SLR - December 2020 - Vincent G. Vacketta
Early Return to Play After Intramedullary Screw Fixation of Acute Jones Fractures in Collegiate Athletes: 22-Year Experience
Reference: Watson S, Trammell A, Tanner S, Martin S, Bowman L. Early Return to Play After Intramedullary Screw Fixation of Acute Jones Fractures in Collegiate Athletes: 22-Year Experience. Orthopaedic Journal of Sports Medicine. April 2020.
Level of Evidence: IV
Scientific Literature Review
Reviewed By: Vincent G. Vacketta, DPM
Residency Program: West Penn Hospital – Pittsburgh, PA
Podiatric Relevance: The fifth metatarsal Jones fracture is a common injury seen by foot and ankle surgeons. Both conservative and surgical management of this injury are quite common and the determination for operative intervention versus conservative care is based on a variety of patient-dependent factors. An area of contention surrounding this injury pertains to the period of non-weight bearing following surgical intervention, especially in the young, athletic population where return to sport is paramount. This article investigates when athletes with a Jones fracture can be allowed to return to play intramedullary screw fixation.
Methods: A level IV, retrospective case series was performed evaluating 26 acute Jones fractures treated with intramedullary screw fixation in 25 collegiate athletes. All fractures were fixated through a percutaneous approach with intramedullary screw fixation. A five-phase rehabilitation protocol was implemented immediately post-operatively. This protocol included an aggressive rehabilitation regimen which included: stretching and strengthening exercises, under-water treadmill training, and sport-specific exercises throughout the post-operative period. Progression through this rehabilitation protocol was guided by the patient’s pain and patients were allowed to advance in their activity level when pain was no longer significant with the current level of activity. Weightbearing to tolerance was permitted immediately postoperatively. Shoe gear was progressively transitioned from walking boot to cross-training shoe with insert, and finally to a sport-specific athletic shoe or cleat. Lastly, a bone stimulator was used twice daily throughout the course of the rehabilitation period. Patients were allowed to transition to full sport participation once asymptomatic. Patient-reported outcome measures were evaluated using the Foot and Ankle Measure (FAAM).
Results: Twenty-six fractures in 25 athletes were treated with intramedullary fixation. Twenty-two male and three female athletes were involved in the study with an average age 20 years. Ten athletes received stainless steel cannulated screws, 13 athletes received titanium variable-pitch headless compression screws and three athletes received solid titanium screws. All athletes returned to play within six weeks of surgery, at an average of 3.6 weeks. There was no incidence of surgical wound complications, infections, nonunions or malunions. Three screws were removed because of soft tissue irritation. One athlete suffered a re-fracture following hardware removal and ultimately returned to play within two weeks following revision surgery. At an average follow-up of 8.6 years, athletes reported average FAAM scores of 94.9 percent for the activities of daily living subscale and 89.1 percent for the sports subscale.
Conclusions: This study suggests that athletes that received intramedullary fixation for treatment of acute Jones fractures may return to sport and full activity as early as four weeks following surgery. One must consider the rehabilitation protocol and use of bone stimulator that was employed in this patient population which may expedite the healing process. Results of this study are promising for reducing immobilization periods and time to return to sport in the athletic population. Strengths of this study were the long-term follow-up. Weaknesses of this study include the limited sample size, inconsistency in screw fixation used, as well as lack of preoperative patient reported validated outcome scores.