We evaluated the radiological and functional outcome of one-stage total knee arthroplasty (TKA) and long stem for patients with varied grades of knee arthritis and proximal tibia stress fractures. To conclude, Proximal tibial stress fracture associated with osteoarthritis and varus deformity adds the complexity of the situation. Two stage surgery will also lead to prolonged treatment and increase the morbidity in these elderly patient group. Before High energy injuries such as a fall from a height, sports related trauma or motor vehicle accidents may be responsible for fracture in young adults. (Suppl 1), 189191 (2012). Would you like email updates of new search results? 2006 Jan;25(1):117-28, x. doi: 10.1016/j.csm.2005.08.015. The incidence of bilateral tibial stress fractures is low, and the incidence of simultaneous bilateral cases is even lower [6, 7]. Proximal tibia stress fracture with Osteoarthritis of knee - Radiological and functional analysis of one stage TKA with long stem. No other fractures are seen, bone alignment is preserved. Early detection and intervention is the key to prevent the progression of . A A triplanar osteotomy (6.5 cm in height with a width of 1.5 cm) was created on the medial cortex of the proximal tibia along the 3 sides (proximal, distal, and lateral) of the rectangle; the medial margin of the tibia was used as the medial side of the rectangle.B-D 2 curved skin incisions were made. Acute stress fracture treated with long stem TKA. Anterior . Descriptive statistics were presented as Mean (SD) for continuous variables. Total knee arthroplasty after failed high tibial osteotomy: a systematic review of open versus closed wedge osteotomy. Knee 7(3):187190, Article Medial distal femoral angle and medial proximal tibial angle were calculated. Diagnosis and treatment of stress fractures located at the mid-tibial shaft in athletes. The mean knee society score improved from 21.9 (range, 10 to 45) to 82.8 (range, 1599) [p<0.05]. The average BMI is 31.2 (21.642.0).The mean follow-up period was 28 (range, 660) months. The other conditions reported are rheumatoid arthritis, pyrophosphate arthropathy, Pagets disease [48] and after knee arthroplasty (unicondylar and navigated) [1517]. It can be divided into two groups, namely Fatigue and Insufficiency fractures. Preoperative Knee Society scores and the functional score was compared with postoperative KSS and functional scores using the paired t-test to compare the means between two related groups on the same continuous, dependent variableFigure 5. (A) Anteroposterior view. Takai H, Kii S, Murayama M, Nakane N, Takahashi T. Int J Surg Case Rep. 2018;45:17-21. doi: 10.1016/j.ijscr.2018.02.042. Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete, initially treated with intramedullary nailing: a case report. Fracture of the tibia after a fibula graft for mandibular reconstruction: A rare complication, report of a case. Two patients had two level stress fracture of tibia in the same leg. The proximal part of the tibia is that segment of the tibia bone, which extends to the knee to form the knee joint. https://doi.org/10.1007/s00590-011-0918-3, DOI: https://doi.org/10.1007/s00590-011-0918-3. Stress fractures of the proximal tibia in runners. Stress fracture of the proximal tibia after PFO has not been previously reported. 17 patients had low serum Vitamin D levels (less than 30ng/mL). CAS Radiographs taken 3months after open reduction. Most of these injuries are treated conservatively; however, some may require operative intervention. Thus, your risk of stress fractures in this area rises considerably. No conflict of interest exits in the submission of this manuscript. January Disclaimer, National Library of Medicine Early detection and intervention is the key to prevent the progression of the disease and deformity. Two stage procedure like plating initially followed by TKA in treating these stress fracture will lead to prolonged treatment and pain due to arthritis and malalignment will be persisting till the second procedure and this is not an appealing option. In our series, four patients initially treated with cast immobilisation subsequently went for non-union or malunion with deformity and they eventually underwent long stem TKA, of which, two patient requiring plate fixation and bone grafting. Of which, incidence is more common in shaft of tibia, which accounts for more than 50% of fractures [14]. Case presentation: Advert Symptoms Tibial stress fracture symptoms are very similar to shin splints (medial tibial stress syndrome) and include: Pain on the inside of the shin, usually on the lower third. medial et lateral.10 Pada extremitas inferior dapat menjadi tumpuan permukaan anterior bagian proximal yang stabil saat berdiri, berjalan, dan corpus tibiae . In doubtful scenario, Magnetic resonance scan and bone scan may help in the diagnosis [18]. The proximal tibia is the upper portion of the bone where it widens to help form the knee joint. Clipboard, Search History, and several other advanced features are temporarily unavailable. Accessibility FOIA The surgical procedure of triplanar osteotomy and transverse distraction. This fracture is significant for its tendency to develop a late valgus deformity, known as a Cozen's phenomenon, that must be monitored closely. Version 19 (Chicago, Illinois). 8600 Rockville Pike We believe Low vitamin D level with female sex and concomitant osteoporosis predispose to proximal tibia stress fracture along with osteoarthritis. Although much less common, the proximal medial tibial condyle has been cited as an area subject to stress fracture. Soundarrajan D, Rajkumar N, Dhanasekararaja P, Rajasekaran S. SICOT J. and transmitted securely. One patient had infection and wound dehiscence at six months for which debridement done and had poor functional outcome. (A) Anteroposterior view. https://doi.org/10.1007/s00590-011-0918-3. After placing the tibial tray, the entry point for the tibial stem taken and serial reaming done and fracture site bypassed using long tibial stem. 2021 Sep 1;21(3):434-439. The patient was followed up at the hospital three months after open reduction, and the proximal tibia stress fracture began to heal. Although the pathology of this injury is understood, the aetiology is less agreed upon. The mean deformity at the malunited fracture site in the two patients is 14.6 degrees. No abnormal amount of joint effusion. 1991 Aug;12(4):419-22. doi: 10.1055/s-2007-1024705. Acta Orthop Scand 62(6):531534, Fredericson M, Bergman AG, Hoffman KL, Dillingham MS (1995) Tibial stress reaction in runners. Careers. Dhanasekaran Soundarrajan*, Natesan Rajkumar, Palanisamy Dhanasekararaja and Shanmuganathan Rajasekaran, Department of Orthopaedics, Ganga hospital, A fracture, or break, in the shinbone just below the knee is called a proximal tibia fracture. Most, however, are the result of trauma (injury). Here, we report an unusual case of an otherwise fit, young, adult male who presented with bilateral insufficiency stress fractures occurring simultaneously in both proximal tibiae. Epub 2019 Mar 28. 20 Stress fractures about the tibia, foot, and ankle. Proximal Tibia Metaphyseal Fractures are fractures of the proximal tibia usually seen in children from 3 to 6 years of age. Pes anserine bursitis: pain will be proximal and medial: the bursa does not over lap with the region of tibial MTSS or fracture. There are various causes of these fractures, the most common being a sudden increase in training intensity. Three months after . government site. Pseudoarthrosis described more commonly with stress fractures being diagnosed late or treated conservatively [10,12,19] and makes definitive treatment even more difficult. Reduction and stability are dependent on control of the proximal fragment. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-57457. with tibial fractures treated using the Ilizarov . There were five acute (fracture line visible) and fifteen chronic fractures (endosteal callus and sclerosis at the proximal tibial level) based on the radiographs at presentation. Key words: Stress fracture / Proximal tibia / Osteoarthritis / TKA with long stem, The Authors, published by EDP Sciences, 2018. Introduction: A two-sided p-value (p<0.05) was taken as statistically significant. (B) Lateral view. All patients had unilateral stress fracture and were evaluated preoperatively using the Knee Society score and knee society functional score. This is the American ICD-10-CM version of M84.362A - other international versions of ICD-10 M84.362A may differ. Radiographs of left knee after proximal fibula osteotomy. This site needs JavaScript to work properly. Provided by the Springer Nature SharedIt content-sharing initiative, Over 10 million scientific documents at your fingertips, Not logged in If the fracture is open or comminuted, healing time may take longer. All patients were treated with posterior stabilised TKA with long stem, of which, four patients had screw augmentation for medial tibial bone defect and two patients with malunited fracture at stress fracture site required osteotomy, plating and bone grafting. The muscles in the front of the leg aren't usually worked much, and instead, we favor the back. Proximal fibula osteotomy (PFO) is a new method for treating medial compartment osteoarthritis of the knee, which is based on the theory of differential settlement (nonuniform settlement). They ignored the treatment of stress fracture of the proximal tibia, and the stress fracture was further aggravated after surgery. Planar bone scan showing intense uptake in proximal right tibia and low grade uptake in medial left tibia. A fracture of the proximal tibia may be caused by stress or trauma or secondary to weakening of the bone due to cancer or infection. 2010;19(6):490492. A fracture just below the knee is called a fracture of the proximal end of the tibia. This can make it difficult for clinicians to diagnose and treat this common injury. Record of 15 patients, 14 females and one male who underwent one stage long stem TKAfrom the year January 2008 till December 2014 were reviewed retrospectively. Radiographs taken after total knee arthroplasty. This is rare phenomenon where second stress fracture occur in the same tibia. (A) Anteroposterior view of left knee. Stress fractures should be a differential diagnosis in any young, fit adult who presents with spontaneous knee pain. We report a 62-year-old woman with chronic rheumatoid arthritis (RA) underwent left PFO for chronic knee pain, who developed a stress fracture of the proximal tibia more than 1 year after PFO. PMC Malalignment secondary to osteoarthritis increases the stress at the fracture site, which predisposes to delayed or non-union [13]. (A) Anteroposterior view. Stres fraktur merupakan cedera yang sering terjadi pada kegiatan yang banyak melibatkan aktifitas fisik seperti pada atlet dan militer. Concurrent Bilateral Anterior Tibial Stress Fractures and Vitamin D Deficiency in an Adolescent Female Athlete: Treatment With Early Surgical Intervention. Cite this article as: Soundarrajan D, Rajkumar N, Dhanasekararaja P, Rajasekaran S (2018) Proximal tibia stress fracture with Osteoarthritis of knee Radiological and functional analysis of one stage TKA with long stem. (B) Lateral view. Transverse stress fracture of a low signal intensity of the proximal tibia with surrounding bone marrow edema of high signal. Correction of lateral tibial plateau depression and valgus malunion of the proximal tibia. Knee society functional score Pre and Postop. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Case Rep. Orthop. By restoring limb alignment and bypassing the fracture site, it facilitates fracture healing. Patients treated by TKA and long stem for acute or chronic stress fractures, gives excellent outcome, irrespective of severity of arthritis. (A) Anteroposterior view. (B) Lateral view. Google Scholar, Vossinakis IC, Tasker TP (2000) Stress fractures of the medial tibial condyle. (B) Lateral view of left knee. 2011 May-Jun;35(3):208213. SICOT J, 4, 13. A proximal tibia fracture, or any fracture for that matter, may be classified into the following categories based on several other factors: Compression fracture The bone may appear flatter or wider due to a crushing break. A: 20: . Clinical discussion: The current usage metrics is available 48-96 hours after online publication and is updated daily on week days. HHS Vulnerability Disclosure, Help No abnormal amount of joint effusion. While the distal and middle third of the tibia is the most frequent site for stress fractures (almost 50%), stress fractures of the proximal tibia is relatively rare and could be confused with other types of tibial fractures, thus altering management plans for the clinician. The data were analysed using SPSS for Windows Inc. Patients with tibial stress fracture may use a pneumatic compression device to reduce the time to resumption of full activity. We also assessed any preoperative predictive factors which may lead to stress fracture in this patient group. Through standard midline approach and medial parapatellar arthrotomy, posterior stabilised TKA (19 cases PFC, Depuy and one case Genesis II, Smith and Nephew) done. Stress fractures of the proximal tibiae are common in elderly patients with osteoarthritis, and they are also reported in children. We believe, this is one of the largest series and unique, since we included only proximal tibia stress fracture along with osteoarthritis and reported two cases of two-level stress fracture of tibia of same leg. Clin Case Rep. 2021 May 24;9(5):e03987. The site is secure. This is a preview of subscription content, access via your institution. Radiographs taken before total knee arthroplasty. Accepted: 1986 Dec;(213):167171. There is a transverse fracture line at the lateral aspect of the proximal tibial diaphysis, incomplete, surrounded by faint marrow hyperdensity, and showing new periosteal bone formation. . You can use Radiopaedia cases in a variety of ways to help you learn and teach. PMID: 30879448 Abstract To evaluate the outcome of one stage long stem total knee arthroplasty (TKA) of patients with stress fracture of the proximal tibia of the knee joint. The stem bypassing the fracture site acted as an internal splint and stabilised the fracture. All patients were evaluated using knee society score, knee society functional score and radiologically assessed using full length radiographs Figure 4. Previous surgery in the same limb, rheumatoid arthritis, valgus deformity were excluded. 2016 Aug;24(8):2567-77. doi: 10.1007/s00167-015-3807-1. Radiographs taken 1day after open reduction. All patients were treated with posterior stabilised TKA with long stem, of which, four patients had screw augmentation for medial tibial bone defect. 2016 doi: 10.1155/2016/5094906. This site needs JavaScript to work properly. The mean Medial distal femoral angle was 93.4 and mean medial proximal tibial angle was 83.8. HHS Vulnerability Disclosure, Help -, Hooghof J.T., Mellema J.J., Posthumus M.D., van Raaij J.J. A woman with rheumatoid arthritis and a bilateral fracture of the proximal tibia. A total of 25 who underwent a distal tibial osteotomy were analyzed and compared to a group of 34 who had a standard proximal tibial osteotomy. Published by Elsevier Ltd.. All rights reserved. High energy injuries such as a fall from a height, sports related trauma or motor vehicle accidents may be responsible for fracture in young adults. A tibial stress fracture is a hairline fracture of the tibia bone. 2018;4:13. doi: 10.1051/sicotj/2018006. Radiographs taken 6months after TKA. The length of the stem decided peroperatively bypassing the fracture site and confirmed with fluoroscopy. ICD-9 code: 733.93 Tibial Stress Fracture 719.46 Lower extremity pain Tibial stress injuries, commonly called "shin splints", result when the bone remodeling process . Before Fractures of the proximal tibia can present unique treatment challenges. Epub 2015 Sep 30. Total knee arthroplasty (TKA) with long stem address both the problems by arthritis correction, restoring limb alignment and bypassing the fracture site which aids in union and helps faster recovery in these elderly patient group Figure 1. The mean preoperative tibiofemoral angle is 18.27 varus. -, Tsuchie H., Okada K., Nagasawa H., Chida S., Shimada Y. volume22,pages 189191 (2012)Cite this article. Unable to load your collection due to an error, Unable to load your delegates due to an error. Therefore, PFO is not an appropriate procedure for this type of patient. 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. See this image and copyright information in PMC. In the early stage of proximal tibia stress fracture, due to the concealment of radiography manifestations , and the pain of knee masked the symptoms of the tibial fracture, doctors from another hospital performed total knee arthroplasty(TKA) for the patient, but ignored the treatment of stress fracture of the proximal tibia. Augmentation with plate and bone grafting allows rotational stability [21] and two patients in our series with pseudoarthrosis underwent osteotomy with augmentation plating and bone grafting which eventually healed. Radiographs taken at onset of postoperative pain. The preoperative Vitamin D level is 23.8ng/mL. M84.362A is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Early detection and prompt intervention is necessary to prevent the progression to recalcitrant non-union or malunion. The critical biomechanical factor involved in the etiology and healing of these stress fractures is determined by the coronal plane alignment [11]. Stress fractures of the medial tibial plateau The mean Knee Society functional score improved from 15.5 (range, 10 to 40) to 76.8 (range, 10100) [p<0.05]. A pilot study, Is standard total knee arthroplasty with lateral femoral overhanging a cause of anterior knee pain? Out of 20 patients, five were acute fresh fractures. The mean age was 64 years (range, 5278) which includes three men and 17 women. A randomized controlled trial, Outcomes of double level osteotomy for osteoarthritic knees with severe varus deformity. Princ. Epidemiology /Etiology. Proximal tibia stress fracture caused by severe arthrosis of the knee with varus deformity A case of bilateral stress fractures in an old woman: three years of pain. Epub 2018 Mar 2. Insufficiency fractures of this area have been reported. In the early stage of proximal tibia stress fracture, due to the concealment of radiography manifestations, doctors from another hospital performed total knee arthroplasty (TKA) for the patient. Bilateral stress fracture of the fibulae and periostitis of the tibiae. Res. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. Copyright 2016 Elsevier Inc. All rights reserved. Intraarticular stress fractures, Patients with rheumatoid arthritis, valgus deformity, abnormal bone disease like Pagets or severe osteoporosis are excluded from the study. Cast immobilisation, knee bracing or internal fixation are advocated for treating stress fracture [12]. (B) Lateral view. (C), Radiographs taken 1 day after open reduction. For treating deformity at stress fracture site, osteotomy and plate fixation or long stem TKA with unicortical plating were described. Even for that patient, stress fracture found united at four months followup. doi: 10.1002/ccr3.3987. An official website of the United States government. FOIA Methods: We analysed 20 patients from April 2012 to March 2017 with proximal tibia stress fractures associated with knee osteoarthritis of varied grades. Coimbatore, India, * Corresponding author: soundarortho@gmail.com, Received: Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. Unable to process the form. No abnormal amount of joint effusion. Moderate medial compartment osteoarthritis, with mild changes within the patellofemoral joint, both advanced for age. This procedure has been widely recognized for its advantages of relative simplicity, low rate of postoperative complications, and low postoperative costs. (C) Full-length radiograph of both lower limbs in standing position. One-stage procedure with long tibial stem bypassing the fracture site addresses both the problems of correcting the arthritis and malalignment and acts as an internal splint for the fracture. Learn more about Institutional subscriptions, Resnick D, Niwayama G (1981) Physical injury. The mean tibiofemoral angle improved from 18.27 varus to 1.8 valgus. Patients were followed up at months 1, 3, 6, and 12, and yearly thereafter. Recovery time for a tibia fracture typically takes 4-6 months to heal completely. Stress fracture of the proximal fibula after total knee arthroplasty. sharing sensitive information, make sure youre on a federal Pract. Preoperative serum Vitamin D levels, calcium, phosphorous, alkaline phosphatase and paratharmone levels were recorded. Symptoms often occur after running long distances. One patient had infection and wound dehiscence at six months for which debridement done and had poor functional outcome. Tibial stress fractures are common in the athlete. We diagnosed all patients with the help of radiographs. Bookshelf This is the inner border of the tibia (closest to the midline of the body) toward the back of the leg. Our case is unusual as the patient was a young and otherwise t man who presented with simultaneous bilat-eral proximal tibial fractures. 2022 Springer Nature Switzerland AG. Sudden worsening in severe osteoarthritis patient with pain over proximal tibia should arouse the suspicion of stress fracture and full length radiographs and serial radiographs are necessary to detect the stress fracture. (C) Full-length radiograph of both lower limbs in standing position. Moreover, prolonged cast immobilisation will be associated with morbidity in these patient age group. Please enable it to take advantage of the complete set of features! Editor-in-Chief: Jacques Caton, AndreasF.Mavrogenis - Editorial board On Xray, features suggestive of stress fractures include frank fracture line, periosteal bone formation, endosteal callus, and horizontal or oblique linear patterns of sclerosis [13]. Bethesda, MD 20894, Web Policies Young people experience these fractures often as a result of a high-energy injury, such as a fall from considerable height, sports . The authors declare that they have no conflicts of interest in relation to this article. There are no conflicts of interest. The site is secure. A fracture of the proximal tibia may be caused by stress or trauma or secondary to weakening of the bone due to cancer or infection. Keywords: A prospective study of its cause among military recruits. Stress fracture in the elderly people are reported in association with abnormal underlying bone like osteoporosis. Am J Sports Med. The surgical options described in the literature include internal fixation with plates, osteotomy for correction of axis deformity with plate fixation and TKA at a later date, TKA and nonweightbearing until fracture healing, long-stem TKA for fracture bridging, TKA and intramedullary nailing and combined TKA with long-stem and internal fixation with plate and bone grafting for rotary stability and fracture bridging [10,12,19,20]. Google Scholar, Speed CA, Fordham JN, Cunningham JL (1996) Simultaneous bilateral tibial stress fractures in a 15-year-old milkmana case report. (A) Anteroposterior view. Med. Radiographs taken during followup to examine for bony union. (B) Lateral, Radiographs taken at onset of postoperative pain. No other fractures are seen, bone alignment is preserved. In: Resnick D, Niwayama G (eds) Diagnosis of bone and joint disorders. Foot Ankle Int 19(7):479484, PubMed CAS (A) Anteroposterior view of left knee.. The https:// ensures that you are connecting to the Twenty patients were included in the study. Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK, The Royal Bournemouth Hospital, Bournemouth, Dorset, UK, 48 Southfield Park, Harrow, Middlesex, HA2 6HE, UK, You can also search for this author in Shindle MK, Endo Y, Warren RF, Lane JM, Helfet DL, Schwartz EN, Ellis SJ. Metabolic disease workup with calcium, phosphorous, alkaline phosphatase and parathormone found within normal limits in all patients. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. There is time delay in diagnosing the stress fracture and the various reasons quoted in the literatures are lack of suspicion, ignoring pain and tenderness over the proximal tibia, sudden worsening of arthritis attributed to degenerative meniscal tear or dislodged loose body and not ordering full length radiographs [12]. Tibial stress fractures are small cracks in the cortex of the bone which are usually due to overuse and repetitive stress, such as due to long distance . Medicina (Kaunas). Correlation of clinical symptoms with a new magnetic resonance imaging grading system. Fractures occurring due to repeated micro trauma on the bone over a prolonged time period are called stress fractures [1]. Persistent physes of the proximal tibia may be prone to stress fracture and subsequent collapse of the articular surface and may benefit from resection and fixation when recognized in active duty soldiers and athletes. Two weeks after surgery, he developed pain proximal and lateral to the knee. J Pediatr Orthop B 10(1):7377, Greaney RB, Gerber FH, Laughlin RL, Kmet JP, Metz CD, Kilcheski TS, Rao BR, Silverman ED (1983) Distribution and natural history of stress fractures in US marine recruits. (C) Full-length radiograph of both lower limbs in standing position. (A) Anteroposterior view. Careers. Copyright 2021 The Authors. From the case: Proximal tibial stress fracture ct MRI Knee MRI eCollection 2019. Part of Springer Nature. Conservative management includes Non-weight bearing alone, cast immobilisation or electrical stimulation [12]. Our aim is to analyse the radiological and functional outcome of stress fracture associated with osteoarthritis and varus deformity treated with one stage TKA and long stem Figure 2. Case Discussion Stress fractures are frequently found during competitive sports or intense exercise. The https:// ensures that you are connecting to the To the best of our knowledge, it has not reported in the literature. Oper Orthop Traumatol. Introduction: Proximal tibia stress fractures with knee osteoarthritis pose a challenging situation. No other fractures are seen, bone alignment is preserved. sharing sensitive information, make sure youre on a federal All stress fractures diagnosed by plain radiographs. Soft tissue compromise can present as a component of the injury, or can result from surgical dissection. Unable to load your collection due to an error, Unable to load your delegates due to an error. Animashawun, A.M., Bhattee, G. & Ravikumar, K. Bilateral tibial stress fractures: a case report. Multiple bar diagram was used to represent two sets of inter-related data. By restoring limb alignment and bypassing the fracture site, it facilitates fracture healing. J Am Acad Orthop Surg. Disclaimer, National Library of Medicine Two patients had two level stress fracture of tibia of the same leg. Mil. Conservative treatment with prolonged cast immobilisation in these patients may lead to pseudoarthrosis or non-union and morbidities associated with immobilisation. Milgrom C., Giladi M., Stein M., Kashtan H., Margulies J., Chisin R., Steinberg R., Swissa A., Aharonson Z. Medial tibial pain. The mean tibiofemoral angle improved from 16.57 varus to 1.8 valgus. One patient in our series had periprosthetic joint infection and she underwent wound debridement at six months postop and she had poor functional outcome. Mohile N, Perez J, Rizzo M, Emerson CP, Foremny G, Allegra P, Greditzer HG 4th, Jose J. HSS J. This is compounded by underlying osteoporotic bone in these elderly patient group. eISSN: 2426-8887, http://creativecommons.org/licenses/by/4.0, Mid-term results of impaction bone grafting in tibial bone defects in complex primary knee arthroplasty for severe varus deformity, Medium term results of total knee arthroplasty as a primary treatment for knee fractures, Angular limit for coronal joint deformity correction using intramedullary guidance in total knee arthroplasty. Methods: We analysed 20 patients from April 2012 . Comminuted fracture Three or more fragments are involved in the fracture. (C) Full-length radiograph of both lower limbs in standing position. Clipboard, Search History, and several other advanced features are temporarily unavailable. 8600 Rockville Pike MeSH 2018. Diagnosis can be confirmed with plain radiographs. Often wearing a boot to decrease pain and a period of rest or activity modification can get these injuries to heal in 6 to 8 weeks. eCollection 2021 May. PubMedGoogle Scholar. Would you like email updates of new search results? It is more likely to be seen in patients with osteoporosis and. Patients with proximal tibia stress fracture associated with degenerative osteoarthritis and varus deformity from April 2012 to March 2017 in our institution were analysed. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Di Muzio B, Proximal tibia stress fracture. (A) Anteroposterior view. J Comput Assist Tomogr 22(2):265269. G. Bhattee. Mild to moderate osteoarthritis also may present with stress fracture and one should not hesitate to treat with total knee arthroplasty. Other risk factors reported in the literature were hyperparathyroidism, rheumatoid arthritis, Paget's disease, pyrophosphate arthropathy and after total knee arthroplasty [49]. Knee Surg Sports Traumatol Arthrosc. Federal government websites often end in .gov or .mil. Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum). TIBIAL STRESS FRACTURE Reza Maulana Abstrak. Two patients presented with Nonunion at stress fracture site also treated with TKA with long stem. 2021 Mar 1;57(3):223. doi: 10.3390/medicina57030223. The tibia, or shinbone, is the larger of the two bones in the lower leg. RA is usually not confined to the medial compartment and its pathogenesis is different from that of osteoarthritis. To conclude, Proximal tibial stress fracture associated with osteoarthritis and varus deformity adds the complexity of the situation. December Conclusion: TKA with long stem gives excellent outcome, irrespective of severity of arthritis associated with stress fracture. The incidence of overuse injuries in military recruits during basic military training. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. For two patients who underwent augmentation plating, six weeks of partial weight bearing allowed and then switched over to full weight bearing mobilisation. Bethesda, MD 20894, Web Policies Mild to moderate osteoarthritis also may present with stress fracture and one should not hesitate to treat with total knee arthroplasty. Transverse stress fractures of low signal intensity of the proximal tibia bilaterally with surrounding bone marrow edema of high signal. A fracture of the upper tibia can occur from stress (minor breaks from unusual excessive activity) or from already compromised bone (as in cancer or infection). Knee Surg Sports Traumatol Arthrosc. The mean age was 64 years (range, 5278) which includes three men and 17 women. MRI Knee MRI 2020 Feb;16(1):86-100. doi: 10.1007/s11420-019-09669-z. Most tibial stress fractures occur posteromedially, along the popliteal-soleal line in the middle and distal third of the tibial diaphysis [1,2]. Radiographs taken after total knee arthroplasty. Proximal Tibia Fractures are non-specific and can occur in individuals of all age, race, ethnic group, and gender Adolescent males, who participate in high-impact sports have the highest incidence rate The fracture is also seen in middle-aged and elderly adults, who develop osteoarthritis of the leg In osteoarthritis, coronal deformities like varus or valgus deformity shift the mechanical axis away from the knee and load in the proximal tibia become uneven which leads to abnormal repetitive stress concentration in the metaphyseal area of proximal tibia and this stress also compounded by sagittal deformities in moderate and severe arthritis [10]. Bursitis or tendonitis. Many cases [10,11] treated conservatively described in the literature subsequently went for non-union or pseudoarthrosis with persistent malalignment and further aggravating the symptoms of osteoarthritis which later required surgery. (B) Lateral view. Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management. They result from a failure of the bone to resist and adapt to stress that is too intense and repetitive. Front Pediatr. Eleven patients had involvement in right proximal tibia and nine had left sided stress fractures. 2012 Mar;20(3):167-76. doi: 10.5435/JAAOS-20-03-167. Han JH, Yang JH, Bhandare NN, Suh DW, Lee JS, Chang YS, Yeom JW, Nha KW. Radiographs taken 3 months after open reduction. Your doctor will often prescribe medications for pain-relief for a short period of time after the injury or surgery. (A) Anteroposterior view. PubMed (B) Lateral view. doi: 10.1016/j.clinimag.2010.05.005. Full Record; Other . There is a transverse fracture line at the lateral aspect of the proximal tibial diaphysis, incomplete, surrounded by faint marrow hyperdensity, and showing new periosteal bone formation. Diagnosis is made with orthogonal radiographs of the tibia with CT scan often required to assess for intra-articular extension. Introduction: Proximal tibia stress fractures with knee osteoarthritis pose a challenging situation. Proximal tibial stress fracture associated with mild osteoarthritis of the knee: case report. 1997 May-Jun;25(3):322-8. doi: 10.1177/036354659702500309. Serum calcium, phosphorous, alkaline phosphatase, parathormone help to ruleout any underlying metabolic bone disease. (C), Radiographs taken 6 months after TKA. Federal government websites often end in .gov or .mil. Hence, we believe stress fracture are more common in bilateral osteoarthritis of knees with instability. In our series, we also included patient with six months followup, since we believe that fracture union can be visualised and functional outcome can be evaluated at this period of time. Data correspond to usage on the plateform after 2015. Normal bones when subjected to repeated abnormal stress will lead to fatigue fractures. Eighteen patients had bilateral osteoarthritis of knees of which 12 patients underwent total knee arthroplasty of the next knee within 4 months. 2017 These injuries have a broad spectrum of severity and prognosis. Chung JS, Sabatino MJ, Fletcher AL, Ellis HB. Eighteen patients had bilateral osteoarthritis of knees of which 12 patients underwent total knee arthroplasty of the next knee within 4 months. Clin. Accessibility The authors have no financial and/or personal relationship with other persons or organizations that could inappropriately influence (bias) this body of work. Knechtle B, Jastrzbski Z, Hill L, Nikolaidis PT. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Minimally impacted transverse oblique fracture through the medial tibial diametaphysis, with cortical interruption and a faint sclerotic line continuing to reach the lateral cortex. Am J Sports Med 23(4):472481, Shearman CM, Brandser EA, Parman LM, el-Khoury GY, Saltzman CL, Pyevich MT, Boles CA (1998) Longitudinal tibial stress fractures: a report of eight cases and review of the literature. What is a tibia fracture? (A) Anteroposterior view. 2019 Oct 4;7:397. doi: 10.3389/fped.2019.00397. Osteoarthritis of knees with associated coronal deformities like varus or valgus will lead to asymmetrical loading and abnormal repeated stress concentration in the metaphyseal area of proximal tibia leading to insufficiency stress fractures [10,11]. and transmitted securely. Vitamin D and Stress Fractures in Sport: Preventive and Therapeutic Measures-A Narrative Review. Epub 2018 Apr 18. All our patients had metabolic parameters within their normal levels. Transverse fracture line through the proximal tibia. Br J Rheumatol 35(9):905907, Keret D, Segev E, Hayek S, Lokiec F, Wientroub S (2001) Bilateral symmetric stress fractures in a toddler. It is caused by overuse or repetitive stress. Initial download of the metrics may take a while. Tibial stress fractures are common in the athlete. such as knee pain with a proximal tibial injury, . Five patients had mild varus (less than 10 degrees), six patients had moderate varus (1020 degrees) and Nine patients had severe varus (more than 20 degrees). Two level stress fracture with malunion at stress fracture site treated with TKA with long stem augmented with plating and bone grafting. Stress fractures in the tibia are quite common. On initial history, he did not have any apparent risk factors for stress . Evaluation and treatment of tibial stress fractures. In these patient group, treating stress fracture alone will lead to persistent malalignment at knee level and may lead to non-union and progression of deformity. Arthritis Rheum 40(2):385387, Article A systematic review. Tibial plateau fractures are typically caused by a strong force on the lower leg with the leg in varus or valgus position, or simultaneous vertical stress and flexion of the knee. Proximal tibia stress fractures in elderly are usually associated with primary osteoarthritis of knee joint [1, 2] . Management of these stress fractures is challenging and is either conservative or surgical. Check for errors and try again. Symptoms of a fracture in your. Simultaneous bilateral posteromedial tibial epiphysis stress fractures in a healthy young man: A case report. Current usage metrics show cumulative count of Article Views (full-text article views including HTML views, PDF and ePub downloads, according to the available data) and Abstracts Views on Vision4Press platform. Normal stress on an abnormal underlying bones will cause Insufficiency fractures [3]. All fractures were united at the four to six months follow-up. The mean knee society score improved from 21.9 (range, 10 to 45) to 82.8 (range, 1599) [p<0.05].The mean Knee Society functional score improved from 15.5 (range, 10 to 40) to 76.8 (range, 10100) [p<0.05]. Orava S, Karpakka J, Hulkko A, Vnnen K, Takala T, Kallinen M, Aln M. Int J Sports Med. In addition to the fractured bone, soft tissues (skin, muscles, nerves, vessels and ligaments) can be injured at the time of the fracture. doi: 10.1136/bcr-2016-214886. In addition to the broken bone, soft tissues (skin, muscle, nerves, blood vessels, and ligaments) may be injured at the time of the fracture. The .gov means its official. For stress fracture associated with Nonunion and deformity, long tibial stem alone may not be sufficient. Focal uptake in right proximal tibia with linear lucency on CT. . Tibial stress fractures are not rare--they have been extensively studied in young athletes and soldiers and in elderly people with rheumatoid arthritis, osteoporosis, Paget's disease, pyrophosphate arthropathy, and hyperparathyroidism--but they seldom occur in patients with severe primary degenerative knee osteoarthritis. official website and that any information you provide is encrypted The .gov means its official. Mullaji et al. government site. Swenson EJ Jr, DeHaven KE, Sebastianelli WJ, Hanks G, Kalenak A, Lynch JM. J Med Case Rep. 2018 Jun 29;12(1):183. doi: 10.1186/s13256-018-1718-8. Thorough clinical and laboratory evaluation and careful preoperative planning is essential in managing this complex problem. We evaluated the radiological and functional outcome of one-stage total knee arthroplasty (TKA) and long stem for patients with varied grades of knee arthritis and proximal tibia stress fractures. Most of these injuries are treated conservatively; however, some may require operative intervention. Bilateral knee osteoarthritis, Elderly females, obesity and concomitant osteoporosis are the risk factors associated with these stress fractures. Radiographs of left knee after proximal fibula osteotomy. Case presentation: We report a 62-year-old woman with chronic rheumatoid arthritis (RA) underwent left PFO for chronic knee pain, who developed a stress fracture of the proximal tibia more than 1 year after PFO. Keywords: In our series, eleven patients had mild to moderate osteoarthritis (less than 20 degrees), but presented with stress fracture. Clin. For patients who are unable to stand, full length alignment X rays not taken, but long films taken to cover metadiaphyseal area on either side of the affected knee. Radiology 146(2):339346, Nielsen MB, Hansen K, Holmer P, Dyrbye M (1991) Tibial periosteal reactions in soldiers: a scintigraphic study of 29 cases of lower leg pain. Please enable it to take advantage of the complete set of features! No patients had any trauma or fall. Clin Sports Med. Relat. (A) Anteroposterior view. ADVERTISEMENT: Supporters see fewer/no ads. MeSH Mild joint knee degenerative changes are noted. Full length alignment X rays, Anteroposterior, Lateral and skyline views of knees were taken for preoperative workup. - 27.121.85.226. There are various causes of these fractures, the most common being a sudden increase in training intensity. official website and that any information you provide is encrypted Two patients had two level stress fracture of tibia of the same leg. [18] also showed in their series, that the presence of malalignment at knee level and associated stress fracture may lead to recalcitrant non-union. The amount of varus deformity quantified by tibiofemoral angle and graded into mild (less than 10 degrees), moderate (1020 degrees) and severe (more than 20 degrees). Young athletes and military personnel's with normal bones are more prone for tibial stress fractures [2]. Symptoms of stress fractures in the tibia. There is a transverse fracture line at the lateral aspect of the proximal tibial diaphysis, incomplete, surrounded by faint marrow hyperdensity, and showing new periosteal bone formation. Two patients initially treated with cast application which went into malunion at stress fracture site required osteotomy, plating and bone grafting Figure 3. Stress fractures can be classified according to the condition of the bone affected as: 1) fatigue stress fractures occurring when normal bone is exposed to repeated abnormal stresses; and 2) insufficiency stress fractures that occur when normal stress is applied to bone weakened by an underlying condition. Stress fracture of the proximal tibia after PFO has not been previously reported. Early detection and prompt intervention is necessary to prevent the progression to recalcitrant non-union or malunion. It's one of the most commonly fractured bones in the body. Fig 2a and 2b. Intervention is mostly dictated by locat Tibial Stress Fractures in Athletes The diagnosis of stress fracture in most of the patients described in the literature are by plain radiographs [12]. Treatment options for these dual problem of stress fracture along with osteoarthritis described in the literature include treating the stress fracture alone or to combine with osteoarthritis treatment. This means that the muscle in the back is pulling the tibia without any resistance. BMJ Case Rep. 2016 Apr 22;2016:bcr2016214886. -, Jordaan G., Schwellnus M.P. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. As he returned to play, the pain worsened with jumping and lateral movement and improved with rest. European Journal of Orthopaedic Surgery & Traumatology Partial weight bearing walking with walker support for four weeks and full weight bearing allowed after four weeks for eighteen patients. Even without severe osteoarthritis, stress fracture may occur. This also requires single anaesthesia, allows fracture healing because of its load sharing function of the stem and aids in quicker recovery [20,21]. The first significant symptom of the stress fracture should be recognised and promptly addressed, since the delay in instituting treatment will lead to progression and affect the healing pattern of stress fracture due to malalignment associated with coexisting osteoarthritis. Six months later, the patient underwent open reduction and internal fixation with a plate and screw in the left proximal tibia fracture at our hospital. Med. Ipsilateral stress fracture of the proximal fibula after total knee arthroplasty in a patient with severe valgus knee deformity on a background of Rheumatoid arthritis. The imaging features are those of a subacute stress fracture of the proximal tibia. (A) Anteroposterior view. Skeletal Radiol 28(1):4648, Ekenman I, Halvorsen K, Westblad P, Fellander-Tsai L, Rolf C (1998) Local bone deformation at two predominant sites for stress fractures of the tibia: an in vivo study. 2016. (B) Lateral view. doi: 10.1159/000320310. On cementing the components, care was taken to avoid the intrusion of cement into the fracture site and only the base plate was cemented. The condition is commonly associated with osteoporosis. 2007 Mar;19(1):101-13. doi: 10.1007/s00064-007-1197-3. They have been reported in almost all bones of the body, with the lower extremity weight bearing bones, especially the tibia, tarsals and metatarsals, being affected most often. Commonly seen in road traffic accidents, sports accidents with a high velocity such as skiing, horse riding, and certain water sports. All fractures got united at the last follow-up. Eur J Orthop Surg Traumatol 22 An official website of the United States government. (B) Lateral view.. PubMed Ethical Approval Tibial stress fractures located on the posteromedial border of the tibia often heal uneventfully. Thus conservative treatment which holds good in young patients with stress fracture may not be successful in treating patients associated with osteoarthritis with deformity. The 2023 edition of ICD-10-CM M84.362A became effective on October 1, 2022. Imaging. PMC Correspondence to Mild joint knee degenerative changes are noted. Young people, especially athletes are prone for stress fractures and commonly reported sites include tibial shaft, femoral neck, metatarsal neck and fibula. Athlete; Intramedullary fixation; Stress fracture; Tension band plate; Tibia. 1994 Jun;159(6):421426. We report the case of a 28-year-old male semiprofessional basketball player who presented to an outside hospital with nonhealing stress fractures for which he underwent tibial intramedullary nailing (IMN). Tibial cuts taken using extramedullary jigs. Chronic proximal tibial stress fracture treated with long stem TKA. Conclusion: We have not checked Bone mineral density in our patients, to grade the amount of osteoporosis. Fyllos A, Mitrousias V, Raoulis V, Lampridis V, Vassalou E, Karantanas A, Zibis A. J Musculoskelet Neuronal Interact. A stress fracture can be defined as a fracture of a bone caused by repeated (rather than sudden) mechanical stress. -, Iwasaki K., Yamamoto T., Motomura G., Mawatari T., Nakashima Y., Iwamoto Y. Subchondral insufficiency fracture of the femoral head in young adults. Fatigue fracture; Proximal fibula osteotomy (PFO); Proximal tibia fracture; Rheumatoid arthritis (RA); Stress fracture. In elderly people, stress fractures are associated with abnormal underlying bone. Mild joint knee degenerative changes are noted. Google Scholar, Ohashi K, Ohnishi T, Ishikawa T, Tani H, Uesugi K, Takagi M (1999) Oncogenic ostemalacia presenting as bilateral stress fractures of the tibia. (B) Lateral view. Female patients are far more compared to the male patients in our series. Goey RS, van Drunen B, van der Linden E, van Merkesteyn JPR. Saunders Company, Philadelphia, pp 22402326, Belzunegui J, Maiz O, Lopez L, Gonzalez C, Figueroa M (1997) Leg pain with a periosteal and endosteal reaction. Long term immobilization causes knee stiffness to worsen and does not resolve the pain and symptoms caused by osteoarthritis [10]. -. Bookshelf One patient died at final followup leaving nineteen patients for functional analysis. Orthop. Results: The mean follow-up period was 28 (range, 660) months. 27 . Stress fractures are injuries most commonly seen in the lower limbs and are usually caused by repetitive stress. (B) Lateral view. 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