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The Knee 13 (2006

Tibial plateau fracture following gracilis-semitendinosus anterior cruciate

ligament reconstruction: The tibial tunnel stress-riser

R.O. Sundaram *, D. Cohen, N. Barton-Hanson

Department of Orthopaedics, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL, United Kingdom

Received 1 November 2004; received in revised form 2 July 2005; accepted 22 August 2005

Abstract

Tibial plateau fractures following anterior cruciate ligament (ACL) reconstruction are extremely rare. This is the first reported case of a

tibial plateau fracture following four-strand gracilis-semitendinosus autograft ACL reconstruction. The tibial tunnel alone may behave as a

stress riser which can significantly reduce bone strength.

D 2005 Elsevier B.V. All rights reserved.

Keywords: Gracilis-semitendinosus; ACL reconstruction; Tibial plateau fracture; Tibial tunnel; Stress riser

1. Case report

A 40-year-old lady presented with an acute painful

swollen left knee following a simple fall onto her knee

whilst walking. One year earlier the patient underwent an

arthroscopically assisted ACL reconstruction using four-

strand gracilis-semitendinosus (GS) autograft by the senior

author. The tibial tunnel was drilled to 8 mm in diameter and

the GS autograft was fixed using a 9�25 mm RCI

interference screw (Smith and Nephew, Andover, Ma,

USA). The femoral tunnel graft fixation was performed

with an Endobutton (Smith and Nephew). Clinical exami-

nation in the first 24 h following the fall showed a large

haemarthrosis. The patellar tendon was clinically intact. The

knee was too painful to determine the stability of the knee

and range of movement was restricted to 30-. A plain

radiograph of the knee did not show any fracture on

standard anterior–posterior or lateral views. The differential

diagnoses were a meniscal tear or ACL graft rupture.

Magnetic resonance imaging (MRI) scan of the knee

0968-0160/$ - see front matter D 2005 Elsevier B.V. All rights reserved.

doi:10.1016/j.knee.2005.08.009

* Corresponding author. 5 Tunbridge Close, Great Sankey, Warrington

WA5 3RF, United Kingdom. Tel.: +44 1925 710908; mobile: +44 7713

883777.

E-mail address: rathers74@yahoo.co.uk (R.O. Sundaram).

showed an undisplaced fracture of the proximal tibia

passing through the tibial tunnel and extending into the

lateral tibial plateau (Figs. 1a,b and 2a,b). The patient was

treated in a non-weight bearing cylinder plaster cast for 6

weeks, followed by a functional weight bearing knee brace

for a further 6 weeks. At 3 months following the injury the

patient was able to walk unaided and had a clinically stable

knee with a range of motion from 0 to 120 degrees.

2. Discussion

Bone-patella tendon-bone (BPTB) and four-strand GS

autografts are considered the grafts of choice for ACL

reconstruction [1]. BPTB autograft harvesting may result in

donor site fracture. Patella fracture [2], patella tendon

avulsion [3], and tibial tubercle fractures have been reported

[4]. Hamstring autografts have become more popular; and as

graft harvest does not interfere with the extensor mechanism

of the knee, risks of fractures are avoided.

Recently three fractures of the tibial plateau have been

reported after patients have undergone BPTB autograft

ACL reconstruction [5–7]. These fractures occurred as a

result of trauma. All 7 months following ACL reconstruc-

tion. In all of these cases, the fractures passed through the

tibial tunnel. Moen et al. have reported a case of a

) 238 – 240

Fig. 1. (a) Coronal MRI showing the tibial plateau fracture through the tibial tunnel. (b) Diagrammatic representation of the coronal MRI.

R.O. Sundaram et al. / The Knee 13 (2006) 238–240 239

minimally displaced transverse fracture of the proximal

tibia as a result of trauma, 6 weeks following a BPTB

autograft ACL reconstruction. Here the fracture passed

through the tibial harvest site and tibial tunnel [8].

Although no studies have shown bone strength of the tibia

following BPTB graft harvest or following tibial tunnel

Fig. 2. (a) Sagittal MRI showing the tibial plateau fracture through the t

drilling, it is well-documented in the orthopaedic literature

that drilling of holes in bone significantly reduces bone

strength [9–11]. It is likely that the BPTB tibial harvest site

together with the tibial tunnel may have contributed

synergistically as stress-risers in the reported cases to

reduce proximal tibial bone strength [5–7]. A tibial plateau

ibial tunnel. (b) Diagrammatic representation of the Sagittal MRI.

R.O. Sundaram et al. / The Knee 13 (2006) 238–240240

fracture through the tibial tunnel has been reported in a

patient who had undergone an ACL reconstruction 18

months earlier; with freeze dried Achilles tendon allograft

[12]. This is the first reported case of a tibial plateau

fracture where the ACL was reconstructed using GS

autograft. Such fractures can occur following ACL recon-

struction, without the anterior tibial cortex being disrupted

by graft harvesting. We believe that the tibial tunnel alone

can behave as a stress-riser that decreases the strength of

the proximal tibial metaphysis.

BPTB and GS autografts are the two most popular grafts

for ACL reconstruction. Tibial plateau fractures following

ACL reconstruction are extremely rare. This is the first

reported case of a tibial plateau fracture following GS ACL

reconstruction, where the tibial tunnel alone may have

contributed as a stress riser. We recommend that all

traumatic acutely painful swollen knees following ACL

reconstruction where plain radiographs do not show

fractures are investigated with MRI to determine the

underlying pathology. MRI has been shown to be a sensitive

instrument to exclude occult fractures that may not be seen

on plain radiographs [13,14].

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