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Operative Versus Nonoperative Treatment of Jones Fractures: A Decision Analysis Model
The optimal management strategy for acute fractures of the metadiaphyseal fifth metatarsal (Jones fractures) is controversial. Patients can be successfully treated nonoperatively with non-weight-bearing and immobilization in a short leg cast1-7 or operatively with placement of an intramedullary screw.8-10 The primary advantage of nonoperative treatment is avoiding the risks and discomfort of surgery; disadvantages include the need for prolonged immobilization and protected weight-bearing as well as a decreased union rate.8,9 Advantages of operative treatment include accelerated functional recovery and an improved union rate; disadvantages include exposure to the risks, inconvenience, and discomfort of surgery. Clear, definitive evidence for guiding treatment is not available in the orthopedic literature, and treatment strategies vary substantially according to surgeon and patient preference.
Expected-value decision analysis, a research tool that helps guide decision-making in situations of uncertainty, has been effectively applied to other areas of uncertainty in the orthopedic literature.11-14 Borrowed from gaming theory, the technique involves creating a decision tree to define the clinical problem, determining outcome probabilities and utilities, performing a fold-back analysis to determine the optimal decision-making strategy, and performing a sensitivity analysis to model the effect of varying outcome probabilities and utilities on decision-making. Decision analysis may therefore allow the clinician and the patient to optimize decision-making based on best available evidence and patient preferences. It also helps determine the most important factors affecting management strategies and the decision-making process, which may not always be intuitive.
In the present study, we used expected-value decision analysis to determine the optimal management strategy, operative or nonoperative, for acute Jones fracture. We also explored factors with the most influence on the model and identified important questions for future research.
Materials and Methods
Institutional review board approval was obtained for this study. Analysis was performed with Treeage Pro statistical software (Treeage Software).
Outcome Probabilities
Outcome probabilities were determined by reviewing the literature for articles on Jones fractures. This body of literature was summarized in a comprehensive review by Dean and colleagues15, who extracted data from 19 studies: 1 randomized controlled trial, 1 prospective case series, and 17 retrospective case series.15 We used data from these studies to determine outcome probabilities (Table).
Outcome Utilities
Utilities represent patient preferences for various disease states. Outcome utility values were obtained from 32 adults (25 women, 7 men) with no history of foot injury. Mean age was 32.4 years (range, 20-69 years). The questionnaire presented scenarios for the different outcomes and asked patients to rate these outcomes on a scale ranging from 0 (worst possible outcome) to 10 (best possible outcome). The Sports subscale of the Foot and Ankle Ability Measure (FAAM) 16 was used to quantify patient activity level.
Decision Tree and Fold-Back Analysis
A decision tree was constructed with 1 decision node, 4 chance nodes, and 7 terminal nodes (Figure 1). The decision tree demonstrates 2 different strategies for managing a Jones fracture. The decision node divides the tree into 2 branches: initial operative or nonoperative treatment. Both branches are followed by various chance nodes, each terminating in a discrete clinical outcome. Per convention, utility data were placed to the right of the terminal nodes, and probability data were placed under the terminal nodes.
Fold-back analysis was performed to identify the optimal strategy. Fold-back analysis involves multiplying each outcome utility by its associated probability, thereby providing an “expected value” for each clinical endpoint. Then, the expected values for each endpoint can be summed for a given management strategy, and the ultimate expected values of the different strategies can be compared. The management strategy associated with the highest expected value is optimal for the given outcome utilities and probabilities.
Sensitivity Analysis
One-way sensitivity analysis was performed to model the effect on decision-making of changing the values for utility for uncomplicated surgery, utility for healing with nonoperative treatment, utility for uncomplicated treatment of nonunion, likelihood of healing with nonoperative treatment, likelihood of healing with surgery, and likelihood of minor complication with surgery. These were the variables found to affect the decision-making strategy within their clinically plausible ranges.
Results
Outcome Probabilities and Utilities
Outcome probabilities and utilities are illustrated in Figure 1. By convention, probabilities appear below the corresponding branches of the decision tree, and utilities appear at the end of each branch. Mean (SD) FAAM Sports subscale score was 84.6 (27.4). This subscale is scored as a percentage from 0% to 100%, with higher scores indicating a higher level of physical function.
Decision Analysis
The expected value for nonoperative treatment was 7.74, and the expected value for intramedullary screw fixation was 7.88 (Figure 1). Therefore, operative treatment was identified as the optimal treatment strategy.
Sensitivity analyses revealed that the optimal decision making strategy was very sensitive to small changes in several variables. Nonoperative treatment becomes the preferred strategy when the utility value for uncomplicated surgery falls below 8.04 (Figure 2), when the utility for healing with nonoperative treatment rises above 8.49 (Figure 3), when the likelihood of healing with nonoperative treatment rises above 82% (Figure 4), or when the probability of healing after surgery falls below 92% (Figure 5). Nonoperative treatment is also favored when the probability of minor complication with surgery is above 17% (Figure 6) and when utility for a successfully treated nonunion is higher than 6.9 (Figure 7).
Discussion
Optimal management of a metadiaphyseal fracture of the fifth metatarsal (Jones fracture) remains controversial. The decision between initial operative or nonoperative treatment lends itself to expected-value decision analysis because of well-defined treatment options and relatively discrete outcomes. The principal advantages of nonoperative treatment are that it allows the patient to avoid the risks and discomfort of surgery, and the principal advantages of operative treatment are that it maximizes the chance of fracture union and may accelerate functional recovery.
Our decision analysis determined that operative fixation is the optimal decision path, given the outcome probabilities derived from the literature and the utilities obtained from surveys. This finding is in accordance with several expert opinions in foot and ankle fracture surgery.17,18 However, the expected values of the operative and nonoperative treatment strategies differed by only 0.3 on a 10-point scale. Such similar expected values in our model are not surprising given the controversy surrounding clinical decision making in the treatment of these fractures.19
In addition, our analysis identified the important variables in the decision-making process. Patients averse to surgery, patients not averse to successful nonoperative treatment, and patients who view successful nonunion surgery after initial nonoperative treatment as a relatively positive outcome may be best treated nonoperatively. These findings emphasize the importance of patient preferences and shared decision-making. Higher rates of healing with nonoperative treatment, lower rates of healing with surgery, and higher complication rates with surgery also favor nonoperative management. It would therefore be valuable to identify risk factors for nonunion with nonoperative treatment and to identify the technical details of surgery that maximize rates of healing and minimize the risk of complications.
The limitations of decision analysis involve the methods by which probabilities and utilities are obtained. In general, the most accurate, stable, and robust estimates of outcome probabilities are derived from a meta-analytic synthesis of randomized clinical trials, the highest level of clinical evidence. In our model, data were extracted primarily from level IV studies; only 1 level III study20 and 1 level II study21 were available for analysis. Thus, as is the case with many foot and ankle disorders22, the information on treatment of Jones fractures is very limited in its level of clinical evidence.
Determination of outcome utility also has limitations. Utility is a subjective value that an individual places on a specific outcome. This can be very difficult to quantify. In general, the most robust estimates of patient-derived utilities are derived from complex qualitative methods, such as the standard reference gamble or time trade-offs, in which patients are asked to gamble or choose between health states usually referenced to death. In this study, we determined patient-derived utility values from a direct scaling method using a Likert scale because of the complexity of the standard reference gamble and the difficulty of referencing to death for metatarsal fracture. Although use of a direct scale to determine utility values is less rigorous than the standard reference gamble, this technique has been corroborated methodologically,23 is advantageous in terms of feasibility and reliability,24 and has been successfully used in other orthopedic decision analysis models.12,25,26 In our estimation, generally active patients without a history of foot pathology constituted a sample of convenience but also were representative of individuals at risk for Jones fracture. Although specific scenarios were presented, the patients who completed the questionnaire may not have had deep insights into the subtleties and implications of the various disease states and treatments. Regardless of how outcome probabilities and utilities are determined, they are considered point estimates in decision analysis, and sensitivity analyses are therefore performed to assess how decision making changes over a range of values.
Conclusion
The results of this study may help optimize the process of deciding between operative and nonoperative treatment for Jones fracture. For a given patient, the optimal strategy depends not only on the probabilities of the various outcomes but also on personal preference. Thus, there may not be one right answer for all patients. Patients who value a higher chance of fracture healing with initial treatment or an earlier return to sports are best treated operatively, whereas patients who are risk-averse and place a high value on fracture healing without surgery should be managed nonoperatively. We therefore advocate a model of shared medical decision-making in which the physician and the patient are jointly involved, considering both outcome probabilities and patient preferences. Ongoing research efforts should focus on predictors of nonunion with nonoperative treatment.
1. Dameron TB Jr. Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg. 1995;3(2):110-114.
2. Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006;25(1):139-150, x.
3. Konkel KF, Menger AG, Retzlaff SA. Nonoperative treatment of fifth metatarsal fractures in an orthopaedic suburban private multispeciality practice. Foot Ankle Int. 2005;26(9):704-707.
4. Lawrence SJ, Botte MJ. Jones’ fractures and related fractures of the proximal fifth metatarsal. Foot Ankle. 1993;14(6):358-365.
5. Nunley JA. Fractures of the base of the fifth metatarsal: the Jones fracture. Orthop Clin North Am. 2001;32(1):171-180.
6. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995;26(2):353-361.
7. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984;66(2):209-214.
8. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;11(5):349-353.
9. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am. 1978;60(6):776-782.
10. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and recreational athlete: a clinical and radiographic evaluation. Am J Sports Med. 2005;33(5):726-733.
11. Aleem IS, Jalal H, Sheikh AA, Bhandari M. Clinical decision analysis: Incorporating the evidence with patient p. Patient Prefer Adherence. 2009;3:21-24.
12. Bishop J, Ring D. Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. J Hand Surg Am. 2009;34(6):991-996.e1.
13. Chen NC, Shauver MJ, Chung KC. A primer on use of decision analysis methodology in hand surgery. J Hand Surg Am. 2009;34(6):983-990.
14. Kocher MS, Henley MB. It is money that matters: decision analysis and cost-effectiveness analysis. Clin Orthop Relat Res. 2003(413):106-116.
15. Dean BJ, Kothari A, Uppal H, Kankate R. The jones fracture classification, management, outcome, and complications: a systematic review. Foot Ankle Spec. 2012;5(4):256-259.
16. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26(11):968-983.
17. Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1307-1315.
18. Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010;41(6):555-562.
19. McBryde AM Jr. The complicated Jones fracture, including revision and malalignment. Foot Ankle Clin. 2009;14(2):151-168.
20. Porter DA, Rund AM, Dobslaw R, Duncan M. Comparison of 4.5- and 5.5-mm cannulated stainless steel screws for fifth metatarsal Jones fracture fixation. Foot Ankle Int. 2009;30(1):27-33.
21. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33(7):970-975.
22. Hunt KJ, Hurwit D. Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am. 2013;95(16):e118(1-9).
23. Stiggelbout AM, Eijkemans MJ, Kiebert GM, Kievit J, Leer JW, De Haes HJ. The ‘utility’ of the visual analog scale in medical decision making and technology assessment. Is it an alternative to the time trade-off? International journal of technology assessment in health care. Spring. 1996;12(2):291-298.
24. Parkin D, Devlin N. Is there a case for using visual analogue scale valuations in cost-utility analysis? Health Econ. 2006;15(7):653-664.
25. Bishop JA, Crall TS, Kocher MS. Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis. J Shoulder Elbow Surg. 2011;20(7):1087-1094.
26. Kocher MS, Bishop J, Marshall R, Briggs KK, Hawkins RJ. Operative versus nonoperative management of acute Achilles tendon rupture: expected-value decision analysis. Am J Sports Med. 2002;30(6):783-790.
27. Nagao M, Saita Y, Kameda S, et al. Headless compression screw fixation of jones fractures: an outcomes study in Japanese athletes. Am J Sports Med. 2012;40(11):2578-2582.
28. Thomas JL, Davis BC. Treatment of Jones fracture nonunion with isolated intramedullary screw fixation. J Foot Ankle Surg. 2011;50(5):566-568.
29. Habbu RA, Marsh RS, Anderson JG, Bohay DR. Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture. Foot Ankle Int. 2011;32(6):603-608.
30. Hunt KJ, Anderson RB. Treatment of Jones fracture nonunions and refractures in the elite athlete: outcomes of intramedullary screw fixation with bone grafting. Am J Sports Med. 2011;39(9):1948-1954.
31. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008;466(8):1966-1970.
32. DeVries JG, Cuttica DJ, Hyer CF. Cannulated screw fixation of Jones fifth metatarsal fractures: a comparison of titanium and stainless steel screw fixation. J Foot Ankle Surg. 2011;50(2):207-212.
33. Reese K, Litsky A, Kaeding C, Pedroza A, Shah N. Cannulated screw fixation of Jones fractures: a clinical and biomechanical study. Am J Sports Med. 2004;32(7):1736-1742.
34. Lombardi CM, Connolly FG, Silhanek AD. The use of external fixation for treatment of the acute Jones fracture: a retrospective review of 10 cases. J Foot Ankle Surg. 2004;43(3):173-178.
35. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones’ fractures. Foot Ankle Int. 2003;24(11):829-833.
36. Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal. Analysis of a fracture registry. Clin Orthop Relat Res. 1995(315):238-241.
37. Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Closed treatment of Jones fracture. Good results in 40 cases after 11-26 years. Orthop Scand. 1994;65(5):545-547.
38. Mindrebo N, Shelbourne KD, Van Meter CD, Rettig AC. Outpatient percutaneous screw fixation of the acute Jones fracture. Am J Sports Med. 1993;21(5):720-723.
39. Zogby RG, Baker BE. A review of nonoperative treatment of Jones’ fracture. Am J Sports Med. 1987;15(4):304-307.
40. Dameron TB Jr. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am. 1975;57(6):788-792.
41. Fernandez Fairen M, Guillen J, Busto JM, Roura J. Fractures of the fifth metatarsal in basketball players. Knee Surg Sports Traumatol Arthrosc. 1999;7(6):373-377.
The optimal management strategy for acute fractures of the metadiaphyseal fifth metatarsal (Jones fractures) is controversial. Patients can be successfully treated nonoperatively with non-weight-bearing and immobilization in a short leg cast1-7 or operatively with placement of an intramedullary screw.8-10 The primary advantage of nonoperative treatment is avoiding the risks and discomfort of surgery; disadvantages include the need for prolonged immobilization and protected weight-bearing as well as a decreased union rate.8,9 Advantages of operative treatment include accelerated functional recovery and an improved union rate; disadvantages include exposure to the risks, inconvenience, and discomfort of surgery. Clear, definitive evidence for guiding treatment is not available in the orthopedic literature, and treatment strategies vary substantially according to surgeon and patient preference.
Expected-value decision analysis, a research tool that helps guide decision-making in situations of uncertainty, has been effectively applied to other areas of uncertainty in the orthopedic literature.11-14 Borrowed from gaming theory, the technique involves creating a decision tree to define the clinical problem, determining outcome probabilities and utilities, performing a fold-back analysis to determine the optimal decision-making strategy, and performing a sensitivity analysis to model the effect of varying outcome probabilities and utilities on decision-making. Decision analysis may therefore allow the clinician and the patient to optimize decision-making based on best available evidence and patient preferences. It also helps determine the most important factors affecting management strategies and the decision-making process, which may not always be intuitive.
In the present study, we used expected-value decision analysis to determine the optimal management strategy, operative or nonoperative, for acute Jones fracture. We also explored factors with the most influence on the model and identified important questions for future research.
Materials and Methods
Institutional review board approval was obtained for this study. Analysis was performed with Treeage Pro statistical software (Treeage Software).
Outcome Probabilities
Outcome probabilities were determined by reviewing the literature for articles on Jones fractures. This body of literature was summarized in a comprehensive review by Dean and colleagues15, who extracted data from 19 studies: 1 randomized controlled trial, 1 prospective case series, and 17 retrospective case series.15 We used data from these studies to determine outcome probabilities (Table).
Outcome Utilities
Utilities represent patient preferences for various disease states. Outcome utility values were obtained from 32 adults (25 women, 7 men) with no history of foot injury. Mean age was 32.4 years (range, 20-69 years). The questionnaire presented scenarios for the different outcomes and asked patients to rate these outcomes on a scale ranging from 0 (worst possible outcome) to 10 (best possible outcome). The Sports subscale of the Foot and Ankle Ability Measure (FAAM) 16 was used to quantify patient activity level.
Decision Tree and Fold-Back Analysis
A decision tree was constructed with 1 decision node, 4 chance nodes, and 7 terminal nodes (Figure 1). The decision tree demonstrates 2 different strategies for managing a Jones fracture. The decision node divides the tree into 2 branches: initial operative or nonoperative treatment. Both branches are followed by various chance nodes, each terminating in a discrete clinical outcome. Per convention, utility data were placed to the right of the terminal nodes, and probability data were placed under the terminal nodes.
Fold-back analysis was performed to identify the optimal strategy. Fold-back analysis involves multiplying each outcome utility by its associated probability, thereby providing an “expected value” for each clinical endpoint. Then, the expected values for each endpoint can be summed for a given management strategy, and the ultimate expected values of the different strategies can be compared. The management strategy associated with the highest expected value is optimal for the given outcome utilities and probabilities.
Sensitivity Analysis
One-way sensitivity analysis was performed to model the effect on decision-making of changing the values for utility for uncomplicated surgery, utility for healing with nonoperative treatment, utility for uncomplicated treatment of nonunion, likelihood of healing with nonoperative treatment, likelihood of healing with surgery, and likelihood of minor complication with surgery. These were the variables found to affect the decision-making strategy within their clinically plausible ranges.
Results
Outcome Probabilities and Utilities
Outcome probabilities and utilities are illustrated in Figure 1. By convention, probabilities appear below the corresponding branches of the decision tree, and utilities appear at the end of each branch. Mean (SD) FAAM Sports subscale score was 84.6 (27.4). This subscale is scored as a percentage from 0% to 100%, with higher scores indicating a higher level of physical function.
Decision Analysis
The expected value for nonoperative treatment was 7.74, and the expected value for intramedullary screw fixation was 7.88 (Figure 1). Therefore, operative treatment was identified as the optimal treatment strategy.
Sensitivity analyses revealed that the optimal decision making strategy was very sensitive to small changes in several variables. Nonoperative treatment becomes the preferred strategy when the utility value for uncomplicated surgery falls below 8.04 (Figure 2), when the utility for healing with nonoperative treatment rises above 8.49 (Figure 3), when the likelihood of healing with nonoperative treatment rises above 82% (Figure 4), or when the probability of healing after surgery falls below 92% (Figure 5). Nonoperative treatment is also favored when the probability of minor complication with surgery is above 17% (Figure 6) and when utility for a successfully treated nonunion is higher than 6.9 (Figure 7).
Discussion
Optimal management of a metadiaphyseal fracture of the fifth metatarsal (Jones fracture) remains controversial. The decision between initial operative or nonoperative treatment lends itself to expected-value decision analysis because of well-defined treatment options and relatively discrete outcomes. The principal advantages of nonoperative treatment are that it allows the patient to avoid the risks and discomfort of surgery, and the principal advantages of operative treatment are that it maximizes the chance of fracture union and may accelerate functional recovery.
Our decision analysis determined that operative fixation is the optimal decision path, given the outcome probabilities derived from the literature and the utilities obtained from surveys. This finding is in accordance with several expert opinions in foot and ankle fracture surgery.17,18 However, the expected values of the operative and nonoperative treatment strategies differed by only 0.3 on a 10-point scale. Such similar expected values in our model are not surprising given the controversy surrounding clinical decision making in the treatment of these fractures.19
In addition, our analysis identified the important variables in the decision-making process. Patients averse to surgery, patients not averse to successful nonoperative treatment, and patients who view successful nonunion surgery after initial nonoperative treatment as a relatively positive outcome may be best treated nonoperatively. These findings emphasize the importance of patient preferences and shared decision-making. Higher rates of healing with nonoperative treatment, lower rates of healing with surgery, and higher complication rates with surgery also favor nonoperative management. It would therefore be valuable to identify risk factors for nonunion with nonoperative treatment and to identify the technical details of surgery that maximize rates of healing and minimize the risk of complications.
The limitations of decision analysis involve the methods by which probabilities and utilities are obtained. In general, the most accurate, stable, and robust estimates of outcome probabilities are derived from a meta-analytic synthesis of randomized clinical trials, the highest level of clinical evidence. In our model, data were extracted primarily from level IV studies; only 1 level III study20 and 1 level II study21 were available for analysis. Thus, as is the case with many foot and ankle disorders22, the information on treatment of Jones fractures is very limited in its level of clinical evidence.
Determination of outcome utility also has limitations. Utility is a subjective value that an individual places on a specific outcome. This can be very difficult to quantify. In general, the most robust estimates of patient-derived utilities are derived from complex qualitative methods, such as the standard reference gamble or time trade-offs, in which patients are asked to gamble or choose between health states usually referenced to death. In this study, we determined patient-derived utility values from a direct scaling method using a Likert scale because of the complexity of the standard reference gamble and the difficulty of referencing to death for metatarsal fracture. Although use of a direct scale to determine utility values is less rigorous than the standard reference gamble, this technique has been corroborated methodologically,23 is advantageous in terms of feasibility and reliability,24 and has been successfully used in other orthopedic decision analysis models.12,25,26 In our estimation, generally active patients without a history of foot pathology constituted a sample of convenience but also were representative of individuals at risk for Jones fracture. Although specific scenarios were presented, the patients who completed the questionnaire may not have had deep insights into the subtleties and implications of the various disease states and treatments. Regardless of how outcome probabilities and utilities are determined, they are considered point estimates in decision analysis, and sensitivity analyses are therefore performed to assess how decision making changes over a range of values.
Conclusion
The results of this study may help optimize the process of deciding between operative and nonoperative treatment for Jones fracture. For a given patient, the optimal strategy depends not only on the probabilities of the various outcomes but also on personal preference. Thus, there may not be one right answer for all patients. Patients who value a higher chance of fracture healing with initial treatment or an earlier return to sports are best treated operatively, whereas patients who are risk-averse and place a high value on fracture healing without surgery should be managed nonoperatively. We therefore advocate a model of shared medical decision-making in which the physician and the patient are jointly involved, considering both outcome probabilities and patient preferences. Ongoing research efforts should focus on predictors of nonunion with nonoperative treatment.
The optimal management strategy for acute fractures of the metadiaphyseal fifth metatarsal (Jones fractures) is controversial. Patients can be successfully treated nonoperatively with non-weight-bearing and immobilization in a short leg cast1-7 or operatively with placement of an intramedullary screw.8-10 The primary advantage of nonoperative treatment is avoiding the risks and discomfort of surgery; disadvantages include the need for prolonged immobilization and protected weight-bearing as well as a decreased union rate.8,9 Advantages of operative treatment include accelerated functional recovery and an improved union rate; disadvantages include exposure to the risks, inconvenience, and discomfort of surgery. Clear, definitive evidence for guiding treatment is not available in the orthopedic literature, and treatment strategies vary substantially according to surgeon and patient preference.
Expected-value decision analysis, a research tool that helps guide decision-making in situations of uncertainty, has been effectively applied to other areas of uncertainty in the orthopedic literature.11-14 Borrowed from gaming theory, the technique involves creating a decision tree to define the clinical problem, determining outcome probabilities and utilities, performing a fold-back analysis to determine the optimal decision-making strategy, and performing a sensitivity analysis to model the effect of varying outcome probabilities and utilities on decision-making. Decision analysis may therefore allow the clinician and the patient to optimize decision-making based on best available evidence and patient preferences. It also helps determine the most important factors affecting management strategies and the decision-making process, which may not always be intuitive.
In the present study, we used expected-value decision analysis to determine the optimal management strategy, operative or nonoperative, for acute Jones fracture. We also explored factors with the most influence on the model and identified important questions for future research.
Materials and Methods
Institutional review board approval was obtained for this study. Analysis was performed with Treeage Pro statistical software (Treeage Software).
Outcome Probabilities
Outcome probabilities were determined by reviewing the literature for articles on Jones fractures. This body of literature was summarized in a comprehensive review by Dean and colleagues15, who extracted data from 19 studies: 1 randomized controlled trial, 1 prospective case series, and 17 retrospective case series.15 We used data from these studies to determine outcome probabilities (Table).
Outcome Utilities
Utilities represent patient preferences for various disease states. Outcome utility values were obtained from 32 adults (25 women, 7 men) with no history of foot injury. Mean age was 32.4 years (range, 20-69 years). The questionnaire presented scenarios for the different outcomes and asked patients to rate these outcomes on a scale ranging from 0 (worst possible outcome) to 10 (best possible outcome). The Sports subscale of the Foot and Ankle Ability Measure (FAAM) 16 was used to quantify patient activity level.
Decision Tree and Fold-Back Analysis
A decision tree was constructed with 1 decision node, 4 chance nodes, and 7 terminal nodes (Figure 1). The decision tree demonstrates 2 different strategies for managing a Jones fracture. The decision node divides the tree into 2 branches: initial operative or nonoperative treatment. Both branches are followed by various chance nodes, each terminating in a discrete clinical outcome. Per convention, utility data were placed to the right of the terminal nodes, and probability data were placed under the terminal nodes.
Fold-back analysis was performed to identify the optimal strategy. Fold-back analysis involves multiplying each outcome utility by its associated probability, thereby providing an “expected value” for each clinical endpoint. Then, the expected values for each endpoint can be summed for a given management strategy, and the ultimate expected values of the different strategies can be compared. The management strategy associated with the highest expected value is optimal for the given outcome utilities and probabilities.
Sensitivity Analysis
One-way sensitivity analysis was performed to model the effect on decision-making of changing the values for utility for uncomplicated surgery, utility for healing with nonoperative treatment, utility for uncomplicated treatment of nonunion, likelihood of healing with nonoperative treatment, likelihood of healing with surgery, and likelihood of minor complication with surgery. These were the variables found to affect the decision-making strategy within their clinically plausible ranges.
Results
Outcome Probabilities and Utilities
Outcome probabilities and utilities are illustrated in Figure 1. By convention, probabilities appear below the corresponding branches of the decision tree, and utilities appear at the end of each branch. Mean (SD) FAAM Sports subscale score was 84.6 (27.4). This subscale is scored as a percentage from 0% to 100%, with higher scores indicating a higher level of physical function.
Decision Analysis
The expected value for nonoperative treatment was 7.74, and the expected value for intramedullary screw fixation was 7.88 (Figure 1). Therefore, operative treatment was identified as the optimal treatment strategy.
Sensitivity analyses revealed that the optimal decision making strategy was very sensitive to small changes in several variables. Nonoperative treatment becomes the preferred strategy when the utility value for uncomplicated surgery falls below 8.04 (Figure 2), when the utility for healing with nonoperative treatment rises above 8.49 (Figure 3), when the likelihood of healing with nonoperative treatment rises above 82% (Figure 4), or when the probability of healing after surgery falls below 92% (Figure 5). Nonoperative treatment is also favored when the probability of minor complication with surgery is above 17% (Figure 6) and when utility for a successfully treated nonunion is higher than 6.9 (Figure 7).
Discussion
Optimal management of a metadiaphyseal fracture of the fifth metatarsal (Jones fracture) remains controversial. The decision between initial operative or nonoperative treatment lends itself to expected-value decision analysis because of well-defined treatment options and relatively discrete outcomes. The principal advantages of nonoperative treatment are that it allows the patient to avoid the risks and discomfort of surgery, and the principal advantages of operative treatment are that it maximizes the chance of fracture union and may accelerate functional recovery.
Our decision analysis determined that operative fixation is the optimal decision path, given the outcome probabilities derived from the literature and the utilities obtained from surveys. This finding is in accordance with several expert opinions in foot and ankle fracture surgery.17,18 However, the expected values of the operative and nonoperative treatment strategies differed by only 0.3 on a 10-point scale. Such similar expected values in our model are not surprising given the controversy surrounding clinical decision making in the treatment of these fractures.19
In addition, our analysis identified the important variables in the decision-making process. Patients averse to surgery, patients not averse to successful nonoperative treatment, and patients who view successful nonunion surgery after initial nonoperative treatment as a relatively positive outcome may be best treated nonoperatively. These findings emphasize the importance of patient preferences and shared decision-making. Higher rates of healing with nonoperative treatment, lower rates of healing with surgery, and higher complication rates with surgery also favor nonoperative management. It would therefore be valuable to identify risk factors for nonunion with nonoperative treatment and to identify the technical details of surgery that maximize rates of healing and minimize the risk of complications.
The limitations of decision analysis involve the methods by which probabilities and utilities are obtained. In general, the most accurate, stable, and robust estimates of outcome probabilities are derived from a meta-analytic synthesis of randomized clinical trials, the highest level of clinical evidence. In our model, data were extracted primarily from level IV studies; only 1 level III study20 and 1 level II study21 were available for analysis. Thus, as is the case with many foot and ankle disorders22, the information on treatment of Jones fractures is very limited in its level of clinical evidence.
Determination of outcome utility also has limitations. Utility is a subjective value that an individual places on a specific outcome. This can be very difficult to quantify. In general, the most robust estimates of patient-derived utilities are derived from complex qualitative methods, such as the standard reference gamble or time trade-offs, in which patients are asked to gamble or choose between health states usually referenced to death. In this study, we determined patient-derived utility values from a direct scaling method using a Likert scale because of the complexity of the standard reference gamble and the difficulty of referencing to death for metatarsal fracture. Although use of a direct scale to determine utility values is less rigorous than the standard reference gamble, this technique has been corroborated methodologically,23 is advantageous in terms of feasibility and reliability,24 and has been successfully used in other orthopedic decision analysis models.12,25,26 In our estimation, generally active patients without a history of foot pathology constituted a sample of convenience but also were representative of individuals at risk for Jones fracture. Although specific scenarios were presented, the patients who completed the questionnaire may not have had deep insights into the subtleties and implications of the various disease states and treatments. Regardless of how outcome probabilities and utilities are determined, they are considered point estimates in decision analysis, and sensitivity analyses are therefore performed to assess how decision making changes over a range of values.
Conclusion
The results of this study may help optimize the process of deciding between operative and nonoperative treatment for Jones fracture. For a given patient, the optimal strategy depends not only on the probabilities of the various outcomes but also on personal preference. Thus, there may not be one right answer for all patients. Patients who value a higher chance of fracture healing with initial treatment or an earlier return to sports are best treated operatively, whereas patients who are risk-averse and place a high value on fracture healing without surgery should be managed nonoperatively. We therefore advocate a model of shared medical decision-making in which the physician and the patient are jointly involved, considering both outcome probabilities and patient preferences. Ongoing research efforts should focus on predictors of nonunion with nonoperative treatment.
1. Dameron TB Jr. Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg. 1995;3(2):110-114.
2. Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006;25(1):139-150, x.
3. Konkel KF, Menger AG, Retzlaff SA. Nonoperative treatment of fifth metatarsal fractures in an orthopaedic suburban private multispeciality practice. Foot Ankle Int. 2005;26(9):704-707.
4. Lawrence SJ, Botte MJ. Jones’ fractures and related fractures of the proximal fifth metatarsal. Foot Ankle. 1993;14(6):358-365.
5. Nunley JA. Fractures of the base of the fifth metatarsal: the Jones fracture. Orthop Clin North Am. 2001;32(1):171-180.
6. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995;26(2):353-361.
7. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984;66(2):209-214.
8. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;11(5):349-353.
9. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am. 1978;60(6):776-782.
10. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and recreational athlete: a clinical and radiographic evaluation. Am J Sports Med. 2005;33(5):726-733.
11. Aleem IS, Jalal H, Sheikh AA, Bhandari M. Clinical decision analysis: Incorporating the evidence with patient p. Patient Prefer Adherence. 2009;3:21-24.
12. Bishop J, Ring D. Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. J Hand Surg Am. 2009;34(6):991-996.e1.
13. Chen NC, Shauver MJ, Chung KC. A primer on use of decision analysis methodology in hand surgery. J Hand Surg Am. 2009;34(6):983-990.
14. Kocher MS, Henley MB. It is money that matters: decision analysis and cost-effectiveness analysis. Clin Orthop Relat Res. 2003(413):106-116.
15. Dean BJ, Kothari A, Uppal H, Kankate R. The jones fracture classification, management, outcome, and complications: a systematic review. Foot Ankle Spec. 2012;5(4):256-259.
16. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26(11):968-983.
17. Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1307-1315.
18. Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010;41(6):555-562.
19. McBryde AM Jr. The complicated Jones fracture, including revision and malalignment. Foot Ankle Clin. 2009;14(2):151-168.
20. Porter DA, Rund AM, Dobslaw R, Duncan M. Comparison of 4.5- and 5.5-mm cannulated stainless steel screws for fifth metatarsal Jones fracture fixation. Foot Ankle Int. 2009;30(1):27-33.
21. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33(7):970-975.
22. Hunt KJ, Hurwit D. Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am. 2013;95(16):e118(1-9).
23. Stiggelbout AM, Eijkemans MJ, Kiebert GM, Kievit J, Leer JW, De Haes HJ. The ‘utility’ of the visual analog scale in medical decision making and technology assessment. Is it an alternative to the time trade-off? International journal of technology assessment in health care. Spring. 1996;12(2):291-298.
24. Parkin D, Devlin N. Is there a case for using visual analogue scale valuations in cost-utility analysis? Health Econ. 2006;15(7):653-664.
25. Bishop JA, Crall TS, Kocher MS. Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis. J Shoulder Elbow Surg. 2011;20(7):1087-1094.
26. Kocher MS, Bishop J, Marshall R, Briggs KK, Hawkins RJ. Operative versus nonoperative management of acute Achilles tendon rupture: expected-value decision analysis. Am J Sports Med. 2002;30(6):783-790.
27. Nagao M, Saita Y, Kameda S, et al. Headless compression screw fixation of jones fractures: an outcomes study in Japanese athletes. Am J Sports Med. 2012;40(11):2578-2582.
28. Thomas JL, Davis BC. Treatment of Jones fracture nonunion with isolated intramedullary screw fixation. J Foot Ankle Surg. 2011;50(5):566-568.
29. Habbu RA, Marsh RS, Anderson JG, Bohay DR. Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture. Foot Ankle Int. 2011;32(6):603-608.
30. Hunt KJ, Anderson RB. Treatment of Jones fracture nonunions and refractures in the elite athlete: outcomes of intramedullary screw fixation with bone grafting. Am J Sports Med. 2011;39(9):1948-1954.
31. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008;466(8):1966-1970.
32. DeVries JG, Cuttica DJ, Hyer CF. Cannulated screw fixation of Jones fifth metatarsal fractures: a comparison of titanium and stainless steel screw fixation. J Foot Ankle Surg. 2011;50(2):207-212.
33. Reese K, Litsky A, Kaeding C, Pedroza A, Shah N. Cannulated screw fixation of Jones fractures: a clinical and biomechanical study. Am J Sports Med. 2004;32(7):1736-1742.
34. Lombardi CM, Connolly FG, Silhanek AD. The use of external fixation for treatment of the acute Jones fracture: a retrospective review of 10 cases. J Foot Ankle Surg. 2004;43(3):173-178.
35. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones’ fractures. Foot Ankle Int. 2003;24(11):829-833.
36. Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal. Analysis of a fracture registry. Clin Orthop Relat Res. 1995(315):238-241.
37. Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Closed treatment of Jones fracture. Good results in 40 cases after 11-26 years. Orthop Scand. 1994;65(5):545-547.
38. Mindrebo N, Shelbourne KD, Van Meter CD, Rettig AC. Outpatient percutaneous screw fixation of the acute Jones fracture. Am J Sports Med. 1993;21(5):720-723.
39. Zogby RG, Baker BE. A review of nonoperative treatment of Jones’ fracture. Am J Sports Med. 1987;15(4):304-307.
40. Dameron TB Jr. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am. 1975;57(6):788-792.
41. Fernandez Fairen M, Guillen J, Busto JM, Roura J. Fractures of the fifth metatarsal in basketball players. Knee Surg Sports Traumatol Arthrosc. 1999;7(6):373-377.
1. Dameron TB Jr. Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg. 1995;3(2):110-114.
2. Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006;25(1):139-150, x.
3. Konkel KF, Menger AG, Retzlaff SA. Nonoperative treatment of fifth metatarsal fractures in an orthopaedic suburban private multispeciality practice. Foot Ankle Int. 2005;26(9):704-707.
4. Lawrence SJ, Botte MJ. Jones’ fractures and related fractures of the proximal fifth metatarsal. Foot Ankle. 1993;14(6):358-365.
5. Nunley JA. Fractures of the base of the fifth metatarsal: the Jones fracture. Orthop Clin North Am. 2001;32(1):171-180.
6. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995;26(2):353-361.
7. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984;66(2):209-214.
8. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;11(5):349-353.
9. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am. 1978;60(6):776-782.
10. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and recreational athlete: a clinical and radiographic evaluation. Am J Sports Med. 2005;33(5):726-733.
11. Aleem IS, Jalal H, Sheikh AA, Bhandari M. Clinical decision analysis: Incorporating the evidence with patient p. Patient Prefer Adherence. 2009;3:21-24.
12. Bishop J, Ring D. Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. J Hand Surg Am. 2009;34(6):991-996.e1.
13. Chen NC, Shauver MJ, Chung KC. A primer on use of decision analysis methodology in hand surgery. J Hand Surg Am. 2009;34(6):983-990.
14. Kocher MS, Henley MB. It is money that matters: decision analysis and cost-effectiveness analysis. Clin Orthop Relat Res. 2003(413):106-116.
15. Dean BJ, Kothari A, Uppal H, Kankate R. The jones fracture classification, management, outcome, and complications: a systematic review. Foot Ankle Spec. 2012;5(4):256-259.
16. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26(11):968-983.
17. Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1307-1315.
18. Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010;41(6):555-562.
19. McBryde AM Jr. The complicated Jones fracture, including revision and malalignment. Foot Ankle Clin. 2009;14(2):151-168.
20. Porter DA, Rund AM, Dobslaw R, Duncan M. Comparison of 4.5- and 5.5-mm cannulated stainless steel screws for fifth metatarsal Jones fracture fixation. Foot Ankle Int. 2009;30(1):27-33.
21. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33(7):970-975.
22. Hunt KJ, Hurwit D. Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am. 2013;95(16):e118(1-9).
23. Stiggelbout AM, Eijkemans MJ, Kiebert GM, Kievit J, Leer JW, De Haes HJ. The ‘utility’ of the visual analog scale in medical decision making and technology assessment. Is it an alternative to the time trade-off? International journal of technology assessment in health care. Spring. 1996;12(2):291-298.
24. Parkin D, Devlin N. Is there a case for using visual analogue scale valuations in cost-utility analysis? Health Econ. 2006;15(7):653-664.
25. Bishop JA, Crall TS, Kocher MS. Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis. J Shoulder Elbow Surg. 2011;20(7):1087-1094.
26. Kocher MS, Bishop J, Marshall R, Briggs KK, Hawkins RJ. Operative versus nonoperative management of acute Achilles tendon rupture: expected-value decision analysis. Am J Sports Med. 2002;30(6):783-790.
27. Nagao M, Saita Y, Kameda S, et al. Headless compression screw fixation of jones fractures: an outcomes study in Japanese athletes. Am J Sports Med. 2012;40(11):2578-2582.
28. Thomas JL, Davis BC. Treatment of Jones fracture nonunion with isolated intramedullary screw fixation. J Foot Ankle Surg. 2011;50(5):566-568.
29. Habbu RA, Marsh RS, Anderson JG, Bohay DR. Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture. Foot Ankle Int. 2011;32(6):603-608.
30. Hunt KJ, Anderson RB. Treatment of Jones fracture nonunions and refractures in the elite athlete: outcomes of intramedullary screw fixation with bone grafting. Am J Sports Med. 2011;39(9):1948-1954.
31. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008;466(8):1966-1970.
32. DeVries JG, Cuttica DJ, Hyer CF. Cannulated screw fixation of Jones fifth metatarsal fractures: a comparison of titanium and stainless steel screw fixation. J Foot Ankle Surg. 2011;50(2):207-212.
33. Reese K, Litsky A, Kaeding C, Pedroza A, Shah N. Cannulated screw fixation of Jones fractures: a clinical and biomechanical study. Am J Sports Med. 2004;32(7):1736-1742.
34. Lombardi CM, Connolly FG, Silhanek AD. The use of external fixation for treatment of the acute Jones fracture: a retrospective review of 10 cases. J Foot Ankle Surg. 2004;43(3):173-178.
35. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones’ fractures. Foot Ankle Int. 2003;24(11):829-833.
36. Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal. Analysis of a fracture registry. Clin Orthop Relat Res. 1995(315):238-241.
37. Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Closed treatment of Jones fracture. Good results in 40 cases after 11-26 years. Orthop Scand. 1994;65(5):545-547.
38. Mindrebo N, Shelbourne KD, Van Meter CD, Rettig AC. Outpatient percutaneous screw fixation of the acute Jones fracture. Am J Sports Med. 1993;21(5):720-723.
39. Zogby RG, Baker BE. A review of nonoperative treatment of Jones’ fracture. Am J Sports Med. 1987;15(4):304-307.
40. Dameron TB Jr. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am. 1975;57(6):788-792.
41. Fernandez Fairen M, Guillen J, Busto JM, Roura J. Fractures of the fifth metatarsal in basketball players. Knee Surg Sports Traumatol Arthrosc. 1999;7(6):373-377.