Short Leg Cast Versus Orthotic Removable Support for The Management of Pseudo-Jones Avulsion Fracture: A Systemic Review and Meta-Analysis 

SLR - February 2022 - Abshan Malik

Reference: Mohammed S Alquhaibi, Abdullah A Ghaddaf, Mohammed S Alomari, Ahmed S Abdulhamid, Ehab F Alsaygh, Mohammed S Alshehri, Ali H Alyami, Short Leg Cast Versus Orthotic Removable Support for The Management of Pseudo-Jones Avulsion Fracture: A Systemic Review and Meta-Analysis. Injury, 2021, ISSN 0020-1383, https://doi.org/10.1016/j.injury.2021.11.032. (https://www.sciencedirect.com/science/article/pii/S0020138321009396)

Level of Evidence: II

Scientific Literature Review 

Reviewed By: Abshan Malik, DPM
Residency Program: St. Mary’s General Hospital – Passaic, NJ

Podiatric Relevance: When it comes to treatment options for fractures of the base of the 5th metatarsal, there is no “gold standard.” Treatments range from various surgical techniques to conservative methods. Often, patients are not the  best surgical candidates due to their co-morbidities. For these patients, the type of conservative treatment method selected can significantly impact their quality of life and return to pre-injury level of activities. In this systematic review and meta-analysis, the authors present a comparison of outcome measures between short-leg cast and orthotic removable support.  

Methods: A systematic review was conducted using a pre-specified protocol. Inclusion criteria were adults who sustained a fifth metatarsal base avulsion fracture. Treatment was either orthotic removable support where ankle ROM is intact or short-leg cast. Prespecified outcomes tested were AOFAS score, VAS pain score, VAS-FA score, EQ-5D VAS score, and non-union rate. All statistical analyses were performed through using random-effects model. The standardized mean difference (SMD) was used for the continuous outcomes AOFAS, VAS, VAS-FA, and EQ-5D VAS; and the risk ratio (RR) was used for the dichotomous outcome non-union rate. 

Results: Three thousand two hundred eighty-six (3,286) records were included in this study. Six RCTs were deemed eligible for the systematic review and meta-analysis. A total of 403 conservatively treated individuals were included in this systematic review. Of them, 206 individuals were randomized to orthotic removable support cast and 197 were randomized to short-leg cast. The mean age ranged from 36 years to 47 years in the orthotic removable support group and from 39 years to 45.5 years in the short-leg cast group. The mean follow-up time for most of the included studies was 6 months. The weighted mean in AOFAS score for orthotic removable support was 93.44 and 88.90 in short-leg casting group. There was no significant difference between orthotic removable support and short-leg casting regarding the overall AOFAS score, and there was evidence of significant heterogeneity. A total of 82 individuals were allocated to orthotic removable support and 86 allocated to short-leg cast. The weighted mean in VAS score for orthotic removable support was 4.94 and 4.19 for short-leg casting. Orthotic removable support showed similar results compared to short-leg casting in terms of the overall VAS score, and there was no evidence of heterogeneity. There was only one non-union event in the orthotic removable support group and 4 non-union events in the short-leg cast group. No significant difference was found between orthotic removable support and short-leg cast in terms of non-union rate. 

Conclusions: This study demonstrated that orthotic removable support and short-leg casting were similar with respect to AOFAS score, VAS score, VAS-FA score, EQ-5D VAS score and non-union rate. The statistical heterogeneity was not significant for all the outcomes measured except AOFAS score. This may shed some light into deciding which conservative method to choose when dealing with patients with several co-morbidities who may not necessarily do well with an immobilized ankle joint.