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Tibial Tubercle Fracture After Bone–Patellar Tendon–Bone Autograft
A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.1,2 The patient provided written informed consent for print and electronic publication of this case report.
Case Report
Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.
During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.
After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).
At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°). 
The patient returned to the operating room 5 days later and underwent open reduction and internal fixation (ORIF) of the tibial tubercle avulsion. After sterile preparation and draping, the previous incision was used. The bony fragment was isolated and the hematoma débrided. Repair was performed with two No. 2 running locked FiberWire sutures (Arthrex) placed through bony drill holes in the fragment (1 medial, 1 lateral). The fragment was reduced and the sutures tied, with further fixation provided with a DePuy Synthes small-fragment 3.5-mm cortical screw with washer. A No. 5 Ethibond suture (Ethicon) was then placed as a secondary cerclage figure-of-8 stitch to protect the repair. 
The patient was seen in follow-up 6 weeks after right ACL reconstruction and 4 weeks after left tibial tubercle ORIF. He continued with right knee restrictions, with the weight-bearing brace locked in extension. Left knee ROM was more than 0° to 90° even before any formal physical therapy. At this point, the patient began physical therapy on both knees with ROM limited to 0° to 30° and weight-bearing as tolerated on the right knee (no restrictions on the left knee). 
Discussion
Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation1 and 1 in the contralateral knee.2 The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.3 Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.4 These fractures are universally treated with ORIF.1,2
Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.8 Lee and colleagues9 found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.
Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.10 In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.
Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.1
The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.
Conclusion
Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.
Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.
1. Acton KJ, Dowd GS. Fracture of the tibial tubercle following anterior cruciate ligament reconstruction. Knee. 2002;9(2):157-159.
2. Busfield BT, Safran MR, Cannon WD. Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction. Arthroscopy. 2005;21(10):1268.e1-e1268.e6.
3. Jones KG. Reconstruction of the anterior cruciate ligament. A technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
4. Tjoumakaris FP, Herz-Brown AL, Bowers AL, Sennett BJ, Bernstein J. Complications in brief: anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2012;470(2):630-636.
5. Morgan-Jones RL, Cross TM, Caldwell B, Cross MJ. “Silent” transverse patellar fracture following anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(9):997-999.
6. Viola R, Vianello R. Three cases of patella fracture in 1,320 anterior cruciate ligament reconstructions with bone–patellar tendon–bone autograft. Arthroscopy. 1999;15(1):93-97.
7. Berg EE. Management of patella fractures associated with central third bone–patella tendon–bone autograft ACL reconstructions. Arthroscopy. 1996;12(6):756-759.
8. Stein DA, Hunt SA, Rosen JE, Sherman OH. The incidence and outcome of patella fractures after anterior cruciate ligament reconstruction. Arthroscopy. 2002;18(6):578-583.
9. Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008;24(2):162-166.
10. Wong JJ, Muir B. Insufficiency fracture of the tibial plateau after anterior cruciate ligament reconstructive surgery: a case report and review of the literature. J Can Chiropr Assoc. 2013;57(2):123-131.
11. Morgan E, Steensen RN. Traumatic proximal tibial fracture following anterior cruciate ligament reconstruction. Am J Knee Surg. 1998;11(3):193-194.
12. Delcogliano A, Chiossi S, Caporaso A, Franzese S, Menghi A. Tibial plateau fracture after arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(4):E16.
13. Mithöfer K, Gill TJ, Vrahas MS. Tibial plateau fracture following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004;12(4):325-328.
14. Moen KY, Boynton MD, Raasch WG. Fracture of the proximal tibia after anterior cruciate ligament reconstruction: a case report. Am J Orthop. 1998;27(9):629-630.
A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.1,2 The patient provided written informed consent for print and electronic publication of this case report.
Case Report
Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.
During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.
After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).
At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).
The patient returned to the operating room 5 days later and underwent open reduction and internal fixation (ORIF) of the tibial tubercle avulsion. After sterile preparation and draping, the previous incision was used. The bony fragment was isolated and the hematoma débrided. Repair was performed with two No. 2 running locked FiberWire sutures (Arthrex) placed through bony drill holes in the fragment (1 medial, 1 lateral). The fragment was reduced and the sutures tied, with further fixation provided with a DePuy Synthes small-fragment 3.5-mm cortical screw with washer. A No. 5 Ethibond suture (Ethicon) was then placed as a secondary cerclage figure-of-8 stitch to protect the repair.
The patient was seen in follow-up 6 weeks after right ACL reconstruction and 4 weeks after left tibial tubercle ORIF. He continued with right knee restrictions, with the weight-bearing brace locked in extension. Left knee ROM was more than 0° to 90° even before any formal physical therapy. At this point, the patient began physical therapy on both knees with ROM limited to 0° to 30° and weight-bearing as tolerated on the right knee (no restrictions on the left knee).
Discussion
Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation1 and 1 in the contralateral knee.2 The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.3 Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.4 These fractures are universally treated with ORIF.1,2
Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.8 Lee and colleagues9 found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.
Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.10 In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.
Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.1
The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.
Conclusion
Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.
Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.
A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.1,2 The patient provided written informed consent for print and electronic publication of this case report.
Case Report
Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.
During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.
After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).
At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).
The patient returned to the operating room 5 days later and underwent open reduction and internal fixation (ORIF) of the tibial tubercle avulsion. After sterile preparation and draping, the previous incision was used. The bony fragment was isolated and the hematoma débrided. Repair was performed with two No. 2 running locked FiberWire sutures (Arthrex) placed through bony drill holes in the fragment (1 medial, 1 lateral). The fragment was reduced and the sutures tied, with further fixation provided with a DePuy Synthes small-fragment 3.5-mm cortical screw with washer. A No. 5 Ethibond suture (Ethicon) was then placed as a secondary cerclage figure-of-8 stitch to protect the repair.
The patient was seen in follow-up 6 weeks after right ACL reconstruction and 4 weeks after left tibial tubercle ORIF. He continued with right knee restrictions, with the weight-bearing brace locked in extension. Left knee ROM was more than 0° to 90° even before any formal physical therapy. At this point, the patient began physical therapy on both knees with ROM limited to 0° to 30° and weight-bearing as tolerated on the right knee (no restrictions on the left knee).
Discussion
Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation1 and 1 in the contralateral knee.2 The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.3 Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.4 These fractures are universally treated with ORIF.1,2
Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.8 Lee and colleagues9 found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.
Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.10 In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.
Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.1
The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.
Conclusion
Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.
Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.
1. Acton KJ, Dowd GS. Fracture of the tibial tubercle following anterior cruciate ligament reconstruction. Knee. 2002;9(2):157-159.
2. Busfield BT, Safran MR, Cannon WD. Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction. Arthroscopy. 2005;21(10):1268.e1-e1268.e6.
3. Jones KG. Reconstruction of the anterior cruciate ligament. A technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
4. Tjoumakaris FP, Herz-Brown AL, Bowers AL, Sennett BJ, Bernstein J. Complications in brief: anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2012;470(2):630-636.
5. Morgan-Jones RL, Cross TM, Caldwell B, Cross MJ. “Silent” transverse patellar fracture following anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(9):997-999.
6. Viola R, Vianello R. Three cases of patella fracture in 1,320 anterior cruciate ligament reconstructions with bone–patellar tendon–bone autograft. Arthroscopy. 1999;15(1):93-97.
7. Berg EE. Management of patella fractures associated with central third bone–patella tendon–bone autograft ACL reconstructions. Arthroscopy. 1996;12(6):756-759.
8. Stein DA, Hunt SA, Rosen JE, Sherman OH. The incidence and outcome of patella fractures after anterior cruciate ligament reconstruction. Arthroscopy. 2002;18(6):578-583.
9. Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008;24(2):162-166.
10. Wong JJ, Muir B. Insufficiency fracture of the tibial plateau after anterior cruciate ligament reconstructive surgery: a case report and review of the literature. J Can Chiropr Assoc. 2013;57(2):123-131.
11. Morgan E, Steensen RN. Traumatic proximal tibial fracture following anterior cruciate ligament reconstruction. Am J Knee Surg. 1998;11(3):193-194.
12. Delcogliano A, Chiossi S, Caporaso A, Franzese S, Menghi A. Tibial plateau fracture after arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(4):E16.
13. Mithöfer K, Gill TJ, Vrahas MS. Tibial plateau fracture following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004;12(4):325-328.
14. Moen KY, Boynton MD, Raasch WG. Fracture of the proximal tibia after anterior cruciate ligament reconstruction: a case report. Am J Orthop. 1998;27(9):629-630.
1. Acton KJ, Dowd GS. Fracture of the tibial tubercle following anterior cruciate ligament reconstruction. Knee. 2002;9(2):157-159.
2. Busfield BT, Safran MR, Cannon WD. Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction. Arthroscopy. 2005;21(10):1268.e1-e1268.e6.
3. Jones KG. Reconstruction of the anterior cruciate ligament. A technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
4. Tjoumakaris FP, Herz-Brown AL, Bowers AL, Sennett BJ, Bernstein J. Complications in brief: anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2012;470(2):630-636.
5. Morgan-Jones RL, Cross TM, Caldwell B, Cross MJ. “Silent” transverse patellar fracture following anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(9):997-999.
6. Viola R, Vianello R. Three cases of patella fracture in 1,320 anterior cruciate ligament reconstructions with bone–patellar tendon–bone autograft. Arthroscopy. 1999;15(1):93-97.
7. Berg EE. Management of patella fractures associated with central third bone–patella tendon–bone autograft ACL reconstructions. Arthroscopy. 1996;12(6):756-759.
8. Stein DA, Hunt SA, Rosen JE, Sherman OH. The incidence and outcome of patella fractures after anterior cruciate ligament reconstruction. Arthroscopy. 2002;18(6):578-583.
9. Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008;24(2):162-166.
10. Wong JJ, Muir B. Insufficiency fracture of the tibial plateau after anterior cruciate ligament reconstructive surgery: a case report and review of the literature. J Can Chiropr Assoc. 2013;57(2):123-131.
11. Morgan E, Steensen RN. Traumatic proximal tibial fracture following anterior cruciate ligament reconstruction. Am J Knee Surg. 1998;11(3):193-194.
12. Delcogliano A, Chiossi S, Caporaso A, Franzese S, Menghi A. Tibial plateau fracture after arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(4):E16.
13. Mithöfer K, Gill TJ, Vrahas MS. Tibial plateau fracture following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004;12(4):325-328.
14. Moen KY, Boynton MD, Raasch WG. Fracture of the proximal tibia after anterior cruciate ligament reconstruction: a case report. Am J Orthop. 1998;27(9):629-630.
