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The Journal of Bone and Joint Surgery (American) 84:1933-1938 (2002)
© 2002 The Journal of Bone and Joint Surgery, Inc.

Scientific Article

The Anatomy of Tibial Eminence Fractures: Arthroscopic Observations Following Failed Closed Reduction

J. Lowe, MD, G. Chaimsky, MD, A. Freedman, MD, I. Zion, MD and C. Howard, FRCS

Investigation performed at the Hadassah University Hospital, Jerusalem, Israel

J. Lowe, MD
G. Chaimsky, MD
A. Freedman, MD
I. Zion, MD
C. Howard, FRCS
Sports Injury and Arthroscopy Unit, Hadassah University Hospital, Mount Scopus, Jerusalem 91240, Israel. E-mail address for J. Lowe: dlowe{at}cc.huji.ac.il

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Failed manipulative reduction of avulsion fractures of the tibial insertion of the anterior cruciate ligament has been attributed to interposition of soft tissues, particularly the anterior horn of the medial meniscus. The objectives of the present report were (1) to show that the failure to reduce Meyers and McKeever type-III tibial eminence fractures was not due to interposition of soft tissues and (2) to discuss the relevance of the finding that the anterior third of the lateral meniscus was attached to the avulsed anterior cruciate ligament insertion site in all patients studied.

Methods: Twelve patients who had had a failed manipulative reduction of a type-III tibial eminence fracture underwent arthroscopic reduction and fixation of the avulsed fragment.

Results: A number of consistent findings were noted. The avulsed intercondylar eminence was displaced superiorly into the intercondylar notch. Attached to this fragment was not only the anterior cruciate ligament, but also, in all cases, the anterior horn of the lateral meniscus. The anterior third of the lateral meniscus had been torn from its tibial attachment and displaced together with the osseous fragment into the intercondylar notch. No interposition of bone or soft tissue was observed. Reduction of the osseous fragment was facilitated by traction on, or sutures passed around, the anterior horn of the lateral meniscus. Standard fixation methods were utilized.

Conclusions: The concept that avulsion fractures of the tibial insertion of the anterior cruciate ligament cannot be reduced by manipulation because of soft-tissue interposition was not supported by the findings of the present study. The attachment of the anterior horn of the lateral meniscus to the avulsed tibial insertion of the anterior cruciate ligament may not be an irrelevant incidental finding. The observation that the displaced osseous fragment was attached simultaneously to the anterior cruciate ligament and to the anterior horn of the lateral meniscus, both pulling in different directions, may explain why type-III tibial eminence fractures are irreducible by manipulation.


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