Fracture of the supracondylar femur after anterior cruciate ligament reconstruction using patellar tendon and iliotibial band tenodesis A case report JOSEPH NOAH,* MD, ORRIN H. SHERMAN, MD, AND CRAIG ROBERTS, MD From the New York
University Medical Center, Department of Orthopedic Surgery,
New York, New York
Surgical management of the chronic ACL-deficient knee can present a difficult problem, even to the experienced surgeon.
and moderate medial joint line tenderness. Range of motion 0° to 110°, with moderate discomfort at terminal flexion. Further examination revealed positive Lachman and anterior drawer tests, as well as a moderate pivot shift. There was no evidence of either a posterior sag or posterior drawer. Anteroposterior and lateral radiographs of the involved knee were unremarkable (Fig. 1). Initially, treatment was directed toward improving lower extremity strength and range of motion. Despite a wellwas
Although
procedures are commonly performed, they specific risks.l2 Well-established complications of surgical reconstructions include patellar fracture,l8 patellar tendon rupture,’ loss of motion,1O,l9 infection, and hardware failure.&dquo; We present a case of a 29-year-old man who had an ACL reconstruction using autogenous patellar tendon graft and an iliotibial band tenodesis. Six months postoperatively, he sustained a fracture at the level of the iliotibial band screw, requiring open reduction and internal fixation. To the authors’ knowledge, this complication has not been previously reported. are
many not without
supervised trial of physical therapy, the patient’s symptoms of instability did not improve. After some discussion, he agreed with our recommendation for an arthroscopic meniscal debridement and an intraarticular reconstruction using the central third of the patellar tendon (bone-tendon-bone). Diagnostic arthroscopy revealed an old complete tear of the
CASE REPORT A 29-year-old
ACL and a small radial tear within the substance of the medial meniscus. The posterior cruciate ligament and lateral meniscus were intact.
evaluated at our outpatient clinic for recurrent instability of the right knee. The patient was an avid recreational athlete who had injured his knee 4 years earlier while playing basketball. He noted that the injury was associated with an audible &dquo;pop,&dquo; immediate swelling, and inability to continue playing, but he did not seek medical attention at that time. At the initial evaluation, the patient complained of moderate medial knee pain and giving way with activities requiring running or pivoting. His medical history was otherwise unremarkable. Physical examination revealed a well-developed man with moderate right quadriceps atrophy, a mild joint effusion, man was
A
partial medial meniscectomy was performed, leaving a large stable rim. The patellar graft was harvested in the standard fashion with its bony attachments.’ Isometrically determined bony tunnels were created in the femur and tibia using arthroscopic assistance and C-loop drill guides. The graft was then passed through the tunnels and was provisionally secured. At this point, examination of the knee revealed a full range of motion with only a trace positive Lachman test and elimination of the pivot shift. The graft secured with interference screws and an extraarticular tenodesis of the iliotibial band was performed. Postoperative radiographs, taken with the knee in a brace, revealed good position of the interference screws but a was
*
Address correspondence and reprint requests to: Joseph Noah, MD, 1308 DeKalb Street, Norristown, PA 19401.
615
616
Figure 2. Immediate postoperative radiographs showing the placement of the interference screws.
Figure 1. Preoperative AP (A) and lateral (B) radiographs were unremarkable.
617
Figure 3. Radiographs taken 6 months after surgery showed a
fracture at the level of the iliotibial band
screw.
Figure 4. Postoperative radiographs showing internal fixation with an AO supracondylar blade plate.
618
slightly long and superiorly placed iliotibial band screw (Fig. 2). The patient had an uneventful recovery and progressed to full weightbearing by 6 weeks. The patient progressed well with physical therapy, regaining his preoperative motion by 3 months and participating in straight-ahead jogging activities by 5 months. The patient was doing well until approximately 6 months postoperatively. At that time he returned to the clinic after a fall with left knee swelling, pain, and inability to bear weight on his left leg. Examination of the extremity was limited by pain, although radiographs revealed that the patient had fractured his femur at the level of the iliotibial band screw (Fig. 3). The patient was admitted and underwent open reduction and internal fixation using an AO supracondylar blade plate (Fig. 4). Knee examination performed at the completion of the procedure revealed a trace positive Lachman test, but no anterior drawer or pivot shift. DISCUSSION The goal of any surgical procedure directed toward the ACLdeficient knee is to control anterolateral rotatory instability.l3,17.20 In the past, many have tried extraarticular reconstructions,2.3,9 often using the iliotibial band, to control the anterior subluxation of the tibia on the femur. These procedures were less demanding than the intraarticular reconstructions and were often successful in eliminating the pivot shift phenomenon. Unfortunately, the results of most of these procedures deteriorated in studies with longer followups.’ With the advent of improved technology and better understanding of the normal ACL, many surgeons have come to prefer intraarticular procedures with extraarticular
augmentation.’, 8, &dquo;, l4, 22 Even though at the time of this case we routinely performed extraarticular augmentations in all of our intraarticular reconstructions, we currently reserve the use of an extraarticular augmentation for residual instability. When performing an extraarticular augmentation, we prefer to use a 6.5-mm AO cancellous screw with a soft tissue washer, placing the iliotibial band in a position along the posterolateral edge of the femur, proximal to the condylar flare.l5 Often, this position is at the same point as the isometric femoral point. Although some have used one screw for the fixation of the graft and the iliotibial band tenodesis,zl we feel that this compromises the interference fixation of the graft in the femoral tunnel. Therefore, we prefer to modify the position of the iliotibial band screw, often slightly more
the lateral femur. Although it is generally agreed that a hole constituting less than 20% of a bone diameter tends to be of little significance,5 the fact that more than one hole was produced in the lateral femur may, in effect, have created a significant defect. This defect may have led to the fracture more than 6 months after the procedure.
CONCLUSION It is
important to realize that a malpositioned iliotibial band in an extraarticular procedure can effect not only long-term joint stability, it can also predispose the patient to increased risk of fracture, even several months postoperatively, secondary to stress-riser effect. screw
REFERENCES JR, Carson WG: The role of extraarticular anterior cruciate in Jackson DW, Drez D (eds): The Anterior Cruciate Deficient Knee. St. Louis, CV Mosby, 1987, pp 168-192 2. Andrews JR, Sanders RA: A "mini-reconstruction" technique in treating anterolateral rotatory instability. Clin Orthop 172: 93-96, 1983 3. Bechtol CO, Lepper H Jr: Fundamental studies in the design of metal 1. Andrews
ligament stabilization,
screws for internal fixation of bone. J Bone Joint Surg 38A: 1385, 1956 4. Bonamo JJ, Krinick RM, Sporn AA: Rupture of the patellar ligament after use of its central third for anterior cruciate ligament reconstruction. J Bone Joint Surg 66A: 1294-1297, 1984 5. Burstein AH, Currey J, Frankel VH, et al: Bone strength. The effect of screw holes. J Bone Joint Surg 54A: 1143-1156, 1972 6. Carson WG: Extra-articular reconstruction of the anterior cruciate ligament. Lateral procedures. Orthop Clin North Am 16: 191-211, 1985 7. Clancy WG Jr: Arthroscopic anterior cruciate reconstruction with patellar tendon. Techniques Orthop 2: 13-22, 1988 8. Clancy WG Jr, Nelson DA, Reider B, et al: Anterior cruciate ligament reconstruction using one-third of the patellar tendon, augmented by extraarticular tendon transfers. J Bone Joint Surg 64A: 352-359, 1982 9. Ellison AE: Distal iliotibial-band transfer for anterolateral rotatory instability of the knee. J Bone Joint Surg 61A: 330-337, 1979 10. Fullerton LR, Andrews JR: Mechanical block to extension following augmentation of the anterior cruciate ligament: Case report. Am J Sports Med
12: 166-169, 1984 11.
12. 13.
14.
15.
16.
17. 18.
19.
posterior. It is clear from the postoperative radiographs that the iliotibial band screw was more proximal then the recommended position. Placement of the screw within the diaphyseal region of the femur produced a more pronounced stressriser effect.3 In addition, the radiographs also reveal that while placing the screw, more than one hole was created in
20. 21.
22.
Higgins RW, Steadman JR: Anterior cruciate ligament repairs in World Class Skiers. Am J Sports Med 15: 441-447, 1987 Hughston J: Complications of anterior cruciate ligament surgery. Orthop Clin North Am 16: 237-240, 1985 Hughston JC, Andrews JR, Cross MJ, et al: Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg 58A: 159-172, 1976 Jensen JE, Slocum DB, Larson RL, et al: Reconstruction procedures for the anterior cruciate ligament insufficiency: A computer analysis of clinical results. Am J Sports Med 11: 240-248, 1983 Krackow KA, Brooks RL: Optimization of knee ligament position for lateral extraarticular reconstruction. Am J Sports Med 11: 293-302, 1983 Kurosaka M, Yoshiya S, Andrish JT: A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med 15: 225-229, 1987 Losee, RE, Johnson TR, Southwick WO: Anterior subluxation of the lateral tibial plateau. J Bone Joint Surg 60A: 1015-1030, 1978 McCarroll JR: Fracture of the patella during a golf swing following reconstruction of the anterior cruciate ligament. A case report. Am J Sports Med 11: 26-27, 1983 Paulos LE, Rosenberg TD, Drawbert J, et al: Infrapatellar contracture syndrome. An unrecognized cause of knee stiffness with patella entrapment and patella infera. Am J Sports Med 15: 331-341, 1987 Warren RF: Primary repair of the anterior cruciate ligament. Clin Orthop 172: 65-70, 1983 Wilcox PG, Jackson DW: Factors affecting choices of anterior cruciate ligament surgery, in Jackson DW, Drez D (eds): The Anterior Cruciate Deficient Knee. St Louis, CV Mosby, 1987, pp 127-141 Zarins B, Rowe CR: Combined anterior cruciate-ligament reconstruction using semitendinosus tendon and iliotibial tract. J Bone Joint Surg 68A: 160-177,1986
University Medical Center, Department of Orthopedic Surgery,
New York, New York
Surgical management of the chronic ACL-deficient knee can present a difficult problem, even to the experienced surgeon.
and moderate medial joint line tenderness. Range of motion 0° to 110°, with moderate discomfort at terminal flexion. Further examination revealed positive Lachman and anterior drawer tests, as well as a moderate pivot shift. There was no evidence of either a posterior sag or posterior drawer. Anteroposterior and lateral radiographs of the involved knee were unremarkable (Fig. 1). Initially, treatment was directed toward improving lower extremity strength and range of motion. Despite a wellwas
Although
procedures are commonly performed, they specific risks.l2 Well-established complications of surgical reconstructions include patellar fracture,l8 patellar tendon rupture,’ loss of motion,1O,l9 infection, and hardware failure.&dquo; We present a case of a 29-year-old man who had an ACL reconstruction using autogenous patellar tendon graft and an iliotibial band tenodesis. Six months postoperatively, he sustained a fracture at the level of the iliotibial band screw, requiring open reduction and internal fixation. To the authors’ knowledge, this complication has not been previously reported. are
many not without
supervised trial of physical therapy, the patient’s symptoms of instability did not improve. After some discussion, he agreed with our recommendation for an arthroscopic meniscal debridement and an intraarticular reconstruction using the central third of the patellar tendon (bone-tendon-bone). Diagnostic arthroscopy revealed an old complete tear of the
CASE REPORT A 29-year-old
ACL and a small radial tear within the substance of the medial meniscus. The posterior cruciate ligament and lateral meniscus were intact.
evaluated at our outpatient clinic for recurrent instability of the right knee. The patient was an avid recreational athlete who had injured his knee 4 years earlier while playing basketball. He noted that the injury was associated with an audible &dquo;pop,&dquo; immediate swelling, and inability to continue playing, but he did not seek medical attention at that time. At the initial evaluation, the patient complained of moderate medial knee pain and giving way with activities requiring running or pivoting. His medical history was otherwise unremarkable. Physical examination revealed a well-developed man with moderate right quadriceps atrophy, a mild joint effusion, man was
A
partial medial meniscectomy was performed, leaving a large stable rim. The patellar graft was harvested in the standard fashion with its bony attachments.’ Isometrically determined bony tunnels were created in the femur and tibia using arthroscopic assistance and C-loop drill guides. The graft was then passed through the tunnels and was provisionally secured. At this point, examination of the knee revealed a full range of motion with only a trace positive Lachman test and elimination of the pivot shift. The graft secured with interference screws and an extraarticular tenodesis of the iliotibial band was performed. Postoperative radiographs, taken with the knee in a brace, revealed good position of the interference screws but a was
*
Address correspondence and reprint requests to: Joseph Noah, MD, 1308 DeKalb Street, Norristown, PA 19401.
615
616
Figure 2. Immediate postoperative radiographs showing the placement of the interference screws.
Figure 1. Preoperative AP (A) and lateral (B) radiographs were unremarkable.
617
Figure 3. Radiographs taken 6 months after surgery showed a
fracture at the level of the iliotibial band
screw.
Figure 4. Postoperative radiographs showing internal fixation with an AO supracondylar blade plate.
618
slightly long and superiorly placed iliotibial band screw (Fig. 2). The patient had an uneventful recovery and progressed to full weightbearing by 6 weeks. The patient progressed well with physical therapy, regaining his preoperative motion by 3 months and participating in straight-ahead jogging activities by 5 months. The patient was doing well until approximately 6 months postoperatively. At that time he returned to the clinic after a fall with left knee swelling, pain, and inability to bear weight on his left leg. Examination of the extremity was limited by pain, although radiographs revealed that the patient had fractured his femur at the level of the iliotibial band screw (Fig. 3). The patient was admitted and underwent open reduction and internal fixation using an AO supracondylar blade plate (Fig. 4). Knee examination performed at the completion of the procedure revealed a trace positive Lachman test, but no anterior drawer or pivot shift. DISCUSSION The goal of any surgical procedure directed toward the ACLdeficient knee is to control anterolateral rotatory instability.l3,17.20 In the past, many have tried extraarticular reconstructions,2.3,9 often using the iliotibial band, to control the anterior subluxation of the tibia on the femur. These procedures were less demanding than the intraarticular reconstructions and were often successful in eliminating the pivot shift phenomenon. Unfortunately, the results of most of these procedures deteriorated in studies with longer followups.’ With the advent of improved technology and better understanding of the normal ACL, many surgeons have come to prefer intraarticular procedures with extraarticular
augmentation.’, 8, &dquo;, l4, 22 Even though at the time of this case we routinely performed extraarticular augmentations in all of our intraarticular reconstructions, we currently reserve the use of an extraarticular augmentation for residual instability. When performing an extraarticular augmentation, we prefer to use a 6.5-mm AO cancellous screw with a soft tissue washer, placing the iliotibial band in a position along the posterolateral edge of the femur, proximal to the condylar flare.l5 Often, this position is at the same point as the isometric femoral point. Although some have used one screw for the fixation of the graft and the iliotibial band tenodesis,zl we feel that this compromises the interference fixation of the graft in the femoral tunnel. Therefore, we prefer to modify the position of the iliotibial band screw, often slightly more
the lateral femur. Although it is generally agreed that a hole constituting less than 20% of a bone diameter tends to be of little significance,5 the fact that more than one hole was produced in the lateral femur may, in effect, have created a significant defect. This defect may have led to the fracture more than 6 months after the procedure.
CONCLUSION It is
important to realize that a malpositioned iliotibial band in an extraarticular procedure can effect not only long-term joint stability, it can also predispose the patient to increased risk of fracture, even several months postoperatively, secondary to stress-riser effect. screw
REFERENCES JR, Carson WG: The role of extraarticular anterior cruciate in Jackson DW, Drez D (eds): The Anterior Cruciate Deficient Knee. St. Louis, CV Mosby, 1987, pp 168-192 2. Andrews JR, Sanders RA: A "mini-reconstruction" technique in treating anterolateral rotatory instability. Clin Orthop 172: 93-96, 1983 3. Bechtol CO, Lepper H Jr: Fundamental studies in the design of metal 1. Andrews
ligament stabilization,
screws for internal fixation of bone. J Bone Joint Surg 38A: 1385, 1956 4. Bonamo JJ, Krinick RM, Sporn AA: Rupture of the patellar ligament after use of its central third for anterior cruciate ligament reconstruction. J Bone Joint Surg 66A: 1294-1297, 1984 5. Burstein AH, Currey J, Frankel VH, et al: Bone strength. The effect of screw holes. J Bone Joint Surg 54A: 1143-1156, 1972 6. Carson WG: Extra-articular reconstruction of the anterior cruciate ligament. Lateral procedures. Orthop Clin North Am 16: 191-211, 1985 7. Clancy WG Jr: Arthroscopic anterior cruciate reconstruction with patellar tendon. Techniques Orthop 2: 13-22, 1988 8. Clancy WG Jr, Nelson DA, Reider B, et al: Anterior cruciate ligament reconstruction using one-third of the patellar tendon, augmented by extraarticular tendon transfers. J Bone Joint Surg 64A: 352-359, 1982 9. Ellison AE: Distal iliotibial-band transfer for anterolateral rotatory instability of the knee. J Bone Joint Surg 61A: 330-337, 1979 10. Fullerton LR, Andrews JR: Mechanical block to extension following augmentation of the anterior cruciate ligament: Case report. Am J Sports Med
12: 166-169, 1984 11.
12. 13.
14.
15.
16.
17. 18.
19.
posterior. It is clear from the postoperative radiographs that the iliotibial band screw was more proximal then the recommended position. Placement of the screw within the diaphyseal region of the femur produced a more pronounced stressriser effect.3 In addition, the radiographs also reveal that while placing the screw, more than one hole was created in
20. 21.
22.
Higgins RW, Steadman JR: Anterior cruciate ligament repairs in World Class Skiers. Am J Sports Med 15: 441-447, 1987 Hughston J: Complications of anterior cruciate ligament surgery. Orthop Clin North Am 16: 237-240, 1985 Hughston JC, Andrews JR, Cross MJ, et al: Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg 58A: 159-172, 1976 Jensen JE, Slocum DB, Larson RL, et al: Reconstruction procedures for the anterior cruciate ligament insufficiency: A computer analysis of clinical results. Am J Sports Med 11: 240-248, 1983 Krackow KA, Brooks RL: Optimization of knee ligament position for lateral extraarticular reconstruction. Am J Sports Med 11: 293-302, 1983 Kurosaka M, Yoshiya S, Andrish JT: A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med 15: 225-229, 1987 Losee, RE, Johnson TR, Southwick WO: Anterior subluxation of the lateral tibial plateau. J Bone Joint Surg 60A: 1015-1030, 1978 McCarroll JR: Fracture of the patella during a golf swing following reconstruction of the anterior cruciate ligament. A case report. Am J Sports Med 11: 26-27, 1983 Paulos LE, Rosenberg TD, Drawbert J, et al: Infrapatellar contracture syndrome. An unrecognized cause of knee stiffness with patella entrapment and patella infera. Am J Sports Med 15: 331-341, 1987 Warren RF: Primary repair of the anterior cruciate ligament. Clin Orthop 172: 65-70, 1983 Wilcox PG, Jackson DW: Factors affecting choices of anterior cruciate ligament surgery, in Jackson DW, Drez D (eds): The Anterior Cruciate Deficient Knee. St Louis, CV Mosby, 1987, pp 127-141 Zarins B, Rowe CR: Combined anterior cruciate-ligament reconstruction using semitendinosus tendon and iliotibial tract. J Bone Joint Surg 68A: 160-177,1986
