Patellar Tendon Lengthening: Rescue Procedure for Patella Baja

Patellar tendon lengthening and augmentation with quadriceps tendon graft for treatment of severe patella infera

BACKGROUND

Patella infera represents a permanent abnormally low position of the patella with three characteristics: distal position of the patella in the femoral trochlea, permanent shortening of the patellar tendon, and decreased distance between the inferior pole of the patella and the articular surface of the tibia. Several surgical techniques have been described to resolve this disabling condition with varying outcomes.

HYPOTHESIS

Lengthening of the shortened patellar tendon with augmentation using a quadriceps tendon graft in combination with excessive intra-articular release improve knee function in patients presenting with severe and permanent patella infera.

METHODS

Nine patients (four males, five females) with significant patella infera were treated between 2004 and 2020. The low position of the patella was documented using the Caton-Deschamps index. The Tegner Lysholm knee scoring scale and the Numerical Rating Scale (NRS) for pain were used as outcome measures before surgery and at follow up. Complete data were available in 100% of cases at 12 months follow up, and in 78% at final follow up.

RESULTS

The average follow up was 4.2 years (range, 1-16 years). The Tegner Lysholm score improved from a mean preoperative score of 43.8 to a mean postoperative score of 80.5. The median NRS status decreased from an average of 6.7 (range, 5-8) to 2.3 (range, 1-7). The median preoperative flexion was 103.3° (range, 40-125°), rising to 126.6° (range, 40-145°). The median preoperative Caton-Deschamps ratio of 0.32 (range, 0-0.6) improved to 0.99 (range, 0.9-1.1) at final follow up. Two patients needed additional surgical treatment (arthroscopic scar tissue removal and proximalisation of the tibial tuberosity).

CONCLUSION

Lengthening of a shortened patellar tendon with augmentation using a quadriceps tendon graft combined with excessive intra-articular release is an individually adapted surgical salvage procedure to treat permanent patella infera. It improves knee function and yields good to excellent results in most cases.

Surgical Treatment of Iatrogenic Patella Baja

PURPOSE OF REVIEW

Patella baja is characterized by a loss of patellar height and can develop as either an acute or chronic complication following a knee injury or surgical procedure. The purpose of this review is to describe the diagnosis and management of patella baja and highlight the senior author's surgical technique.

RECENT FINDINGS

The pathogenesis of patella baja involves a complex interaction between quadriceps dysfunction, immobilization, and inflammation leading to infrapatellar scarring and adhesions. It is associated with fractures about the knee and can result as a complication of surgical procedures such as anterior cruciate ligament (ACL) reconstruction, particularly bone-patellar tedon-bone autografts, high tibial osteotomies (HTOs), tibial tubercle osteotomies (TTOs), and total knee arthroplasties (TKAs). Patients with patella baja can have limited knee range of motion, anterior knee pain, significant weakness with active knee extension, and an extensor lag. Surgical intervention is indicated in cases of symptomatic patella baja. Treatment strategies include tibial tubercle proximalization, patellar tendon lengthening, and patellar tendon reconstruction. Allografts and autografts can be utilized to augment tendon lengthening or reconstructive procedures. Various small case series have reported favorable outcomes for these procedures. The treatment of patella baja is challenging and little consensus exists on optimal management, as much of the literature is limited to small case series. The preferred surgical technique of the senior author involves an end-to-end patellar tendon lengthening with hamstring autograft augmentation.

Treatment of acquired patella baja by proximalization tibial tubercle osteotomy significantly improved knee joint function but overall patient-reported outcome measures remain diminished after two to four years of follow-up

INTRODUCTION

Acquired patella baja is often characterized by painful limitation of knee joint range of motion and anterior knee pain (AKP). Only few studies have evaluated the effectiveness of surgical treatment in terms of patient-reported outcome measures (PROM's) and sports activity. Thus, the goal of this study was to assess PROM's and sports activity after proximalization tibial tubercle osteotomy (P-TTO) in patients with symptomatic patella baja.

METHODS

Between 2016 and 2018, a case series of 11 patients (male/female 4/7; age 48 ± 12 years) were treated by P-TTO and were retrospectively evaluated after a mean of 33.7 months (range 24-51 months). The Tegner activity score and the Kujala anterior knee pain scale were used in addition to a visual analogue scale (VAS; 0-10) regarding self-reported knee joint function and intensity of AKP. Radiographic assessment included the measure of patellar height using the Caton-Deschamps (CD) and Blackburne-Peel (BP) index.

RESULTS

Postoperatively both the CD and the BP index increased to normality (p < 0.0001; p = 0.0012). Knee joint flexion improved from 100 ± 32° preoperatively to 123 ± 14° postoperatively (p = 0.0235). AKP decreased from 6.5 ± 2.1 points preoperatively to 3.7 ± 2.1 points postoperatively (p = 0.0061). This was accompanied by a significant increase in self-reported knee joint function from 1.8 ± 1.2 points preoperatively to 6.8 ± 2.3 points postoperatively (p = 0.0001) and an increase of the Tegner activity score from 1.8 ± 1.6 points preoperatively to 3.9 ± 1.5 points postoperatively (p = 0.0074). Although the Kujala score improved significantly by an average of 31.55 points (p = 0.001) overall score results remained reduced at 65.6 ± 17.9 points at final follow-up.

CONCLUSION

P-TTO yielded significant improvements in terms of AKP, subjective knee joint function and sports activity. However, the overall Kujala score results remained reduced, indicating that surgical correction of patellar height is not sufficient to relieve all patients' complaints. In addition, the incidence of postoperative complications was high.

Chronic Quadriceps Tendon Ruptures: Primary Repair of Quadriceps Via Bioaugmentation and Patellar Tendon Lengthening

Quadriceps tendon ruptures are devastating injuries that impair the extensor mechanism of the knee. Complete tears require prompt surgical intervention in order to ensure optimal clinical outcomes. Chronic, neglected ruptures- marked by severe extensor lag, muscular atrophy, and tendon retraction- are difficult to treat. Further, severe patella baja complicates surgical planning. While there is no consensus on optimal treatment for these injuries, many different techniques have been proposed. Unlike many of these approaches, our technique focuses on restoration of patellar height via patellar tendon lengthening. Once patellar height is restored, quadriceps tendon repair can be performed using the native quadriceps tendon. Both the patellar tendon lengthening and the quadriceps tendon repair are augmented with bioinductive implants to ensure optimal healing environments, enabling us to reestablish native extensor mechanism function.

An Unusual Cause of Sudden Bilateral Lower Extremity Weakness

Acute bilateral quadriceps tendon rupture is a musculoskeletal injury that requires urgent orthopedic surgical evaluation. Bilateral quadriceps tendon rupture is exceptionally rare, yet a missed diagnosis can result in long-term disability for the patient. This article presents a patient's case including the history, physical examination, key imaging findings, and management. This article emphasizes the importance of a detailed physical examination in patients presenting with musculoskeletal complaints as well as maintaining a broad differential diagnosis, which will assist the advanced practice provider in recognizing both the common and rare diagnoses in the emergency department.

Extreme stiff knee recurvatum following manipulation under anesthesia and botulinum neurotoxin injection

In this article we report a case of stiff, neglected extreme recurvatum knee deformity in a 17-year-old female. This is the first reported case in the literature of an acquired ligamentous stiff extreme knee recurvatum following manipulation under anesthesia and botulinum neurotoxin injection. Μodified Judet quadricepsplasty combined with Ilizarov external hinged frame fixation was implemented. This dual technique can be considered as a rational approach for such an extreme deformity as it stabilizes, progressively corrects, and prevents recurrence. A patellar tendon rupture caused by the increasing tension of the extensor mechanism following the correction was treated successfully using a cadaveric Achilles tendon allograft.