Tension Band Plating of a Nonunion Anterior Tibial Stress Fracture in an Athlete

n sports medicine update Section Editor: Darren L. Johnson, MD

Jarrad A. Merriman, MPH; Diego Villacis, MD; Curtis J. Kephart, MD, ATC; George F. Rick Hatch III, MD

Treatment is often depen- The authors present a surgi- Abstract: The authors present a rare technique of tension band dent on the broad classifica- cal technique for tension band plating of the anterior tibia in the setting of a nonunion stress tion of the fracture as either plating supplemented with fracture. Surgical management with an intramedullary nail is a low or high risk. Low-risk drilling of the fracture site viable and proven option for treating such injuries. However, in stress fractures are often di- and bone morphogenic protein treating elite athletes, legitimate concerns exist regarding the agnosed with a thorough his- pads for a delayed union or surgical disruption of the extensor mechanism and the risk of tory and physical, supported nonunion anterior tibial stress anterior knee pain associated with intramedullary nail use. The with radiographic evidence, fracture in an elite athlete. described surgical technique demonstrates the use of tension and require rest with limited band plating as an effective treatment of delayed union and weight bearing for up to 6 Materials and Methods nonunion anterior tibial stress fractures in athletes without the weeks. High-risk stress frac- The indication for surgery potential risks of intramedullary nail insertion. tures, such as those in the is failed nonoperative manage- anterior tibial cortex, are per- ment of an anterior tibial cor- sistent and have a predilection tex stress fracture in an elite- ibial stress fractures oc- most common bone in which for complete fracture, delayed level athlete. The senior author Tcur in individuals who stress fractures occur is the union, or nonunion and require (G.F.R.H.) begins treatment participate in rigorous activ- tibia,6 and the prognosis of a more aggressive approach.8 with rest, CAM walker boot ity and present a formidable the injury is dependent on Two surgical interventions immobilization, and physio- challenge to clinicians with the location of the fracture. have been described by Chang therapy modalities, includ- respect to treatment and the Posterior tibial cortex frac- and Harris9 and Borens et al13 ing ultrasound. If the patient facilitation of a prompt re- tures are the most common and include intramedullary is pain free at 3 months after turn to action. Commonly de- and favorable in terms of nailing and tension band plat- onset of treatment, then the scribed in high-performance treatment and speed in return ing, respectively. The most patient can return to play. If athletes and military person- to sport.7-10 Fractures of the frequently reported complica- pain persists, then surgical in- nel, the reported incidences anterior cortex are less likely tion of tibial nailing is chronic tervention is considered. Time are 8% to 21%1,2 and 2.4% to occur, accounting for 2.7% anterior knee pain.14 This can of season (in- vs off-season) to 13.4%,3-5 respectively. The to 4.6% of stress fractures.11,12 be devastating to a jumping factors into decision making athlete who is already predis- for advancing to surgical treat- The authors are from the Department of Orthopedic Surgery, USC Keck posed to anterior knee pain as ment after the initial 3 months School of Medicine, Los Angeles, California. a result of forceful quadriceps of conservative treatment. The authors have no relevant financial relationships to disclose. contraction with concurrent Correspondence should be addressed to: Jarrad A. Merriman, MPH, knee flexion that increases Surgical Technique Department of Orthopedic Surgery, USC Keck School of Medicine, 1200 N State St, GNH 3900, Los Angeles, CA 90033 ([email protected]). pressure on the posterior The patient is placed in the doi: 10.3928/01477447-20130624-08 kneecap. supine position on the operat-

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Cover illustration © Lisa Clark

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cluding a CAM walker boot and crutches, the pain per- sisted and the fracture pro- gressed to a nonunion. To promote healing and facilitate the patient’s return to sport, he underwent anterior tension band plating of the tibia with drilling of the fracture site and recombinant human bone mor- 1 2 3 phogenic protein-2 (rhBMP-2) Figure 1: Preoperative lateral radio- Figure 2: Postoperative anteropos- Figure 3: Intraoperative photograph supplementation. graph of the right tibia showing a terior radiograph of the right tibia of the right lower extremity showing stress fracture of the anterior cortex. showing a healed fracture site. the markings for an 8-cm longitudi- The initial postopera- nal incision that is 1 cm lateral to the tive course was uneventful. anterior tibial crest and centered over However, on postoperative ing room table. A tourniquet is cortex. However, the main goal the fracture site. day 5, the patient developed placed on the thigh of the op- is to provide compression at the erythema about the incision. erative extremity, which is then near cortex. A 3.2-mm drill bit is used on the skin. Steri-stips Complete blood count was prepared and draped by sterile is drilled in the neutral position (3M, St Paul, Minnesota) are within normal limits, the area technique. C-arm fluoroscopy of the distal hole closest to the applied, followed by gauze was not warm or purulent, and is used to identify the fracture fracture site with placement of and a bio-occlusive dressing. the erythema appeared to be site. With the tourniquet in- a cortical 4.5-mm screw. The A bandage is wrapped loosely centered over the rhBMP-2 flated, an 8-cm longitudinal screw should be angled posteri- starting distally at the foot and pad. Therefore, it was deter- incision is made 1 cm lateral orly to avoid being prominent on moving proximally. Final fluo- mined that the patient had an to the anterior tibial crest and the subcutaneous surface of the roscopy radiographs are taken inflammatory reaction to the centered over the fracture site anterior tibia. Next, the proxi- with large C-arm fluoroscopy rhBMP-2, a known compli- (Figure 3). The fascia over the mal screw hole closest to the (Figure 5). cation, and the incision was tibialis anterior is sharply divid- fracture site is similarly drilled Postoperatively, the patient is closely monitored for signs ed longitudinally, leaving a cuff with insertion of a 4.5-mm placed in a CAM boot and told of infection.15 The erythema of fascia on the medial side to cortical screw in the com- not to bear weight for 6 weeks resolved by postoperative day repair later. The muscle is lift- pression (load) position. The postoperatively. The patient is 10, and no further complica- ed off the lateral cortex of the 3.2-mm threaded drill guide was advanced to bearing weight as tions were observed. tibia with an elevator. The frac- used to drill and place 4.0-mm tolerated at the end of 6 weeks Rehabilitation for return to ture site is directly visualized unicortical locking screws in the postoperatively. Physical thera- sport was as follows: 8 weeks and carefully debrided using a remaining 4 holes (Figure 4). py consisting of range of motion postoperatively, he began par- small curette and rongeur. It is Care should be taken to avoid exercises for the ankle and knee tial weight bearing; 12 weeks a paramount to debride all soft being prominent on the ante- and isometric exercises without postoperatively, he began run- bone and callus. Next, trans- rior surface of the tibia because resistance are started at the first ning on the AlterG anti-gravity versal drilling with a 2.0-mm these locking screws cannot be postoperative visit. treadmill (AlterG, Fremont, drill is performed. A small angled posteriorly. California); 14 weeks post- strip of rhBMP-2 using an The tourniquet is released Case Report operatively, he began under- Infuse bone graft (Medtronic, and proper hemostasis is A 22-year-old collegiate water running and jumping; Minneapolis, Minnesota) is achieved. The fascia is closed male volleyball player pre- and 18 weeks postoperatively, placed in the fracture site. with a running 2-0 Vicryl su- sented with a 3-month his- he began traditional agil- A 6-hole, 4.5-mm locking ture (Ethicon, Inc, Somerville, tory of insidious anterior shin ity and plyometric exercises. compression plate (Synthes, New Jersey). A buried pain and tenderness. Initial Radiographs taken 8 months Paoli, Pennsylvania) was used 3-0 Vicryl suture is used to radiographs revealed a stress postoperatively were void of for stabilization. Minimal pre- close the subcutaneous tissue, fracture of the anterior cortex any visible black line, indi- bending was used to provide and a running subcuticular (Figure 1). After 12 months cating a healed fracture site some compression of the far 3-0 Monocryl (Ethicon, Inc) of conservative treatment, in- (Figure 2).

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Discussion Anterior tibial stress fractures in athletes present a dif- ficult challenge to clinicians. Immobilization and rest are often inadequate and can extensively delay the return to competition. Previous studies evaluating nonoperative treatment of tibia stress fractures found a mean of 12 months for 4A 4B return to former level of play.16 Figure 4: Intraoperative anteroposterior (A) and lateral oblique (B) photographs of the right tibia showing a 6-hole, 4.5- This lengthy period of inactiv- mm locking compression plate centered over the fracture site with recombinant human bone morphogenic protein-2 ity can have significant psy- supplementation. chological effects on athletes and even represent financial athlete, rest and immobiliza- loss in terms of potential earn- tion are the recommended ini- ings for professional athletes. tial treatment. Once imaging In the case of nonunion or reveals hypertrophic tibial cor- delayed union, surgical inter- tex and a widening fissure, the vention must be explored. The self-curative capacity is mini- technique presented in this ar- mal and surgical intervention ticle is advised for use in elite is likely warranted.8 athletes with a delayed union Intramedullary nailing of or nonunion of an anterior tib- tibial shaft fractures has been ial stress fracture. described extensively, yet the Stress fractures of the ante- most common complication rior tibia are most commonly is anterior knee pain.14 Vaisto 5A 5B related to overuse and are de- et al19 noted that 21 (75%) of Figure 5: Postoperative anteroposterior (A) and lateral (B) radiographs of the rived from an imbalance in 28 patients who underwent in- right tibia showing hardware placement. host injury and repair.17 The tramedullary nailing of tibial injury is commonly derived shaft fractures had chronic tients who solely underwent lute compression of the perios- from excessive tensile forces anterior knee pain at 8-year tension band plating were teum that may be detrimental to from posterior muscle activity follow-up. Borens et al13 used symptom free with respect to blood supply in an area where that, under circumstances of an anterior tension band plat- anterior knee pain at 1-year vascular compromise already attenuated bone strength from ing technique in 4 athletes. follow-up.13 exists.21 intensive exercise, can result in They postulated that the plate Gaining absolute stability is Bone healing involves bio- microfractures.18 Stress frac- offers a biomechanical advan- critical for healing in nonunion, logical and mechanical com- tures in recreational athletes tage secondary to its distance transverse tibial stress fractures. ponents. Previous studies have who suddenly elevate the force from the central axis of the To gain rigid fixation at the demonstrated the effectiveness of exertion have a predilection bone that alleviates tensile fracture site, the current authors of proper fracture site debride- for healing because the meta- forces and fracture motion. In used compression plating on ment and supplemental trans- bolic equilibrium is intact.3 addition, intramedullary nail the anterolateral aspect of the versal drilling for delayed- High-level athletes who con- insertion site pain is avoided, tibia (Figure 4B). Additional union or nonunion tibial stress stantly train create an asym- thus abstaining from possibly stability was obtained by us- fractures.22 Bone morphogenic metry in osteoclast and osteo- contributing to the likelihood ing locking screws to support proteins are regarded as a key blast activity, thus producing of debilitating anterior knee the initial reduction and com- regulator in skeletal repair.23 an unfavorable environment pain. All 4 athletes returned pression.20 Combining locking Swiontkowski et al24 noted for healing.8,9 Although heal- to competition at 10 weeks and nonlocking compression that rhBMP-2 reduced the ing may be less likely in an postoperatively. The 3 pa- screws also minimizes abso- frequency of bone grafting

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procedures and secondary pro- runners. J Sports Med Phys 11. Blank S. Transverse tibial ment of delayed union stress Fitness. 1990; 30(3):307-315. stress fractures. A special prob- fractures of the anterior cortex cedures in patients with severe lem. Am J Sports Med. 1987; of the tibia. Am J Sports Med. tibial fractures. The current 3. Jones BH, Bovee MW, Harris JM III, Cowan DN. Intrinsic 15(6):597-602. 1988; 16(3):250-255. authors used rhBMP-2 to sup- risk factors for exercise-related 12. Hulkko A, Orava S. Diagnosis 19. Vaisto O, Toivanen J, Kannus P, plement the biologic response injuries among male and female and treatment of delayed and Jarvinen M. Anterior knee pain army trainees. Am J Sports non-union stress fractures in after intramedullary nailing of fracture healing to improve Med. 1993; 21(5):705-710. athletes. Ann Chir Gynaecol. of fractures of the tibial shaft: the likelihood of union. 4. Jones BH, Cowan DN, 1991; 80(2):177-184. an eight-year follow-up of a Tomlinson JP, Robinson JR, 13. Borens O, Sen MK, Huang RC, prospective, randomized study Polly DW, Frykman PN. et al. Anterior tension band comparing two different nail- J Trauma Conclusion Epidemiology of injuries as- plating for anterior tibial stress insertion techniques. . Anterior tension band plat- sociated with physical training fractures in high-performance 2008; 64(6):1511-1516. ing of chronic anterior tibial among young men in the army. female athletes: a report of 4 20. Wagner M. General principles Med Sci Sports Exerc. 1993; cases. J Orthop Trauma. 2006; for the clinical use of the LCP. stress fractures can dramati- 25(2):197-203. 20(6):425-430. Injury. 2003; 34:B31. cally accelerate recovery and 5. Kaufman KR, Brodine SK, 14. Court-Brown CM, Gustilo T, 21. Zura RD, Browne JA. Current return to play for patients. It Shaffer RA, Johnson CW, Shaw AD. Knee pain after in- concepts in locked plating. also offers several advantages Cullison TR. The effect of foot tramedullary tibial nailing: its J Surg Orthop Adv. 2006; structure and range of motion incidence, etiology, and out- 15(3):173-176. over intramedullary nailing, J Orthop Trauma on musculoskeletal overuse in- come. . 1997; 22. Orava S, Karpakka J, Hulkko A, Am J Sports Med with no violation of the exten- juries. . 1999; 11(2):103-105. et al. Diagnosis and treatment 27(5):585-593. sor mechanism and no associ- 15. Woo EJ. Adverse events after of stress fractures located at the 6. Matheson GO, Clement DB, recombinant human BMP2 in mid-tibial shaft in athletes. Int ated risk of anterior knee pain. McKenzie DC, Taunton JE, nonspinal orthopaedic proce- J Sports Med. 1991; 12(4):419- This technique should be re- Lloyd-Smith DR, MacIntyre dures. Clin Orthop Relat Res. 422. served for those who have JG. Stress fractures in athletes. 2013; 471(5):1707-1711. 23. Ghodadra N, Singh K. Am J A study of 320 cases. 16. Batt ME, Kemp S, Kerslake R. Recombinant human bone failed initial conservative Sports Med . 1987; 15(1):46-58. Delayed union stress fractures morphogenetic protein-2 in the treatment and, due to involve- 7. Barrick EF, Jackson CB. of the anterior tibia: conserva- treatment of bone fractures. ment in high-level athletics, Prophylactic intramedullary tive management. Br J Sports Biologics. 2008; 2(3):345-354. Med cannot accept a prolonged pe- fixation of the tibia for stress . 2001; 35(1):74-77. 24. Swiontkowski MF, Aro HT, fracture in a professional ath- 17. Beck BR. Tibial stress inju- Donell S, et al. Recombinant riod of activity restriction. J Orthop Trauma lete. . 1992; ries. An aetiological review for human bone morphogenetic 6(2):241-244. the purposes of guiding man- protein-2 in open tibial frac- References 8. Boden BP, Osbahr DC. High-risk agement. Sports Med. 1998; tures. A subgroup analysis of stress fractures: evaluation and 26(4):265-279. data combined from two pro- 1. Bennell KL, Malcolm SA, J Am Acad Orthop treatment. 18. Rettig AC, Shelbourne KD, spective randomized studies. Thomas SA, Wark JD, Brukner Surg J Bone Joint Surg Am . 2000; 8(6):344-353. McCarroll JR, Bisesi M, Watts . 2006; PD. The incidence and distribu- 88(6):1258-1265. tion of stress fractures in com- 9. Chang PS, Harris RM. J. The natural history and treat- petitive track and field athletes. Intramedullary nailing for A twelve-month prospective chronic tibial stress fractures. A study. Am J Sports Med. 1996; review of five cases. Am J Sports 24(2):211-217. Med. 1996; 24(5):688-692. 2. Brunet ME, Cook SD, Brinker 10. Green NE, Rogers RA, Lipscomb Coming next issue... MR, Dickinson JA. A survey AB. Nonunions of stress frac- of running injuries in 1505 tures of the tibia. Am J Sports competitive and recreational Med. 1985; 13(3):171-176. trauma update

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