Working Diagnosis:
Closed fracture of proximal left tibia below healed osteotomy.

Treatment:
The athlete underwent emergency surgery with removal of previous internal fixation screws and an open reduction and internal fixation of tibia with intramedullary nail placement (a 40 cm nail was placed which was the longest available, despite the tibia measuring 48 cm). Post-operatively, calcium was started, vitamin D was continued for bone healing, and teriparatide was discontinued due to the fracture and cost concerns.

Outcome:
Post-operatively, the athlete restarted physical therapy, began using a bone stimulator, and saw sports nutrition. He began progressive weight bearing for 9 weeks with expected return to play and complete recovery anticipated to require 6 months to over a year. He will be monitored for complications affiliated with short intramedullary nail placement.

Author's Comments:
Tibial fractures are rare complications following tibial tubercle osteotomy usually occurring 8-14 weeks postoperatively. Only 4 cases have been reported after 6 months. Proximal tibial fractures have a high risk of complication, such as acute compartment syndrome. In our athlete, further work up to rule out stress injury or inadequate bone healing prior to return to sport should have been initiated due to a variety of signs and symptoms.

First, given the patient endorsed ongoing tibial tubercle pain in the extended post-operative period, this should have prompted further evaluation. Second, the patient was at risk for delayed healing due to a known history of low vitamin D. Third, the role of teriparatide in this fracture is unclear. Unlike bisphosphates, teriparatide is not associated with atypical femur fractures as it is an anabolic not an antiresorptive agent. Currently, teriparatide is used off label to stimulate bone healing for fracture non-union or delayed healing. Further studies are still needed to evaluate the utility and risk of teriparatide in promoting bone healing after surgery, as well as cases of delayed healing or fractures with non-union.

Despite being around the age of skeletal maturity, our 18-year-old patient still had slightly open physes. With the continued growth potential, there is a theoretical risk affiliated with teriparatide use. This risk includes abnormal bone deposition and a previous black box warning of osteosarcoma. Therefore, extreme caution should be used when prescribing teriparatide in patients with open physes.

This injury emphasizes the importance of ensuring adequate healing prior to return to sport despite the introduction of accelerated postoperative rehabilitation protocols aiming for return to sport in 16-22 weeks versus prior prolonged 24-week protocols following tibial tubercle osteotomy. These accelerated protocols emphasize weight bearing and lower extremity strengthening starting at four weeks when previous protocols recommended non-weight bearing activities for at least four weeks and then progressive weight bearing and passive range of motion exercises for the following two to four weeks. With the increased pressures for faster return to sport, integrating routine screening for stress injury and emphasizing bone health protocols postoperatively for high-level athletes should be further investigated.

Editor's Comments:
Tibial osteotomies can either be a high tibial osteotomy which is utilized for varus malalignment or a tibial tubercle osteotomy for patellofemoral instability. With our patient, who had a concurrent medial patellofemoral ligament reconstruction they would have had a tibial tubercle osteotomy which can be further characterized by medialization, distalization, or anteriorization in regards to placement of the patella post surgery in relation to the patellofemoral groove. Decision to utilize a tibial tubercle osteotomy is often based on standing alignment and a patients TT-TG measurement. When the TT-TG is found to be 17-20mm or higher a tibial tubercle osteotomy often is considered though the outcomes are conflicted regarding how much functional improvement occurs. When combined, the MPFL reconstruction is meant to prevent re-dislocation while the tibial tubercle osteotomy is meant to offload patellar contact pressure.

References:
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10. Morgan C, Bell RM, Burland JP, et al. Effectiveness of an Accelerated Rehabilitation Protocol After Tibial Tubercle Osteotomy. Orthop J Sports Med. 2022;10(11):23259671221133105. doi:10.1177/23259671221133105.

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12. Vivekanantha P, Kahlon H, Cohen D, de Sa D. Isolated medial patellofemoral ligament reconstruction results in similar postoperative outcomes as medial patellofemoral ligament reconstruction and tibial-tubercle osteotomy: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2023 Jun;31(6):2433-2445. doi: 10.1007/s00167-022-07186-x. Epub 2022 Oct 10. PMID: 36214831.

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