Page 33 - ISAKOS 2019 Newsletter Volume 1
P. 33

We prefer to use the largest possible cannulated screw (usually 3.2 to 5.5 mm diameter), with the threads extending just beyond the fracture site in order to generate maximum compression (Fig. 1).
01 23-year-old professional soccer player who had a symptomatic Torg grade-3 fifth metatarsal stress fracture in the right foot.
  01A Standing posterior view of the feet,
showing a neutral forefoot and a diminished subtalar arch.
Photograph 01C made during
open curettage
and harvesting
of cancellous autograft from the left calcaneus.
Oblique radiograph and direct photograph made during internal fixation with a cannulated compression screw.
 01D Oblique radiograph and direct
01E Radiographs made 1 month postoperatively.
2 02A, 02B, 02C and 02D Chronic bilateral anterior tibial stress fracture in a 29-year-old professional soccer player that failed initial treatment with reamed intramedullary nail; a compression plate in tension band mode and open tibial curettage anteriorly was associated to the initial treatment in a later surgery.
(Images from André Pedrinelli, Grupo de Medicina do Esporte e do Exercício HCFMUSP.)
That review also demonstrated that conservative management resulted in decreased rates of return to sport compared with surgical management (71% compared with 96%, respectively). Our preferred method is to use a locked reamed intramedullary nail in order to stimulate bone-healing; in chronic or revision cases and high-performance athletes, we may opt for tension band plating as described by Zbeda et al.5 (Fig. 2).
photograph made
duringinternalfixation (ImagesfromAndréPedrinelli,
with a cannulated compression screw.
Grupo de Medicina do Esporte e do Exercício HCFMUSP.)
Anterior Tibial Shaft Stress Fracture
Stress fractures involving the anterior cortex of the tibia have a different prognosis than those involving the posteromedial cortex and are associated with a high risk of chronicity and displacement under continuous loading. The severity of the fracture can be graded according to the presence of changes on MRI sequences; periosteal and bone marrow edema with the presence of a fracture line has been shown to be associated with an increased return to running time and delayed healing.
Current treatment protocols advocate a trial of 3 to 6 months of conservative management as the initial treatment of these injuries; if symptoms persist following attempted conservative management, surgical intervention (reamed tibial intramedullary nailing, compression plating, or drilling of the stress fracture with bone-grafting) should be advised. A recent systematic review by Robertson and Wood demonstrated that intramedullary nailing and compression plating provided the highest return rates and lowest return times of all the surgical treatments available.

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