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| CASE REPORTS |
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| Year : 2023 | Volume
: 38
| Issue : 1 | Page : 106-110 |
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Management of traumatic proximal tibia fracture with migrated bioscrew after anterior cruciate ligament reconstruction: A case report and a brief review of literature
Santanu Kar, Mohit Singh, Sarvesh K Pandey, Ajay K Yadav, Rahul Khare, Satish Kumar
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences & Dr. Ram Manohar Lohia Hospital, New Delhi, India
| Date of Submission | 30-Nov-2022 |
| Date of Acceptance | 17-Jan-2023 |
| Date of Web Publication | 20-Apr-2023 |
Correspondence Address:
Sarvesh K Pandey
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences & Dr. Ram Manohar Lohia Hospital, New Delhi (110001)
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jbjd.jbjd_47_22
The anterior cruciate ligament (ACL) is injured most during sports activity, which has to be reconstructed to regain painless, functional, and stable knee. Tibial plateau fractures after arthroscopic ACL reconstruction (ACLR) are being increasingly reported in the literature. Revision ACLR may be required after fracture union due to possible disruption of the previous reconstruction. Here is the case of operated bicondylar tibial plateau fracture with the excellent outcome at 2-year follow-up with a previous history of ACLR 5 years back with abutting of the tibial-sided biodegradable screw to the knee joint in a recreational soccer player. This case report of a 46-year-old male patient hereby describes the management of the fracture and possible factors responsible for bioscrew migration. Keywords: ACL reconstruction, bioscrew migration, bioscrew removal, periarticular fractures, tibial plateau fracture
How to cite this article:
Kar S, Singh M, Pandey SK, Yadav AK, Khare R, Kumar S. Management of traumatic proximal tibia fracture with migrated bioscrew after anterior cruciate ligament reconstruction: A case report and a brief review of literature. J Bone Joint Dis 2023;38:106-10 |
How to cite this URL:
Kar S, Singh M, Pandey SK, Yadav AK, Khare R, Kumar S. Management of traumatic proximal tibia fracture with migrated bioscrew after anterior cruciate ligament reconstruction: A case report and a brief review of literature. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:106-10. Available from: http://www.jbjd.in/text.asp?2023/38/1/106/374432 |
| Introduction | |  |
Anterior cruciate ligament (ACL) injury is one of the most common sports-related injuries. ACL reconstruction (ACLR) is done to provide the patient with a painless, stable, and functional knee joint. Like any other surgical procedure, ACLR is also associated with complications. Some of the complications that can arise include persistent instability, knee stiffness, anterior knee pain, surgical site infection, periarticular fractures, etc. Apart from the above, there are also complications related to various types of fixation devices such as graft laceration, tunnel widening, and bioscrew migration.[1]
Both distal femur and proximal tibial plateau are prone to fractures, and only a few case reports have been described. Tibial plateau fracture after ACL injury is an uncommon clinical entity despite the sharp rise of arthroscopic ACLR surgeries. The management of such fracture is usually straightforward with anatomical reduction and rigid internal fixation. In this case report, we describe a proximal tibia fracture that occurred postoperatively in a primary ACLR with bioscrew migration and its management.
Revision ACLR may be required after fracture union due to possible disruption of the previous reconstruction. There are the chances of tibial bioscrew migration in these complex revision cases due to tunnel widening, because multiple drilling for fixation of the plate as well as for revision ACLR decreases the strength of proximal tibia metaphysis. This case report hereby describes the management of the fracture and possible factors responsible for bioscrew migration and technical modification of tibial-sided bioscrew fixation to prevent this migration.
| Case Report | | |
A 46-year-old male presented to the emergency department with injury over his right knee following a road traffic accident. The patient was managed as per the standard advance trauma life support (ATLS) protocol. On examination, the patient had no other injury except severe pain over the right knee and inability to bear weight with no distal neurovascular deficit. The patient mentioned that he sustained an injury to the right knee 5 years back during playing recreational soccer and was diagnosed with a complete ACL tear and underwent arthroscopic ACLR elsewhere. Other operative details were not available. The patient returned to his normal work as a sales representative after 3 months and asymptomatic till now. Radiograph of right knee anteroposterior and lateral view was performed, which revealed a bicondylar tibial plateau fracture (A.O. type 41 C1) with two bioscrews (one each at femoral and tibial side) [Figure 1]a and [Figure 1]b. The bioscrew of the tibial side was almost abutting the knee joint. A subsequent computed tomography (CT) scan scan clearly defined the fracture and confirmed the bioscrew migration to the joint surface ([Figure 1]c), but the fracture lines were not violating the tibial tunnel. | Figure 1: Plain radiograph of affected right knee anteroposterior (a); and lateral (b) view bicondylar tibial plateau fracture with two bioscrews (one each at femoral and tibial side)
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The patient was planned for operative intervention 5 days after injury due to swelling. A standard anteromedial approach was used, and a regenerated hamstring tendon was retracted to delineate the fracture site. The bioscrew of the tibial side was removed [[Figure 2]a], and the fracture was reduced with a reduction clamp. The fracture was fixed with a medial tibial anatomical plate (LCP Medial Proximal Tibial Plate; DePuy Synthes, Oberdorf, Switzerland), and one percutaneous 6.5-mm canulated cancellous screws (DePuy Synthes) was used for Lateral plateau before plate application [Figure 2]b with the help of image intensifier [Figure 2]c. After 2 days of the surgery, X-ray of the knee was performed [Figure 3]a and b, and the patient was encouraged to perform active knee range of motion (ROM) and was discharged with a knee ROM brace. | Figure 2: Intraoperative picture during the procedure after anteromedial approach and removal of the bioscrew (a); the fracture was fixed with a medial tibial anatomical plate and a percutaneous 6.5 mm canulated cancellous screw (b); with the help of image intensifier (c)
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 | Figure 3: X-ray of the knee joint on day 2 of postoperative period anteroposterior (a); and lateral (b) view
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He started full weight-bearing at 14 weeks postsurgery after clinical and radiological evidence of fracture union. At the final follow-up at 2 years, the patient was absolutely free of symptoms, returned to his work without any compromise of knee ROM.
| Discussion | | |
Periarticular fracture following ACL reconstruction is a rare complication with only a few case reports described.[2],[3],[4],[5],[6],[7] Wong and Muir[2] in their case report described a patient who underwent primary ACLR using hamstring graft and presented postoperatively at 3 weeks with an undisplaced fracture of the proximal tibia, which was managed conservatively. They proposed that, in the young population, there is a greater loss of trabecular cancellous bone than cortical bone, which decreases the transosseous bone strength after ACLR. They suggested that biomechanical factors such as graft motion in the tunnel, fixation devices, graft swelling may contribute to tunnel enlargement and act as a stress riser and reduce the proximal tibial bone strength. There are also reports of intraoperative distal femur facture during revision ACLR.[3]
Voos et al.[4] described a patient who presented with proximal tibia fracture 9 weeks postsurgery of ACLR with Bone patellar tendon bone (BPTB) graft. The patient was treated with open reduction and internal fixation (ORIF), and the postoperative period was uneventful. They described that the risk of fracture is higher in BPTB-grafted patients because of the synergistic effects of the tibial tunnel and tibial harvest site compared with hamstrings autograft used patients.
de Oliveira Carneiro et al.[5] described a case of 17-year-old patient who underwent ACLR with BPTB graft and presented with proximal tibia fracture after 4 months post index surgery. The fracture was extending up to the tibial tuberosity, which was the graft harvest site and was treated with ORIF. They described that the tibial tunnel acts as a cortical defect, which is a stress riser and diminishes the bone resistance to torsional forces.
Bae et al.[6], in their study, described a patient who sustained a bilateral proximal tibia fracture following a road traffic accident. The patient underwent ACLR for both the knees with tibialis posterior allograft at different time frames. He was operated on for both fractures, and the patient recovered with no instability. They described that screw holes can act as stress risers and that a diaphyseal drill hole with more than 20% diameter can reduce the bone strength by up to 90%.
Delcogliano et al.[7] described a patient who presented with proximal tibia fracture 7 months post ACLR with BPTB graft and was treated with ORIF. They described that a screw hole can decrease bone strength and alter the spatial distribution of stress. Biomechanical analysis of femoral tunnel as a stress raiser by Han et al.[8] suggested that an anatomically placed single femoral tunnel does not act as a significant stress raiser, whereas a double femoral tunnel can act. The same analysis for the tibial tunnel by Aldebeyan et al.[9] suggested that the tibial tunnel does not act as a stress raiser for the propagation of the fracture. They also suggested that a standard and more vertical tunnel decreases the risk of graft compromise in the event of a fracture.
Tibial plateau fractures after ACLR can be a result of stress concentration at metaphyseal bone due to the presence of a bony tunnel. The fracture may or may not violate the previously reconstructed ligament fixation. But the fracture must be fixed anatomically when encountered. The assessment of ACL integrity can be done after fracture union. As there was no clinical laxity after fracture union, we did not perform revision surgery on this patient. If there was any clinical laxity, an MRI evaluation would be performed to confirm ACL integrity and later ACLR could be planned. But, complications of ACL revision surgeries are higher.[10] The chances of bioscrew migration in these cases of revision are increased as a result of poor osteointegration of graft bioscrew composite in the metaphyseal bone due to multiple drilling of screws for plate fixation as well as revision ACL tibial tunnel.[6] This may cause the failure of revision ACLR leading to devastating complications. If we had to perform revision ACLR in this case, we would prefer a fixation device other than a bioscrew. We noted that tibial plateau fractures that occur within few months after ACLR have a greater propensity to violate the bony tunnels.[2],[4],[5],[6],[7] But fractures occurring after years of ACLR may not violate them due to greater remodeling of the bony tunnels (in this described case) negating the stress concentration.
| Conclusion | | |
Tibial plateau fractures after ACLR can be successfully managed by early anatomical reduction and fixation. Evaluation of ACL should be done clinically and radiologically after fracture union. If revision ACLR is needed, bioscrew fixation of the tibial tunnel should be avoided due to the possibility of migration of bioscrew.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Declaration of Patient Consent
Written informed consent was obtained from the patients for publication of this case report, and written permission was also obtained for possible printing and circulation of the accompanying radiological images solely for educational and academic purposes.
| References | | |
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| 2. | Wong JJ, Muir B Insufficiency fracture of the tibial plateau after anterior cruciate ligament reconstructive surgery: A case report and review of the literature. J Can Chiropr Assoc 2013;57:123-31. |
| 3. | Keyhani S, Vaziri AS, Shafiei H, Mardani-Kivi M Femoral condyle fracture during revision of anterior cruciate ligament reconstruction: Case report and a review of literature. Arch Bone Jt Surg 2015;3:137-40. |
| 4. | Voos JE, Drakos MC, Lorich DG, Fealy S Proximal tibia fracture after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft: A case report. HSS J 2008;4:20-4. |
| 5. | de Oliveira Carneiro M, de Almeida Monteiro T, Zenovello Bueno MR, Augustin Júnior JL Fracture of the proximal extremity of the tibia after anterior cruciate ligament reconstruction: Case report. Rev Bras Ortop 2015;50:356-9. |
| 6. | Bae KC, Cho CH, Lee KJ, Jeon JH Bilateral medial tibial plateau fracture after arthroscopic anterior cruciate ligament reconstruction. Knee Surg Relat Res 2015;27:129-32. |
| 7. | Delcogliano A, Chiossi S, Caporaso A, Franzese S, Menghi A Tibial plateau fracture after arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 2001;17:E16. |
| 8. | Han Y, Sardar Z, McGrail S, Steffen T, Martineau PA Peri-anterior cruciate ligament reconstruction femur fracture: A biomechanical analysis of the femoral tunnel as a stress riser. Knee Surg Sports Traumatol Arthrosc 2011;19:77S77-85. |
| 9. | Aldebeyan W, Liddell A, Steffen T, Beckman L, Martineau PA Proximal tibial fracture following anterior cruciate ligament reconstruction surgery: A biomechanical analysis of the tibial tunnel as a stress riser. Knee Surg Sports Traumatol Arthrosc 2017;25:2397-404. |
| 10. | Su CA, Knapik DM, Trivedi NN, Megerian MF, Salata MJ, et al. Femoral interference screw fixation in ACL reconstruction using bone-patellar tendon-bone grafts. JBJS Rev 2020;8:e0066. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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