Long- Stem Total Knee Arthroplasty for Proximal Tibial Stress Fractures in the Elderly Patients

Document Type : RESEARCH PAPER


1 Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran

2 Taleghani Hospital Research Development Unit, Shahid Beheshti University of Medical Sciences, Tehran, Iran


Background: Presentation of proximal tibia stress fracture is not infrequent among elderly patients due to their poor
bone stock. Optimal management of patients with severe gonarthrosis of the knee and concurrent tibial stress fracture is
not known yet. In this study we report the outcome of primary total knee arthroplasty (TKA) using stemmed components
in elderly patients.
Methods: Between 2009 and 2014, a total of 16 elderly patients with proximal tibial stress fractures and concurrent
gonarthrosis were treated with TKA using long stemmed components. The diagnosis of stress fractures was confirmed
based on the radiographic changes. A standing alignment view was obtained for all patients preoperatively. Union of
the fracture site was investigated using plain anteroposterior (AP) and lateral leg x-rays.
Results: All patients experienced significant relieve of symptoms. The Knee Society score and Knee Society functional
score averaged 86±4 and 85±6, respectively. The mean arc of motion of the knee was 118°±2° at the latest follow-up. All
stress fractures resolved at a mean of 8.3±1.1 weeks. The medial proximal tibial angle was increased from 74.7°±5.7°
preoperatively to 90.3°±1.1° (P<0.05) postoperatively. Tegner activity scale was increased from 2.1±1.3 to 3.4±0.9
Conclusion: According to our findings, patients with stress fracture of proximal tibia and concurrent gonarthrosis
can be treated with primary TKA using stemmed components that may bypass the stress fracture and allow
healing of the fracture.
Level of evidence: IV


Main Subjects

1. Pommering TL, Kluchurosky L. Overuse injuries
in adolescents. Adolesc Med State Art Rev. 2007;
2. Papagelopoulos PJ, Karachalios T, Themistocleous GS,
Papadopoulos EC, Savvidou OD, Rand JA. Total knee
arthroplasty in patients with pre-existing fracture
deformity. Orthopedics. 2007; 30(5):5373-8.
3. Satku K, Kumar VP, Pho RW. Stress fractures of the
tibia in osteoarthritis of the knee. J Bone Joint Surg Br.
1987; 69(2):309-11.
4. Haspl M, Jeli´c M, Pe´cina M. Arthroplasty in treating
knee osteoarthritis and proximal tibia stress fracture.
Acta Chir Orthop Traumatol Cech. 2003; 70(5):303-5.
5. Kopacz J, Warda E, Mazurkiewicz T. Stress fractures
of the tibia in elderly women. Chir Narzadow Ruchu
Orthop Pol. 2002; 67(5):515-20.
6. Young A, Kinsella P, Boland P. Stress fractures of the
lower limb in patients with rheumatoid arthritis. J
Bone Joint Surg Br. 1981; 63-B(2):239-43.
7. Akamatsu Y, Mitsugi N, Hayashi T, Kobayashi H, Saito
T. Low bone mineral density is associated with the
onset of spontaneous osteonecrosis of the knee. Acta
Orthop. 2012; 83(3):249-55.
8. Parvizi J, Klein GR, Sim FH. Surgical management
of Paget disease of bone. J Bone Miner Res. 2007;
9. Parvizi J, Frankle MA, Tiegs RD, Sim FH. Corrective
osteotomy for deformity in Paget disease. J Bone Joint
Surgery Am. 2003; 85-A(4):697-702.
10. Sarzaeem MM, Jabalameli M. Stress fracture of the
lateral femoral condyle after total knee arthroplasty.
Arch Bone Jt Surg. 2017; 5(2):125-8.
11. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis,
treatment, and prevention. Am Fam Physician. 2011;
12. Moran DS, Evans RK, Hadad E. Imaging of lower
extremity stress fracture injuries. Sports Med. 2008;
13. Sterling JC, Edelstein DW, Calvo RD, Webb R 2nd. Stress
fractures in the athlete. Diagnosis and management.
Sports Med. 1992; 14(5):336-46.
14. Arendt E, Agel J, Heikes C, Griffiths H. Stress injuries
to bone in college athletes: a retrospective review of
experience at a single institution. Am J Sports Med.
2003; 31(6):959-68.
15. Varner KE, Younas SA, Lintner DM, Marymont JV.
Chronic anterior midtibial stress fractures in athletes
treated with reamed intramedullary nailing. Am J
Sports Med. 2005; 33(7):1071-6.
16. Sourlas I, Papachristou G, Pilichou A, Giannoudis PV,
Efstathopoulos N, Nikolaou SA. Proximal tibial stress
fractures associated with primary degenerative knee
osteoarthritis. Am J Orthop. 2009; 38(3):120-4.
17. Mittal A, Bhosale PB, Suryawanshi AV, Purohit S. Onestage
long-stem total knee arthroplasty for arthritic
knees with stress fractures. J Orthop Surg. 2013;
18. Larsson S. Treatment of osteoporotic fractures. Scand
J Surg. 2006; 95(2):111-8.
19. Sawant MR, Bendall P, Kavanagh TG, Citron ND.
Nonunion of tibial stress fractures in patients with
deformed arthritic knees. J Bone Joint Surg Br. 1999;
20. Orava S, Karpakka J, Hulkko A, Väänänen K, Takala T,
Kallinen M, et al. Diagnosis and treatment of stress
fractures located at the mid-tibial shaft in athletes. Int
J Sports Med. 1991; 12(4):419-22.
21. Chen WM, Huang CK, Chen TH, Chiang CC, Lo
WH. Bilateral proximal tibial stress fractures in
osteoarthritic knee treated with simultaneous
corrective osteotomy and internal fixation. J Chin Med
Assoc. 2004; 67(1):48-50.
Volume 6, Issue 5
September 2018
Pages 376-380
  • Receive Date: 03 October 2017
  • Revise Date: 08 December 2017
  • Accept Date: 13 December 2017
  • First Publish Date: 01 September 2018