SLR - March 2022 - Seth Ashraf
Reference: Attia AK, Mahmoud K, Bariteau J, Labib SA, DiGiovanni CW, D'Hooghe P. Return to Sport following Navicular Stress Fracture: A Systematic Review and Meta‑Analysis of Three Hundred and Fifteen Fractures. Int Orthop. 2021 Oct;45(10):2699-2710. doi: 10.1007/s00264-021-05147-6. Epub 2021 Aug 20. PMID: 34415421; PMCID: PMC8514373.Level of Evidence: 3
Scientific Literature Review
Reviewed By: Seth Ashraf, DPM
Residency Program: Our Lady of Lourdes – Binghamton, NY
Podiatric Relevance: The navicular stress fracture (NSF) has been estimated to comprise up to 35% of stress fractures in the foot and ankle amongst competitive athletes. The injury most frequently occurs in the middle third of the navicular bone, which is notorious for its watershed hypo-vascularity, and is often detrimental to an athlete's season and career. Therefore, proper treatment selection is pivotal for successful return of the athlete to their respective sport at a high level and in a timely fashion. In this systematic review and meta-analysis, the authors present a comparison of outcome measures for navicular stress fractures treated surgically versus conservatively.
Methods: A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using electronic databases from inception through February 2021. Criteria for inclusion were clinical studies on NSFs that reported at least one of the following outcomes: Return to Play (RTP) rate, time to RTP, success rate, time to diagnosis, non-union rate, or refracture rate. Case reports, small case studies, and studies exclusively examining non-union management were excluded. A meta-analysis was performed using a fixed-effects model on studies that were clinically and statistically homogenous with adequately reported data. The primary outcomes were management success rate, RTP rate, and time to RTP. A successful outcome was defined as an outcome in which the patient was pain-free, able to return to previous activity level, and did not have recurrence of the fracture. Secondary outcomes were non-union rate, time to diagnosis, and refracture rate. Data for NSFs treated surgical and conservatively were compared.
Results: Eleven studies met criteria for inclusion in the meta-analysis. A total of 315 NSFs in 307 patients were included. 97.46 percent of the reported NSFs occurred in patients identified as athletes. The male to female ratio was nearly 1:1 with a mean age of 24.58 years old. In studies which the specific sport was reported, track and field made up the largest portion of athletes. One hundred eight of the NSFs were treated surgically while 207 were treated conservatively. The mean follow up was 45.77 months. Successful outcomes were reported in 96.30 percent treated surgically vs. 71.98 percent treated conservatively, which was statistically significant. RTP rate was 98.98 percent in the surgical group vs. 73.43 percent in the conservative group. Time to RTP was 4.17 months in the surgical group vs. 4.67 months in the conservative treatment group. There was a 1.28 percent refracture rate in the surgical group vs. 23.53 percent in the conservative group. The non-union rate was 3.19 percent in the surgical group vs. 21.57 percent in the conservative group.
Conclusions: This study demonstrated superior outcomes in NSFs treated surgically vs. conservatively in athletes. A weakness of the study was that surgical and conservative treatment protocols both varied among the studies analyzed. Surgical treatments differed on their use of bone grafting while conservative treatments differed on their use of bone stimulators. Additional variability was seen in non-weightbearing protocols. However, the findings of this study may aid both physicians and athletes when choosing among treatment options for these notoriously difficult injuries.