Paper 15: Surgical Treatment of Chronic Stress Fractures in Athletes

Abstract

During 25 years (1982-2007) 170 chronic, painful, risk or nonunion stress fractures in athletes and dancers were treated surgically. The patients represented several sports events, mainly track and field athletics. Endurance athletes, as runners, cross-country skiers, orienteerers and triathlonists were represented with the biggest number of these stress fractures (appr. 65% of all operations). There were 131 stress fracture operations in males (77%) and 39 in females (23%) in the series. The mean age of the patients was 23 years (14-37 years). The number of operations/bones in the material were: anterior mid-tibia 49, tarsal navicular 25, sesamoid bones of the first MTP joint 16, metatarsal bones 15, tarsal bones 14, medial malleolus 12, and patella 7 cases. There were from 1 to 5 stress fracture operations in the following bones/sites: proximal tibia, femoral shaft, femoral neck, pubis, olecranon, humeral shaft, distal fibula, first rib, calcaneal bone, cuboid bone, pisiform bone and hamulus ossis hamati of the wrist. The fracture caused local pain and training/competing was usually not possible. The diagnosis was done by radiographs (100%). It was confirmed by Technetium scan (30%) and MRI (23%). CT examination was used in a few cases. All patients were treated at first conservatively by rest from causative training, non weight- bearing, crutches, casts, local ultrasound, magnetotherapy, osteoporosis medicines, D-vitamin and extra calcium. Delayed or non-union developed in 125 cases (76%). The risk for a complete fracture was estimated in 21 cases (12.5%) and in the rest of the cases, persistent pain and non healing was indication for surgery. A complete fracture had occurred 14 times, during training or competition. Different surgical techniques were used in the treatment. High risk stress fractures, as femoral neck, distal femoral shaft, mid-tibia, patella, tarsal navicular and MT V basis were treated with internal fixation (nail, screws, plates or tension band method). Pseudoarthrosis surgery included sometims curettage and bone grafting. Some stress fractures were treated with drilling of the fracture site. Postoperative treatment consisted of short immobilization, non weight-bearing and rest, followed by early isometric exercises, swimming, water training, bicycling, weight training and gym trainig. The patients were followed clinically and by radiographs as long as the healing had occurred and the end result was clear. The training pause depended on the bone and surgical treatment method. The patients were able to return to there sports 2-12 months after surgery. The patients were followed appr. for 2 years. The result from surgery was good or excellent in 86 per cent of the cases. All these athletes were able to come back to the same level as before. There were some complications and recurrences in the series. A reoperation was needed in 9 cases. Removal of the osteosynthesis material was done in 91 cases.