KEYSTONE, COLO — For patients with tarsal navicular stress fractures, healing rates and return-to-activity times are similar, regardless of whether they are managed with non-weight-bearing cast immobilization or surgery, according to a meta-analysis.
This finding undercuts the basis for the growing trend of surgical management of these challenging foot injuries. The assumption—now shown to be baseless—has been that operating on tarsal navicular stress fractures facilitates early return to activity, said Dr. Barry P. Boden, an orthopedic surgeon at the Uniformed Services University of the Health Sciences in Bethesda, Md.
He presented a systematic review and meta-analysis of 31 articles, mostly case series, which included 253 partial or complete tarsal navicular stress fractures, at the annual meeting of the American Orthopaedic Society for Sports Medicine.
His conclusion: “Non-weight bearing is indicated as initial therapy and following failed weight-bearing management of both partial and complete fractures.”
“With increased awareness and today's improved imaging techniques, it's rare for a tarsal navicular stress fracture to present as a nonunion or displaced fracture,” he added. “Thus, surgery in the form of open reduction and internal fixation plus or minus bone grafting is rarely if ever indicated.”
Six weeks of immobilization in a non-weight-bearing cast showed a strong trend for a higher rate of fracture healing and freedom from pain than did surgery, but the difference didn't reach statistical significance. (See chart.) Time to return to activity was approximately 5 months with either therapy.
“Return to play takes a long time. You're talking 6-8 weeks in a cast, then gradually advancing to weight bearing, and then to full activity,” Dr. Boden said.
Non-weight-bearing cast immobilization and surgery both had significantly higher successful outcome rates than did weight-bearing casting and/or rest.
“Again, non-weight bearing is an absolute in the management of these injuries. Clinical and imaging findings should determine return to activity,” Dr. Boden continued.
Dr. Thomas O. Clanton, the session moderator, said “this is a great meta-analysis” but added that he doesn't consider it to be the final word because the available literature is all level 4 evidence. “Even the paper by Saxena purported to be level 1 is not a level 1 study,” he said (J. Foot Ankle Surg. 2000;39:96-103).
“Almost all the papers rely on x-ray diagnosis and follow-up of patients, and nowadays we use CT scans. So I don't think you can say all those fractures in the literature that are said to be healed really did heal. We've found a number of patients we've treated nonoperatively who, when you look at them again at 6 or 8 weeks, may be asymptomatic, but they still have obvious fracture lines on CT scans,” said Dr. Clanton of the University of Texas, Houston.
It's also very difficult to convince someone who weighs more than 250 pounds to be non-weight bearing for 6 weeks, with the possibility that they might be non-weight bearing even longer if that were to fail, he added.
Dr. Boden's coinvestigator in the meta-analysis, Dr. Joseph S. Torg of Temple University, Philadelphia, is credited with developing the non-weight-bearing cast immobilization regimen for navicular tarsal stress fractures a quarter century ago. That method entails 6 weeks of cast immobilization. Dr. Boden said recent data suggest successful outcomes are achievable with less than 6 weeks of immobilization, although this issue requires further study.
'Open reduction and internal fixation plus or minus bone grafting is rarely if ever indicated.'
Source DR. BODEN
Source ELSEVIER GLOBAL MEDICAL NEWS