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

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.

Intramedullary Nailing of Concurrent Bilateral Tibial Stress Fractures Followed by Unilateral Tension Plating for a Nonunion in a Vitamin D-Deficient Elite Football Player

Stress fractures consist of a type of bone fracture that occurs due to repetitive mechanical stress instead of acute forceful injuries that cause common fractures. They are quite common among athletes at all competition levels and in army recruits who are expected to undergo extremely demanding exercises. While stress fractures can occur in any long bone, they are usually associated with the most common weight-bearing sites of lower extremities such as phalanges, metatarsals, tarsal bones, the tibia, and fibula. In this study, we report the surgical management of a 23-year-old African football player who sustained concurrent bilateral anterior cortex tibial midshaft fractures. His initial symptom was persistent subacute pain in both tibias. The initial conservative treatment was not successful and the patient was surgically treated with bilateral tibial intramedullary nails. However, the right tibia subsequently developed nonunion. Both intramedullary nails were removed and a tension plate was applied with an autologous iliac crest graft on the right tibia. Further blood test analysis revealed a significant vitamin D deficiency. The purpose of this article is to report different outcomes of the same primary surgical treatment for concurrent bilateral tibia stress fracture syndrome in an elite athlete due to vitamin D deficiency. To our knowledge, this is the first study that highlights the necessity of revising one of the intramedullary nailed concurrent tibia stress fractures with a tension plate and autologous graft to treat the established nonunion in an elite football player.

Chronic anterior tibial stress fractures in athletes: No crack but intense remodeling

PURPOSE

Delayed healing of anterior tibial stress fractures in athletes is related to high tensional forces acting across a putative fracture gap. These forces lead to crack propagation and create strains that exceed tissue differentiation thresholds for new bone to form in the gap. The "dreaded black line" is a radiographic hallmark sign of stress fractures considered to represent a transverse fracture gap. However, whether a fracture gap truly exists at the microscopic level remains unclear. The aim of this study was to describe the area of the "dreaded black line" microscopically and to identify signs of delayed healing.

METHODS

Between 2011 and 2016, we included seven athletes with chronic anterior mid-shaft tibial stress fractures. The fracture site was excised as a cylindrical biopsy. The biopsy was evaluated with micro-CT and histology. The formation of new bone in the defect was evaluated radiographically.

RESULTS

The "dreaded black line" seen on pre-operative radiographs in all patients could not be seen on the microscopic level. Instead, the area of the putative crack showed widened resorption cavities, lined with active osteoblasts, and surrounded by immature bone. This area of intense remodeling seemed to create a false impression of a fracture line on radiographs. Complete cortical continuity was restored at the biopsy site at median 8 months (range 6-13 months).

CONCLUSION

Tibial stress fractures in athletes normally show no fracture defect, but a region of increased remodeling. The healing process is already ongoing but seems mechanically insufficient.

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.

Concurrent Bilateral Anterior Tibial Stress Fractures and Vitamin D Deficiency in an Adolescent Female Athlete: Treatment With Early Surgical Intervention

Case: A 16-year-old African American multi-sport female athlete presents with bilateral worsening activity-related leg pain for 5 months. Multiple bilateral anterior tibial diaphyseal stress fractures and significant vitamin D deficiency were identified. She was treated with a combination of vitamin D supplements and static intramedullary nailing of the bilateral tibias resulting in clinical and radiographic healing and return to sports. Discussion: Vitamin D deficiency and high level of activity in a young athlete may be the etiology to atypical multiple stress fractures. In athletes who may want to return to sport rapidly, early operative intervention and correction of vitamin D deficiency may be treatment options. Level of Evidence: Level V- case report.

Case report: ischial stress fracture non-union in a college football player

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.

Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete, initially treated with intramedullary nailing: a case report

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.

Outcome of surgical management of stress fractures in high demand individuals

Stress fractures represent one-fifth of overuse injuries in sport. Successful healing of stress fractures in high demand individuals is important to prevent complications upon early return to activity. This article reviews the literature on outcomes of surgical management of stress fractures in high demand individuals. An online literature search was carried out for articles published up to and including January 2017. Twenty five papers were reviewed. In the majority of studies, no complications were reported, clinical and radiographic healing was achieved, and patients returned to their premorbid level of activity. Current literature suggests good outcomes after surgical management of stress fractures in high demand individuals, particularly those in whom conservative treatment has failed. Further studies comparing surgical techniques are necessary to demonstrate the most efficacious.

Lateral fixation: an alternative surgical approach in the prevention of complete atypical femoral fractures

Little evidence is available on how to treat incomplete atypical fractures of the femur. When surgery is chosen, intramedullary nailing is the most common invasive technique. However, this approach is adopted from the treatment of other types of ordinary femoral fracture and does not aim to prevent the impending complete fracture by interrupting the mechanism underlying the pathology. We suggest a different surgical approach that intends to counteract the underlying biomechanical conditions leading to a complete atypical fracture and thus could be better suited in selected cases. Here, we share an alternative surgical approach and present two cases treated accordingly.

Plantar Plating for the Treatment of Proximal Fifth Metatarsal Fractures in Elite Athletes

Proximal fifth metatarsal fractures, zones II and III, are commonly treated surgically, especially in elite athletes. Intramedullary screw fixation remains the most used construct despite nonunion and refracture. High tensile forces on the plantar-lateral aspect of the fifth metatarsal are difficult to control, and intramedullary screw fixation depends on ideal screw position, length, and width. The authors present a plantar plating technique with cancellous bone autograft for zones II and III proximal fifth metatarsal fractures. Rotational instability and plantar-lateral gapping are resisted by applying a compression plate to the tension side of the fracture, eliminating causes for failure. [Orthopedics. 2017; 40(3):e563-e566.].

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.