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Many different surgical methods and implants for the treatment of fifth metatarsal fractures have been established yet. A high rate of complications, such as nonunion, fragment dislocation, refracture, implant deformation and irritation are widely occurring due to the insufficient ability of the implants to compensate the tension applied to the proximal fragment through the peroneal tendon combined with an impaired blood supply at the fracture zone. Therefore, the search for improved surgical solutions is thoroughly understandable. Thus, we have introduced the XS-nail as an intramedullary nail system that bears the ability to provide a compression to the fracture zone through a grub screw. In this work, we have analyzed the position of the XS-nail in relationship to other methods with special regard to the tension-band wiring.In a retrospective analysis, we examined 77 cases, where a proximal fifth metatarsal fracture has been treated with the XS-nail. As a comparison group, we collected data from 47 patients who had been treated with tension-band wiring for the same indication in our hospital. Altogether, we included 124 patients, representing the largest study population of surgically treated cases of proximal fifth metatarsal fractures as compared to the actual literature.When compared with the tension-band wiring group, we found in mean a shorter duration of the surgery, a lower necessity of an open reduction (18 vs. 100%), fewer postsurgical weight-bearing restrictions (54 vs. 100%) and a shorter duration of rehabilitation (48 vs. 71 days). Especially, the fracture compression was distinctively higher in the XS-nail group (postsurgical lateral dislocation was 0-59%). The advantages of the tension-band wiring were found in the fixation of small fragments and an easier implant removal. Generally, nonunion and refracture were not seen in both methods. When compared with the results from literature, we found positive results regarding the hospitalization duration, the weight-bearing ability, the rehabilitation course and the patients' satisfaction.Thus, the XS-nail proved to be an effective and technical optimized implant for the treatment of proximal fifth metatarsal fractures that provides a rapid full-weight-bearing mobilization and shows good long-term results.