Case Reports

Avulsion of the Anterior Lateral Meniscal Root Secondary to Tibial Eminence Fracture

Publish date: May 8, 2018

Travis J. Menge, MD

Jorge Chahla, MD

Justin J. Mitchell, MD

Chase S. Dean, MD

Robert F. LaPrade, MD

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.

References

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.

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