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.
Keywords
Tibial stress fractures, which are caused by repetitive microtrauma, are estimated to account for 18.9% to 63.0% of all fractures seen in athletes. 6 However, stress fractures of the midanterior tibia are a relatively uncommon injury among athletes and comprise only 5% to 15% of all tibial stress fractures.12,13,18 Stress fractures of the anterior tibial cortex are located on the tension side of the tibia and are resistant to nonoperative management in many cases; moreover, this type of fracture has been associated with delayed healing.2,4 A trial of nonoperative management of 3 to 6 months is recommended as the initial treatment of midanterior tibial stress fractures.5,7 Nonoperative management may include cessation of sports, partial weightbearing, bracing, and casting.
The success rate of nonoperative management is variable, and the literature reports rates of return to sport as low as 40% 4 and as high as 100%. 19 Using combined data from the literature and their own practice, Beals and Cook 4 examined a total of 51 anterior tibial stress fractures and noted that treatment by rest alone resulted in a 40% rate of return to full activity even after patients reported symptomatic improvement. In contrast, Orava et al 19 reported a 100% rate of return to sports and an average healing time of 6 months in 8 patients treated with modified rest alone. Similarly, results for pneumatic bracing have been variable, with 1 randomized prospective study noting expedited return to full activity among patients treated with pneumatic bracing and rest versus those treated with rest alone (21 days vs 77 days) and another study noting no difference between groups.1,20 Regardless of the treatment modality, patients are generally cleared to return to full-intensity sports once radiographic union and clinical union are achieved. If symptoms persist after a trial of nonoperative management, surgical intervention should be considered.
Although most tibial stress fractures heal with nonoperative treatment, some may require surgical management. Surgical treatment options include intramedullary nailing, tension band or compression plating, and drilling with debridement and bone grafting. Some surgeons prefer reamed intramedullary nailing, and it is the preferred treatment modality at our institution as it results in satisfactory rates of clinical and radiographic union9,23; however, intramedullary nailing of tibial shaft fractures has frequently been reported to be associated with anterior knee pain.21,22 This can be a debilitating and career-ending problem in high-performance athletes. In a cohort of 50 patients with traumatic tibial shaft fractures, 67% of patients treated with transtendinous nailing and 71% of patients treated with paratendinous nailing and routine nail removal at 1.5 years after fixation reported anterior knee pain at an average follow-up of 3 years, with the majority of these patients reporting that they were impaired by the pain. 21 Moreover, at an average follow-up of 8 years, 29% of patients in the same cohort reported chronic anterior knee pain. 22 More recently, tension band plating has been advocated to avoid the risk of anterior knee pain associated with intramedullary nailing, but this treatment may result in symptomatic hardware requiring removal. 25
To our knowledge, the current literature lacks a comprehensive review of surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in elite or high-performance athletes. Therefore, we performed a systematic review to present a comprehensive assessment of the literature reporting outcomes for anterior tibial stress fractures in high-performance athletes who were treated surgically.
Methods
Search Strategy
A literature search of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL (Cumulative Index of Nursing and Allied Health) databases from inception to February 2017 was performed by use of various combinations of the following keywords: tibia/tibial, stress, fracture, surgery/surgical, operative, tension band plating, plate fixation, intramedullary nailing, bone grafting, curettage, excision, and drilling. Two reviewers independently screened the titles and abstracts for all search results to evaluate their appropriateness for inclusion. When required, the full-text articles were obtained for further screening. Level 1-4 studies on the surgical treatment outcomes of anterior tibial stress fractures were eligible for inclusion. Technique reports or studies that lacked outcome data, review articles, single case reports, non-English articles, and cadaveric or otherwise in vitro studies were excluded.
A total of 711 articles were screened on the basis of title/abstract, and 25 full-text articles were reviewed to determine their eligibility for inclusion. In addition, to ensure that no relevant articles were missed in the search, the reference lists for each article were carefully screened. The items in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 checklist for systematic reviews were used as a guide for this review. 16
Data Extraction
The 2 independent reviewers used a standardized review form for data collection. Each of the articles meeting the inclusion criteria underwent careful review, and several data points were extracted. When available, demographics (ie, age, sex), sport, and follow-up time were recorded. Time to radiographic union, defined as complete anterior bridging of the callus across the stress fracture site, and time to clinical union, defined as cessation of pain with activity, were also recorded. Moreover, ability and time to return to play as well as return to preinjury level of competition were recorded. The types and incidence rates of complications reported in each article were recorded, including infection, delayed union, nonunion, anterior knee pain, subsequent fracture, and symptomatic hardware. Data regarding revision surgery and any removal of hardware were recorded. The extracted data were used to summarize the surgical outcomes of tibial stress fracture reported in the literature.
Results
Study Characteristics
An initial search of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases yielded a total of 711 articles. After duplicate publications were excluded, a total of 390 articles were further evaluated. Once these articles were screened by title, the abstracts for 161 articles were carefully reviewed. A total of 12 studies, published between 1984 and 2015, reporting surgical outcomes for anterior tibial stress fractures met the inclusion criteria and were included in this review. A PRISMA flow diagram detailing our literature search and rationale for inclusion and exclusion is presented in Figure 1. Two relevant articles reporting the general surgical outcomes of stress fractures at various anatomic sites were excluded because they did not report specific outcome measures for surgically treated anterior tibial stress fractures.12,17
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram describing the inclusion process for studies in the systematic review.
All 12 studies were retrospective case series (level 4 evidence). Seven of the studies reported follow-up times.4,8 -10,13,23,25 The overall mean follow-up time for these studies was 23.3 months. The remaining 5 studies did not report such data. A summary of the characteristics of the included studies is presented in Table 1.
Study Characteristics a
NR, not reported; ORIF, open reduction internal fixation.
Original data were not averaged.
Article did not specify whether use of the term healing represents radiographic healing or clinical healing.
Patient Demographics
Collectively, surgical outcomes for 115 patients with 123 anterior tibial stress fractures were reported in the literature. Of the 115 patients, 74 were male (64.3%) and 41 were female (35.7%). The mean age in each case series ranged from 16.7 to 32.6 years. However, Beals and Cook 4 did not report mean age. Body mass index was not reported in any of the studies. The top 3 most common sports played by patients were running, track and field, and basketball. Table 2 summarizes the frequencies of the sports played by patients in the included studies.
Participation in Sports
Multiple sports were reported for several patients.
Surgical Treatment
Eight studies reported that a trial of nonoperative treatment was attempted before surgical intervention; for the studies that reported such data, the overall mean duration of nonoperative management was 10.9 months (range, 2.7-25.8 months).8-11,13,15,24,25 The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). In this review, the term compression plating collectively refers to tension band plating, laminofixation, and open reduction with internal fixation (ORIF) with plating. The frequency of each treatment modality is presented in Table 3. In the case series by Beals and Cook, 4 patients underwent a variety of procedures, including excision, drilling, cancellous bone grafting, ORIF with plate fixation, and closed reamed nailing. Only 7 studies provided additional details regarding surgical technique.8-10,13,15,23,25
Frequency of Surgical Procedures
Borens et al 8 and Zbeda et al 25 reported the outcomes of patients who underwent tension band plating with concomitant bone grafting, whereas Cruz et al 10 reported outcomes for isolated tension band plating. In all 3 studies, the fracture was stabilized with either a 2.7-mm or 3.5-mm, 6-hole Synthes locking compression plate.8,10,25 Both Borens et al and Cruz et al placed a minimum of 3 screws on each side of the fracture, whereas Zbeda et al placed a minimum of 2 screws proximal and distal to the fracture. In addition, Borens et al and Zbeda et al performed concomitant bone grafting with demineralized bone matrix (Grafton DBX Flex). In the case series by Liimatainen et al, 13 the laminofixation cohort underwent plate fixation with either a dynamic compression plate or a reconstruction plate, with the plate set on the lateral side of the tibia and 6 screws drilled through both cortices or 4 screws drilled through 1 cortex; the drilling cohort underwent anteromedial and lateral drilling, with holes made by use of a 2-mm drill bit through the medial and lateral cortices and through the thick anterior cortex.
In the case series by Miyamoto et al, 15 patients with completed or multiple refractory stress fractures underwent intramedullary nailing with a 10-mm nail (Synthes) with proximal and distal locking, whereas patients with single, nondisplaced stress fractures underwent drilling and bone grafting of the lesion with iliac crest aspirate, demineralized matrix putty (Grafton DBM Flex; Osteotech), and/or BMP-7 (OP-1; Stryker) at the surgeon’s discretion. Chang and Harris 9 performed reamed intramedullary nailing using the Russel-Taylor system (Smith & Nephew), and concomitant percutaneous drilling was performed in 2 of 5 patients in their case series. The patients in the case series by Varner et al 23 underwent intramedullary nailing with placement of a single proximal locking screw.
Clinical and Radiographic Union
Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). Of the 15 fractures that remained symptomatic despite surgical treatment, 10 were treated with drilling, 3 with compression plating, 1 with intramedullary nailing, and 1 with excision alone. Time to clinical union, defined as cessation of pain with activity, was reported in only 2 studies.15,23 In the case series by Miyamoto et al, 15 clinical union was achieved at an average of 1.4 months for the group who underwent drilling and concomitant bone grafting; although these data were not reported for two-thirds of the patients in the intramedullary nailing group, the authors noted that clinical union was achieved at 2.5 months for a single patient. Varner et al 23 reported a mean time to clinical union of 2.7 months in their cohort of patients treated with intramedullary nailing.
Time to radiographic union, defined as complete anterior bridging of the callus across the stress fracture site, was reported in 5 studies.8,15,19,23,25 In 2 case series reports, patients treated with compression plating and concomitant bone grafting had a mean time to radiographic union of 2.4 months.8,25 In the case series by Orava et al, 19 the mean time to radiographic union for patients treated with transverse drilling was 7.1 months. Moreover, Miyamoto et al 15 reported that fractures treated with drilling and concomitant bone grafting demonstrated radiographic healing at an average of 5.3 months; in this same case series, radiographic union was achieved at 4 months for a single patient in the intramedullary nailing group. Varner et al 23 reported a mean time to radiographic union of 3 months among patients treated with intramedullary nailing. A summary of select outcome measures is presented in Table 4.
Summary of Surgical Outcomes a
NR, not reported; RTP, return to play.
Original data were not averaged.
P = .002.
Complications
There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Delayed union was noted in 1 patient who was initially treated with compression plating. 4 Moreover, Liimatainen et al 13 reported that the fracture line was persistent for 3 patients in the drilling group. No postoperative infections were reported in any of the studies. Subsequent tibial fractures were reported in 8 patients (7.0%).4,19,23,24 Beals and Cook 4 reported that 1 patient refractured after undergoing bone grafting and another refractured after undergoing reamed nailing. In the case series by Orava et al, 19 2 patients refractured after transverse drilling. Varner et al 23 reported that 1 patient who underwent intramedullary nailing experienced a traumatic tibial fracture distal to the nail 1 year after the index procedure. In the case series by Yamada and Leamor, 24 all 3 patients developed painful stress reactions distal to the nail, and 1 of these patients also developed a flexion contracture.
In the case series by Zbeda et al, 25 38% of patients treated with compression plating developed symptomatic hardware; the authors also noted that 1 patient in their case series developed a seroma secondary to a previously undiagnosed nickel allergy. Moreover, Borens et al 8 reported that 1 patient experienced mild discomfort related to the plate. Among patients treated with compression plating in the case series by Liimatainen et al, 13 tibial pain was noted in 4 patients, whereas tibial pain was noted in only 1 patient treated with drilling. A patient treated with drilling and concomitant bone grafting in the case series by Miyamoto et al 15 developed posterior tibial tendinitis.
In the case series by Chang and Harris, 9 2 of 3 patients with proximally locked nails developed persistent discomfort over the screws. Chang and Harris also noted that mild peripatellar or patellar tendon pain was the most commonly reported symptom in the 6-month period after intramedullary nailing, although they did not specify how many patients experienced this symptom. This was the only report of anterior knee pain among patients treated with intramedullary nailing. Varner et al 23 reported that a patient treated with reamed intramedullary nailing developed bursitis at the nail insertion site. A summary of the complications reported in the included studies is presented in Table 5.
Complications According to Treatment Modality
Revisions and Subsequent Surgery
A total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. In the study by Beals and Cook, 4 1 patient initially treated with bone grafting experienced recurrent symptoms and subsequently underwent excision, drilling, and bone grafting with resolution of symptoms. The same patient also developed a stress fracture in the contralateral tibia, which was initially treated with compression plating but failed to heal and subsequently underwent plate removal and bone grafting; this patient refractured 7 months later and was treated with compression plating and concomitant bone grafting, which resulted in healing and resolution of symptoms. In the case series by Orava et al, 19 1 patient who was initially treated with drilling completed the fracture after a fall a few weeks postoperatively and subsequently underwent bone grafting, which resulted in healing without further complications.
In the comparative case series by Liimatainen et al, 13 6 patients underwent subsequent procedures. In the drilling group, 1 patient underwent reoperation with drilling, another patient underwent reoperation with plating, and 1 patient underwent a fasciotomy for medial tibial pain despite uneventful healing of the fracture; all 3 patients ultimately had good outcomes. 13 In the compression plating group, 1 patient underwent reoperation with drilling, which resulted in a poor outcome; 2 patients underwent a fasciotomy for tibial pain and 2 patients underwent plate removal combined with a fasciotomy for tibial pain, with good outcomes noted in all 4 patients at follow-up. 13
Moreover, in the case series by Zbeda et al, 25 5 patients who underwent compression plating with concomitant bone grafting subsequently underwent hardware removal for plate prominence; 1 of these patients remained symptomatic despite fracture union and subsequently underwent intramedullary nailing at the time of plate removal. Borens et al 8 also reported that 1 patient who was treated with compression plating and concomitant bone grafting experienced symptomatic hardware and underwent hardware removal 2 years after the index procedure.
In the study by Yamada and Leamor, 24 all 3 patients treated with intramedullary nailing required subsequent procedures due to complications. One patient underwent revision intramedullary nailing due to a stress reaction at the distal end of the nail, with resolution of symptoms noted at follow-up; the initial nail was inserted and fixed proximally without a distal screw, whereas the subsequent nail was also fixed distally. Another patient underwent manipulation under anesthesia to correct a flexion contracture, with full range of motion achieved after the procedure; this patient also subsequently underwent nail removal due to a painful stress reaction at the distal end of the nail. At the time of their report, a third patient in the case series by Yamada and Leamor was scheduled to undergo insertion of distal interlocking screws to correct a painful stress reaction.
Return to Sport
Of 115 patients, return to sport status after surgery was reported for 113 patients; return to sport status was not reported for 2 patients in the case series by Green et al. 11 A total of 107 patients (94.7%) were able to return to play after surgery. However, 6 patients did not return to play after surgery. In the case series by Beals and Cook, 4 1 patient treated with excision alone was unable to return to play because of persistent symptoms. In the comparative case series by Liimatainen et al, 13 3 patients in the drilling group and 1 patient in the compression plating group had to end their sports careers early because they were unable to return to full sports activities after surgery, although these patients did not have symptoms in the absence of rigorous activity. Yamada and Leamor 24 reported that 1 patient treated with intramedullary nailing had not returned to sports at the time of their report.
Return to preinjury level of competition was reported in only 3 studies.13,15,25 Liimatainen et al 13 reported that 10 of 20 patients (50%) and 27 of 29 patients (93.1%) in the drilling and compression plating groups, respectively, were able to return to their preinjury level of competition after surgery. Miyamoto et al 15 noted that all 5 patients treated with drilling and concomitant bone grafting as well as the 3 patients treated with intramedullary nailing were able to return to their preinjury competition level. Moreover, Zbeda et al 25 reported that 12 of 13 patients (92.3%) treated with compression plating and concomitant bone grafting were able to return to their preinjury level of competition after surgery.
Discussion
To our knowledge, this is the first systematic review to evaluate outcomes of surgically treated anterior tibial stress fractures. Although the literature is limited, general conclusions can be drawn regarding clinical outcomes after operative management of this injury in athletes. Our findings indicate that rates of symptom resolution and return to sport are high across all surgical treatment modalities, with the exception of patients who underwent drilling in 1 case series. 13 Liimatainen et al 13 reported that patients treated with drilling had lower rates of symptom resolution (50% vs 93.1%) and radiographic union (85% vs 100%) than patients treated with compression plating. It is important to note that this was the only study that performed statistical comparisons between treatment modalities.
Over a quarter of patients experienced complications after their index procedure, and approximately 15% of patients required a subsequent surgery. The highest rate of symptomatic hardware was noted among patients treated with intramedullary nailing, with the screws and not the nail itself appearing to cause symptoms. Multiple reports indicate that intramedullary nailing may also be associated with subsequent fractures, particularly distal tibial stress fractures, that require surgical intervention.23,24 This complication may be related to nail placement; failure to insert the nail more distally, down to the physeal scar, may place patients at increased risk for developing distal fractures or stress reactions. Moreover, Baublitz and Shaffer 3 reported on a single case in which a patient with a midanterior tibial stress fracture was treated with concomitant corticotomy and intramedullary nailing and subsequently developed a spiral fracture at the cortical debridement site; in light of this complication, the authors recommended against aggressive corticotomy and advocated the use of percutaneous drilling instead. 3 However, the existing literature suggests that violating the fracture through bone grafting or drilling may predispose patients to refracture.
In their case series of 5 patients, Chang and Harris 9 noted that anterior knee pain was the most common symptom within the 6-month period after intramedullary nailing but did not specify how many patients experienced this symptom or whether it was a transient finding. While multiple studies have indicated that anterior knee pain is a common complication after intramedullary nailing of traumatic tibial shaft fractures,21,22 this complication was not a major finding in the studies that evaluated outcomes of intramedullary nailing in the setting of midanterior tibial stress fractures included in this review. This may be due to the absence of acute trauma, which may affect the knee joint at the time of the tibia fracture and the ability to countersink the tibial nail when treating a stress fracture, thereby preventing proximal irritation from the nail. The disparity in postoperative anterior knee pain suggests that the complications associated with intramedullary nailing of traumatic tibial fractures and tibial stress fractures differ in this regard.
Although compression plating presumably carries a lower risk of postoperative anterior knee pain compared with intramedullary nailing, the high rate of symptomatic hardware and plate removal reported in the current literature presents an important consideration. While the current literature does not allow for comparisons with respect to plate positioning, future studies should examine whether rates of radiographic union and symptomatic hardware are associated with plate placement. It is also important to note that plate fixation may not be suitable for concomitant fixation of multiple stress fractures, particularly if the fractures are not in close proximity.
Of the 5 studies that reported time to radiographic union, the shortest mean time to union (2.4 months) was noted in patients treated with compression plating and concomitant bone grafting in 2 studies,8,25 whereas the longest mean time to radiographic union (7.1 months) was noted in patients treated with transverse drilling in a single case series. 19 Although further research is necessary to determine whether healing occurs at a faster rate with compression plating compared with other treatment modalities, the current literature suggests that compression plating may be superior to transverse drilling in this regard. Such information would be of interest to orthopaedic surgeons and high-performance athletes who may be eager to return to competition in a timely manner.
While there is a paucity of literature on the biomechanical properties of different fixation methods used for the treatment of midanterior tibial stress fractures, a recently published cadaveric study by Markolf et al 14 reported that locked or unlocked plate fixation, with the plate edge placed on the lateral surface of the tibia 1 mm from the anterior tibial crest, resulted in superior resistance to the opening of a simulated midtibial stress fracture compared with intramedullary nailing with or without locking screws. However, further research is required to help guide the selection of fixation hardware in the setting of midanterior tibial stress fractures.
Limitations
This systematic review is not without its limitations. First, a limited number of studies were available that reported outcomes of surgically treated anterior tibial stress fractures. Second, all of the included studies were retrospective case series; due to their inherent biases, such studies cannot be used to draw definitive conclusions regarding the optimal treatment modality for this injury. However, the data presented in this review summarize the empirical evidence currently available to orthopaedic surgeons and can be used as a general guide for surgical planning. Third, the current literature does not allow for conclusions about long-term outcomes as the mean follow-up was approximately 23 months for the studies that reported such data. Fourth, the lack of homogeneity of the reported outcome measures in each study is also a limitation of this review, as meaningful comparisons for each outcome measure were not possible for all treatment modalities. Further research using prospective comparative study designs is warranted to determine the optimal operative treatment method for arresting the progression of midanterior tibial stress fractures while promoting bone healing; however, conducting such studies may be particularly challenging due to the relative infrequency of this injury.
Conclusion
The existing 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 orthopaedic surgeons and their patients. Intramedullary nailing appears to have the highest rates of symptomatic hardware and subsequent fracture. However, evidence suggests that in contrast to traumatic tibial shaft fractures treated with intramedullary nailing, anterior tibial stress fractures treated in this fashion are not commonly complicated by postoperative anterior knee pain. Moreover, evidence indicates that drilling may be associated with inferior clinical outcomes compared with compression plating. While compression plating results in favorable outcomes, it is also associated with high rates of symptomatic hardware and subsequent plate removal. Our findings, while informative, should be viewed in the context of the associated limitations. Higher level evidence is required to make specific recommendations regarding the optimal treatment modality for high-performance athletes presenting with anterior tibial stress fractures that are refractory to nonoperative management.
Footnotes
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
An online CME course associated with this article is available for 1 AMA PRA Category 1 Credit™ at 
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