Open reduction of metatarsal fractures is associated with a safer risk profile than percutaneous fixation

Despite open reduction internal fixation (ORIF) and percutaneous fixation being commonly used for the treatment of metatarsal fractures, the relative complication profiles are unclear.

To compare short- and medium-term complications between ORIF and percutaneous fixation of metatarsal fractures using a large multi-center database.

We used the TriNetX research network to identify two patient cohorts with metatarsal fractures: those who underwent ORIF, and those that underwent percutaneous fixation.

Two propensity-matched cohorts of 846 patients each who underwent percutaneous fixation or internal fixation between 2010 and 2024. We compared complication rates at 30 days, 90 days, and 1 year by calculating rates, odds ratios, and p-values.

At 30 and 90-days, ORIF was associated with lower rates of ED visits and inpatient admission, with no differences in revision procedures at 1 year. Subgroup analysis by fracture location demonstrated that ORIF of 1st metatarsal fractures was associated with higher short-term complication rates than central metatarsal fractures, while patients who underwent ORIF of a 5th metatarsal fracture had lower rates of early adverse events and revision surgery within 1 year.

Despite greater surgical exposure, open reduction internal fixation was associated with fewer short-term ED presentations and inpatient admissions. These findings challenge assumptions about the relative safety of percutaneous fixation and suggest that open techniques for metatarsal fracture fixation may offer a favorable risk profile, especially when considering hospital utilization. Further prospective trials are warranted to validate these results and explore whether patient- or injury-specific factors meaningfully impact complication risk.