Neglected Total Tear Right ACL Post Reconstruction and Right Medial Meniscus Tear: A

Case Report

Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo Hospital;

Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Tirza Z Tamin

ABSTRACT :
Injury to anterior cruciate ligament (ACL) is one of the most common sports injuries affecting the knee
and ligament.1ACL injury is the cause knee laxity so that the knee becomes unstable and becomes more
susceptible to meniscal injury during dynamic abrupt movements.2 We present a case report of
neglected total tear right ACL post reconstruction and right medial meniscus tear. This in a good case
to highlight the importance of patient motivation and compliance to obey the instruction. We really
needed good education to improve patient compliance.
Key words: Anterior cruciate ligament; medial meniscus tear; neglected; reconstruction, education,
compliance

INTRODUCTION
Injury to anterior cruciate ligament (ACL) is one of the most common and serious injuries affecting the
knee and ligament.1 In the 2012, prevalence ACL injury has been reported 1.5–1.7% per year.3 The
main mechanisms in sports are the pivoting and cutting maneuvers.4ACL injury is the cause knee laxity
so that the knee becomes unstable and becomes more susceptible to meniscal injury during dynamic
abrupt movements.2 Surgical procedure involves introducing a graft to replace the original injured
ligament we will refer to this as a reconstruction. In multiple studies,the time between anterior cruciate
ligament (ACL) injury and reconstruction surgery can be a risk factor for meniscal tears.2 In theWest
Point area, this case was reported to be 3.2% for men and 3.5% for women.Meniscal tears are cause of
disability and time lost from work, and are associated with a four fold increase in the long-term risk of
knee osteoarthritis.5

CASE REPORT
Mr. A, age 23 years old, a college student, came to the medical rehabilitation department of RSUPN
DR. Cipto Mangunkusumo as consulted from orthopedics with the diagnosis of post-reconstruction
ACL (Anterior Cruciate Ligament) in March 2019. Patient was unable to reach maximum extension of
his right knee since May 2019. This was accompanied with swelling of the knee and pain sensation
with VAS (Visual Analog Scale) score of 6-7. Pain was felt worst with movement such as walking,
thereby limiting patient’s daily activities. Patient is able to walk approximately 500 m with the help of
bilateral cruthches.
 On May 2018, patient had an injury on his right knee while kicking a ball and twisted the joint.
After that incidence, he complaint of pain with VAS score of 9 and swollen knee. There was no special
treatment given, patient only took medication and rest, then the pain VAS score was 6-7. Independent
ambulation, without any help. On August 2018, patient underwent a MRI for his right genu, and exam
revealed a total tear in the ACL, partial medial meniscus tear, and suprapatellar joint effusion. Based
on the examination, patient was suggested to have surgery, but it was postponed because of his
undergoing education in Cairo, Egypt.

MRI genue dextra on 18th August 2018

On 18th March 2019, an ACL reconstruction was done with arthroscopy technique, with a fatal
tear of ACL and posterior medial meniscus tear. A graft from peroneus longus with the length of 24 cm
was inserted. After surgery was done, patient have to use bilateral brace extension and crutches for
a month. The patient also need to undergo physical rehabilitation at UNJ and laser treatment with
cold compression, but the patient did not consistently came to rehab.
On June 2019, the patient came to medical rehabilitation department because his right knee
could not be extent and flexed optimally. The complaints were accompanied with swelling of the
knee, d u l l pain especially when he walks, VAS score of 6-7. Ambulation with bilateral crutches
shows walking distance of approximately 500 m. Patient was given laser therapy and isotonic
exercises
without weights, AAROM (Active Assistive Range of Motion) exercises, and ankle pumping exercises.
On 5thof July 2019, an ultrasound of the dextra genu was perfomed, showing a suprapatellar effusion.
An genu aspiration and prolotherapy was done on the patient, and pain was reduced with VAS score
drops to 3-4. On 29th July 2019, the patient was instructed to undergo training in water, exercise
consisting of a mini squat, knee extension, flexion, forward and backward walk, sideways walk (3x10
reps) for 3 days. But the patient’s pain is increasing to VAS score of 7-8 and swelling. A pain
management consists, PRICE, laser, NSAIDs, and taping were given. The pain then reduced to VAS
score of 3-4.

USG genue dextra on 18th August 2018

Physical examination showed that the patient was fully awake, mildly ill, body mass index was
24.3 (overweight). Vital sign within normal limits. Borg scale 6-0-0. Proprioceptive, static balance and
dynamic balance were adequate, but an inadequate test result for Romberg test. Musculoskeletal status
of right genue revealed edema with signs of inflammation. Warm, tenderness and palpation in the
suprapatellar area, medial right genu, and on bursa pes anserinus. patellar immobility movement
positive, ROM for knee flexion 250 - 1150 / 0-1350, extension 1150-250 / 0-1350. MMT knee flexor
4/5 and knee extensor 4/5. A circle 5 cm above the patella 42/41 cm, and the circumference of the
patella 41/40 cm.
Mc Murray test shows positive / positive, Apley compression test also shows positive / positive.
Cardiorespiratory status within normal limits. Daily physical activity 0.9 Mets - 4 Mets. Barthel index
has a total score of 20 (independent). A fall risk assessment using the Morse Fall Scale was obtained,
with the score of 45 (high risk of fall), and a Lysholm knee scale had a score of 54. Assessment of the
knee function using KOOS (Knee Injury and Osteoarthritis Outcome Score) and IKDC (International
Knee Documentation Commission) instrument for the right genu shows the scores of 50.6 and 52.96%,
respectively. Modified Cincinnati Knee Rating System Summary revealed 29%. Muscle strength
examination using a Hand held dynamometer test showed the results for M. quadriceps femoris were
17.73 kg / 19.28 kg (8% difference), M. hamstring 16.84 kg / 16.89 kg (1% difference), and the HQ
ratio between two sides is 1.09.
The rehabilitation issues for this case were limitation of right knee ROM, pain in the right knee,
medial meniscus tear, disruption of ambulation post ACL reconstruction, and overweight. The short
term goal of this medical rehabilitation therapy as expected was to reduce pain and edema of the right
knee (with VAS score <3) in 6 weeks, increase right knee ROM (full extension and knee flexion of >
1200), maintain muscle strength, maintain proprioceptive function, and weight loss. While the long-
term goals is to achive ambulation without pain, return to normal function for activity or recreational
sports (VAS score 0, full bilateral ROM), and prevent recurrent of injuries.
The aim of medical rehabilitation for right knee pain as a targeted was to reduce edema and
VAS score of <3, by carrying out several programs, such as laser 6 J / cm 2 in the area of pain, especially
the medial and anterior sides, home program of RICE (Rest-Ice-Compression) –Elevation), giving ice
after exercise with an interval of 20 minutes (20 minutes on, 20 min off, repeating), and given pain
management medication (Na diclofenac 3x50mg). Fluid aspiration of suprapatellar right rheses was
carried out with ultrasound guided, then prolotherapy with dextrose 40% 10cc. For the meniscus
medial tear, we need consult to orthopedic surgeon for the next management. The location of meniscal
medial tear make patient feel pain, and disturb the body alignment. Patient need reduce the weight
bearing in meniscus with using bilateral crutches while walk, reduce the frequency of up and down the
stairs in his house.
To achive an optimal ROM, several programs were carried out, such as training inside the
swimming pools with a water level at neck. The program is, minisquats, isotonic exercise, walking,
balance exercise, for the frequency 2x10 repetition gradually increasing, 2 times every week. For the
home program he need positioning knee extension, prop a towel on the patient's heel in supine position,
3 times / day. AAROM exercises, knee flexion, (target extension 00, flexi 1350). US hamstring dextra
every 2x / week, and ankle pumping 2x10 reps every 3x / day, and patella mobilization exercises
as much as 3x10 reps, hold 6 seconds, every 3x / day.
For ambulation problems, bilateral crutches program were given with long distance and short
distance ambulation performed without crutches. Patella mobilization exercises for 3x10 reps, hold 6
seconds, and proprioceptive exercises, with a hand rail on the stairs to the patient's room. To lose
some weight, a diet program with low carbohydrates and fats, but high in protein food was
suggested, as well as aerobic exercise with arm ergocycle for 30 minutes / day every 3x / week.
Ad Vitam prognosis for these patients is bonam, whereas ad functionam and ad sanationam
prognosis are dubia ad bonam.
DISCUSSION
Injury to anterior cruciate ligament (ACL) is one of the most common sports injuries affecting the knee
and ligament.1 Anterior cruciate ligament injuries account for about 25 and 50% of ligamentous knee
injuries.6 The most common mechanism of injury is a forceful quadriceps contraction to hold the full
body weight, where the knee is bent.7The injury mechanism in our case was the same as others reported
in the literature, where the patients relatively young, and so was our patient. Several risk factors that
affect primary knee pain such as age, gender, level of sports activity, anatomical variability like
posterior tibial slope, narrow notch width, small size ACL, limb alignment and multiple neuromuscular
factors.8
Injury to anterior cruciate ligament (ACL) are difficult to recover quickly due to local intra-
articular conditions. This is due to synovial fluid and intra-articular movement prevents formation of a
stable fibrin-platelet scaffold. Without this scaffold, no primary healing can take place can occur
quickly.9 Currently the surgical procedure is the gold standar for injuries to ACL is ACL reconstruction
with autograft from either the hamstrings or patella tendon.10 The time between anterior cruciate
ligament (ACL) injury and reconstruction surgery can be a risk factor for meniscal tears. Meniscal tears
can be found anterior cruciate ligament reconstruction.
Several degenerative meniscal tears risk factors, this literature review provides strong evidence
that age (greater than 60 years), gender (being male), work-related kneeling and squatting, and climbing
stairs (greater than 30 flights) are risk factors for meniscal tears. Also, there was strong evidence that
sitting greater than 2 hours per day may reduce the risk of degenerative meniscal tears. For cases of
acute meniscal tears, there was strong evidence that playing soccer and playing rugby are risk factors.
In addition, waiting more than 12 months between ACL injury and reconstruction surgery is a risk
factor for a tear of the medial meniscus.11
There are two menisci in the knee, which are medial (U-shaped) and lateral (S-shaped)
semilunar shaped, hydrated, biphasic fibrocartilaginous soft-tissue structures in the medial and lateral
tibiofemoral compartments of the knee joint. They are a part of the ‘meniscus-meniscal ligament
complex’ and with the surrounding ligamentous structures (menisco-tibial, menisco-femoral, menisco-
patellar, intermeniscal ligaments) and bony attachments as anterior and posterior roots.12
MRI is the recommended imaging method for diagnosing meniscal tears. This is 97% of medial
and 96% of lateral meniscal tears could be identified on sagittal MR images. Menisci have a low signal
intensity on MR images because of their fibrocartilage composition. In the arthroscopic procedur of
1086 medial meniscal tears, the posterior horn was involved in 98% of the torn medial menisci.There
are two primary MR criteria for the diagnosis of meniscal tears, first, contact of intrameniscal signal
with the superior or the inferior surface of a meniscus (or with both surfaces) and, second, distortion of
the normal appearance of a meniscus.12
Criteria for progressive out of the initial or acute phase, include progression of tissue healing
where the tissue is healed or sufficiently stabilized for active motion, passive range of motion to 75%
of the opposite side, minimal pain or tenderness less than level II, MMT strength in non pathologic area
4+ to 5, control of the particular regions, and continued kinetic chain function.13 Post reconstruction
rehabilitation consist of several phases. That phase, among others early post operative phase (days 1-
14), mid post operative phase (weeks 2-6), late post operative and early exercise phase (weeks 6-12),
strength and recovery phase (month 3-6), sport specific training and preparation to play phase (month
6-9), and return to sport phase. Early post operative phase to restore full passive knee extension,
diminish joint swelling and pain, and partial weight bearing on crutches when walking. Mid post
operative phase to minimize swelling, maintain some fitness without stressing the knee, and begin to
walk normally. Late post operative and early exercise phase to increase strength, proprioceptive work,
and preparation for next stage. Strength and recovery phase to focused strength work, advanced
proprioceptive work, running, and sport specific activities. Sport specific training and preparation to
play phase to improve fitness, improve strength, improve proprioception, and return to sports training.
Last phase is return to sport phase to begin actual sport not just training and continue to train knee.14

Possible causes in the case of neglected total tear right ACL post reconstruction and right
medial meniscus tear, the patient is still in a prolonged acute phase so that the inflammatory process
can still occur, recurrent reinjury, and torn meniscus. In addition, noncompliance of patients with illness
and lack of motivation and support from family, especially parents are also the main causes. This is
very important for the treatment and recovery of the patient's condition. Therefore, in this case good
education should be given to patients and families, because if ignored, the degenerative changes in the
knee develop, especially patellar-femoral arthritis and medial arthritis.15 It is also necessary to consult
a psychologist, to find a solution to increase patient motivation. Patient will be treated in stages and
will also be consulted to an orthopedic specialist for meniscus surgery.

CONCLUSION
Neglected total tear right ACL post reconstruction and right medial meniscus tear is one of the most
common sports injuries affecting the knee and ligament. Appropriate and rapid diagnosis, prompt
treatment and controlled rehabilitation are keys to successful management of this condition. In addition,
good education is needed for patients and and families to increase patient motivation and compliance.

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