A 14-year-old male recreational player presented 4 weeks after an injury to his left knee. He described a twisting injury on his planted left leg. At the time of injury, he experienced a popping sensation, was unable to continue due to knee pain and developed a swollen knee within an hour. He then reported that his symptoms seemed to settle very quickly, and he attempted to play again three weeks later. Within one minute of starting this game his knee “gave way”. He then experienced further pain and swelling and reports being unable to fully extend his knee. The main findings at the time of his consultation were a loss of the final 20 degrees of knee extension, a positive Lachman’s test, a moderate effusion and medial joint line tenderness.
X-ray images showed an effusion but no bony injury. A subsequent MRI scan shows that there is complete disruption through the mid-substance of the anterior cruciate ligament (ACL). In association with this there are subchondral fractures of the lateral femoral condyle and posterior margin of the lateral tibial plateau and a bucket-handle tear of the medial meniscus with a large fragment flipped into the intercondylar notch. The chondral surfaces are well maintained. The other major knee ligaments are intact.
The player was managed with an early ACL reconstruction (using hamstring autograft) and medial meniscal repair. The post-operative plan involved six weeks in a hinged knee brace limiting flexion to 90 degrees. He otherwise followed a standard ACL post-operative rehabilitation plan with physiotherapy supervision. He is currently five months post-op and has started running and integrating some basic ball skills. It is hoped that he will be able to return to play approximately nine months after his surgery. He will have a functional assessment prior to return to play.
Meniscal tears are commonly seen in association with injuries to the ACL. In most cases efforts are made to repair, rather than resect the injured meniscal tear. This especially true in younger patients and when the tear is large or displaced to try to reduce the risk of subsequent arthritis. Unfortunately, despite a surgeon’s best efforts this is not always possible, nor is it always successful. In some situations, the repair does not heal and a further procedure is required to remove unstable meniscal tissue (a partial meniscectomy). A number of authors have reported a success rate of meniscal repair (when performed along with an ACL reconstruction) of approximately 90 %. When the ruptured ACL was treated non-operatively the failure rate rises to approximately 30–40%. It is thought that this difference may be due to the additional stability that the reconstruction confers, as well as the potential benefit that the intra-articular bleeding following a reconstruction may have on healing. Available data appears to suggest that the failure rate is lower after lateral (rather than medial) meniscal repairs and that early surgical treatment may also lead to better healing.
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