Rev. bras. ortop. vol.50 número3

r e v b r a s o r t o p . 2015;50(3):356–359

w w w . r b o . o r g . b r

Case

Report

Fracture

of

the

proximal

extremity

of

the

tibia

after

anterior

cruciate

ligament

reconstruction:

case

report

夽

Márcio

de

Oliveira

Carneiro,

Thiago

de

Almeida

Monteiro

_,

Marcos

Renato

Zenovello

Bueno,

Jorge

Luis

Augustin

Júnior

FaculdadedeMedicinadeSãoJosédoRioPreto(FAMERP),SãoJosédoRioPreto,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received26May2014

Accepted27June2014

Availableonline27April2015

Keywords:

Tibialfractures

Anteriorcruciateligament

reconstruction

Autologoustransplantation

a

b

s

t

r

a

c

t

Wereportarareconditionthathasbeenlittledescribedintheliterature:afractureofthe

proximalextremityofthetibiaafteranteriorcruciateligamentreconstructionusingan

autologouspatellarbone-tendongraft.Inthisreport,wediscussthefactorsthatpredisposed

towardthisepisode,thetreatmentandtheevolutionofthecaseafterthesurgicaltreatment.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.Allrightsreserved.

Fratura

da

extremidade

proximal

da

tíbia

após

reconstruc¸ão

do

ligamento

cruzado

anterior:

relato

de

caso

Palavras-chave:

Fraturasdatíbia

Reconstruc¸ãodoligamentocruzado

anterior

Transplanteautólogo

r

e

s

u

m

o

Relatamosumacondic¸ãorara,poucodescritanaliteratura,queéafraturadaextremidade

proximaldatíbiaapósreconstruc¸ãodoligamentocruzadoanteriorcomenxertoautólogo

osso-tendãopatelar-osso.Nesterelato,discutiremosfatorespredisponentesaoepisódio,

tratamentoeevoluc¸ãodocasoapóstratamentocirúrgico.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Todososdireitosreservados.

Introduction

Reconstruction surgery on the anterior cruciate ligament

(ACL)performedarthroscopicallypresentsahighrateofgood

夽

WorkdevelopedattheBaseHospital,FaculdadedeMedicinadeSãoJosédoRioPreto(FAMERP),SãoJosédoRioPreto,SP,Brazil.

∗ _{Correspondingauthor.}

E-mails:thiagomonteiro33@yahoo.com.br,goianomonteiro@yahoo.com.br(T.deAlmeidaMonteiro).

results.1 _{Morethan100,000newcasesareperformedinthe}

UnitedStateseveryyear.2_{However,thisprocedureisnotfree}

fromcomplications,3_{withanincidencerateofbetween1.8%}

and24%.4

http://dx.doi.org/10.1016/j.rboe.2015.04.009

rev bras ortop.2015;50(3):356–359

357

Fig.1–Frontalradiographonkneeshowingfractureof proximaltibia.

The complications that have been described include:

arthrofibrosis,patellarfracture, “Cyclops”lesions,synovitis,

patellartendinitis,paininthegraftdonorareaandosteolysis,3

amongothers. Thecommonestofthese is joint stiffness.4

Fracturingoftheproximaltibiaisaseriouscomplicationthat

hasonlybeendescribedinafewcasesintheliterature.5,6_In

thepresentreport,wedescribethiscomplication.

Thiscaseconsistedofafractureoftheproximal

extrem-ityofthetibiathatoccurredinapatient4.5monthsafteran

arthroscopicoperationtoreconstructtheACL.

Case

report

The project for this study was approved by our

institu-tion’sresearchethicscommitteeundertheprotocolnumber

5985/2011.

Thepatientwasa17-year-oldmalewhowasattendedat

ourhospital,withahistory ofspraininghisleft knee after

steppingintoaholeintheasphaltwhencrossingastreet.He

arrivedattheemergencyservicewithaconditionofpainin

hisleft kneeandleg, accompaniedbyfunctionallimitation

andinabilitytobearweightontheaffectedleg.Hesaidthat

hehadundergoneACLreconstructionsurgery4months

previ-ously,inwhichagraftfromtheipsilateralpatellartendonhad

beenused.Radiographsofthekneewereproducedinfontal

andlateralviews,fromwhichanextra-articularfractureofthe

proximaltibiawasdiagnosed.Thefracturelinereachedthe

regionoftheanteriortibialtuberosity(ATT),whichwasthesite

fromwhichtheboneplugforthebone-patellartendon-bone

grafthadbeenharvested(Figs.1and2).Thepatientunderwent

surgicaltreatmentinwhichopenreductionandinternal

fixa-tionusingaplateandscrewswereperformed(Figs.3and4).No

looseningofthetibialinterferencescrewthathadbeenused

intheACL reconstructionwasseen.Thepatientpresented

goodevolutionwiththe treatmentthathad beenproposed

anddidnotpresentany functionalalterationsorany

alter-ationsinspecifictestsforevaluatingthereconstructedACL.

Consolidationofthefracturewasachievedbytheendofthe

Fig.2–Lateralradiographonkneeshowingfractureof proximaltibia.

358

Fig.4–Lateralradiographafteroperation.

fourthpostoperativemonth.Thepatientreturnedtohis

recre-ationalsportsactivitiesandratedhisdegreeofsatisfactionas

high.Oneyearaftertheoperation,theimplantwasremoved

becauseoflocaldiscomfortthatthepatientreported(Fig.5).

Discussion

Fracturing of the tibial plateau at the site of the tibial

tunnel afterACL reconstruction hasonlybeen described a

few timesintheliterature.5,6 _{Somepublishedstudieshave}

reported occurrencesof fractures ofthe tibial plateau

fol-lowingACLreconstructionusingautograftsfromthegracilis

andsemitendinosus.4,5_{Othershaveusedbone-patellar-bone}

grafts6,7_{andallograftsfromtheAchillestendon.}8_Thisevent

isprobablyindependentofthegraftused,butthereare

the-oriesstating thatthe bonethat isdrilled through inorder

toconstructthetibialtunnelissubjecttostressthatleads

tofatiguewhentorsionalforcesareappliedduringflexion.8

Thepresenceofatibialtunnelisthoughttoactlikeacortical

defect,whichisafactorpredisposingtowardfractures.5,7 _In

thisregard,whenapatellargraftisused,harvestingthebone

plugwouldincreasethesusceptibilityoftheproximaltibiato

fracturing.Thishasbeen welldocumented,sinceacortical

defectdiminishes boneresistanceinsituationsoftorsional

forces.9

Inthecaseinquestion,thecenterofthefracturewasin

thedonorareaoftheboneplug.Thisbonedefectacted

syn-ergicallyinassociationwiththedrillingofthetibialtunnel,

therebyincreasingthezoneoffragilityandallowedtibial

frac-turingduetolow-energytrauma.7,10,11

Concentrationofstressonananteriorpointoftheproximal

tibiacausedbyfixationscrewsthatalterthebone

mechan-icswouldalsobeapredisposingfactor.7 _{Despitethelackof}

specificstudies,abiomechanicalstudybyBrooksetal.found

thatdrilledholeswithdiametersgreaterthan20%ofthebone

width decreasedthetorsionalcapacityby55%.12 _One

addi-tionalfactorthatmightplayaroleinfracturedevelopment

following ACL reconstructionis wideningofthe bone

tun-nel,whichmayoccurinupto68%ofthecases.13_Thefactor

causingthisisstillunknown,butitisbelievedtobean

autoim-munephenomenoneventhoughnoresearchhasconfirmed

thishypothesis.

rev bras ortop.2015;50(3):356–359

359

Mostauthorshaveoptedtoperformsurgicaltreatmenton

thesefractures,withopenreductionandfixationusingplates

ofavarietyofmodels,eventhoughthisisadifficultsurgical

proceduresecondarytoasurgicalcomplication.Mostofthe

casesdescribedevolvedwellthroughthetreatment.

Inthecasereportedhere,surgicaltreatmentwasalso

cho-sen,withmedialaccesstotheproximaltibiaandpositioning

ofanL-shaped supportplate.Thepatient evolvedwithout

immediateorlatecomplicationsandpresentedfullrangeof

motionandconsolidationofthefracture4monthsafterthe

treatment.

Fracturing of the tibial plateau after arthroscopic ACL

reconstruction is a rare complication that is still little

describedintheliterature.Studieshaveshowngoodevolution

ofthiscomplicationfollowingsurgicaltreatment,eventhough

theprocedurehasahighdegreeoftechnicaldifficulty.Inthe

casereportedhere,thepatientevolvedsatisfactorilyafterthe

operation,withconsolidationofthefractureofthelefttibial

plateau,achievementoffullrangeofmotionofthekneejoint,

areturntoworkactivitiesandevenareturntorecreational

soccerpractice.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1. AndersonAF,SnyderRB,LipscombABJr.Anteriorcruciate ligamentreconstruction.Aprospectiverandomizedstudyof threesurgicalmethods.AmJSportsMed.2001;29(3):272–9.

2.OwingsMF,KozakLJ.Ambulatoryandinpatientproceduresin theUnitedStates,1996.VitalHealthStat13.1998;(139):1–119.

3.GrafB,UhrF.Complicationsofintra-articularanterior cruciatereconstruction.ClinSportsMed.1988;7(4):835–48.

4.WienerDF,SiliskiJM.Distalfemoralshaftfracture:a complicationofendoscopicanteriorcruciateligament reconstruction.Acasereport.AmJSportsMed. 1996;24(2):244–7.

5.SundaramRO,CohenD,Barton-HansonN.Tibialplateau fracturefollowinggracilis-semitendinosusanteriorcruciate ligamentreconstruction:thetibialtunnelstress-riser.Knee. 2006;13(3):238–40.

6.DelcoglianoA,ChiossiS,CaporasoA,FranzeseS,MenghiA. Tibialplateaufractureafterarthroscopicanteriorcruciate ligamentreconstruction.Arthroscopy.2001;17(4):E16.

7.MithöferK,GillTJ,VrahasMS.Tibialplateaufracture followinganteriorcruciateligamentreconstruction.Knee SurgSportsTraumatolArthrosc.2004;12(4):325–8.

8.El-HageZM,MohammedA,GriffithsD,RichardsonJB.Tibial plateaufracturefollowingallograftanteriorcruciateligament (ACL)reconstruction.Injury.1998;29(1):73–4.

9.JohnsonBA,FallatLM.Theeffectofscrewholesonbone strength.JFootAnkleSurg.1997;36(6):446–51.

10.MorganE,SteensenRN.Traumaticproximaltibialfracture followinganteriorcruciateligamentreconstruction.AmJ KneeSurg.1998;11(3):193–4.

11.MoenKY,BoyntonMD,RaaschWG.Fractureoftheproximal tibiaafteranteriorcruciateligamentreconstruction:acase report.AmJOrthop(BelleMeadNJ).1998;27(9):629–30.

12.BrooksDB,BursteinAH,FrankelVH.Thebiomechanicsof torsionalfractures.Thestressconcentrationeffectofadrill hole.JBoneJointSurgAm.1970;52(3):507–14.

13.WebsterKE,FellerJA,HameisterKA.Bonetunnel enlargementfollowinganteriorcruciateligament