Abstract
Purpose
Despite a debilitating effect on athletic performance and an incidence of up to 4% of all stress fractures, there have been only 31 documented cases of medial malleolus stress fractures (MMSF) to our knowledge in the literature. The largest series to date is presented in this study, of 16 professional soccer players undergoing uniform operative treatment. The authors attempt to justify their preferred treatment of MMSFs in the professional soccer player, with an emphasis on patient satisfaction, clinical and radiographic union, and return to high level sport. The authors aim to prove an association between lower limb varus alignment and the development of MMSFs.
Method
Sixteen professional soccer players of mean age 23.6 years were analysed. A biomechanic assessment was performed. Preoperative CT+-MRI scan were performed to assess fracture lines and the presence of anteromedial tibial and/or talar spurs; which are the likely pathognomic lesion in the development of MMSFs. All patients underwent open reduction and internal fixation with three screws, as well as arthroscopic debridement of impringement spurs, and concentrated bone marrow aspirate into the fracture site. Patients completed the Ogilvie–Harris score, and all patients had CT scans at 3 months and until union.
Results
All the patients in this cohort had causative bony spurs that were debrided at surgery. All of the cohort achieved clinical union. All patients were able to return to professional football; at the same level as prior to the injury. There was complete cohort follow up; and 81% of patients were graded as excellent and 19% as good by the Ogilvie–Harris score. We noted 50% of our cohort demonstrated varus malalignment, either genu varum or hindfoot varus.
Conclusions
The authors conclude that open reduction and internal fixation of MMSFs with screws combined with arthroscopic spur debridement results in excellent clinical outcomes. It can be concluded that varus lower limb malalignment is a risk factor for MMSFs. Given the treatment controversy for these injuries, the results herein demonstrate that aggressive multimodal operative treatment produces excellent outcomes in high demand professional footballers. This study is the first to report a biomechanic association, which can alert the clinician to preventative measures; such as hindfoot orthoses.
Level of evidence
IV.
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Abbreviations
- MMSF:
-
Medial malleolus stress fractures
- cBMA:
-
Concentrated bone marrow aspirate
References
Bhargava R, Sankhla S, Gupta A et al (2007) Percutaneous autologous bone marrow injection in the treatment of delayed or non-union. Indian J Orthop 41(1):67–71
Chahla J, Mannava S, Cinque M et al (2017) Bone marrow aspirate concentrate harvesting and processing technique. Arthrosc Tech 6(2):e441–e445
Coull R, Raffiq T, James L, Stephens M (2003) Open treatment of anterior impingement of the ankle. J Bone Jt Surg (Br) 85-B:550–553
Hernigou P, Poignard A, Beaujean F et al (2005) Percutaneous autologous bone-marrow grafting for nonunions. Influence of the number and concentration of progenitor cells. J Bone Jt Surg Am 87(7):1430–1437
Irion V, Miller T, Kaeding C (2014) The treatment and outcomes of medial malleolar stress fractures: a systematic review of the literature. Sports Health 6(6):527–530
Jowett A, Birks C, Blackney M (2008) Medial malleolar stress fracture secondary to chronic ankle impingement. Foot Ankle Int 29(7):716–721
Kor A, Saltzman A, Wempe P (2003) Medial malleolar stress fractures: literature review, diagnosis and treatment. J Am Podiatr Med Assoc 93(4):292–297
Lempainen L, Limatainen E, Heikkila J et al (2012) Medial malleolar stress fracture in athletes: diagnosis and operative treatment. Scand J Surg 10(4):261–264
Madry H, Gao L, Eichler H et al (2017) Bone marrow aspirate concentrate-enhanced marrow stimulation of chondral defects. Stem Cells Int 2017:1609865
Menge T, Looney C (2015) Medial malleolar stress fracture in an adolescent athlete. J Foot Ankle Surg 54(2):242–246
Murawski C, Kennedy J (2011) Percutaneous internal fixation of proximal fifth metatarsal jones fractures (zones II and III) with Charlotte Carolina screw and bone marrow aspirate concentrate: an outcome study in athletes. Am J Sports Med 39(6):1295–1301
Orava S, Karpakka J, Taimela S et al (1995) Stress fractures of the medial malleolus. J Bone Jt Surg Am 77(3):362–365
Sanders T, Fults-Ganey C (2003) DeLee and Drez’s orthopaedic sports medicine, 2nd edn. Elsevier Saunders, Philadelphia, pp 2133–2190
Shabat S, Sampson K, Mann G et al (2002) Stress fractures of the medial malleolus-review of the literature and report of a 15-year-old elite gymnast. Foot Ankle Int 23(7):647–650
Shelbourne K, Fisher D, Rettig A et al (1998) Stress fractures of the medial malleolus. Am J Sports Med 16(1):60–63
Sherbondy P, Sebastinaelli W (2006) Stress fractures of the medial malleolus and distal fibula. Clin Sports Med 25(1):129–137
Stoller S, Hekmat F, Kleiger B (1984) A comparative study of the frequency of anterior impingement exostoses of the ankle in dancers and nondancers. Foot Ankle 4(4):201–203
Soni A, Vollans S, Haendlmayer K et al (2015) Bilateral medial malleolus stress fractures due to osteoarthritis of knee: a case report and review of literature. Int J Surg Case Rep 6C:–266
Wenger A, Wolinsky P, Robbins M, Garcia T, Maitra S, Amanatullah D (2016) Antiglide plate of vertical medial malleolus fractures provides stiffer initial fixation than bicortical or unicortical screw fixation. Clin Biomech (Bristol Avon) 31:29–32
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Nguyen, A., Beasley, I. & Calder, J. Stress fractures of the medial malleolus in the professional soccer player demonstrate excellent outcomes when treated with open reduction internal fixation and arthroscopic spur debridement. Knee Surg Sports Traumatol Arthrosc 27, 2884–2889 (2019). https://doi.org/10.1007/s00167-019-05483-6
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DOI: https://doi.org/10.1007/s00167-019-05483-6