Delayed union stress fractures of the anterior tibia: conservative management

Nonoperative Management of Tibial Stress Fractures Result in Higher Return to Sport Rates Despite Increased Failure Versus Operative Management: A Systematic Review

Purpose

To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures.

Methods

A literature search was conducted per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using EMBASE, PubMed, and Scopus computerized data from database inception to February 2023. Studies evaluating RTS sport rates and complications after nonoperative or operative management of tibial stress fractures were included. Failure was defined as defined by persistent stress fracture line seen on radiographic imaging. Study quality was assessed using the Modified Coleman Methodology Score.

Results

Twenty-two studies consisting of 341 patients were identified. The overall RTS rate ranged from 91.2% to 100% in the nonoperative group and 75.5% to 100% in the operative group. Failures rates ranged from 0% to 25% in the nonoperative groups and 0% to 6% in the operative group. Reoperations were reported in 0% to 6.1% of patients in the operative group, whereas 0% to 12.5% of patients initially managed nonoperatively eventually required operative treatment.

Conclusions

Patients can expect high RTS rates after appropriate nonoperative and operative management of tibial stress fractures. Treatment failure rates were greater in patients undergoing nonoperative management, with up to 12.5% initially treated nonoperatively later undergoing operative treatment.

Level of Evidence

Level IV; Systematic Review of level I-IV studies.

Pediatric Sports Injuries

Recreational sports are more popular, with many athletes involved year-round in multiple sports and on multiple teams. Most athletes do not take proper rest, making them more susceptible to stress-related injuries. There are numerous sports-related injuries in the foot and ankle. These issues can be non-traumatic, due to chronic repetitive stresses, or traumatic. Most of these injuries are managed conservatively, and athletes do well and return to play, while some do better with operative management. This article discusses a few of the sports injuries that are common in the leg, foot, and ankle and the recovery process.

Outcomes of Surgical Treatment for Anterior Tibial Stress Fractures in Athletes: A Systematic Review

BACKGROUND

Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes.

PURPOSE

This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented.

RESULTS

A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports.

CONCLUSION

The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.

Tibial Stress Fractures in Athletes

Tibial stress fractures are common in the athlete. There are various causes of these fractures, the most common being a sudden increase in training intensity. Most of these injuries are treated conservatively; however, some may require operative intervention. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. The physician must understand the nature of the fracture and the likelihood for it to heal in a timely manner in order to best treat these fractures in this patient subset.

Plate Versus Intramedullary Nail Fixation of Anterior Tibial Stress Fractures: A Biomechanical Study

BACKGROUND

Anterior midtibial stress fractures are an important clinical problem for patients engaged in high-intensity military activities or athletic training activities. When nonoperative treatment has failed, intramedullary (IM) nail and plate fixation are 2 surgical options used to arrest the progression of a fatigue fracture and allow bone healing.

HYPOTHESIS

A plate will be more effective than an IM nail in preventing the opening of a simulated anterior midtibial stress fracture from tibial bending.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fresh-frozen human tibias were loaded by applying a pure bending moment in the sagittal plane. Thin transverse saw cuts, 50% and 75% of the depth of the anterior tibial cortex, were created at the midtibia to simulate a fatigue fracture. An extensometer spanning the defect was used to measure the fracture opening displacement (FOD) before and after the application of IM nail and plate fixation constructs. IM nails were tested without locking screws, with a proximal screw only, and with proximal and distal screws. Plates were tested with unlocked bicortical screws (standard compression plate) and locked bicortical screws; both plate constructs were tested with the plate edge placed 1 mm from the anterior tibial crest (anterior location) and 5 mm posterior to the crest.

RESULTS

For the 75% saw cut depth, the mean FOD values for all IM nail constructs were 13% to 17% less than those for the saw cut alone; the use of locking screws had no significant effect on the FOD. The mean FOD values for all plate constructs were significantly less than those for all IM nail constructs. The mean FOD values for all plates were 28% to 46% less than those for the saw cut alone. Anterior plate placement significantly decreased mean FOD values for both compression and locked plate constructs, but the mean percentage reductions for locked and unlocked plates were not significantly different from each other for either plate placement. The percentage FOD reductions for all plate constructs and the unlocked IM nail were significantly less with a 50% saw cut depth.

CONCLUSION

Plate fixation was superior to IM nail fixation in limiting the opening of a simulated midtibial stress fracture, and anterior-posterior placement of the plate was an important variable for this construct.

CLINICAL RELEVANCE

Results from these tests can help guide the selection of fixation hardware for patients requiring surgical treatment for a midtibial stress fracture.

Tension Band Plating for Chronic Anterior Tibial Stress Fractures in High-Performance Athletes

BACKGROUND

Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures.

HYPOTHESIS

Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition.

RESULTS

Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion.

CONCLUSION

Anterior tension band plating for chronic tibial stress fractures provides a reliable alternative to intramedullary nailing with excellent results. Compression plating avoids the anterior knee pain associated with intramedullary nailing but may result in symptomatic hardware requiring subsequent removal.

Return to sports after stress fractures of the tibial diaphysis: a systematic review

INTRODUCTION

This review aims to provide information on the time taken to resume sport following tibial diaphyseal stress fractures (TDSFs).

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINHAL, Cochrane, Web of Science, PEDro, Sports Discus, Scopus and Google Scholar was performed using the keywords 'tibial', 'tibia', 'stress', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Twenty-seven studies were included: 16 reported specifically on anterior TDSFs and 5 on posterior TDSFs. The general principles were to primarily attempt non-operative management for all TDSFs and to consider operative intervention for anterior TDSFs that remained symptomatic after 3-6 months. Anterior TDSFs showed a prolonged return to sport.

AREAS OF CONTROVERSY

The best time to return to sport and the optimal management modalities for TDSFs remain undefined.

GROWING POINTS

Management of TDSFs should include a full assessment of training methods, equipment and diet to modify pre-disposing factors.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TDSFs.

Chronic Bilateral Tibial Stress Fractures with Valgus Treated with Bilateral Intramedullary Nailing: A Case Report

Introduction:

Stress fractures are overuse injuries most commonly seen in athletes, military recruits, and individuals with endocrine abnormalities. It has been demonstrated that chronic cases of anterior tibial stress fractures refractory to conservative management respond well to intramedullary nailing. To our knowledge, only one report has been published concerning patients with bilateral tibial stress fractures treated with bilateral intramedullary nailing. All patients in the series were high-level athletes. We present the case of a non-athletic patient with chronic bilateral tibial stress fractures and associated deformity successfully treated with bilateral intramedullary nails.

Case Report:

A 23-year-old Caucasian female full-time student presented with chronic bilateral shin pain for approximately five years. She had failed an extensive regimen of conservative management. She was diagnosed with chronic bilateral tibial stress fractures based on history, physical examination, and radiologic findings. She subsequently underwent sequential intramedullary nailing of her tibiae. Both tibiae were in valgus alignment; however, this did not preclude nail placement. The nails deformed upon insertion into the sclerotic canals to conform to the deformation. Post operatively the tibiae united and patient was relieved of her symptoms.

Conclusion:

Bilateral intramedullary nailing of chronic bilateral tibial stress fractures should be considered as a treatment option for all patients, not just high-level athletes, who fail a trial of conservative management. Additionally, mild to moderate tibial malalignment does not necessarily preclude tibial nailing as the smaller nails placed in sclerotic canals will likely deform on insertion and conform to the canal.

Tension band plating of a nonunion anterior tibial stress fracture in an athlete

The authors present a rare technique of tension band plating of the anterior tibia in the setting of a nonunion stress fracture. Surgical management with an intramedullary nail is a viable and proven option for treating such injuries. However, in treating elite athletes, legitimate concerns exist regarding the surgical disruption of the extensor mechanism and the risk of anterior knee pain associated with intramedullary nail use. The described surgical technique demonstrates the use of tension band plating as an effective treatment of delayed union and nonunion anterior tibial stress fractures in athletes without the potential risks of intramedullary nail insertion.

Stress fractures of the pelvis and legs in athletes: a review

CONTEXT

Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time.

EVIDENCE ACQUISITION

PubMed articles published from 1974 to January 2012.

RESULTS

Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis.

CONCLUSIONS

These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.

Stress fractures about the tibia, foot, and ankle

In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High-risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high-level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.

Stress fracture

Stress fractures are common overuse type injuries, caused by repetitive stresses applied to bone leading to a change within the normal physiological balance and altering key structural properties. These injuries have been well documented within certain groups of the population, as well as related to certain activity types, and pose significant diagnostic and treatment challenges. Complication of stress fractures can vary dependant of the anatomical site and the prognosis of an injury can have wide ranging effects, dependant of lifestyle choices and occupation of the patient. This piece endeavours to outline the most current and evidentiary concepts pertaining to important aspects of stress fractures, from pathophysiology through to prognosis.

Stress fractures in runners

Running has many beneficial effects, including cardiovascular and skeletal health. Poor training technique and a variety of risk factors may predispose runners to lower-limb overuse injuries affecting muscle, tendon, and bone. Injuries to the bone include stress reactions to full-fledged stress fractures. This article is designed to provide an understanding of the general concepts involving bone strain, risk factor assessment, and evaluation and treatment strategies for the runner with a stress fracture. The second half of the article presents more detail regarding each specific fracture seen in runners. The ultimate goal of this article is to provide the basics regarding stress fractures in runners from pathophysiology and general guidelines of evaluation and treatment and provide a quick reference regarding the details of each specific fracture encountered in clinical practice.

Anterior Mid-Tibial Stress Fractures. Results of Surgical Treatment

Background and Aims:

An anterior mid-tibial stress fracture is an uncommon, but possibly career threatening condition for an athlete. We wanted to evaluate the results of the surgical treatment of this notorious stress fracture and compare two different surgical methods.

Material and Methods:

Forty-nine anterior mid-tibial stress fractures were treated surgically in 45 patients during the years 1985–2005. All the patients were athletes, mainly runners. The mean age of the patients was 26 years. Thirty-four of the fractures occurred in men and 15 in women. The first method of treatment (anteromedial and lateral drilling) was used in 20 operations and the second method (laminofixation) in 29 operations.

Results:

Good results were achieved with drilling in only 50% of the operations, where as with laminofixation good results were achieved in 93% of operations. This difference was statistically significant (p = .002). Healing of the stress fracture after laminofixation occurred in less than 6 months. The length of the plate used in the laminofixation had no effect on the end result.

Conclusions:

An anterior mid-tibial stress fracture may often lead to delayed union or non-union in vigorously training athletes. Surgical treatment with laminofixation proved to be superior to tibial fracture site drilling.

Surgical treatment of refractory tibial stress fractures in elite dancers: a case series

BACKGROUND

Treatment of tibial stress fractures in elite dancers is centered on rest and activity modification. Surgical intervention in refractory cases has important implications affecting the dancers' careers.

HYPOTHESIS

Refractory tibial stress fractures in dancers can be treated successfully with drilling and bone grafting or intramedullary nailing.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1992 and 2006, 1757 dancers were evaluated at a dance medicine clinic; 24 dancers (1.4%) had 31 tibial stress fractures. Of that subset, 7 (29.2%) elite dancers with 8 tibial stress fractures were treated operatively with either intramedullary nailing or drilling and bone grafting. Six of the patients were followed up closely until they were able to return to dance. One patient was available only for follow-up phone interview. Data concerning their preoperative treatment regimens, operative procedures, clinical union, radiographic union, and time until return to dance were recorded and analyzed.

RESULTS

The mean age of the surgical patients at the time of stress fracture was 22.6 years. The mean duration of preoperative symptoms before surgical intervention was 25.8 months. Four of the dancers were male and 3 were female. All had failed nonoperative treatment regimens. Five patients (5 tibias) underwent drilling and bone grafting of the lesion, and 2 patients (3 tibias) with completed fractures or multiple refractory stress fractures underwent intramedullary nailing. Clinical union was achieved at a mean of 6 weeks and radiographic union at 5.1 months. Return to full dance activity was at an average of 6.5 months postoperatively.

CONCLUSION

Surgical intervention for tibial stress fractures in dancers who have not responded to nonoperative management allowed for resolution of symptoms and return to dancing with minimal morbidity.

Recurrent fracture after operative treatment for a tibial stress fracture

We report a patient with a recurrent stress fracture and subsequent nonunion around an intramedullary nail placed for treatment of a more proximal, chronic tibial stress fracture. After 9 months of failed nonoperative treatment, we performed an exchange intramedullary nailing with open bone graft. At 8 months postoperatively, the patient showed clinical and radiographic signs of healing.

Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases

Stress fracture of the anterior tibial cortex is an extremely challenging fracture to treat, especially in the high-performance female athlete who requires rapid return to competition. Previous reports have not addressed treating these fractures in the world-class athlete with anterior plating. We hypothesize that anterior plating is a biomechanically sound approach to treatment of these fractures, and will lead to an earlier return to full activity than either nonoperative treatment or intramedullary nailing. We present a retrospective series of 4 case reports of 4 world-class female athletes with stress fractures of the anterior tibial cortex treated by anterior plating between 2001 and 2004. Average follow-up was 15 months (range 12 to 48 mo). Anterior tension band plating resulted in fracture healing in all 4 cases and return to full activity at a mean of 10 weeks. All patients returned to preinjury competitive levels. There were no complications of infection, nonunion, or malunion. Anterior tension-band plating of an anterior tibial stress fracture leads to rapid fracture healing and return to competition for high-performance female athletes. This approach should be considered in those athletes who wish to avoid the more prolonged convalescence associated with nonoperative treatment, or the problems, especially of the knee, associated with intramedullary nailing.

Evaluation and treatment of tibial stress fractures

Tibial stress fractures are relatively common overuse injuries that can often be difficult to treat. Other comorbid medical conditions, including the female athlete triad, need to be carefully evaluated and treated. Nonoperative treatment is the standard, but surgical intervention may be necessary. Intramedullary nailing may allow return to sport but does not guarantee healing.

Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing

BACKGROUND

A chronic anterior midtibial stress fracture is a serious, difficult-to-treat injury that can adversely affect an athlete's career.

HYPOTHESIS

The use of a reamed intramedullary nail for a chronic anterior tibial stress fracture is a safe and effective treatment for an athlete.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Seven collegiate-level athletes with 11 chronic anterior midtibial stress fractures were treated with reamed intramedullary nailing between 1997 and 2000. These patients were followed for a mean duration of 17 months.

RESULTS

The mean age of the patients at the time of stress fracture diagnosis was 17 years. Seven of the fractures occurred in male athletes, whereas 4 occurred in female athletes. All patients had failed nonoperative treatment, including rest, activity modification, use of an orthosis, and low-intensity ultrasound stimulation, for a minimum of 4 months. Patients had experienced symptoms for a mean duration of 12 months. Clinical and radiological union occurred at a mean of 2.7 and 3 months, respectively. The mean duration for return to sports after surgery was 4 months. At last follow-up, all patients had full range of motion at the knee and ankle joints and were satisfied with the results. One patient developed bursitis at the tibial nail insertion site that was resolved with a steroid injection. Another patient sustained a traumatic fracture of the distal tibia 1 year after intramedullary nailing of the tibial stress fracture. This fracture healed with nonoperative treatment. No other complications were observed.

CONCLUSION

Intramedullary nailing of the tibia for chronic stress fracture has a high union rate, allows for a low complication rate, and allows for an early return to competitive sports. This procedure is an excellent alternative treatment for those fractures that have failed nonsurgical treatment.

Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review

A literature search was performed to determine whether non-steroidal anti-inflammatory drugs (NSAIDs) adversely affect the healing of stress fractures. Evidence exists from laboratory studies and animal subjects that NSAIDs can affect fracture healing. This link has not been proved or disproved in human subjects, particularly for stress fractures. In view of the high usage of NSAIDs in treating musculoskeletal disorders, research is required to investigate whether the healing of stress fractures is affected by these drugs.

[Stress fracture in athletes and prevalence of extensive rehabilitation]

OBJECTIVE

The aim of this work was to review the literature for the place of extensive rehabilitation for athletes with stress fractures.

METHOD

We searched the Medline and Embase databases using the keywords stress fracture, sports, rehabilitation, management and treatment. Only French and English articles were included, and articles about bone physiology, animal models, and spine and chest localisations were excluded. From 468 scientific articles, 62 were chosen because they corresponded to literary reviews or to therapeutic evaluations.

RESULTS

Treatment of stress fracture is justified according to risk factors, stress-fracture complications, the precocity of diagnosis, the therapeutic method and when the athlete needs to return to the sport. The most common treatment is discontinuing the sport, followed by rest. The progressive resumption of sport is rarely described but must take into account mechanical constraints that can be controlled by the use of shoes adapted to a supple ground. Some treatments such as immobilization by pneumatic splint surgery or use of electric fields are controversial.

CONCLUSION

Extensive treatment of stress fractures is mainly dedicated to high-level athletes who need to regain previous physical capacities as soon as possible.