Introduction

Reconstruction of the anterior cruciate ligament (ACL) isa common orthopedic procedure. Well-recognized com-plications after reconstruction of the anterior cruciate lig-ament include patella tendon rupture, patella fracture,donor site pain, patella tendinitis and avascular necrosisof the femoral condyles [6]. Fracture of the tibial plateaupresents a serious complication after ACL reconstructionthat has only been reported in isolated cases [3, 4, 9]. Wepresent the case of a patient who suffered from a tibialplateau fracture 7 months after anterior cruciate ligamentreconstruction. The pathogenesis of tibial plateau fractureafter ACL reconstruction and the advantages of mini-mally-invasive surgical fixation are discussed.

Case report

A 61-year-old female presented to the Massachusetts General Hos-pital after falling down some stairs and twisting her left knee. She

complained about left-knee pain with inability to bear weight. Thepatient had undergone arthroscopically-assisted reconstruction ofthe left anterior cruciate ligament 7 months earlier using autolo-gous bone–tendon–bone graft. Placement of the tibial tunnel wasperformed in accordance with recent recommendations [5]. Fixa-tion of the graft in the 10 mm tibial tunnel had been performed us-ing a post-and-washer technique due to significant recession of thegraft into the tibial tunnel. The patient had recovered well and hadreturned to her regular athletic activities. Examination revealed atender knee joint with significant effusion and notable crepitation.Evaluation of knee ligamentous stability was limited due to signif-icant muscle guarding. Neurovascular examination was intact andno other injuries were present. Plain radiographs and computed to-mography of the left knee demonstrated a bicondylar fracture ofthe tibial plateau through the transosseous tibial tunnel. The frac-ture type resembled a Schatzker type V with split depression of thelateral tibial plateau and large medial condyle fragment withoutsignificant medial comminution or joint impaction. (Fig. 1). Therewas no displacement of the bone–tendon–bone graft in the tibialtunnel. Operative treatment was performed through a single mini-mally-invasive incision. Elevation and reduction of the depressedlateral articular surface was performed under direct vision using asubmeniscal approach. Bone grafting was used to support the ele-vated articular fragment and further augmented with percuta-neously placed 3.5 mm rafting screws. Fixation of the bicondylarfracture was completed by placement of the Less Invasive Stabi-

Abstract A case is presented of atibial plateau fracture after previousanterior cruciate ligament reconstruc-tion using patellar tendon autograft.The tibial plateau fracture occurredthrough the transosseous tibial tunneland followed a torsional injury to theinvolved extremity. The stress risereffect of the transosseous tibial tun-nel and the anatomic location of thecortical defect probably facilitateddevelopment of the fracture. Mini-mally invasive fixation of the frac-ture was effective in preserving kneestability without need for revisionanterior cruciate ligament reconstruc-tion.

Keywords Anterior cruciate ligament · Complication · Tibia · Operative treatment

KNEEKnee Surg Sports Traumatol Arthrosc(2004) 12 : 325–328

DOI 10.1007/s00167-003-0445-9

Kai MithöferThomas J. GillMark S. Vrahas

Tibial plateau fracture following anterior cruciate ligament reconstruction

Received: 7 January 2003Accepted: 1 August 2003Published online: 23 January 2004© Springer-Verlag 2004

K. Mithöfer · T. J. Gill · M. S. VrahasDepartment of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA

K. Mithöfer (✉)Department of Orthopedic Surgery, Massachusetts General Hospital, Wang Ambulatory Care Center 525, 15 Parkman Street, Boston, MA 02114, USATel.: +1-617-7262784, Fax: +1-617-7268214,e-mail: mithoeferk@aol.com

lization System (LISS) (Synthes, Paoli, PA, USA) (Fig. 2). Slightlyposterior placement of the LISS implant under fluoroscopic con-trol allowed for avoidance of screw penetration through the ACLgraft in the anterior tibial tunnel. Physical therapy with continuouspassive motion was started immediately and protected weightbear-ing maintained for 8 weeks. Upon follow-up at three months thepatient was walking without limitation. She had a knee range ofmotion of 0–125°. There was no instability to varus or valgus stress,and the Lachmann and pivot shift test were negative with a firmendpoint. There was no subjective feeling of knee instability.

Discussion

Between 50,000 and 100,000 reconstructions of the ante-rior cruciate ligament are preformed every year in theUnited States alone [5]. To date only three reports havedescribed tibial plateau fracture complicating ACL recon-struction [3, 4, 9]. The fractures occurred between sevenand eighteen months postoperatively and were induced by

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Fig. 1a–d Plain radiographsand computed tomographydemonstrating a bicondylar tib-ial plateau fracture through thetransosseous tibial tunnel afterprevious ACL reconstruction

torsional trauma. In all previous cases the fracture occurredthrough the tibial tunnel. Although no biomechanical stud-ies have specifically addressed the mechanical effect ofbone tunnels, the presence of the tibial tunnel probablyacts as a predisposing factor, since the cortical defect actsas a stress riser [3, 4]. It has been well documented thatcortical defects significantly decrease resistance to bend-ing and torsional forces [7]. Depending on the geometryof the defect, strength reductions of up to 90% have beenreported [2, 7]. Additional stress concentration is knownto occur in the region of the anterior starting point of thetibial tunnel from the sudden change of the anatomicgeometry of the tibia at the metaphyseal-diaphyseal junc-tion [1]. Screw holes used for post-and-washer fixation ofthe tibial graft may further increase the stress concentra-tion. It was suggested that tunnel enlargement increasedthe risk for tibial fracture in one reported case [11]. How-ever, experimental data demonstrates that diameter of the

bony defect does not appear to have any significant effecton the risk for fracture [1].

Treatment of tibial plateau fractures after anterior cru-ciate ligament reconstruction can be technically challeng-ing [10]. In previous reports one patient was treated withcast immobilization [9], whilst open reduction and inter-nal fixation was used in two cases [3, 4]. Our report for thefirst time describes successful minimally-invasive frac-ture fixation of an intra-articular tibial plateau fracture af-ter anterior cruciate ligament reconstruction. Minimally-invasive stabilization of proximal tibia fractures has onlyrecently been described [8]. This biologic method of frac-ture treatment involves the use of indirect fracture reduc-tion and new plate designs. The LISS plate used in thiscase presents a new implant system that uses a precon-toured plate inserted through a minimally invasive inci-sion into the epiperiosteal space. Osteosynthesis is achievedby percutaneous insertion of screws through an aimingdevice, and stabilization of the implant is achieved bylocking the screws into the plate, creating angular stabil-ity. This technique offers improved biomechanical fixa-tion and avoids excessive soft tissue dissection and devi-talization in an attempt to preserve blood supply to thefractured bone to improve fracture healing and reduce softtissue complications [8]. Specific training is currently re-quired by the implant manufacturer to familiarize sur-geons with the principles of this new fixation concept. Inour case, the bony anatomy and articular congruity wererestored with minimal postoperative morbidity and earlyfunctional recovery. In addition, no revision of the ante-rior cruciate ligament reconstruction was necessary, as thefixation was able to maintain the graft in the isometric po-sition. In contrast, revision ACL reconstruction was re-quired in a previously reported case [11].

This report confirms the previous observation that thebony defect caused by transosseous tibial tunnels createdfor anterior cruciate ligament reconstruction may predis-pose patients to the serious complication of postoperativefracture. We describe for the first time the successful useof minimally-invasive operative fixation of this complexinjury, with simultaneous restoration of bony and liga-mentous stability and avoidance of revision anterior cruci-ate ligament reconstruction.

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Fig. 2 Plain radiograph of the tibia six months after minimally in-vasive fixation demonstrate a healed tibial plateau fracture

1. Brooks DB, Burstein AH, Franke VH(1970) The biomechanics of torsionalfractures: the stress concentration ef-fect of a drill hole. J Bone Joint SurgAm 52:507–514

2. Clark CR, Morgan C, Sonstegard DA,Mathews LS (1977) The effect ofbiopsy hole shape and size on bonestrength. J Bone Joint Surg Am 59:213–217

3. Delcogliano A, Chiossi S, Caporaso A,Frazese S, Menghi A (2001) Tibialplateau fracture after arthroscopic ante-rior cruciate reconstruction. Arthros-copy 17:E16

4. El-Hage ZM, Mohammed A, GriffithsD, Richardson JB (1998) Tibial plateaufracture following allograft anteriorcruciate ligament (ACL) reconstruc-tion. Injury 29:73–74

5. Fineberg MS, Zarins B, Sherman OH(2000) Practical considerations in ante-rior cruciate ligament replacement sur-gery. Arthroscopy 16:715–724

6. Graf B, Uhr F (1988) Complications ofintraarticular anterior cruciate recon-struction. Clin Sports Med 7:835–848

7. Johnson BA, Fallat LM (1997) The ef-fect of screw holes on bone strength. J Foot Ankle Surg 36:446–451

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