for conservative and 14 weeks for surgical treatment. Surgery consisted of intramedullary screw fixation or tension band wiring. For conservative methods, insufficient details were reported. Overall, there was a high risk of bias; sample sizes were small and GRADE level of evidence was low.ConclusionsStrong conclusions for surgical or conservative therapy for these high-risk stress fractures cannot be drawn; quality of evidence is low and subjected to a high risk of bias. However, there are unsatisfying outcomes of conservative therapy in the anterior tibia. The role of initial surgery is unknown. For the navicular, surgery provided an earlier return to sport; and when treated conservatively, weightbearing should be avoided. For the fifth metatarsal, surgery provided the best results. Treatment decision-making would greatly benefit from further prospective research.Study registration numberPROSPERO database of systematic reviews: CRD42013004201.

Lower limb stress fractures in sport: Optimising their management and outcome

“…Surgical techniques comprise either percutaneous intramedullary cannulated screw fixation or modified tension band wire; screw fixation is the recommended modality as this has the higher volume of evidence at present[4,23]. Conservative management comprises non-weightbearing in a below knee cast or moon boot for 6 wk followed by partial weightbearing for a further 6 wk[27].…”

“…There is a growing trend for surgical management of such injuries in high level athletes and athletes in high intensity repetitive loading sports (running, jumping), with a recent systematic review from Mallee et al[4] showing proven benefit of surgical management, in terms of return times and rates to sport. Reported return rates following surgical management ranged from 75% to 100%[27-31], with return times of 13.8 wk[28].…”

“…A higher Torg grading and a plantar gap greater than 1 mm are predictive of a prolonged return times to sport[4,29]. …”

“…This enables these injuries to be classified by the Saxena Classification[18] (Table 1). This can guide management planning, as well as well provide prognostic information regarding return to sport, with a higher Saxena Grade correlating with a prolonged return to sport[4]. MRI scanning provides a comprehensive picture of the stress injury as well as visualising the surrounding soft tissue structures[24].…”

“…High risk fractures often require specialised imaging to better define and quantify the injury, particularly when first line imaging is equivocal; these injuries also may require surgical management, depending on the location of the injury and the response to initial conservative management[14]. As a consequence of this, return to sport is often more challenging with high risk injuries, and this proves particularly demanding with the high level professional athlete[4,7,14]. For individual fracture types, the severity of the injury can be graded from the extent of the radiological changes, using either generic (Fredericson et al[16] or Arendt et al[17]) or site-specific (Saxena et al[18] or Torg et al[19]) classifications[1,20]; such classifications can further guide management planning as well as provide prognostic information regarding return times to sport[1,20].…”