1 Birgit Hoffmeyer,2 Juri Ruf,1 Max Seidensticker,1 Ingo G Steffen,1 Frank Fischbach,1 Alina Zarva,1 Gero Wieners,1 Gerhard Ulrich,1 Christoph H Lohmann,2 and Holger Amthauer1Background
The aim was to compare the return-to-sports-time (RTST) following stress fractures on the basis of site and severity of injury. This retrospective study was set up at a single institution. Diagnosis was confirmed by an interdisciplinary adjudication panel and images were rated in a blinded-read setting.
Methods
52 athletes (female, n
=30; male, n=22; mean age, 22.8years) with stress fracture (SFX) who had undergone at least one examination, either MRI or bone scintigraphy, were included. Magnetic resonance images (MRI) and/or bone scintigraphy (BS) of SFX were classified as either low- or high-grade SFX, according to existing grading systems. For MRI, high-grade SFX was defined as visibility of a fracture line or bone marrow edema in T1-, T2-weighted and short tau inversion recovery (STIR) sequences, with low-grade SFX showing no fracture line and bone marrow edema only in STIR and/or T2-weighted sequences. In BS images, a mild and poorly defined focal tracer uptake represented a low-grade lesion, whereas an intense and sharply marginated uptake marked a high-grade SFX. In addition, all injuries were categorized by location as high- or low-risk stress fractures. RTST was obtained from the clinical records. All patients were treated according to a non-weight-bearing treatment plan and comprehensive follow-up data was complete until full recovery. Two-sided Wilcoxon’s rank sum test was used for group comparisons.
=30; male, n=22; mean age, 22.8years) with stress fracture (SFX) who had undergone at least one examination, either MRI or bone scintigraphy, were included. Magnetic resonance images (MRI) and/or bone scintigraphy (BS) of SFX were classified as either low- or high-grade SFX, according to existing grading systems. For MRI, high-grade SFX was defined as visibility of a fracture line or bone marrow edema in T1-, T2-weighted and short tau inversion recovery (STIR) sequences, with low-grade SFX showing no fracture line and bone marrow edema only in STIR and/or T2-weighted sequences. In BS images, a mild and poorly defined focal tracer uptake represented a low-grade lesion, whereas an intense and sharply marginated uptake marked a high-grade SFX. In addition, all injuries were categorized by location as high- or low-risk stress fractures. RTST was obtained from the clinical records. All patients were treated according to a non-weight-bearing treatment plan and comprehensive follow-up data was complete until full recovery. Two-sided Wilcoxon’s rank sum test was used for group comparisons.Results
High-risk SFX had a mean RTST of 132days (d) [IQR 64d – 132d] compared to 119d [IQR 50d – 110d] for low-risk sites (p=0.19). RTST was significantly longer (p=0.01) in high-grade lesions [mean, 143d; IQR 66d – 134d] than in low-grade [mean, 95d; IQR 42d – 94d]. Analysis of high-risk SFX showed no difference in RTST (p=0.45) between high- and low-grade [mean, 131d; IQR 72d – 123d vs. mean, 135d; IQR 63d – 132d]. In contrast, the difference was significant for low-risk SFX (p=0.005) [low-grade; mean, 61d; IQR 35d – 78d vs. high-grade; mean, 153d; IQR 64d – 164d].
days (d) [IQR 64d – 132d] compared to 119d [IQR 50d – 110d] for low-risk sites (p=0.19). RTST was significantly longer (p=0.01) in high-grade lesions [mean, 143d; IQR 66d – 134d] than in low-grade [mean, 95d; IQR 42d – 94d]. Analysis of high-risk SFX showed no difference in RTST (p=0.45) between high- and low-grade [mean, 131d; IQR 72d – 123d vs. mean, 135d; IQR 63d – 132d]. In contrast, the difference was significant for low-risk SFX (p=0.005) [low-grade; mean, 61d; IQR 35d – 78d vs. high-grade; mean, 153d; IQR 64d – 164d].Conclusion
For SFX at low-risk sites, the significant difference in RTST between low- and high-grade lesions allows more accurate estimation of RTST by this approach. Both location of the injury and severity determined by imaging should therefore be considered for prediction of RTST.
Keywords: Stress fracture, Grading system, Athletes, MRI, Bone scintigraphy