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Chronic anterior tibial stress fractures in athletes: No crack but intense remodelling
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.ORCID iD: 0000-0003-0677-9265
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
2019 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 29, no 10, p. 1521-1528Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Delayed healing of anterior tibial stress fractures in athletes is related to high tensional forces acting across a putative fracture gap. These forces lead to crack propagation and create strains that exceed tissue differentiation thresholds for new bone to form in the gap. The "dreaded black line" is a radiographic hallmark sign of stress fractures considered to represent a transverse fracture gap. However, whether a fracture gap truly exists at the microscopic level remains unclear. The aim of this study was to describe the area of the "dreaded black line" microscopically and to identify signs of delayed healing.

METHODS: Between 2011 and 2016 we included seven athletes with chronic anterior mid-shaft tibial stress fractures. The fracture site was excised as a cylindrical biopsy. The biopsy was evaluated with micro-CT and histology. The formation of new bone in the defect was evaluated radiographically.

RESULTS: The "dreaded black line" seen on preoperative radiographs in all patients could not be seen on the microscopic level. Instead, the area of the putative crack showed widened resorption cavities, lined with active osteoblasts, and surrounded by immature bone. This area of intense remodelling seemed to create a false impression of a fracture line on radiographs. Complete cortical continuity was restored at the biopsy site at median eight months (range six to 13 months).

CONCLUSION: Tibial stress fractures in athletes normally show no fracture defect, but a region of increased remodelling. The healing process is already ongoing but seems mechanically insufficient. 

Place, publisher, year, edition, pages
John Wiley & Sons, 2019. Vol. 29, no 10, p. 1521-1528
Keywords [en]
Stress fracture, fracture healing, histology, tibia
National Category
Orthopaedics
Identifiers
URN: urn:nbn:se:liu:diva-157071DOI: 10.1111/sms.13466ISI: 000488616400008PubMedID: 31102562OAI: oai:DiVA.org:liu-157071DiVA, id: diva2:1318207
Funder
Region ÖstergötlandSwedish Research CouncilSwedish National Centre for Research in SportsAvailable from: 2019-05-27 Created: 2019-05-27 Last updated: 2019-11-14

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The full text will be freely available from 2020-05-18 11:04
Available from 2020-05-18 11:04

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Schilcher, JörgBernhardsson, MagnusAspenberg, Per

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Schilcher, JörgBernhardsson, MagnusAspenberg, Per
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Division of Surgery, Orthopedics and OncologyFaculty of Medicine and Health SciencesDepartment of Orthopaedics in Linköping
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Scandinavian Journal of Medicine and Science in Sports
Orthopaedics

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