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Stress Fx

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A general description of stress fractures , biomechanics and treatment optios with shockwave therapy

A general description of stress fractures , biomechanics and treatment optios with shockwave therapy

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  • 1. Fracturas Por Stress En el Atleta Segundo Congreso SLARD Foz do Iguassu, Agosto 3, 2006 Carlos Leal M.D. Director de Investigaci ó n en Ortopedia Director Cl í nica de Rodilla Postgrado de Ortopedia y Traumatolog í a Universidad El Bosque - Bogota, Colombia
  • 2.  
  • 3. Structure and Function of Bone
    • Primary structural element of the human body
    • Solid base of the muscle - joint - bone complex
    • Changes form, geometry and physical properties according to mechanical demands
    BONE BIOMECHANICS & STRESS FRACTURES
  • 4. Mechanical Homeostasis BONE BIOMECHANICS & STRESS FRACTURES
  • 5. BONE Highly Efficient System Sinergy Tissue Organization Matrix Structure Bone cell interaction BONE BIOMECHANICS & STRESS FRACTURES
  • 6. Tissue Organization Trabecular bone Cortical bone BONE BIOMECHANICS & STRESS FRACTURES
  • 7. Matrix Structure Inorganic matrix Organic matrix BONE BIOMECHANICS & STRESS FRACTURES
  • 8. Bone Cell Interaction Osteoclast Osteoblast - Osteocyte BONE BIOMECHANICS & STRESS FRACTURES
  • 9. The Function of Bone Remodeling
    • Bone Remodeling is as old as the bone itself
    • Essential for a healthy functional skeleton for millions of years
    • Genes that enable bone remodeling have been continued to be
    • selected because they confer important survival advantages
    • Enlow DH & Brown SO. A Comparative Histological Study of Fossil and
    • Recent Bone Tissues. Texas Journal of Science 1956;8:405-443
    BONE BIOMECHANICS & STRESS FRACTURES
  • 10. The Function of Bone Remodeling … a Dual perspective…
    • 19th Century
      • Havers / Volkmann / Hunter
        • Osteon structure is a nearly perfect mechanical
        • and biological complex
        • It serves a mechanical function
    • 20th Century
      • Serum Ca levels are highly regulated to prevent
      • muscle tetany
      • Bone has 99% of body Ca
      • Skeleton = key organ in Ca regulation
        • It serves a metabolic function
    BONE BIOMECHANICS & STRESS FRACTURES
  • 11. Bone Microdamage & Remodeling Microdamage is a manifestation of fatigue, creep or other accumulative mechanical processes by which the microstructure of a loaded material is permanently altered Martin B. Fatigue Microdamage as an Essential Element of Bone Mechanics and Biology. Calcif Tissue Int 2003;73:101-107 BONE BIOMECHANICS & STRESS FRACTURES
  • 12. BONE BIOMECHANICS & STRESS FRACTURES Repetitive cyclic loading of bones Stress fractures are similar to fatigue failures in engineering materials in a sense that are due to a relatively large number of repetitions, which if applied once, do not cause failure. Burr et al. In vivo measurement of human tibial stregths during vigorous activity. Bone 1996;18:405
  • 13. Bone Microdamage & Remodeling Types and Patterns MICROFRACTURES CROSS-HATCHING DIFUSSE DAMAGE MICROCRACKS Martin B. Fatigue Microdamage as an Essential Element of Bone Mechanics and Biology. Calcif Tissue Int 2003;73:101-107 ACCUMULATIVE FATIGUE STRESS BONE BIOMECHANICS & STRESS FRACTURES
  • 14. Bone Microdamage & Remodeling Microdamage is increased by fatigue loading at physiological strains Such damage is a NORMAL consequence of skeletal function Microdamage can only be removed from bone by means of RESORPTION AND REPLACEMENT of bone tissue through remodeling BONE BIOMECHANICS & STRESS FRACTURES
  • 15. Bone Resorption & Replacement Excessive repetitive cyclic loading of bone will result in increased microdamage Fatigue overuse on bone that accumulates more stress than BMU activation WILL CAUSE MICRODAMAGE BONE BIOMECHANICS & STRESS FRACTURES
  • 16. Material & Structural Biomechanics Fatigue Microdamage Stress Distribution Mechanical Homeostasis Motion Biomechanics Mechanics of Movement Anthropometric Patterns Sports Gesture BONE BIOMECHANICS & STRESS FRACTURES
  • 17. lo A F   O  Y’ U’ Stress = Force / Area  = F / A Strain = Deformation / Length  =  / lo Uniaxial mechanics BONE BIOMECHANICS & STRESS FRACTURES E
  • 18.  O  Y’ U’ BONE BIOMECHANICS & STRESS FRACTURES E
  • 19.  O  Y’ U’ E BONE BIOMECHANICS & STRESS FRACTURES
  • 20. Young´s modulus BONE BIOMECHANICS & STRESS FRACTURES  O  Y’ U’ E
  • 21. Young´s modulus Keaveny & Hayes. Bone 1993;7:285-344 BONE BIOMECHANICS & STRESS FRACTURES
  • 22. Cortical bone Keaveny & Hayes, Bone 1993; 7:285-344 BONE BIOMECHANICS & STRESS FRACTURES
  • 23. BONE BIOMECHANICS & STRESS FRACTURES F Compression Tension
  • 24. BONE BIOMECHANICS & STRESS FRACTURES
  • 25. BONE BIOMECHANICS & STRESS FRACTURES
  • 26. BONE BIOMECHANICS & STRESS FRACTURES
  • 27. Repetitive cyclic loading of bones is the most relevant etiologic factor in the genesis of stress fractures Conclusion BONE BIOMECHANICS & STRESS FRACTURES
  • 28. The fine balance between Bone Microdamage & Remodeling marks the outcome of bone failure Under repetitive loading conditions BONE BIOMECHANICS & STRESS FRACTURES Conclusion
  • 29. Biomechanical Characterization of Stress Fractures FATIGUE FRACTURES INSUFFICIENCY FRACTURES FATIGUE & INSUFFICIENCY FRACTURES BONE BIOMECHANICS & STRESS FRACTURES Conclusion Abnormal Stress on Normal Bone Abnormal Stress on Abnormal Bone Normal Stress on Abnormal Bone
  • 30.
    • First described by B reithaupt ( 1.855 )
    • Radiology description by Stechow ( 1.897 )
    • 10 % of all sports injuries
    • 12 times more frequent in women
    • 5-10 % military recruits
    Tibial Stress Fractures
  • 31. Antropometry & Military Biomechanics Tibial Stress Fractures
  • 32. Breakage of gait kinetic chain Tibial Stress Fractures
  • 33.
    • Complications
    • Mechanical disbalance of axial skeleton
    • Articular derangement of knee and ankle
    • School leave
    • Military leave
    Tibial Stress Fractures
  • 34. Knee Hip Ankle Tibial Stress Fractures
  • 35. Diagnosis Clinical History & Physical Exam
  • 36. Diagnosis Bone scan (6 - 72 hours)
  • 37. Diagnosis Bone scan (6 - 72 hours)
  • 38. Diagnosis Radiology (3 weeks)
  • 39. Core Treatment Progressive Retraining
    • Stage I – WALK & JOG
    • 1. Walk 1 mile.
    • 2. Walk 330 yards (three-quarter lap), jog 110 yards (one-quarter lap), walk 330 yards, jog 110 yards, walk 330 yards, jog 110 yards, walk 330 yards, jog 110 yards, walk 110 yards.
    • 3. Walk 220 yards, jog 220 yards, walk 220 yards, jog 220 yards, walk 220 yards, jog 220 yards, walk 440 yards.
    • 4. Walk 440 yards, jog 440 yards, walk 440 yards, jog 440 yards, walk 100 yards.
    • 5. Walk 440 yards, jog 880 yards, walk 440 yards.
    • 6. Walk 220 yards, jog 3/4 mile, walk 220 yards.
    • Walk 100 yards, jog 1 mile, walk 100 yards.
    • Stage II – JOG & RUN
    • 8. Jog 330 yards, run 110 yards, jog 330 yards, run 110 yards, jog 330 yards, run 110 yards, jog 330 yards, run 110 yards, jog 110 yards.
    • 9. Jog 220 yards, run 220 yards, jog 220 yards, run 220 yards, jog 220 yards, run 220 yards, jog 440 yards.
    • 10. Jog 440 yards, run 440 yards, jog 440 yards, run 440 yards, jog 110 yards.
    • 11. Jog 440 yards, run 880 yards, jog 440 yards.
    • 12. Jog 440 yards, run 3/4 mile, jog 220 yards.
    • Jog 440 yards, run 1 mile, jog 220 yards.
    • Stage III – PROGRESSION TO SPRINT RUNNING
    • 14. Run 50 yards at 50% speed then at 75% for two repetitions and finally at 100% speed for two repetitions taking as much time as needed to rest between intervals.
    • 15. 100 x 2 with 5 minutes.
    • 16. 100 x 4 with 5 minutes.
    • 17. 40 x 6 with 3 minutes.
    • 40 x 10 with 2 minutes. 
    • Stage IV – AGILITY DRILLS
  • 40. Biological Effects of ESWT On Bone PDGF – ILGF – PG´s NO´s - SP Free Radicals Osteoinduction Neovascularization
  • 41.
      • Final Outcome
      • Revascularization
      • Osteoinduction
      • Possible Clinical Use
      • Delayed Unions
      • Pseudoarthrosis
      • Avascular Necrosis
      • Stress Fractures
    ESWT Effects on Bone
  • 42. Tibial Stress Fractures & ESWT
  • 43. Tibial Stress Fractures & ESWT
  • 44. Tibial Stress Fractures & ESWT
  • 45.
    • Conventional treatment too long…
    • Frequent recidives between the third month and the first year
    • Many athletes abandon activity
    • Recruits abandon military training
    Research question Does ESWT improve the clinical outcome of Tibial Stress Fractures in High Performance Athletes ? Hypothesis ESWT can reduce pain and recovery time in high performance athletes with tibial stress fractures Research Problem Tibial Stress Fractures & ESWT
  • 46. Study Design
    • 16 Navy cadets
    • 18 years old
    • Bilateral IDENTICAL Tibial Stress Fractures
    • Mid - distal tibial shaft
    • Symptomatic > 3 months
    • Previous failed standard treatment
    Experimental, Randomized, Single Blinded, Self Controlled Clinical Study
    • VARIABLES
    • Pain
      • Rest
      • Sports or Training
      • After Sports or Training
      • Pressure Pain
    • Time
      • 3 - 6- 7- 9 -12 weeks,
      • 4 – 6 -12 months
    • CONTROLLED VARIABLES
    • Radiographs (initial-12 weeks )
    • Bone scan (initial-12 weeks )
    • Nutritional Assessment
      • Weight
      • Total body fat index
    • Physical activity Protocol
    Tibial Stress Fractures & ESWT
  • 47. Materials & Methods Statistical significance (a=0.5 P<0.05) 3-6-9-12 weeks 4-6-12 months PAIN ASSESMENT during activity after activity withpalpation at rest 2 sessions x 2000 Shockwaves at 0.5 - 0.7 mJ/mm2 One week interval Protocol Tibial Stress Fractures & ESWT
  • 48. Results Rest pain
    • At 3rd month there was a significant pain reduction difference
    Sport pain
    • From 6th week to 12th month there were significant pain reduction differences
    Tibial Stress Fractures & ESWT
  • 49. Results After Sport pain
    • From 7th week to 4th month there were significant differences
    Pressure pain
    • From 7th week to 4th month there were significant pain reduction differences
    • Radiographic follow up
      • Sixth & twelfth months
      • No changes after one year
    • Bone scan Follow Up
      • No changes after one year
    Tibial Stress Fractures & ESWT
  • 50. Discussion
    • ESWT reduced recovery time in high performance athletes with tibial stress fractures
    • Sports and training activity was allowed with no pain in treated tibias 6 – 8 months before untreated control tibias
    • Bone Scans did not change in a one year follow – up
    • Is Bone Scan a good control for follow up ?
    • Tibial Stress Fractures not treated with ESWT recovered after 12 months with conventional treatment
    • ESWT treatment: Improves time of recovery and pain during sports and training
    Tibial Stress Fractures & ESWT
  • 51.
    • Small sample (…but powerful contralateral controls…)
    • Time of symptom reincidence yet to be determined
    Limitations Tibial Stress Fractures & ESWT ESWT significantly reduced pain and recovery time in high performance athletes with tibial stress fractures Conclusion
  • 52. Currently under validation in athletes and ballet dancers In Cuba, Israel and Venezuela Our results have been reproduced so far… We recommend ESWT as the primary treatment for Stress Fractures Orthopaedic Shockwave Surgery In Stress Fractures
  • 53. Thanks!
      • More info ?
      • www.onlat.org
      • [email_address]

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