Presentation
Hyperextension injury of the right knee. Pain and cracking.
Patient Data
moderate T2 hyperintensity of the lower portion of the anterior cruciate ligament (ACL) without discontinuity or fiber disorganization.
anterolateral femoral condyle bone bruise
The patient had rehabilitation and rest. She recovered after a month.
2 years later, the patient had again knee trauma (during skiing).
articular free fluid in the suprapatellar recess
posterior medial meniscal T2 hyperintensity grade 2a
complete rupture of the anterior cruciate ligament (ACL)
bone bruises on the posterolateral tibial plateau, lateral femoral condyle, and the fibular epiphysis
The patient was operated on and had an anterior cruciate ligament (ACL) short single-bundle hamstring semitendinous autograft.
there is no anterior tibial translation (anterior drawer sign)
posterior tibial slope measuring 10°
the tunnels and screws are unremarkable
3 years later, the patient had another sports trauma (basketball).
MRI to rule out graft rupture.
it was challenging to assess the quality of the graft due to the blooming artifact, but it looked continuous (best seen on axial sequences) and there were no signs of rupture
posteromedial and posterolateral tibial bone bruises
post-operative synovial thickening in keeping with fibrous post-operative adhesions
harvested semitendinous for the reconstruction (there is no more tendon, compared to the other MRI)
One year later, the patient complains of pain, cracking, and persistent instability of the injured knee.
Clinical examination demonstrates a positive pivot shift test and there is no firm Lachman endpoint.
The clinical presentation was highly suggestive of graft rupture. An MRI was performed to rule it out.
the graft is unremarkable: there is no fiber discontinuity or increased signal
bucket handle meniscal tear of the body and the posterior horn of the medial meniscus (the posterior horn looks smaller than in the last MRI)
migration of the displaced fragment in the intercondylar notch (best seen in coronal sequences)
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post-operative fibrous adhesions
OPERATIVE REPORT (synopsis):
The arthroscopic exploration of the knee found:
a few post-operative fibrous bands in the suprapatellar recess with otherwise unremarkable femoropatellar joint
a bucket handle tear of the medial meniscus involving the middle and posterior part dislocated in the intercondylar notch, but no chondral lesion of the medial femorotibial compartment
a continuous and viable, but elongated anterior cruciate ligament graft in a good position with no firm endpoint Lachman test and positive pivot shift test which explains the preoperative testing
no meniscal injury or chondral lesion in the lateral femorotibial compartment
otherwise no intra-articular foreign body and no synovitis
The exploration was followed-up by the following procedural steps:
medial meniscal suture
modified Lemaire lateral extra-articular tenodesis with removal of a strip of the iliotibial band
removal of the femoral screw
Case Discussion
A case of operatively confirmed anterior cruciate ligament graft stretching complicated by a bucket-handle meniscal tear that was arthroscopically treated with a meniscal suture and a modified Lemaire extraarticular tenodesis.
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