User login
ABSTRACT
The lateral tibial eminence shares a close relationship with the anterior root of the lateral meniscus. Limited studies have reported traumatic injury to the anterior meniscal roots in the setting of tibial eminence fractures, and reported rates of occurrence of concomitant meniscal and chondral injuries vary widely. The purpose of this article is to describe the case of a 28-year-old woman who had a complete avulsion of the anterolateral meniscal root caused by a tibial eminence fracture with resultant malunion and root displacement. The anterolateral meniscal root was anatomically repaired following arthroscopic resection of the malunited fragment.
The lateral tibial eminence is intimately associated with the root attachment of the anterior horn of the lateral meniscus.1-3 Previous studies have demonstrated both the close proximity of the anterior cruciate ligament (ACL) insertion to the meniscal roots and the potential for disruption in surgical interventions, such as tibial tunnel drilling in ACL reconstruction or placement of intramedullary tibial nails.4-6 The meniscal roots play a crucial role in force distribution, and disruption of these structures has been shown to significantly increase joint contact forces. Despite the deleterious effects of this injury, limited studies have reported on traumatic injury to the meniscal roots in the setting of tibial eminence fractures.
Reported rates of occurrence of concomitant meniscal and chondral injuries occurring with tibial eminence fractures vary widely, ranging from <5% to 40%.7,8 Although fractures to the tibial eminence are more common in children, an association between these injuries and concomitant soft tissue injuries, including meniscal, chondral, and collateral ligament injuries, in the adult population has been reported.7 Monto and Cameron-Donaldson8 used magnetic resonance imaging (MRI) to evaluate tibial eminence fractures in adults and found that 23% of study subjects had associated medial meniscus tears and 18% had lateral meniscus tears. In a similar study, Ishibashi and colleagues9 found that 25% of tibial eminence fractures were associated with lateral meniscus tears and 16% with medial meniscus tears.
These studies demonstrate the potential for meniscus injuries during tibial eminence fractures. However, the authors are unaware of any reports of complete tearing of the anterior horn of the lateral meniscus in association with this injury. This is an important injury to recognize and identify intraoperatively because an injury of this nature could potentially compromise the mechanical loading patterns and health of the articular cartilage of the lateral compartment of the knee. The purpose of this article is to describe a complete avulsion of the anterolateral meniscal root due to a tibial eminence fracture with resultant malunion and displacement of the root in a nonanatomical position. The patient provided written informed consent for print and electronic publication of this case report.
Continue to: A 28-year-old active woman...
CASE
A 28-year-old active woman presented to our clinic 22 months after sustaining a right knee tibial eminence fracture that was initially treated with extension immobilization, which resulted in a fibrous malunion. She subsequently sustained a second injury resulting in displacement of the malunion fracture fragment, and was treated at another institution 10 months prior to presentation at our clinic with arthroscopic reduction and internal fixation with a cannulated screw and washer of the tibial eminence fracture. This was followed by hardware removal 6 months prior to her office visit at our clinic. At presentation, she reported worsening right knee pain, mechanical symptoms, and loss of both flexion and extension compared with her uninjured knee. Conservative management, including activity modification, extensive physical therapy, and anti-inflammatory medication following her most recent procedure, had not resulted in improvement of her symptoms.
Physical examination revealed significantly reduced knee flexion and extension (+15°-120° on the affected side compared with 5° of hyperextension to 130° flexion of the contralateral knee). Ligamentous examination demonstrated no laxity with varus or valgus stress at 0° to 30° of flexion, negative posterior drawer, and a Grade 2 Lachman and positive pivot shift. She also exhibited pain with attempted right knee terminal extension. Radiographs and computed tomography scans were obtained and reviewed. They revealed a malunited tibial eminence fracture (Figures 1A-1D). 
Arthroscopic assessment of the right knee demonstrated the large osseous fragment located in the anterolateral aspect of the joint with the displaced anterior horn of the lateral meniscus attached as well as significant anterior impingement limiting knee extension. Probing of the anterolateral meniscal root in the lateral compartment showed abundant surrounding scar tissue with an abnormal attachment, representing a chronic root avulsion. A mechanical shaver was used to débride the scar tissue and expose the malunited fragment, followed by complete osseous fragment excision with a high-speed burr (Figure 3). 
A soft tissue anterolateral meniscal root repair was performed by creating a 2-cm to 3-cm incision on the anterolateral tibia, just distal to the medial aspect of the Gerdy tubercle. To best restore the footprint of the repair and increase the potential for biologic healing, 2 transtibial tunnels were created at the location of the root attachment. An ACL aiming device with a cannulated sleeve was used to drill 2 bony tunnels approximately 5 mm apart, exiting at the anatomic root footprint. The drill pins were removed, leaving the 2 cannulas in place for later suture passage. A suture-passing device was used to pass 2 separate sutures through the detached meniscal root. 
Continue to: Postoperatively, the patient was placed...
Postoperatively, the patient was placed on a non-weight-bearing protocol for her operative lower extremity for 6 weeks. A brace locked in extension was used for the same period of time (being removed only for physical therapy exercises). Enoxaparin was used for the first 2 weeks for deep vein thrombosis prophylaxis, followed by aspirin for an additional 4 weeks. Physical therapy was started on postoperative day 1 to begin working on early passive ROM exercises. Knee flexion was limited to 0° to 90° of flexion for the first 2 weeks and then progressed as tolerated.
DISCUSSION
This article describes a rare case of a patient with lateral meniscal anterior root avulsion in the setting of a tibial eminence fracture with subsequent malunion and root displacement. In a case such as this, delineation of the true extent of the injury is difficult because the anterior meniscal root can be torn, displaced, and nonanatomically scarred to surrounding soft tissues, making MRI interpretation challenging. Clinically, patients can present with a wide range of symptoms, including pain, mechanical symptoms, instability, and loss of knee motion.10
The anterior root of the lateral meniscus has been reported to be attached anterior to the lateral tibial eminence and adjacent to the insertion of the ACL. Fibrous connections extending from the anterior horn of the lateral meniscus attachment to the lateral tibial eminence are constant.11 Furumatsu and colleagues12 demonstrated the existence of dense fibers linking the anterior root of the lateral meniscus with the lateral aspect of the ACL tibial insertion. Acknowledging the close relationship of these structures is key to comprehending the importance of evaluating the anterior horn of the lateral meniscus in cases of tibial eminence fractures at the initial time of injury. Failure to diagnose this pathology can lead to poor clinical outcomes and early degenerative changes of the knee.
Tibial intercondylar eminence avulsion fractures are most likely to occur in children and adolescents, and are equivalent to an ACL tear in adults.13 When tibial eminence fractures occur in an older cohort, they are often combined with lesions of the menisci, capsule, or collateral ligaments.14 The initial injury in our patient demonstrated concomitant anterior root injury that progressed with time to nonanatomical healing of the root, leading to altered biomechanics. Surgical techniques available for meniscal root repair are broadly divided into transosseous suture repairs and suture anchor repairs.10 The transtibial pullout technique using 2 transtibial bone tunnels as described in this report is the senior author’s (RFL) preference because it provides a strong construct with minimal displacement of the repaired meniscus.15-17
This article describes a complete avulsion of the anterolateral meniscal root caused by a tibial eminence fracture with resultant malunion and displacement of the root in a nonanatomic position. Anterior meniscal root tears have been reported to result in altered biomechanics and force transmission across the knee, and therefore, anatomic repair of the anterior root is indicated.
1. James EW, LaPrade CM, Ellman MB, Wijdicks CA, Engebretsen L, LaPrade RF. Radiographic identification of the anterior and posterior root attachments of the medial and lateral menisci. Am J Sports Med. 2014;42(11):2707-2714. doi:10.1177/0363546514545863.
2. LaPrade CM, Foad A, Smith SD, et al. Biomechanical consequences of a nonanatomic posterior medial meniscal root repair. Am J Sports Med. 2015;43(4):912-920. doi:10.1177/0363546514566191.
3. LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med. 2015;43(2):363-369. doi:10.1177/0363546514559684.
4. Ellman MB, James EW, LaPrade CM, LaPrade RF. Anterior meniscus root avulsion following intramedullary nailing for a tibial shaft fracture. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):1188-1191. doi:10.1007/s00167-014-2941-5.
5. Padalecki JR, Jansson KS, Smith SD, et al. Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics. Am J Sports Med. 2014;42(3):699-707. doi:10.1177/0363546513499314.
6. LaPrade CM, Jisa KA, Cram TR, LaPrade RF. Posterior lateral meniscal root tear due to a malpositioned double-bundle anterior cruciate ligament reconstruction tibial tunnel. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3670-3673. doi:10.1007/s00167-014-3273-1.
7. Mitchell JJ, Sjostrom R, Mansour AA, et al. Incidence of meniscal injury and chondral pathology in anterior tibial spine fractures of children. J Pediatr Orthop. 2015;35(2):130-135. doi:10.1097/BPO.0000000000000249.
8. Monto RR, Cameron-Donaldson ML. Magnetic resonance imaging in the evaluation of tibial eminence fractures in adults. J Knee Surg. 2006;19(3):187-190.
9. Ishibashi Y, Tsuda E, Sasaki T, Toh S. Magnetic resonance imaging AIDS in detecting concomitant injuries in patients with tibial spine fractures. Clin Orthop Relat Res. 2005;(434):207-212.
10. Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears significance, diagnosis, and treatment. Am J Sports Med. 2014;42(12):3016-3030. doi:10.1177/0363546514524162.
11. Ziegler CG, Pietrini SD, Westerhaus BD, et al. Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2011;39(4):743-752. doi:10.1177/0363546510387511.
12. Furumatsu T, Kodama Y, Maehara A, et al. The anterior cruciate ligament-lateral meniscus complex: a histological study. Connect Tissue Res. 2016;57(2):91-98. doi:10.3109/03008207.2015.1081899.
13. Lubowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop Rel Res. 1993;(294):242-246.
14. Falstie-Jensen S, Sondergard Petersen PE. Incarceration of the meniscus in fractures of the intercondylar eminence of the tibia in children. Injury. 1984;15(4):236-238.
15. LaPrade CM, LaPrade MD, Turnbull TL, Wijdicks CA, LaPrade RF. Biomechanical evaluation of the transtibial pull-out technique for posterior medial meniscal root repairs using 1 and 2 transtibial bone tunnels. Am J Sports Med. 2015;43(4):899-904. doi:10.1177/0363546514563278.
16. Menge TJ, Chahla J, Dean CS, Mitchell JJ, Moatshe G, LaPrade RF. Anterior meniscal root repair using a transtibial double-tunnel pullout technique. Arthrosc Tech. 2016;5(3):e679-e684. doi:10.1016/j.eats.2016.02.026.
17. Menge TJ, Dean CS, Chahla J, Mitchell JJ, LaPrade RF. Anterior horn meniscal repair using an outside-in suture technique. Arthrosc Tech. 2016;5(5):e1111-e1116. doi:10.1016/j.eats.2016.06.005.
ABSTRACT
The lateral tibial eminence shares a close relationship with the anterior root of the lateral meniscus. Limited studies have reported traumatic injury to the anterior meniscal roots in the setting of tibial eminence fractures, and reported rates of occurrence of concomitant meniscal and chondral injuries vary widely. The purpose of this article is to describe the case of a 28-year-old woman who had a complete avulsion of the anterolateral meniscal root caused by a tibial eminence fracture with resultant malunion and root displacement. The anterolateral meniscal root was anatomically repaired following arthroscopic resection of the malunited fragment.
The lateral tibial eminence is intimately associated with the root attachment of the anterior horn of the lateral meniscus.1-3 Previous studies have demonstrated both the close proximity of the anterior cruciate ligament (ACL) insertion to the meniscal roots and the potential for disruption in surgical interventions, such as tibial tunnel drilling in ACL reconstruction or placement of intramedullary tibial nails.4-6 The meniscal roots play a crucial role in force distribution, and disruption of these structures has been shown to significantly increase joint contact forces. Despite the deleterious effects of this injury, limited studies have reported on traumatic injury to the meniscal roots in the setting of tibial eminence fractures.
Reported rates of occurrence of concomitant meniscal and chondral injuries occurring with tibial eminence fractures vary widely, ranging from <5% to 40%.7,8 Although fractures to the tibial eminence are more common in children, an association between these injuries and concomitant soft tissue injuries, including meniscal, chondral, and collateral ligament injuries, in the adult population has been reported.7 Monto and Cameron-Donaldson8 used magnetic resonance imaging (MRI) to evaluate tibial eminence fractures in adults and found that 23% of study subjects had associated medial meniscus tears and 18% had lateral meniscus tears. In a similar study, Ishibashi and colleagues9 found that 25% of tibial eminence fractures were associated with lateral meniscus tears and 16% with medial meniscus tears.
These studies demonstrate the potential for meniscus injuries during tibial eminence fractures. However, the authors are unaware of any reports of complete tearing of the anterior horn of the lateral meniscus in association with this injury. This is an important injury to recognize and identify intraoperatively because an injury of this nature could potentially compromise the mechanical loading patterns and health of the articular cartilage of the lateral compartment of the knee. The purpose of this article is to describe a complete avulsion of the anterolateral meniscal root due to a tibial eminence fracture with resultant malunion and displacement of the root in a nonanatomical position. The patient provided written informed consent for print and electronic publication of this case report.
Continue to: A 28-year-old active woman...
CASE
A 28-year-old active woman presented to our clinic 22 months after sustaining a right knee tibial eminence fracture that was initially treated with extension immobilization, which resulted in a fibrous malunion. She subsequently sustained a second injury resulting in displacement of the malunion fracture fragment, and was treated at another institution 10 months prior to presentation at our clinic with arthroscopic reduction and internal fixation with a cannulated screw and washer of the tibial eminence fracture. This was followed by hardware removal 6 months prior to her office visit at our clinic. At presentation, she reported worsening right knee pain, mechanical symptoms, and loss of both flexion and extension compared with her uninjured knee. Conservative management, including activity modification, extensive physical therapy, and anti-inflammatory medication following her most recent procedure, had not resulted in improvement of her symptoms.
Physical examination revealed significantly reduced knee flexion and extension (+15°-120° on the affected side compared with 5° of hyperextension to 130° flexion of the contralateral knee). Ligamentous examination demonstrated no laxity with varus or valgus stress at 0° to 30° of flexion, negative posterior drawer, and a Grade 2 Lachman and positive pivot shift. She also exhibited pain with attempted right knee terminal extension. Radiographs and computed tomography scans were obtained and reviewed. They revealed a malunited tibial eminence fracture (Figures 1A-1D).
Arthroscopic assessment of the right knee demonstrated the large osseous fragment located in the anterolateral aspect of the joint with the displaced anterior horn of the lateral meniscus attached as well as significant anterior impingement limiting knee extension. Probing of the anterolateral meniscal root in the lateral compartment showed abundant surrounding scar tissue with an abnormal attachment, representing a chronic root avulsion. A mechanical shaver was used to débride the scar tissue and expose the malunited fragment, followed by complete osseous fragment excision with a high-speed burr (Figure 3).
A soft tissue anterolateral meniscal root repair was performed by creating a 2-cm to 3-cm incision on the anterolateral tibia, just distal to the medial aspect of the Gerdy tubercle. To best restore the footprint of the repair and increase the potential for biologic healing, 2 transtibial tunnels were created at the location of the root attachment. An ACL aiming device with a cannulated sleeve was used to drill 2 bony tunnels approximately 5 mm apart, exiting at the anatomic root footprint. The drill pins were removed, leaving the 2 cannulas in place for later suture passage. A suture-passing device was used to pass 2 separate sutures through the detached meniscal root.
Continue to: Postoperatively, the patient was placed...
Postoperatively, the patient was placed on a non-weight-bearing protocol for her operative lower extremity for 6 weeks. A brace locked in extension was used for the same period of time (being removed only for physical therapy exercises). Enoxaparin was used for the first 2 weeks for deep vein thrombosis prophylaxis, followed by aspirin for an additional 4 weeks. Physical therapy was started on postoperative day 1 to begin working on early passive ROM exercises. Knee flexion was limited to 0° to 90° of flexion for the first 2 weeks and then progressed as tolerated.
DISCUSSION
This article describes a rare case of a patient with lateral meniscal anterior root avulsion in the setting of a tibial eminence fracture with subsequent malunion and root displacement. In a case such as this, delineation of the true extent of the injury is difficult because the anterior meniscal root can be torn, displaced, and nonanatomically scarred to surrounding soft tissues, making MRI interpretation challenging. Clinically, patients can present with a wide range of symptoms, including pain, mechanical symptoms, instability, and loss of knee motion.10
The anterior root of the lateral meniscus has been reported to be attached anterior to the lateral tibial eminence and adjacent to the insertion of the ACL. Fibrous connections extending from the anterior horn of the lateral meniscus attachment to the lateral tibial eminence are constant.11 Furumatsu and colleagues12 demonstrated the existence of dense fibers linking the anterior root of the lateral meniscus with the lateral aspect of the ACL tibial insertion. Acknowledging the close relationship of these structures is key to comprehending the importance of evaluating the anterior horn of the lateral meniscus in cases of tibial eminence fractures at the initial time of injury. Failure to diagnose this pathology can lead to poor clinical outcomes and early degenerative changes of the knee.
Tibial intercondylar eminence avulsion fractures are most likely to occur in children and adolescents, and are equivalent to an ACL tear in adults.13 When tibial eminence fractures occur in an older cohort, they are often combined with lesions of the menisci, capsule, or collateral ligaments.14 The initial injury in our patient demonstrated concomitant anterior root injury that progressed with time to nonanatomical healing of the root, leading to altered biomechanics. Surgical techniques available for meniscal root repair are broadly divided into transosseous suture repairs and suture anchor repairs.10 The transtibial pullout technique using 2 transtibial bone tunnels as described in this report is the senior author’s (RFL) preference because it provides a strong construct with minimal displacement of the repaired meniscus.15-17
This article describes a complete avulsion of the anterolateral meniscal root caused by a tibial eminence fracture with resultant malunion and displacement of the root in a nonanatomic position. Anterior meniscal root tears have been reported to result in altered biomechanics and force transmission across the knee, and therefore, anatomic repair of the anterior root is indicated.
ABSTRACT
The lateral tibial eminence shares a close relationship with the anterior root of the lateral meniscus. Limited studies have reported traumatic injury to the anterior meniscal roots in the setting of tibial eminence fractures, and reported rates of occurrence of concomitant meniscal and chondral injuries vary widely. The purpose of this article is to describe the case of a 28-year-old woman who had a complete avulsion of the anterolateral meniscal root caused by a tibial eminence fracture with resultant malunion and root displacement. The anterolateral meniscal root was anatomically repaired following arthroscopic resection of the malunited fragment.
The lateral tibial eminence is intimately associated with the root attachment of the anterior horn of the lateral meniscus.1-3 Previous studies have demonstrated both the close proximity of the anterior cruciate ligament (ACL) insertion to the meniscal roots and the potential for disruption in surgical interventions, such as tibial tunnel drilling in ACL reconstruction or placement of intramedullary tibial nails.4-6 The meniscal roots play a crucial role in force distribution, and disruption of these structures has been shown to significantly increase joint contact forces. Despite the deleterious effects of this injury, limited studies have reported on traumatic injury to the meniscal roots in the setting of tibial eminence fractures.
Reported rates of occurrence of concomitant meniscal and chondral injuries occurring with tibial eminence fractures vary widely, ranging from <5% to 40%.7,8 Although fractures to the tibial eminence are more common in children, an association between these injuries and concomitant soft tissue injuries, including meniscal, chondral, and collateral ligament injuries, in the adult population has been reported.7 Monto and Cameron-Donaldson8 used magnetic resonance imaging (MRI) to evaluate tibial eminence fractures in adults and found that 23% of study subjects had associated medial meniscus tears and 18% had lateral meniscus tears. In a similar study, Ishibashi and colleagues9 found that 25% of tibial eminence fractures were associated with lateral meniscus tears and 16% with medial meniscus tears.
These studies demonstrate the potential for meniscus injuries during tibial eminence fractures. However, the authors are unaware of any reports of complete tearing of the anterior horn of the lateral meniscus in association with this injury. This is an important injury to recognize and identify intraoperatively because an injury of this nature could potentially compromise the mechanical loading patterns and health of the articular cartilage of the lateral compartment of the knee. The purpose of this article is to describe a complete avulsion of the anterolateral meniscal root due to a tibial eminence fracture with resultant malunion and displacement of the root in a nonanatomical position. The patient provided written informed consent for print and electronic publication of this case report.
Continue to: A 28-year-old active woman...
CASE
A 28-year-old active woman presented to our clinic 22 months after sustaining a right knee tibial eminence fracture that was initially treated with extension immobilization, which resulted in a fibrous malunion. She subsequently sustained a second injury resulting in displacement of the malunion fracture fragment, and was treated at another institution 10 months prior to presentation at our clinic with arthroscopic reduction and internal fixation with a cannulated screw and washer of the tibial eminence fracture. This was followed by hardware removal 6 months prior to her office visit at our clinic. At presentation, she reported worsening right knee pain, mechanical symptoms, and loss of both flexion and extension compared with her uninjured knee. Conservative management, including activity modification, extensive physical therapy, and anti-inflammatory medication following her most recent procedure, had not resulted in improvement of her symptoms.
Physical examination revealed significantly reduced knee flexion and extension (+15°-120° on the affected side compared with 5° of hyperextension to 130° flexion of the contralateral knee). Ligamentous examination demonstrated no laxity with varus or valgus stress at 0° to 30° of flexion, negative posterior drawer, and a Grade 2 Lachman and positive pivot shift. She also exhibited pain with attempted right knee terminal extension. Radiographs and computed tomography scans were obtained and reviewed. They revealed a malunited tibial eminence fracture (Figures 1A-1D).
Arthroscopic assessment of the right knee demonstrated the large osseous fragment located in the anterolateral aspect of the joint with the displaced anterior horn of the lateral meniscus attached as well as significant anterior impingement limiting knee extension. Probing of the anterolateral meniscal root in the lateral compartment showed abundant surrounding scar tissue with an abnormal attachment, representing a chronic root avulsion. A mechanical shaver was used to débride the scar tissue and expose the malunited fragment, followed by complete osseous fragment excision with a high-speed burr (Figure 3).
A soft tissue anterolateral meniscal root repair was performed by creating a 2-cm to 3-cm incision on the anterolateral tibia, just distal to the medial aspect of the Gerdy tubercle. To best restore the footprint of the repair and increase the potential for biologic healing, 2 transtibial tunnels were created at the location of the root attachment. An ACL aiming device with a cannulated sleeve was used to drill 2 bony tunnels approximately 5 mm apart, exiting at the anatomic root footprint. The drill pins were removed, leaving the 2 cannulas in place for later suture passage. A suture-passing device was used to pass 2 separate sutures through the detached meniscal root.
Continue to: Postoperatively, the patient was placed...
Postoperatively, the patient was placed on a non-weight-bearing protocol for her operative lower extremity for 6 weeks. A brace locked in extension was used for the same period of time (being removed only for physical therapy exercises). Enoxaparin was used for the first 2 weeks for deep vein thrombosis prophylaxis, followed by aspirin for an additional 4 weeks. Physical therapy was started on postoperative day 1 to begin working on early passive ROM exercises. Knee flexion was limited to 0° to 90° of flexion for the first 2 weeks and then progressed as tolerated.
DISCUSSION
This article describes a rare case of a patient with lateral meniscal anterior root avulsion in the setting of a tibial eminence fracture with subsequent malunion and root displacement. In a case such as this, delineation of the true extent of the injury is difficult because the anterior meniscal root can be torn, displaced, and nonanatomically scarred to surrounding soft tissues, making MRI interpretation challenging. Clinically, patients can present with a wide range of symptoms, including pain, mechanical symptoms, instability, and loss of knee motion.10
The anterior root of the lateral meniscus has been reported to be attached anterior to the lateral tibial eminence and adjacent to the insertion of the ACL. Fibrous connections extending from the anterior horn of the lateral meniscus attachment to the lateral tibial eminence are constant.11 Furumatsu and colleagues12 demonstrated the existence of dense fibers linking the anterior root of the lateral meniscus with the lateral aspect of the ACL tibial insertion. Acknowledging the close relationship of these structures is key to comprehending the importance of evaluating the anterior horn of the lateral meniscus in cases of tibial eminence fractures at the initial time of injury. Failure to diagnose this pathology can lead to poor clinical outcomes and early degenerative changes of the knee.
Tibial intercondylar eminence avulsion fractures are most likely to occur in children and adolescents, and are equivalent to an ACL tear in adults.13 When tibial eminence fractures occur in an older cohort, they are often combined with lesions of the menisci, capsule, or collateral ligaments.14 The initial injury in our patient demonstrated concomitant anterior root injury that progressed with time to nonanatomical healing of the root, leading to altered biomechanics. Surgical techniques available for meniscal root repair are broadly divided into transosseous suture repairs and suture anchor repairs.10 The transtibial pullout technique using 2 transtibial bone tunnels as described in this report is the senior author’s (RFL) preference because it provides a strong construct with minimal displacement of the repaired meniscus.15-17
This article describes a complete avulsion of the anterolateral meniscal root caused by a tibial eminence fracture with resultant malunion and displacement of the root in a nonanatomic position. Anterior meniscal root tears have been reported to result in altered biomechanics and force transmission across the knee, and therefore, anatomic repair of the anterior root is indicated.
1. James EW, LaPrade CM, Ellman MB, Wijdicks CA, Engebretsen L, LaPrade RF. Radiographic identification of the anterior and posterior root attachments of the medial and lateral menisci. Am J Sports Med. 2014;42(11):2707-2714. doi:10.1177/0363546514545863.
2. LaPrade CM, Foad A, Smith SD, et al. Biomechanical consequences of a nonanatomic posterior medial meniscal root repair. Am J Sports Med. 2015;43(4):912-920. doi:10.1177/0363546514566191.
3. LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med. 2015;43(2):363-369. doi:10.1177/0363546514559684.
4. Ellman MB, James EW, LaPrade CM, LaPrade RF. Anterior meniscus root avulsion following intramedullary nailing for a tibial shaft fracture. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):1188-1191. doi:10.1007/s00167-014-2941-5.
5. Padalecki JR, Jansson KS, Smith SD, et al. Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics. Am J Sports Med. 2014;42(3):699-707. doi:10.1177/0363546513499314.
6. LaPrade CM, Jisa KA, Cram TR, LaPrade RF. Posterior lateral meniscal root tear due to a malpositioned double-bundle anterior cruciate ligament reconstruction tibial tunnel. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3670-3673. doi:10.1007/s00167-014-3273-1.
7. Mitchell JJ, Sjostrom R, Mansour AA, et al. Incidence of meniscal injury and chondral pathology in anterior tibial spine fractures of children. J Pediatr Orthop. 2015;35(2):130-135. doi:10.1097/BPO.0000000000000249.
8. Monto RR, Cameron-Donaldson ML. Magnetic resonance imaging in the evaluation of tibial eminence fractures in adults. J Knee Surg. 2006;19(3):187-190.
9. Ishibashi Y, Tsuda E, Sasaki T, Toh S. Magnetic resonance imaging AIDS in detecting concomitant injuries in patients with tibial spine fractures. Clin Orthop Relat Res. 2005;(434):207-212.
10. Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears significance, diagnosis, and treatment. Am J Sports Med. 2014;42(12):3016-3030. doi:10.1177/0363546514524162.
11. Ziegler CG, Pietrini SD, Westerhaus BD, et al. Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2011;39(4):743-752. doi:10.1177/0363546510387511.
12. Furumatsu T, Kodama Y, Maehara A, et al. The anterior cruciate ligament-lateral meniscus complex: a histological study. Connect Tissue Res. 2016;57(2):91-98. doi:10.3109/03008207.2015.1081899.
13. Lubowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop Rel Res. 1993;(294):242-246.
14. Falstie-Jensen S, Sondergard Petersen PE. Incarceration of the meniscus in fractures of the intercondylar eminence of the tibia in children. Injury. 1984;15(4):236-238.
15. LaPrade CM, LaPrade MD, Turnbull TL, Wijdicks CA, LaPrade RF. Biomechanical evaluation of the transtibial pull-out technique for posterior medial meniscal root repairs using 1 and 2 transtibial bone tunnels. Am J Sports Med. 2015;43(4):899-904. doi:10.1177/0363546514563278.
16. Menge TJ, Chahla J, Dean CS, Mitchell JJ, Moatshe G, LaPrade RF. Anterior meniscal root repair using a transtibial double-tunnel pullout technique. Arthrosc Tech. 2016;5(3):e679-e684. doi:10.1016/j.eats.2016.02.026.
17. Menge TJ, Dean CS, Chahla J, Mitchell JJ, LaPrade RF. Anterior horn meniscal repair using an outside-in suture technique. Arthrosc Tech. 2016;5(5):e1111-e1116. doi:10.1016/j.eats.2016.06.005.
1. James EW, LaPrade CM, Ellman MB, Wijdicks CA, Engebretsen L, LaPrade RF. Radiographic identification of the anterior and posterior root attachments of the medial and lateral menisci. Am J Sports Med. 2014;42(11):2707-2714. doi:10.1177/0363546514545863.
2. LaPrade CM, Foad A, Smith SD, et al. Biomechanical consequences of a nonanatomic posterior medial meniscal root repair. Am J Sports Med. 2015;43(4):912-920. doi:10.1177/0363546514566191.
3. LaPrade CM, James EW, Cram TR, Feagin JA, Engebretsen L, LaPrade RF. Meniscal root tears: a classification system based on tear morphology. Am J Sports Med. 2015;43(2):363-369. doi:10.1177/0363546514559684.
4. Ellman MB, James EW, LaPrade CM, LaPrade RF. Anterior meniscus root avulsion following intramedullary nailing for a tibial shaft fracture. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):1188-1191. doi:10.1007/s00167-014-2941-5.
5. Padalecki JR, Jansson KS, Smith SD, et al. Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics. Am J Sports Med. 2014;42(3):699-707. doi:10.1177/0363546513499314.
6. LaPrade CM, Jisa KA, Cram TR, LaPrade RF. Posterior lateral meniscal root tear due to a malpositioned double-bundle anterior cruciate ligament reconstruction tibial tunnel. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3670-3673. doi:10.1007/s00167-014-3273-1.
7. Mitchell JJ, Sjostrom R, Mansour AA, et al. Incidence of meniscal injury and chondral pathology in anterior tibial spine fractures of children. J Pediatr Orthop. 2015;35(2):130-135. doi:10.1097/BPO.0000000000000249.
8. Monto RR, Cameron-Donaldson ML. Magnetic resonance imaging in the evaluation of tibial eminence fractures in adults. J Knee Surg. 2006;19(3):187-190.
9. Ishibashi Y, Tsuda E, Sasaki T, Toh S. Magnetic resonance imaging AIDS in detecting concomitant injuries in patients with tibial spine fractures. Clin Orthop Relat Res. 2005;(434):207-212.
10. Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. Meniscal root tears significance, diagnosis, and treatment. Am J Sports Med. 2014;42(12):3016-3030. doi:10.1177/0363546514524162.
11. Ziegler CG, Pietrini SD, Westerhaus BD, et al. Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2011;39(4):743-752. doi:10.1177/0363546510387511.
12. Furumatsu T, Kodama Y, Maehara A, et al. The anterior cruciate ligament-lateral meniscus complex: a histological study. Connect Tissue Res. 2016;57(2):91-98. doi:10.3109/03008207.2015.1081899.
13. Lubowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop Rel Res. 1993;(294):242-246.
14. Falstie-Jensen S, Sondergard Petersen PE. Incarceration of the meniscus in fractures of the intercondylar eminence of the tibia in children. Injury. 1984;15(4):236-238.
15. LaPrade CM, LaPrade MD, Turnbull TL, Wijdicks CA, LaPrade RF. Biomechanical evaluation of the transtibial pull-out technique for posterior medial meniscal root repairs using 1 and 2 transtibial bone tunnels. Am J Sports Med. 2015;43(4):899-904. doi:10.1177/0363546514563278.
16. Menge TJ, Chahla J, Dean CS, Mitchell JJ, Moatshe G, LaPrade RF. Anterior meniscal root repair using a transtibial double-tunnel pullout technique. Arthrosc Tech. 2016;5(3):e679-e684. doi:10.1016/j.eats.2016.02.026.
17. Menge TJ, Dean CS, Chahla J, Mitchell JJ, LaPrade RF. Anterior horn meniscal repair using an outside-in suture technique. Arthrosc Tech. 2016;5(5):e1111-e1116. doi:10.1016/j.eats.2016.06.005.
TAKE-HOME POINTS
- Root tears of all meniscal attachments have been described. A comprehensive anatomic understanding of the meniscal roots is of utmost importance to suspect root lesions.
- A detailed physical examination along with imaging methods should be performed to make the correct diagnosis. In cases of evident injuries, such as a tibial spine fracture, additional soft tissue pathology should also be assessed.
- It is important to restore all torn root attachments to restore joint loading and contact areas. An anatomical root repair is needed to yield optimal results.
- Progressive rehabilitation with early ROM starting on postoperative day 1 can help avoid loss of knee motion and arthrofibrosis.