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

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1 Section Editor: Darren L. Johnson, MD Tension Band Plating of a Nonunion Anterior Tibial Stress Fracture in an Athlete Jarrad A. Merriman, MPH; Diego Villacis, MD; Curtis J. Kephart, MD, ATC; George F. Rick Hatch III, MD Abstract: 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. Tibial stress fractures occur in individuals who participate in rigorous activity and present a formidable challenge to clinicians with respect to treatment and the facilitation of a prompt return to action. Commonly described in high-performance athletes and military personnel, the reported incidences are 8% to 21% 1,2 and 2.4% to 13.4%, 3-5 respectively. The most common bone in which stress fractures occur is the tibia, 6 and the prognosis of the injury is dependent on the location of the fracture. Posterior tibial cortex fractures are the most common and favorable in terms of treatment and speed in return to sport Fractures of the anterior cortex are less likely to occur, accounting for 2.7% to 4.6% of stress fractures. 11,12 The authors are from the Department of Orthopedic Surgery, USC Keck School of Medicine, Los Angeles, California. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Jarrad A. Merriman, MPH, Department of Orthopedic Surgery, USC Keck School of Medicine, 1200 N State St, GNH 3900, Los Angeles, CA (jarrad.merriman@usc.edu). doi: / Treatment is often dependent on the broad classification of the fracture as either low or high risk. Low-risk stress fractures are often diagnosed with a thorough history and physical, supported with radiographic evidence, and require rest with limited weight bearing for up to 6 weeks. High-risk stress fractures, such as those in the anterior tibial cortex, are persistent and have a predilection for complete fracture, delayed union, or nonunion and require a more aggressive approach. 8 Two surgical interventions have been described by Chang and Harris 9 and Borens et al 13 and include intramedullary nailing and tension band plating, respectively. The most frequently reported complication of tibial nailing is chronic anterior knee pain. 14 This can be devastating to a jumping athlete who is already predisposed to anterior knee pain as a result of forceful quadriceps contraction with concurrent knee flexion that increases pressure on the posterior kneecap. The authors present a surgical technique for tension band plating supplemented with drilling of the fracture site and bone morphogenic protein pads for a delayed union or nonunion anterior tibial stress fracture in an elite athlete. Materials and Methods The indication for surgery is failed nonoperative management of an anterior tibial cortex stress fracture in an elitelevel athlete. The senior author (G.F.R.H.) begins treatment with rest, CAM walker boot immobilization, and physiotherapy modalities, including ultrasound. If the patient is pain free at 3 months after onset of treatment, then the patient can return to play. If pain persists, then surgical intervention is considered. Time of season (in- vs off-season) factors into decision making for advancing to surgical treatment after the initial 3 months of conservative treatment. Surgical Technique The patient is placed in the supine position on the operat- 534 ORTHOPEDICS Healio.com/Orthopedics

2 Cover Story Cover illustration Lisa Clark JULY 2013 Volume 36 Number 7 535

3 Figure 1: Preoperative lateral radiograph of the right tibia showing a stress fracture of the anterior cortex. ing room table. A tourniquet is placed on the thigh of the operative extremity, which is then prepared and draped by sterile technique. C-arm fluoroscopy is used to identify the fracture site. With the tourniquet inflated, an 8-cm longitudinal incision is made 1 cm lateral to the anterior tibial crest and centered over the fracture site (Figure 3). The fascia over the tibialis anterior is sharply divided longitudinally, leaving a cuff of fascia on the medial side to repair later. The muscle is lifted off the lateral cortex of the tibia with an elevator. The fracture site is directly visualized and carefully debrided using a small curette and rongeur. It is a paramount to debride all soft bone and callus. Next, transversal drilling with a 2.0-mm drill is performed. A small strip of rhbmp-2 using an Infuse bone graft (Medtronic, Minneapolis, Minnesota) is placed in the fracture site. A 6-hole, 4.5-mm locking compression plate (Synthes, Paoli, Pennsylvania) was used for stabilization. Minimal prebending was used to provide some compression of the far 1 Figure 2: Postoperative anteroposterior radiograph of the right tibia showing a healed fracture site. cortex. However, the main goal is to provide compression at the near cortex. A 3.2-mm drill bit is drilled in the neutral position of the distal hole closest to the fracture site with placement of a cortical 4.5-mm screw. The screw should be angled posteriorly to avoid being prominent on the subcutaneous surface of the anterior tibia. Next, the proximal screw hole closest to the fracture site is similarly drilled with insertion of a 4.5-mm cortical screw in the compression (load) position. The 3.2-mm threaded drill guide was used to drill and place 4.0-mm unicortical locking screws in the remaining 4 holes (Figure 4). Care should be taken to avoid being prominent on the anterior surface of the tibia because these locking screws cannot be angled posteriorly. The tourniquet is released and proper hemostasis is achieved. The fascia is closed with a running 2-0 Vicryl suture (Ethicon, Inc, Somerville, New Jersey). A buried 3-0 Vicryl suture is used to close the subcutaneous tissue, and a running subcuticular 3-0 Monocryl (Ethicon, Inc) 2 3 Figure 3: Intraoperative photograph of the right lower extremity showing the markings for an 8-cm longitudinal incision that is 1 cm lateral to the anterior tibial crest and centered over the fracture site. is used on the skin. Steri-stips (3M, St Paul, Minnesota) are applied, followed by gauze and a bio-occlusive dressing. A bandage is wrapped loosely starting distally at the foot and moving proximally. Final fluoroscopy radiographs are taken with large C-arm fluoroscopy (Figure 5). Postoperatively, the patient is placed in a CAM boot and told not to bear weight for 6 weeks postoperatively. The patient is advanced to bearing weight as tolerated at the end of 6 weeks postoperatively. Physical therapy consisting of range of motion exercises for the ankle and knee and isometric exercises without resistance are started at the first postoperative visit. Case Report A 22-year-old collegiate male volleyball player presented with a 3-month history of insidious anterior shin pain and tenderness. Initial radiographs revealed a stress fracture of the anterior cortex (Figure 1). After 12 months of conservative treatment, including a CAM walker boot and crutches, the pain persisted and the fracture progressed 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 morphogenic protein-2 (rhbmp-2) supplementation. The initial postoperative course was uneventful. However, on postoperative day 5, the patient developed erythema about the incision. Complete blood count was within normal limits, the area was not warm or purulent, and the erythema appeared to be centered over the rhbmp-2 pad. Therefore, it was determined that the patient had an inflammatory reaction to the rhbmp-2, a known complication, and the incision was closely monitored for signs of infection. 15 The erythema resolved by postoperative day 10, and no further complications were observed. Rehabilitation for return to sport was as follows: 8 weeks postoperatively, he began partial weight bearing; 12 weeks postoperatively, he began running on the AlterG anti-gravity treadmill (AlterG, Fremont, California); 14 weeks postoperatively, he began underwater running and jumping; and 18 weeks postoperatively, he began traditional agility and plyometric exercises. Radiographs taken 8 months postoperatively were void of any visible black line, indicating a healed fracture site (Figure 2). 536 ORTHOPEDICS Healio.com/Orthopedics

4 Discussion Anterior tibial stress fractures in athletes present a difficult 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 return to former level of play. 16 This lengthy period of inactivity can have significant psychological effects on athletes and even represent financial loss in terms of potential earnings for professional athletes. In the case of nonunion or delayed union, surgical intervention must be explored. The technique presented in this article is advised for use in elite athletes with a delayed union or nonunion of an anterior tibial stress fracture. Stress fractures of the anterior tibia are most commonly related to overuse and are derived from an imbalance in host injury and repair. 17 The injury is commonly derived from excessive tensile forces from posterior muscle activity that, under circumstances of attenuated bone strength from intensive exercise, can result in microfractures. 18 Stress fractures in recreational athletes who suddenly elevate the force of exertion have a predilection for healing because the metabolic equilibrium is intact. 3 High-level athletes who constantly train create an asymmetry in osteoclast and osteoblast activity, thus producing an unfavorable environment for healing. 8,9 Although healing may be less likely in an 4A Figure 4: Intraoperative anteroposterior (A) and lateral oblique (B) photographs of the right tibia showing a 6-hole, 4.5- mm locking compression plate centered over the fracture site with recombinant human bone morphogenic protein-2 supplementation. Figure 5: Postoperative anteroposterior (A) and lateral (B) radiographs of the right tibia showing hardware placement. 5A 4B 5B athlete, rest and immobilization are the recommended initial treatment. Once imaging reveals hypertrophic tibial cortex and a widening fissure, the self-curative capacity is minimal and surgical intervention is likely warranted. 8 Intramedullary nailing of tibial shaft fractures has been described extensively, yet the most common complication is anterior knee pain. 14 Vaisto et al 19 noted that 21 (75%) of 28 patients who underwent intramedullary nailing of tibial shaft fractures had chronic anterior knee pain at 8-year follow-up. Borens et al 13 used an anterior tension band plating technique in 4 athletes. They postulated that the plate offers a biomechanical advantage secondary to its distance from the central axis of the bone that alleviates tensile forces and fracture motion. In addition, intramedullary nail insertion site pain is avoided, thus abstaining from possibly contributing to the likelihood of debilitating anterior knee pain. All 4 athletes returned to competition at 10 weeks postoperatively. The 3 patients who solely underwent tension band plating were symptom free with respect to anterior knee pain at 1-year follow-up. 13 Gaining absolute stability is critical for healing in nonunion, transverse tibial stress fractures. To gain rigid fixation at the fracture site, the current authors used compression plating on the anterolateral aspect of the tibia (Figure 4B). Additional stability was obtained by using locking screws to support the initial reduction and compression. 20 Combining locking and nonlocking compression screws also minimizes absolute compression of the periosteum that may be detrimental to blood supply in an area where vascular compromise already exists. 21 Bone healing involves biological and mechanical components. Previous studies have demonstrated the effectiveness of proper fracture site debridement and supplemental transversal drilling for delayedunion or nonunion tibial stress fractures. 22 Bone morphogenic proteins are regarded as a key regulator in skeletal repair. 23 Swiontkowski et al 24 noted that rhbmp-2 reduced the frequency of bone grafting JULY 2013 Volume 36 Number 7 537

5 procedures and secondary procedures in patients with severe tibial fractures. The current authors used rhbmp-2 to supplement the biologic response of fracture healing to improve the likelihood of union. Conclusion Anterior tension band plating of chronic anterior tibial stress fractures can dramatically accelerate recovery and return to play for patients. It also offers several advantages over intramedullary nailing, with no violation of the extensor mechanism and no associated risk of anterior knee pain. This technique should be reserved for those who have failed initial conservative treatment and, due to involvement in high-level athletics, cannot accept a prolonged period of activity restriction. References 1. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996; 24(2): Brunet ME, Cook SD, Brinker MR, Dickinson JA. A survey of running injuries in 1505 competitive and recreational runners. J Sports Med Phys Fitness. 1990; 30(3): Jones BH, Bovee MW, Harris JM III, Cowan DN. Intrinsic risk factors for exercise-related injuries among male and female army trainees. Am J Sports Med. 1993; 21(5): Jones BH, Cowan DN, Tomlinson JP, Robinson JR, Polly DW, Frykman PN. Epidemiology of injuries associated with physical training among young men in the army. Med Sci Sports Exerc. 1993; 25(2): Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med. 1999; 27(5): Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987; 15(1): Barrick EF, Jackson CB. Prophylactic intramedullary fixation of the tibia for stress fracture in a professional athlete. J Orthop Trauma. 1992; 6(2): Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000; 8(6): Chang PS, Harris RM. Intramedullary nailing for chronic tibial stress fractures. A review of five cases. Am J Sports Med. 1996; 24(5): Green NE, Rogers RA, Lipscomb AB. Nonunions of stress fractures of the tibia. Am J Sports Med. 1985; 13(3): Blank S. Transverse tibial stress fractures. A special problem. Am J Sports Med. 1987; 15(6): Hulkko A, Orava S. Diagnosis and treatment of delayed and non-union stress fractures in athletes. Ann Chir Gynaecol. 1991; 80(2): Borens O, Sen MK, Huang RC, et al. Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases. J Orthop Trauma. 2006; 20(6): Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome. J Orthop Trauma. 1997; 11(2): Woo EJ. Adverse events after recombinant human BMP2 in nonspinal orthopaedic procedures. Clin Orthop Relat Res. 2013; 471(5): Batt ME, Kemp S, Kerslake R. Delayed union stress fractures of the anterior tibia: conservative management. Br J Sports Med. 2001; 35(1): Beck BR. Tibial stress injuries. An aetiological review for the purposes of guiding management. Sports Med. 1998; 26(4): Rettig AC, Shelbourne KD, McCarroll JR, Bisesi M, Watts J. The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia. Am J Sports Med. 1988; 16(3): Vaisto O, Toivanen J, Kannus P, Jarvinen M. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow-up of a prospective, randomized study comparing two different nailinsertion techniques. J Trauma. 2008; 64(6): Wagner M. General principles for the clinical use of the LCP. Injury. 2003; 34:B Zura RD, Browne JA. Current concepts in locked plating. J Surg Orthop Adv. 2006; 15(3): Orava S, Karpakka J, Hulkko A, et al. Diagnosis and treatment of stress fractures located at the mid-tibial shaft in athletes. Int J Sports Med. 1991; 12(4): Ghodadra N, Singh K. Recombinant human bone morphogenetic protein-2 in the treatment of bone fractures. Biologics. 2008; 2(3): Swiontkowski MF, Aro HT, Donell S, et al. Recombinant human bone morphogenetic protein-2 in open tibial fractures. A subgroup analysis of data combined from two prospective randomized studies. J Bone Joint Surg Am. 2006; 88(6): Coming next issue... trauma update 538 ORTHOPEDICS Healio.com/Orthopedics