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Schundler SF, Jackson GR, McCormick JR, Tuthill T, Lee JS, Batra A, Jawanda H, Kaplan DJ, Chan J, Knapik DM, Verma NN, Chahla J. Nonoperative Management of Tibial Stress Fractures Result in Higher Return to Sport Rates Despite Increased Failure Versus Operative Management: A Systematic Review. Arthrosc Sports Med Rehabil 2023; 5:e881-e889. [PMID: 37388859 PMCID: PMC10300596 DOI: 10.1016/j.asmr.2023.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/21/2023] [Indexed: 07/01/2023] Open
Abstract
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.
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Affiliation(s)
- Sabrina F. Schundler
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R. Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Johnathon R. McCormick
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Trevor Tuthill
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jonathan S. Lee
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Anjay Batra
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Daniel J. Kaplan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jimmy Chan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Derrick M. Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, U.S.A
| | - Nikhil N. Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Allado E, Ankri M, Khiami F, Tamgho T, Hamroun A, Proenca Lopes C, Poussel M, Chenuel B. Case Report: Stress Fracture in an International Triple Jumper: Importance of an Integrated Care Approach Which Also Incorporates Biomechanics. Front Sports Act Living 2021; 3:683691. [PMID: 34124662 PMCID: PMC8193055 DOI: 10.3389/fspor.2021.683691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022] Open
Abstract
Athletes fear stress fracture (SF) injuries as they can put a premature end to their athletic careers. Understanding any mechanical constraints can suggest preventive management approach. Specifically, for the triple jump, the mechanical stresses that occur during the event appear to be the main factors for risk of injury. This clinical case describes three successive episodes of anterior tibial fracture in an international triple jumper between 2011 and 2013. The first fracture received surgical treatment involving intramedullary nailing. The second fracture occurred in the same location and was considered a recurrence requiring medical treatment, whilst the third was a complete fracture of the surgical material and required surgical revision. These recurrent fractures can be explained by the fatigue of materials (bone and nail) induced by triple jump practice and emphasize the importance of integrating biomechanics into an assessment of the case. The use of biomechanical modelization to identify these weaknesses could be an approach for clinical management of such patients. Observation of the intrinsic mechanical stresses during high-level triple jump may lead to identification of modifiable risk factors for bone fragility.
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Affiliation(s)
- Edem Allado
- CHRU-Nancy, University Center of Sports Medicine and Adapted Physical Activity, Nancy, France.,Université de Lorraine, DevAH, Nancy, France
| | - Marine Ankri
- Department of Orthopedic Surgery and Trauma, Hospital Group (GH) Saint-Louis, Lariboisière, Fernand-Widal, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Frédéric Khiami
- Department of Orthopedic Surgery and Trauma, Hospital Group (GH) Pitié-Salpêtrière, Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Teddy Tamgho
- Institut National du Sport, de l'Expertise et de la Performance (INSEP), Paris, France
| | - Aghiles Hamroun
- Centre for Research in Epidemiology and Population Health, Paris-Saclay University, UMRS 1018, Villejuif, France
| | - Catarina Proenca Lopes
- Medicine Department, American Memorial Hospital, Reims, France.,University Hospital of Reims, Reims, France
| | - Mathias Poussel
- CHRU-Nancy, University Center of Sports Medicine and Adapted Physical Activity, Nancy, France.,Université de Lorraine, DevAH, Nancy, France
| | - Bruno Chenuel
- CHRU-Nancy, University Center of Sports Medicine and Adapted Physical Activity, Nancy, France.,Université de Lorraine, DevAH, Nancy, France
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Chaudhry ZS, Raikin SM, Harwood MI, Bishop ME, Ciccotti MG, Hammoud S. Outcomes of Surgical Treatment for Anterior Tibial Stress Fractures in Athletes: A Systematic Review. Am J Sports Med 2019. [PMID: 29528694 DOI: 10.1177/0363546517741137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Shaner AC, Spiker AM, Goolsby MA, Kelly BT, Helfet DL. Case report: ischial stress fracture non-union in a college football player. J Hip Preserv Surg 2018; 5:312-318. [PMID: 30393560 PMCID: PMC6206699 DOI: 10.1093/jhps/hny019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/19/2018] [Indexed: 12/31/2022] Open
Abstract
Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.
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Affiliation(s)
- Adam C Shaner
- Department of Orthopaedic Surgery, Trauma Surgery, Westchester Medical Center, New York Medical College, NY, USA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, Sports Medicine and Hip Preservation, University of Wisconsin – Madison, Madison, WI, USA
| | | | - Bryan T Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David L Helfet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Tsakotos GA, Tokis AV, Paganias CG. Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete, initially treated with intramedullary nailing: a case report. J Med Case Rep 2018; 12:183. [PMID: 29954458 PMCID: PMC6025831 DOI: 10.1186/s13256-018-1718-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 05/15/2018] [Indexed: 11/15/2022] Open
Abstract
Background Leg pain in athletes is a common condition and is often related to tibial stress fracture. When non-operative treatment fails, the optimal surgical treatment is controversial. The aim of this study was to report a case of tension band plating of an anterior tibial stress fracture nonunion, treated previously with intramedullary nailing. To the best of our knowledge, this is the first reported case in which tension band plating was placed without removing the preexisting intramedullary nail. Case presentation The tibial shaft is a common location of stress fracture in athletes. Anterior tibial stress fractures are difficult to manage. When conservative treatment fails, intramedullary nailing is the mainstay of treatment. However, nonunion is a serious complication. In our case, a non-united anterior tibial stress fracture, treated with intramedullary nailing, was addressed with the application of a compression prebended plate over the nail in a 23-year-old French man of African origin who is an elite football player. At 3-months postoperatively he was pain free and started light exercises. At 6-months postoperatively, complete radiologic union of the fracture was evident. He was symptom free; he resumed at that time a full training program and he returned to play football at preinjury high competition level. Conclusions Compression plating is a valuable method of treating non-united anterior tibial stress fractures. We believe that anterior tension band plating is superior to intramedullary nailing in managing anterior tibial stress fractures, not only after failure of intramedullary nailing, but also as a first-line surgical treatment. This technique offers advantages, such as no violation of the extensor mechanism and risk of anterior knee pain, and directly addresses the underlying problem of distraction forces acting on the anterior tibial cortex and compromising fracture healing. Especially in high-level athletes, who cannot tolerate prolonged inactivity, early surgical intervention of anterior tibial stress fractures with tension band plating is a reliable option that can accelerate recovery.
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Affiliation(s)
- George A Tsakotos
- Department of Orthopedics and Sports Medicine, Metropolitan Hospital, Athens, Greece.
| | - Anastasios V Tokis
- Department of Orthopedics and Sports Medicine, Metropolitan Hospital, Athens, Greece
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7
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Hattori H, Ito T. Recurrent Fracture After Anterior Tension Band Plating With Bilateral Tibial Stress Fracture in a Basketball Player: A Case Report. Orthop J Sports Med 2015; 3:2325967115610069. [PMID: 26535378 PMCID: PMC4622293 DOI: 10.1177/2325967115610069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hiroyuki Hattori
- Department of Orthopedic Surgery, Japan Community Health Care Organization, Tokyo Kamata Medical Center, Ohta-ku, Tokyo, Japan
| | - Toshiyuki Ito
- Department of Orthopedic Surgery, Japan Community Health Care Organization, Tokyo Kamata Medical Center, Ohta-ku, Tokyo, Japan
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Zbeda RM, Sculco PK, Urch EY, Lazaro LE, Borens O, Williams RJ, Lorich DG, Wellman DS, Helfet DL. Tension Band Plating for Chronic Anterior Tibial Stress Fractures in High-Performance Athletes. Am J Sports Med 2015; 43:1712-8. [PMID: 25828077 DOI: 10.1177/0363546515577355] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Dean G Lorich
- Hospital for Special Surgery, New York, New York, USA
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Robertson GAJ, Wood AM. Return to sports after stress fractures of the tibial diaphysis: a systematic review. Br Med Bull 2015; 114:95-111. [PMID: 25712999 DOI: 10.1093/bmb/ldv006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2015] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- G A J Robertson
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - A M Wood
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CWC. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med 2014; 49:370-6. [PMID: 25138980 DOI: 10.1136/bjsports-2013-093246] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM 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. STUDY REGISTRATION NUMBER PROSPERO database of systematic reviews: CRD42013004201.
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Affiliation(s)
- Wouter H Mallee
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke Weel
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department Health Sciences, EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Gino M Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Chung-Wei Christine Lin
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
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