CC BY-NC-ND 4.0 · Revista Chilena de Ortopedia y Traumatología 2024; 65(02): e108-e114
DOI: 10.1055/s-0044-1790597
Reporte de Caso | Case Report

Cyclops-type Injury after Tibial Spine Fracture: Case report

Article in several languages: español | English
David Figueroa
1   Facultad de Medicina CAS-UDD, Clínica Alemana de Santiago, Santiago, Chile
,
1   Facultad de Medicina CAS-UDD, Clínica Alemana de Santiago, Santiago, Chile
,
Claudio Yañez
2   Hospital Las Higueras de Talcahuano, Talcahuano, Chile
,
Francisco Figueroa
1   Facultad de Medicina CAS-UDD, Clínica Alemana de Santiago, Santiago, Chile
,
Alex Vaisman
1   Facultad de Medicina CAS-UDD, Clínica Alemana de Santiago, Santiago, Chile
,
Rafael Calvo
1   Facultad de Medicina CAS-UDD, Clínica Alemana de Santiago, Santiago, Chile
,
Jaime Espinoza
3   Hospital San Juan de Dios de Curicó, Maule, Chile
› Author Affiliations
 

Abstract

A tibial spine avulsion fracture is an intra-articular fracture of the bony insertion of the ACL on the tibial plateau, most commonly seen in children and adolescents aged 8 to 14 years. Its incidence has been reported to be between 2% and 5% in the pediatric population, but it is rare in adults. The cyclops lesion is a fibrous proliferation of granulation tissue that forms a soft tissue nodule, limiting extension, and is one of the possible complications of the arthroscopic management of this type of fracture. We report the case of a 25-year-old patient who sustained a tibial spine avulsion fracture, underwent successful anatomical reduction arthroscopically, and subsequently developed extension loss in the postoperative period. Her MRI study revealed a cyclops lesion that required arthroscopic debridement.


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Introduction

A tibial eminence fracture, also known as a tibial spine fracture, is an intra-articular injury affecting the bone insertion of the Anterior Cruciate Ligament (ACL) into the tibial plateau. This pathology is particularly common in children and adolescents aged 8 to 14 years, since the epiphyseal plate at the ACL anchorage site offers less resistance to traction forces compared to the ligament itself. The incidence of this fracture is reported in the range of 2 to 5% within the pediatric population, being unusual in the adult population.[1]

Historically, the Meyers and McKeever (MM)[2] classification system has been the standard for categorizing tibial eminence fractures, distinguishing them into Type I (non-displaced), Type II (hinged), Type III (completely displaced but not rotated), and Type III+ (completely displaced with rotation). However, with the introduction of magnetic resonance imaging, the Green and Tuca (GT) classification emerged,[3] which offers a new perspective by dividing these fractures into Grade 1 (non-displaced or minimally displaced), Grade 2 (posterior hinge), and Grade 3 (posteriorly displaced, with meniscal/intra-meniscal ligament entrapment, or extension to the tibial plateaus). Both injuries classified as Type III MM and Grade 3 GT require surgical treatment, as a conservative approach carries a higher risk of nonunion, increased residual laxity, and loss of range of motion.[4]

Fixation of tibial spine fractures is usually done with screws or sutures. Sutures are the preferred option for treating small avulsions or severely comminuted fragments, while screws are reserved for larger fragments. However, the use of screws may imply the need for a second surgical intervention for their removal, which occurs in up to 66% of cases.[1]

The cyclops-type lesion, also known as localized anterior arthrofibrosis, is characterized by the fibrous proliferation of granulation tissue. This condition was first described in 1990 by Jackson and Schaefer in relation to anterior cruciate ligament reconstruction (ACLR).[5] It is a fibrotic nodule that develops at the base of the graft and, by interfering with the femoral intercondylar notch, causes loss of knee extension. According to magnetic resonance studies, the incidence of this lesion after ACLR ranges from 33.0% to 46.8%, although its symptomatic incidence is only 1.9% to 10.9%.[6] Patients who develop symptoms generally show a loss of 20° extension, with symptoms progressing over 4 months after surgery. The “bounce test” has been described as a rubbery sensation at full knee extension with a rebound into flexion.[7]

This lesion is considered a possible cause behind the limitation in knee extension after reduction and fixation of tibial spine fractures, although it is scarcely reported. MRI has a sensitivity of 85.0% and a specificity of 84.6% in the detection of these lesions; for lesions larger than 10 mm, these values improve, reaching a sensitivity of 100% and a specificity of 91%; however, only 23% of patients with positive results on MRI are symptomatic.[8]

Standard knee arthroscopy is a commonly used procedure for the excision of this type of lesions. Calvisi described a technical variant that involves more proximal displacement of the midpatellar portal. This modification would improve visibility in the coronal plane and reduce crowding of the fat pad, making the removal of this lesion easier.[9]

Extrapolating from post-LRCA lesions, it is advised not to intervene on asymptomatic lesions, while those with symptoms should be treated surgically to restore normal joint biomechanics. It is essential to accurately delineate the margins of the lesion and ensure that there is no impingement during the procedure, which may include performing a “notchplasty” if required. Surgical removal of the lesion within the first 12 weeks after detection usually has favorable results, with most patients regaining full range of motion within weeks of surgery. The prognosis for these cases is generally positive, with only one recurrence reported in a study involving 33 cases.[8]

This review presents the case of a 25-year-old woman who experienced a tibial spine fracture. Treatment consisted of arthroscopic reduction and fixation using sutures and a screw. The patient subsequently developed a cyclops-type lesion as a complication.


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Case Report

A 25-year-old woman with no history of previous illnesses or surgeries suffered a fall while skiing. She reported a clunky feeling, pain, effusion, and functional impotence of her left knee. Physical examination revealed significant effusion, anteroposterior instability, Lachman ++ and anterior drawer ++ tests, while pivot shift could not be assessed. Range of motion (ROM) was 0° extension to 60° flexion.

X-rays ([Fig. 1]), computed tomography (CT) ([Fig. 2]), and magnetic resonance imaging (MRI) of the knee ([Fig. 3]) confirmed a tibial spine fracture, classified as Type III+ MM or Grade 3 GT. It should be noted that the ACL was continuous, with a slight increase in the signal of its fibers.

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Fig. 1 Anteroposterior and lateral X-ray of the left knee showing fracture of the tibial spines, probably Meyers and McKeever type III.
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Fig. 2 Coronal CT of the knee confirming fracture of the tibial spines with a large fragment and significant displacement, Meyers and McKeever type III + .
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Fig. 3 Sagittal MRI projections of PD TSE FS and TSE T2 sequences showing avulsion of the tibial spines with interposition of the anterior horn of the medial meniscus. Grade 3 of the Green and Tuca classification.

Three days later, a reduction and fixation were performed arthroscopically, using a FiberWire suture with an ABS attachable button (Arthrex) assisted by Scorpion® forceps (Arthrex) and fixed to an anteromedial tibial tunnel. In addition, due to the size of the fragment, augmentation was used with a Mini-Monster® headless screw (Paragon 28®'s) of 3.5 × 30 mm ([Figs. 4] and [5]), achieving a satisfactory anatomical reduction. The ACL and intermeniscal ligament were observed to be intact during surgery.

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Fig. 4 Multiple intraoperative arthroscopic views, showing reduction and fixation with fiberwire and a mini monster screw.
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Fig. 5 Anteroposterior and lateral X-ray of the left knee. Control on the first postoperative day, showing an anatomic reduction of the fracture and correct position of the fixation elements.

Initially, the patient progressed satisfactorily, with decreased soft tissue edema and progressive recovery of joint range. However, 2 months after surgery, a loss of extension of 5-10° was evident, with full flexion. Intensive physical therapy was continued until the third month after surgery, with no response. The patient was monitored with an MRI, which showed a cyclops-type fibrous scarring process in the anterior region of the ACL ([Fig. 6]).

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Fig. 6 Multiple MRI sections showing fibrotic process anterior to the ACL. No prominent osteosynthesis or poor reduction is observed.

With this background, a diagnostic and therapeutic arthroscopy was performed, and a large fibrotic lesion anterior to the ACL was found, joined to Hoffa fat and the anterior capsular region, measuring 35 × 50mm ([Fig. 7]). A complete arthroscopic resection was performed, and the patient was mobilized under anesthesia, and finally 80mg depomedrol was injected intra-articularly ([Fig. 8]). The intensive rehabilitation process was reactivated with intravenous analgesia and continuous passive mobilization from the first postoperative day, recovering full extension one month after surgery, and she was discharged with full ROM 6 months after this second surgery.

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Fig. 7 Large fibrotic process anterior to the ACL compatible with a cyclops-type injury.
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Fig. 8 Arthroscopic resection of the fibrotic process and complete release of the ACL without intercondylar impingement. No prominent osteosynthesis or poor reduction is observed.

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Discussion

The incidence of cyclops-type injury following surgical reduction and internal fixation of tibial spine avulsion is unclear and has rarely been reported. The incidence of arthrofibrosis is mainly reported and varies considerably. In the largest published case series, consisting of 205 patients treated arthroscopically with transepiphyseal sutures or screws, this study by Vander Have estimated that 10% developed arthrofibrosis, which was defined as a lack of 10° of extension and/or less than 90° of flexion at 3 months postoperatively.[10] Gans in 2013 reported the development of arthrofibrosis in 7.1% of Meyers and Mckeever type I and II tibial spine fractures and 14.2% of type III and IV fractures.[11] A 2007 study by Park, involving arthroscopic follow-up in 10 patients with arthroscopically treated tibial spine fractures, found that 2 patients had a decreased ability to extend the knee by 5 to 10° due to a cyclops-type injury.[8]

Despite multiple studies in published studies, no single predictive risk factor for cyclops-type injury has been identified, and therefore a multifactorial etiology seems likely. Risk factors described for this injury include: female sex due to narrow notch, bony avulsion of the ACL from the tibia or femur, increased graft volume relative to notch size, anterior placement of the tibial tunnel, double-bundle ACL reconstruction, cruciate-retaining arthroplasty due to ACL injury, and hamstring contracture; age, early RLCA, duration of partial weight-bearing, concomitant meniscal surgery, or collateral ligament injury did not influence the results.[7]

Park suggests that these injuries may be due to drilling residue, use of Kirschner wires, or non-absorbable sutures, which cause synovitis, and his group removes the non-absorbable suture considering it a foreign body, observing local synovitis at the base of the ACL and in the tibial fracture.[8]

On the other hand, possibly in patients with poor reduction of the fracture of the spines, the impingement of the native ACL against the intercondylar notch could lead to repeated microtraumas with tearing of its fibers and the formation of a cyclops-type lesion.[7]


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Conclusion

In those patients who develop extension deficits after reduction and fixation of a tibial spine fractures despite an adequate rehabilitation program and an anatomic reduction of the fracture, cyclops should be suspected as a mechanical cause of the extension deficit and should be studied with an MRI.

In our case, our patient presented the following risk factors: female sex and bone avulsion. In addition, the non-absorbable screw and suture could have generated repeated microtrauma against the intercondylar notch, generating inflammation and the development of the nodule. We believe it is of utmost importance to achieve an anatomic reduction and thoroughly corroborate that there is no impingement in the notch of both the ACL and our osteosynthesis material. In addition, we believe that, despite the little evidence in this regard, we should leave the least amount of residue from the perforations and traumatize the local tissue as little as possible during our reduction and fixation, avoiding too much local inflammation.

Extrapolating from the results of arthroscopic treatment of cyclops-type lesions after ACLR, and based on our experience, we believe that patients with symptomatic cyclops-type lesions should undergo arthroscopic treatment to resolve the problem within 12 weeks of detection. A more proximal midpatellar portal, as described by Calvisi may or may not be used, but the most important thing is to completely remove the lesion.


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  • Bibliografía

  • 1 Salvato D, Green DW, Accadbled F, Tuca M. Tibial spine fractures: State of the art. J ISAKOS 2023; 8 (06) 404-411
  • 2 Meyers MH, McKEEVER FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959; 41-A (02) 209-220 , discussion 220–222
  • 3 Green D, Tuca M, Luderowski E, Gausden E, Goodbody C, Konin G. A new, MRI-based classification system for tibial spine fractures changes clinical treatment recommendations when compared to Myers and Mckeever. Knee Surg Sports Traumatol Arthrosc 2019; 27 (01) 86-92
  • 4 Gans I, Ganley TJ. Tibial eminence fractures: a review and algorithm for treatment. Univ Pa Orthop J 2013; 23: 1-4
  • 5 Jackson DW, Schaefer RK. Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy 1990; 6 (03) 171-178
  • 6 Noailles T, Chalopin A, Boissard M, Lopes R, Bouguennec N, Hardy A. Incidence and risk factors for cyclops syndrome after anterior cruciate ligament reconstruction: A systematic literature review. Orthop Traumatol Surg Res 2019; 105 (07) 1401-1405
  • 7 Kambhampati SBS, Gollamudi S, Shanmugasundaram S, Josyula VVS. Cyclops Lesions of the Knee: A Narrative Review of the Literature. Orthop J Sports Med 2020; 8 (08) 2325967120945671
  • 8 Park HJ, Urabe K, Naruse K, Aikawa J, Fujita M, Itoman M. Arthroscopic evaluation after surgical repair of intercondylar eminence fractures. Arch Orthop Trauma Surg 2007; 127 (09) 753-757
  • 9 Calvisi V, Lupparelli S, Giuliani P. A view from above: a modified Patel's medial midpatellar portal for anterior cruciate ligament arthroscopic surgery. Arthroscopy 2007; 23 (03) 324.e1-324.e5
  • 10 Vander Have KL, Ganley TJ, Kocher MS, Price CT, Herrera-Soto JA. Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. Am J Sports Med 2010; 38 (02) 298-301
  • 11 Gans I, Baldwin KD, Ganley TJ. Treatment and management outcomes of tibial eminence fractures in pediatric patients: a systematic review. Am J Sports Med 2014; 42 (07) 1743-1750

Address for correspondence

Héctor Cifuentes Aedo
Facultad de Medicina CAS-UDD, Clínica Alemana de Santiago
Santiago
Chile   

Publication History

Received: 01 December 2023

Accepted: 29 August 2024

Article published online:
25 September 2024

© 2024. Sociedad Chilena de Ortopedia y Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • Bibliografía

  • 1 Salvato D, Green DW, Accadbled F, Tuca M. Tibial spine fractures: State of the art. J ISAKOS 2023; 8 (06) 404-411
  • 2 Meyers MH, McKEEVER FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959; 41-A (02) 209-220 , discussion 220–222
  • 3 Green D, Tuca M, Luderowski E, Gausden E, Goodbody C, Konin G. A new, MRI-based classification system for tibial spine fractures changes clinical treatment recommendations when compared to Myers and Mckeever. Knee Surg Sports Traumatol Arthrosc 2019; 27 (01) 86-92
  • 4 Gans I, Ganley TJ. Tibial eminence fractures: a review and algorithm for treatment. Univ Pa Orthop J 2013; 23: 1-4
  • 5 Jackson DW, Schaefer RK. Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy 1990; 6 (03) 171-178
  • 6 Noailles T, Chalopin A, Boissard M, Lopes R, Bouguennec N, Hardy A. Incidence and risk factors for cyclops syndrome after anterior cruciate ligament reconstruction: A systematic literature review. Orthop Traumatol Surg Res 2019; 105 (07) 1401-1405
  • 7 Kambhampati SBS, Gollamudi S, Shanmugasundaram S, Josyula VVS. Cyclops Lesions of the Knee: A Narrative Review of the Literature. Orthop J Sports Med 2020; 8 (08) 2325967120945671
  • 8 Park HJ, Urabe K, Naruse K, Aikawa J, Fujita M, Itoman M. Arthroscopic evaluation after surgical repair of intercondylar eminence fractures. Arch Orthop Trauma Surg 2007; 127 (09) 753-757
  • 9 Calvisi V, Lupparelli S, Giuliani P. A view from above: a modified Patel's medial midpatellar portal for anterior cruciate ligament arthroscopic surgery. Arthroscopy 2007; 23 (03) 324.e1-324.e5
  • 10 Vander Have KL, Ganley TJ, Kocher MS, Price CT, Herrera-Soto JA. Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. Am J Sports Med 2010; 38 (02) 298-301
  • 11 Gans I, Baldwin KD, Ganley TJ. Treatment and management outcomes of tibial eminence fractures in pediatric patients: a systematic review. Am J Sports Med 2014; 42 (07) 1743-1750

Zoom Image
Fig. 1 Radiografía anteroposterior y lateral de rodilla izquierda que evidencia fractura de espinas tibiales, probablemente Meyers y McKeever tipo III.
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Fig. 2 TAC de rodilla proyección coronal que confirma fractura de espinas tibiales con gran fragmento y desplazamiento significativo Meyers y McKeever Tipo III + .
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Fig. 3 RNM proyecciones sagitales de secuencias PD TSE FS y TSE T2 que evidencian la avulsión de espinas tibiales con interposición del cuerno anterior del menisco medial. Grado 3 de la clasificación de Green y Tuca.
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Fig. 4 Múltiples visiones artroscopias intraoperatorias, se evidencia la reducción y fijación con fiberwire y tornillo mini monster.
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Fig. 5 Radiografía anteroposterior y lateral de rodilla izquierda. Control primer día postoperatorio que muestra una reducción anatómica de la fractura y correcta posición de elementos de fijación.
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Fig. 6 Múltiples cortes de RNM que evidencia proceso fibrótico anterior al LCA. No se observa osteosíntesis prominente ni mal reducción.
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Fig. 7 Gran proceso fibrótico anterior al LCA compatible con lesión tipo ciclops.
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Fig. 8 Resección artroscópica del proceso fibrótico y liberación completa de LCA, sin pinzamiento en intercondíleo. No se observa osteosíntesis prominente o mal reducción.
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Fig. 1 Anteroposterior and lateral X-ray of the left knee showing fracture of the tibial spines, probably Meyers and McKeever type III.
Zoom Image
Fig. 2 Coronal CT of the knee confirming fracture of the tibial spines with a large fragment and significant displacement, Meyers and McKeever type III + .
Zoom Image
Fig. 3 Sagittal MRI projections of PD TSE FS and TSE T2 sequences showing avulsion of the tibial spines with interposition of the anterior horn of the medial meniscus. Grade 3 of the Green and Tuca classification.
Zoom Image
Fig. 4 Multiple intraoperative arthroscopic views, showing reduction and fixation with fiberwire and a mini monster screw.
Zoom Image
Fig. 5 Anteroposterior and lateral X-ray of the left knee. Control on the first postoperative day, showing an anatomic reduction of the fracture and correct position of the fixation elements.
Zoom Image
Fig. 6 Multiple MRI sections showing fibrotic process anterior to the ACL. No prominent osteosynthesis or poor reduction is observed.
Zoom Image
Fig. 7 Large fibrotic process anterior to the ACL compatible with a cyclops-type injury.
Zoom Image
Fig. 8 Arthroscopic resection of the fibrotic process and complete release of the ACL without intercondylar impingement. No prominent osteosynthesis or poor reduction is observed.