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Section Editor: Darren L. Johnson, MD

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Tibial stress fractures oc-cur in individuals who

participate in rigorous activ-ity and present a formidable challenge to clinicians with respect to treatment and the facilitation of a prompt re-turn to action. Commonly de-scribed in high-performance athletes and military person-nel, 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 frac-tures are the most common and favorable in terms of treatment and speed in return to sport.7-10 Fractures of the anterior cortex are less likely to occur, accounting for 2.7% to 4.6% of stress fractures.11,12

Treatment is often depen-dent on the broad classifica-tion of the fracture as either low or high risk. Low-risk stress fractures are often di-agnosed with a thorough his-tory and physical, supported with radiographic evidence, and require rest with limited weight bearing for up to 6 weeks. High-risk stress frac-tures, such as those in the anterior tibial cortex, are per-sistent 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 Harris9 and Borens et al13 and include intramedullary nailing and tension band plat-ing, respectively. The most frequently reported complica-tion of tibial nailing is chronic anterior knee pain.14 This can be devastating to a jumping athlete who is already predis-posed 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 surgi-cal 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 MethodsThe indication for surgery

is failed nonoperative manage-ment of an anterior tibial cor-tex stress fracture in an elite-level athlete. The senior author (G.F.R.H.) begins treatment with rest, CAM walker boot immobilization, and physio-therapy modalities, includ-ing 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 in-tervention is considered. Time of season (in- vs off-season) factors into decision making for advancing to surgical treat-ment after the initial 3 months of conservative treatment.

surgical techniqueThe patient is placed in the

supine position on the operat-

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.

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 90033 (jarrad.merriman@usc.edu).

doi: 10.3928/01477447-20130624-08

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

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Cover Story

Cover illustration © Lisa Clark

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ing room table. A tourniquet is placed on the thigh of the op-erative extremity, which is then prepared and draped by sterile technique. C-arm fluoroscopy is used to identify the fracture site. With the tourniquet in-flated, 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 divid-ed longitudinally, leaving a cuff of fascia on the medial side to repair later. The muscle is lift-ed off the lateral cortex of the tibia with an elevator. The frac-ture 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, trans-versal 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 pre-bending was used to provide some compression of the far

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 posteri-orly to avoid being prominent on the subcutaneous surface of the anterior tibia. Next, the proxi-mal screw hole closest to the fracture site is similarly drilled with insertion of a 4.5-mm cortical screw in the com-pression (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 ante-rior 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 su-ture (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)

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 fluo-roscopy 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 thera-py consisting of range of motion exercises for the ankle and knee and isometric exercises without resistance are started at the first postoperative visit.

case reportA 22-year-old collegiate

male volleyball player pre-sented with a 3-month his-tory 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, in-

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-phogenic protein-2 (rhBMP-2) supplementation.

The initial postopera-tive 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 deter-mined that the patient had an inflammatory reaction to the rhBMP-2, a known compli-cation, and the incision was closely monitored for signs of infection.15 The erythema resolved by postoperative day 10, and no further complica-tions were observed.

Rehabilitation for return to sport was as follows: 8 weeks postoperatively, he began par-tial weight bearing; 12 weeks postoperatively, he began run-ning on the AlterG anti-gravity treadmill (AlterG, Fremont, California); 14 weeks post-operatively, he began under-water running and jumping; and 18 weeks postoperatively, he began traditional agil-ity and plyometric exercises. Radiographs taken 8 months postoperatively were void of any visible black line, indi-cating a healed fracture site (Figure 2).

Figure 1: Preoperative lateral radio-graph of the right tibia showing a stress fracture of the anterior cortex.

1Figure 2: Postoperative anteropos-terior radiograph of the right tibia showing a healed fracture site.

2

Figure 3: Intraoperative photograph of the right lower extremity showing the markings for an 8-cm longitudi-nal incision that is 1 cm lateral to the anterior tibial crest and centered over the fracture site.

3

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discussionAnterior tibial stress frac-

tures in athletes present a dif-ficult challenge to clinicians. Immobilization and rest are often inadequate and can ex-tensively delay the return to competition. Previous studies evaluating nonoperative treat-ment of tibia stress fractures found a mean of 12 months for return to former level of play.16 This lengthy period of inactiv-ity can have significant psy-chological effects on athletes and even represent financial loss in terms of potential earn-ings for professional athletes. In the case of nonunion or delayed union, surgical inter-vention must be explored. The technique presented in this ar-ticle is advised for use in elite athletes with a delayed union or nonunion of an anterior tib-ial stress fracture.

Stress fractures of the ante-rior tibia are most commonly related to overuse and are de-rived 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 frac-tures in recreational athletes who suddenly elevate the force of exertion have a predilection for healing because the meta-bolic equilibrium is intact.3 High-level athletes who con-stantly train create an asym-metry in osteoclast and osteo-blast activity, thus producing an unfavorable environment for healing.8,9 Although heal-ing may be less likely in an

athlete, rest and immobiliza-tion are the recommended ini-tial treatment. Once imaging reveals hypertrophic tibial cor-tex and a widening fissure, the self-curative capacity is mini-mal 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 al19 noted that 21 (75%) of 28 patients who underwent in-tramedullary nailing of tibial shaft fractures had chronic anterior knee pain at 8-year follow-up. Borens et al13 used an anterior tension band plat-ing technique in 4 athletes. They postulated that the plate offers a biomechanical advan-tage 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 pa-

tients 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 us-ing locking screws to support the initial reduction and com-pression.20 Combining locking and nonlocking compression screws also minimizes abso-

lute compression of the perios-teum that may be detrimental to blood supply in an area where vascular compromise already exists.21

Bone healing involves bio-logical and mechanical com-ponents. Previous studies have demonstrated the effectiveness of proper fracture site debride-ment and supplemental trans-versal drilling for delayed-union or nonunion tibial stress fractures.22 Bone morphogenic proteins are regarded as a key regulator in skeletal repair.23 Swiontkowski et al24 noted that rhBMP-2 reduced the frequency of bone grafting

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.

4A 4B

Figure 5: Postoperative anteroposterior (A) and lateral (B) radiographs of the right tibia showing hardware placement.

5A 5B

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procedures and secondary pro-cedures in patients with severe tibial fractures. The current authors used rhBMP-2 to sup-plement the biologic response of fracture healing to improve the likelihood of union.

conclusionAnterior tension band plat-

ing of chronic anterior tibial stress fractures can dramati-cally accelerate recovery and return to play for patients. It also offers several advantages over intramedullary nailing, with no violation of the exten-sor mechanism and no associ-ated risk of anterior knee pain. This technique should be re-served for those who have failed initial conservative treatment and, due to involve-ment in high-level athletics, cannot accept a prolonged pe-riod of activity restriction.

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