title: 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: OBJECTIVE
  To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal.
  
  
  METHODS
  Systematic 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.
  
  
  RESULTS
  18 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.
  
  
  CONCLUSIONS
  Strong 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.
  
  
  BACKGROUND
  PROSPERO database of systematic reviews: CRD42013004201.
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Wouter H
authors.initials: WH
authors.lastname: Mallee
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Hanneke
authors.initials: H
authors.lastname: Weel
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands.
authors.forename: C Niek
authors.initials: CN
authors.lastname: van Dijk
authors.affiliation: Department Health Sciences, EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.
authors.forename: Maurits W
authors.initials: MW
authors.lastname: van Tulder
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Gino M
authors.initials: GM
authors.lastname: Kerkhoffs
authors.affiliation: The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia.
authors.forename: Chung-Wei Christine
authors.initials: CW
authors.lastname: Lin
mesh_terms: D000328:Adult; D005260:Female; D015775:Fractures, Stress / Q000601:surgery*; D006801:Humans; D008297:Male; D008682:Metatarsal Bones / Q000293:injuries* / Q000601:surgery; D015983:Selection Bias; D013639:Tarsal Bones / Q000293:injuries / Q000601:surgery; D013978:Tibial Fractures / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Lowever extremity; Sporting injuries; Stress fracture