Femoral Stress Fractures Research Articles

Fractures Associated with Computer-Navigated Total Knee Arthroplasty

Computer navigation for total knee arthroplasty has become increasingly popular because of its potential to improve the accuracy of placement of the femoral and tibial components1-4. However, complications related to the navigation system have only rarely been reported in the orthopaedic literature3,5,6. Ossendorf et al. reported on a femoral stress fracture that occurred after computer-navigated total knee arthroplasty7. This nondisplaced stress fracture occurred at the pin-hole site for the navigation trackers. We present two cases of stress fracture that were associated with a transcortical pin track that had been drilled to allow placement of navigation trackers. These two cases provide information about the risk of the development of a stress fracture after placement of a transcortical pin. Hopefully the risk of a stress fracture can be reduced by making surgeons aware of this complication. The patients were informed that data concerning their cases would be submitted for publication, and they consented. Case 1. A seventy-year-old woman presented to our institution with painful osteoarthritis of both knees. The condition had begun six years earlier. She subsequently underwent two computer-navigated total knee arthroplasties: the right knee was replaced first, with use of a low-contact-stress rotating-platform prosthesis (New Jersey LCS; DePuy, Warsaw, Indiana); and the left knee was replaced one week later, with insertion of a press-fit condylar rotating-platform prosthesis (PFC Sigma RPF; DePuy). The operations were performed by one team (Y.-B.J. and H.-J.J.), the members of which had together performed several hundred conventional total knee arthroplasties and more than eighty computer-assisted procedures before this operation. The Kolibri computed tomography-free knee navigation system (BrainLAB, Munich, Germany) and Ci software (DePuy) were used. With the patient under general anesthesia and with the use of tourniquet control, a modified subvastus approach to …

Bone marrow edema syndromes of the hip: MRI features in different hip disorders

The objectives of this study were to describe the essential magnetic resonance imaging (MRI) features of bone marrow edema syndromes affecting the hip joint. In addition, to evaluate the role of MRI in the assessment of hip joint involvement in different clinical settings that may share similar clinical findings. Thirty-four patients who complained of hip pain were studied consecutively. Of these, 21 were men (61.8%) and 13 were women (38.2%). After clinical assessment of possible hip disease, plain radiograph and MRI study of both hips were performed. The literature was searched using keywords: bone marrow edema, hip, and MRI. All patients had antalgic gait and limping. Initial clinical examination revealed painful limited internal and external rotation of the affected hip/hips suspect for hip disease. Unilateral hip involvement was identified in 31 patients (91.2%), and bilateral hip involvement was found in three patients (8.8%), with a total of 37 hips evaluated by MRI. The final diagnoses in our patients were: reactive arthritis (1), transient osteoporosis (7), avascular necrosis (10), osteoarthritis (2), tuberculous arthritis (4), septic arthritis (2), osteomyelitis (2), sickle cell anemia (2), lymphocytic leukemia (1), and femoral stress fracture (3). Bone marrow edema affecting the hip is neither a specific MR imaging finding nor a specific diagnosis and may be encountered in a variety of hip disorders due to different etiologies. MR imaging is the modality of choice when clinical examination is suspect for hip disease and plain radiographs are normal or equivocal. Early diagnosis and treatment is important in many of the disorders. The literature is reviewed regarding bone marrow edema of the hip.

Poster 119: Rare Recurrent Left Femoral Shaft Stress Fractures in a 19-Year-old Female Collegiate Long-Distance Runner: A Case Report

Poster 119: Rare Recurrent Left Femoral Shaft Stress Fractures in a 19-Year-old Female Collegiate Long-Distance Runner: A Case Report

Bilateral Periprosthetic Stress Fractures in a Juvenile Chronic Arthritis Patient Secondary to Bilateral Genu Valgum

Lateral insufficiency fractures following total hip replacement have been reported with the femoral stems positioned in varus, together with osteopenia of the lateral femoral cortex. Any abnormal alignment of the lower limbs, such as genu valgum, will alter the load distribution across the femoral cortices, and repetitive loading during walking will predispose the bones to stress fractures at any stress riser point, such as the tip of a femoral component. Bilateral femoral stress fractures post total hip replacements have not been previously described. We present a 55-year-old woman, diagnosed with juvenile idiopathic arthritis, who had undergone bilateral total hip replacements and bilateral knee replacements. The knees 15 years postoperatively were in valgus and the left knee was extremely stiff, flexing to just 5. The patient presented with bilateral thigh pain, with plain radiographs confirming bilateral periprosthetic fractures of the femur at the tip of well-fixed femoral components. There was no history of injury and her hips were functioning well up to this time. The patient required revision of both hips to long-stem uncemented components, bypassing the fractures, and revision of both knees to stemmed semi-constrained implants, thereby correcting the alignment of both lower limbs. Both fractures healed and the patient is currently pain-free and mobile with walking aids. Surgeons must remain aware that when implants are in situ, abnormal alignments will lead to abnormal forces, and stress fractures are likely to occur at any stress riser around the implant. Avoiding malalignment will avoid this complication.

Bilateral periprosthetic stress fractures in a juvenile chronic arthritis patient secondary to bilateral genu valgum

Lateral insufficiency fractures following total hip replacement have been reported with the femoral stems positioned in varus, together with osteopenia of the lateral femoral cortex. Any abnormal alignment of the lower limbs, such as genu valgum, will alter the load distribution across the femoral cortices, and repetitive loading during walking will predispose the bones to stress fractures at any stress riser point, such as the tip of a femoral component. Bilateral femoral stress fractures post total hip replacements have not been previously described. We present a 55-year-old woman, diagnosed with juvenile idiopathic arthritis, who had undergone bilateral total hip replacements and bilateral knee replacements. The knees 15 years postoperatively were in valgus and the left knee was extremely stiff, flexing to just 5. The patient presented with bilateral thigh pain, with plain radiographs confirming bilateral periprosthetic fractures of the femur at the tip of well-fixed femoral components. There was no history of injury and her hips were functioning well up to this time. The patient required revision of both hips to long-stem uncemented components, bypassing the fractures, and revision of both knees to stemmed semi-constrained implants, thereby correcting the alignment of both lower limbs. Both fractures healed and the patient is currently pain-free and mobile with walking aids. Surgeons must remain aware that when implants are in situ, abnormal alignments will lead to abnormal forces, and stress fractures are likely to occur at any stress riser around the implant. Avoiding malalignment will avoid this complication.

Simulated effects of marathon training on bone density, remodeling, and microdamage accumulation of the femur

Stress fractures are mechanically induced injuries resulting from fatigue damage to bone due to repetitive loading and are common injuries occurring in runners. In this study, we used computer simulations of marathon training programs to examine the effects of endurance running on femoral density, remodeling, and microdamage accumulation. Simulated remodeling activity increased in the femoral neck and proximal cortex and predicted microdamage increased in all regions examined after 16 weeks for each program. Daily running for three years produced more microdamage than the advanced training schedule over the same time period. Areas of high remodeling and damage corresponded to clinically observed locations of femoral stress fractures, indicating that the simulation may be useful in designing training programs to reduce fracture risk.

Association Between Serum 25(OH)D Concentrations and Bone Stress Fractures in Finnish Young Men

Low vitamin D level may predict rickets, osteomalacia, or osteoporosis. We examined serum 25(OH)D concentration as a predisposing factor for bone stress fracture in 756 military recruits. The average serum 25(OH)D concentration was significantly lower in the group with fracture, suggesting a relationship between vitamin D and fatigue bone stress fracture. Low vitamin D level may predict rickets, osteomalacia, or osteoporosis. Fatigue bone stress fracture is one of the most frequently seen types of overuse injuries in athletes and military recruits. An association was recently shown between vitamin D and BMC. A correlation has also been found between low femoral BMD and stress fractures. We measured serum 25(OH)D concentration in a population sample of military recruits to determine if vitamin D is a predisposing factor for fatigue bone stress fracture. We prospectively followed 800 randomly selected, healthy Finnish military recruits with a mean age of 19 years for developing stress fractures in homogenous circumstances. Blood for serum 25(OH)D concentration was drawn at entry into military service, and the weight, height, body mass index (BMI), muscle strength, and 12-minute running were measured for all subjects. Serum 25(OH)D concentrations were measured with enzyme immunoassay. At end of the 90-day follow-up, 756 subjects completed the study. Subjects without fracture constituted controls. Twenty-two recruits with stress fracture were identified (2.9%), the incidence being 11.6 (95% CI: 6.8-16.5) per 100 person-years. In the final multivariate analysis, the significant risk factor for stress fracture in conscripts was a below median serum 25(OH)D level (75.8 nM), OR being 3.6 (95% CI: 1.2-11.1). No significant associations between BMI (p = 0.255), age (p = 0.216), or smoking (p = 0.851) and bone stress fracture were found in this study population. A lower level of serum 25(OH)D concentration may be a generally predisposing element for bone stress fractures. Considering the obvious need of additional vitamin D in prevention of stress fractures, the effects of vitamin D fortification of foods and supplementation will be subjects of interest for future research.

Femoral stress fracture after computer navigated total knee arthroplasty

Computer navigation for total knee arthroplasty is increasingly used because it improves the accuracy of femoral and tibial components implantation. However, every new technique is associated with its own complications. Here, we report on a patient who developed a distal femoral stress fracture after two attempts at fixing the navigation tracker.

Comminuted femur fracture secondary to stress during the Boston marathon

We report a case of a comminuted femur fracture secondary to repetitive stress in a healthy marathon runner. Stress fractures are common orthopedic injuries that result from normal muscular activity on deficient bone (“insufficiency fractures”) or excessive, repetitive stresses on normal bone (“fatigue fractures”). Of recreational and professional sports, running accounts for a higher incidence of stress fractures, which have been reported to cause up to 15% of all injuries to runners. We report a case of a sub-trochanteric comminuted femoral stress fracture in a female marathon runner.

Stress fractures of the femoral shaft in athletes: a new treatment algorithm

Background: Femoral shaft stress fractures in athletes are not common but pose a great diagnostic challenge to clinicians. Because of few clinical signs, diagnosis and treatment are often delayed. Furthermore,...

Imaging findings in symptomatic patients with femoral diaphyseal stress injuries

To assess the imaging findings seen in symptomatic patients with stress injuries of the femoral diaphysis. Seven patients (5 F, 2 M, age range 16 to 56 years, mean 38 years) underwent imaging evaluation of the symptomatic lower extremity due to an insidious onset of thigh or groin pain unrelated to trauma. Imaging studies included radiography and magnetic resonance imaging (MRI) in seven patients, bone scintigraphy in five, and computed tomography (CT) in three. Radiographs depicted three frank fractures in two patients, and revealed findings of stress injury in six patients. Available scintigraphic and CT findings were abnormal. On MR images, a solitary fracture was seen in two patients; two patients presented with bilateral stress fractures of the femoral diaphysis; and all seven patients had the imaging features of stress injury. Femoral diaphyseal stress fractures (n = 6) appeared as linear regions of T1- and T2-weighted low signal intensity, surrounded by diffuse bone marrow edema. Three of the six frank fractures, with an evident fracture line, were longitudinal and parallel to the cortical surface. Femoral diaphyseal stress fractures are often inconspicuous with conventional radiography. MRI depicts the changes of stress injury in the femoral diaphysis, and is particularly useful in documenting the presence, morphology, and extent of fracture(s), information valuable for definitive diagnosis and appropriate management.

Femoral Stress Fractures in a Team of Elite Cross-Country Runners

Femoral Stress Fractures in a Team of Elite Cross-Country Runners

Concurrent Bilateral Femoral Neck Stress Fractures and Osteonecrosis of the Hip: A Case Report

Although bilateral osteonecrosis of the femoral head and bilateral stress fracture of the femoral neck are well-documented conditions, the occurrence of both conditions in the same patient has not been reported, to our knowledge. We present the case of a patient with both entities who was managed with internal fixation of both hips, which provided stabilization of the stress fractures as well as treatment of the osteonecrosis with core decompression. Two years after treatment, the stress fractures had healed and there was no evidence of progression of the osteonecrosis. The patient granted permission for the publication of data concerning the case. Aforty-six-year-old woman presented to us with a six-month history of bilateral groin pain. The right hip was more painful than the left. There was no history of trauma. The medical history included interstitial nephritis, diagnosed on the basis of a renal biopsy performed five years earlier, and osteopenia, diagnosed on the basis of a bone mineral densitometry value that was -1.25 standard deviations below the mean for age and sex-matched controls. The nephritis was treated with a three-month course of prednisone at the time of the initial diagnosis. The serum creatinine level remained elevated at 2.0 to 3.2 mg/dL (176.8 to 282.9 μmol/L), but that level had remained stable since the diagnosis of interstitial nephritis five years earlier. The patient had not received medical treatment for the osteopenia although it was recommended to her at the time that the densitometry was performed. The patient had a history of drug and alcohol abuse more than twenty years previously, but she stated that she had not used drugs or alcohol since that time. There was no history of amenorrhea or an eating disorder. The patient stated that she was an “avid” runner, running >5 mi (>8 km) every morning, prior to …

Predictors of Stress Fracture Susceptibility in Young Female Recruits

Background Stress fractures account for substantial morbidity for young women undergoing U.S. Marine Corps basic training. Hypothesis Certain pretraining characteristics identify women at increased risk of stress fractures during boot camp. Study Design Cohort study; Level of evidence, 2. Methods Data collected included baseline performance on a timed run (a measure of aerobic fitness), anthropometric measurements, and a baseline questionnaire highlighting exercise and menstrual status among 2962 women undergoing basic training at the Marine Corps Recruit Depot, Parris Island, in 1995 and 1996. Results One hundred fifty-two recruits (5.1%) had 181 confirmed lower extremity stress fractures, with the most common sites being the tibia (25%), metatarsals (22%), pelvis (22%), and femur (20%). Logistic regression models revealed that having low aerobic fitness (a slower time on the timed run) and no menses during the past year were significantly associated with the occurrence of any stress fracture and with pelvic or femoral stress fracture during boot camp. Conclusion These findings suggest that stress fractures may be reduced if women entering Marine Corps Recruit Depot training participated in pretraining activities designed to improve aerobic fitness. Furthermore, women reporting no menses during the previous year may need additional observation during training. Clinical Relevance Consistent with previous studies, we found that low aerobic fitness was the only modifiable risk factor associated with stress fractures during boot camp.

The Completely Asymptomatic Displaced Femoral Stress Fracture: A Case Report and Review of the Literature

Pain is protective in stress fractures. Its presence usually signals to the trainee to decrease or halt training. This prevents a microstress fracture from progressing into a macrofracture. A case is presented in which an infantry recruit sustained a displaced femoral diaphyseal stress fracture which was totally asymptomatic until the bone broke in the middle of a run.

Stress fractures of the femoral shaft in women’s college lacrosse: a report of seven cases and a review of the literature

Background: Stress fractures do not often occur in the shaft of the femur. They are more common in the femoral neck, the tibial shaft, the metatarsals, and other bones of...

Identification and Management of 2 Femoral Shaft Stress Injuries

Resident's case problem. Although femoral shaft stress fractures in the general population are rare, they are more common among endurance athletes and military recruits. Such individuals presenting with a complaint of hip, thigh, or knee pain should raise suspicion for femoral shaft stress injury. A United States Military Academy cadet presented to West Point's Physical Therapy-Sports Medicine clinic with a complaint of thigh pain related to training with the local marathon team. A second cadet presented to the same clinic during Cadet Basic Training with a complaint of vague but increasing hip, thigh, and knee pain. Both cadets were suspected of having femoral stress injuries, based on clinical exams, and both diagnoses were confirmed with diagnostic imaging. The 2 cadets were both treated conservatively with progressive rehabilitation once healing was confirmed with radiographs. They both responded favorably to conservative management and returned to full athletic activity at approximately 12 weeks. Symptoms from a femoral shaft stress fracture can be vague and mimic those of other etiologies. Providers should consider a broad differential diagnosis, to include femoral shaft stress fracture, when treating endurance athletes and military recruits with anterior hip, thigh, or knee pain. Proper imaging confirms the diagnosis and sequential radiographs assist in rehabilitation planning.

Bilateral Mid-Diaphyseal Femoral Stress Fractures in the Elderly

Osteoporosis is characterized by low bone density and poor bone mineralization. Mid-diaphyseal stress (insufficiency) fractures of the femur caused by osteoporosis are rare. The symptoms of these lesions are vague and confusing. The physician must be alert to the possibility of femoral shaft stress fractures when evaluating an elderly patient complaining of back, hip or leg pain. A 72-year-old osteoporotic female patient with bilateral mid-diaphyseal stress fractures of the femur is reported. The diagnosis of femoral shaft stress fracture in the elderly is very difficult when based on physical findings and plain radiography only. A magnetic resonance imaging (MRI) scan or nuclear scintigraphy is necessary for early diagnosis. In the described case, the patient had an excellent result after surgical treatment with intramedullary nails. MRI or nuclear scintigraphy must be obtained to exclude the possibility of femoral shaft stress fractures in the elderly. In the absence of contraindications, surgery is the best solution for this kind of lesion.

The effect of prophylactic treatment with risedronate on stress fracture incidence among infantry recruits

When subjected to strains or strain rates higher than usual, the bone remodels to repair microdamage and to strengthen itself. During the initial resorption phase of remodeling, the bone is transitorily weakened and microdamage can accumulate leading to stress fracture. To determine whether short-term suppression of bone turnover using bisphosphonates can prevent the initial loss of bone during the remodeling response to high bone strain and strain rates and potentially prevent stress fracture, we conducted a randomized, double-blind, placebo-controlled trial of 324 new infantry recruits known to be at high risk for stress fracture. Recruits were given a loading dose of 30 mg of risedronate or placebo daily for 10 doses during the first 2 weeks of basic training and then a once a week maintenance dose for the following 12 weeks. Recruits were monitored by biweekly orthopedic examinations during 15 weeks of basic training for stress fractures. Bone scans for suspected tibial and femoral stress fractures and radiographs for suspected metatarsal stress fractures were used to verify stress fracture occurrence. By the intention-to-treat analysis and per-protocol analysis, there was no statistically significant difference in the tibial, femoral, metatarsal, or total stress fracture incidence between the treatment group and the placebo. We conclude that prophylactic treatment with risedronate in a training population at high risk for stress fracture using a maintenance dosage for the treatment of osteoporosis does not lower stress fracture risk.

Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance imaging evaluation in 25 runners

Objective: The purpose of this study was to evaluate femoral diaphyseal stress injuries in runners and to document the results of a systematic grading system based on magnetic resonance imaging (MRI) and radionuclide bone study. Design: A retrospective review of medical records and radiologic findings on patients seen between 1992–2002. Grading was preformed of triple phase bone scan and MRI results. Setting: Stanford University Medical Center, Sports Medicine Clinic. Patients: Twenty-five track and field varsity team members and recreational runners subsequently diagnosed with 31 femoral diaphyseal stress injuries. Outcome measures: Sixteen MRI's and 19 bone scans were evaluated with previously established grading systems. Results: Injury location in 31 femoral diaphyseal stress fractures included the proximal femur in 18 (58.1%), the midfemur in 11 (35.5%), and the distal femur in two legs (6.5%). MRI grading revealed grade I in two of 16 (12.5%), grade II in seven of 16 (43.8%), and grade III in seven of 16 (43.8%) runners. Radionuclide bone study grading revealed grade I in four of 19 (21.1%), grade II in nine of 19 (47.4%), and grade III in six of 19 (31.6%) runners. There was close correlation between grade of MRI and radionuclide bone study in the 12 athletes who had both exams, with 91.7% coincidence. Conclusion: These data of 25 femoral diaphyseal stress fractures show that women were more frequently affected than men and nearly half of these injuries occurred in first-year collegiate runners. The location was mainly in the proximal femur, on the compressive side of bone. If routine radiographs are negative, a radionuclide bone study or MRI with fat-suppression technique can be used to detect and grade bony changes in the femoral diaphyses and to help plan an appropriate rehabilitation program.