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Sandoval LA, Reiter CR, Satalich JR, O’Neill CN, Cyrus JW, Vap AR. Partial Patellar Tendon Tears in Athletes: A Systematic Review of Treatment Options, Outcomes, and Return to Sport. Orthop Rev (Pavia) 2024; 16:92644. [PMID: 38343530 PMCID: PMC10853059 DOI: 10.52965/001c.92644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/01/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Partial patellar tendon tears (PPTTs) are overuse injuries in sports with frequent jumping, such as basketball and volleyball. There are several treatment options, including both operative and non-operative modalities. Current literature is largely focused broadly on patellar tendinopathy; however, there are few studies which specifically evaluate treatment outcomes for PPTTs. Objective To systematically review the literature on treatment options, clinical outcomes, and return to sport (RTS) in athletes with a PPTT. Methods PubMed, Embase, and Cochrane were searched through May 1st, 2023 for studies reporting treatment outcomes in athletes with partial patellar tendon tears. Data was extracted on the following topics: treatment modalities, surgical failures/reoperations, surgical complications, RTS, and postoperative time to RTS. Results The review covers 11 studies with 454 athletes: 343 males (86.2%) and 55 females (13.8%). The average age was 25.8 years, ranging from 15 to 55 years. 169 patients (37.2%) received only non-operative treatments, while 295 (65.0%) underwent surgery. 267 patients (92.1%) returned to sports after 3.9 months of treatment. The average follow-up was 55.8 months. Conclusion Our review of current literature on PPTTs in athletes illustrates over 90% return to sport following either conservative or surgical treatment. There is currently little data that directly compares the treatment options to establish an evidence-based "gold-standard" treatment plan. The data we present suggests that current treatment options are satisfactory but would benefit from future study.
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Affiliation(s)
- Luke A. Sandoval
- Department of Orthopaedic SurgeryVirginia Commonwealth University Health System
| | - Charles R. Reiter
- Department of Orthopaedic SurgeryVirginia Commonwealth University Health System
| | - James R. Satalich
- Department of Orthopaedic SurgeryVirginia Commonwealth University Health System
| | | | - John W. Cyrus
- Health Sciences LibraryVirginia Commonwealth University
| | - Alexander R. Vap
- Department of Orthopaedic SurgeryVirginia Commonwealth University Health System
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Gaudiani MA, Castle JP, Pfennig MT, Jawanda HS, Meta F, Lynch TS. Suture Anchor Fixation Has Less Gap Formation and No Difference in Complications or Revisions for Patellar Tendon Repair: A Systematic Review. Arthroscopy 2024; 40:149-161. [PMID: 37230184 DOI: 10.1016/j.arthro.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE To evaluate the literature on suture anchor (SA) usage for patellar tendon repair, summarize the overall biomechanical and clinical outcomes, and assess whether the cumulative research supports the adoption of this technique compared with transosseous (TO) repair. METHODS A systematic literature review using the Preferred Reporting Items for Systematic and Meta-Analyses guidelines was performed. Multiple electronic databases were searched to identify studies focusing on surgical outcomes of patellar tendon repair with suture anchor usage. Cadaver and animal biomechanical studies, technical studies, and clinical studies were included. RESULTS A total of 29 studies met the inclusion criteria: 6 cadaver, 3 animal, 9 technical, and 11 clinical reports. Four of the 6 cadaver studies and 1 of the 2 animal studies found significantly less gap formation from SA than from TO repair. Average gap formation in human studies ranged from 0.9 to 4.1 mm in the SA group compared with 2.9 to 10.3 mm in TO groups. Load to failure was significantly stronger in 1 of 5 cadaver studies and 2 of 3 animal studies, with human studies SA load to failure ranging from 258 to 868 N and TO load to failure ranging from 287 to 763 N. There were 11 clinical studies that included 133 knees repaired using SA. Nine studies showed no difference between complication rate or risk for reoperation, where one study reported a significantly lower re-rupture rate after SA repair compared with TO repair. CONCLUSIONS SA repair is a viable option for patellar tendon repair and could have several advantages over TO repair. Multiple studies indicate that SA repair has less gap formation during biomechanical testing compared with TO repair in human cadaver and animal models. No differences in complications or revisions were found in the majority of clinical studies. CLINICAL RELEVANCE Both animal and human models suggest SA fixation has potential biomechanical benefits when compared with TO tunnels for patellar tendon repair, whereas clinical studies show no difference in complications and revisions postoperatively.
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Affiliation(s)
- Michael A Gaudiani
- Department of Orthopedic Surgery, Henry Ford Health, Detroit, Michigan, U.S.A..
| | - Joshua P Castle
- Department of Orthopedic Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
| | - Mitchell T Pfennig
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, U.S.A
| | - Harkirat S Jawanda
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, U.S.A
| | - Fabien Meta
- Department of Orthopedic Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
| | - T Sean Lynch
- Department of Orthopedic Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
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3
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Hinz M, Geyer S, Winden F, Braunsperger A, Kreuzpointner F, Irger M, Imhoff AB, Mehl J. Clinical and biomechanical outcomes following patellar tendon repair with suture tape augmentation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3569-3576. [PMID: 37233797 PMCID: PMC10651537 DOI: 10.1007/s00590-023-03572-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE Patellar tendon ruptures (PTR) occur predominantly in middle-aged patients following indirect trauma. The aim of this study was to quantify the short-term results using a suture tape augmentation technique for the repair of PTR. METHODS All consecutive patients with acute (< 6 weeks) PTR who underwent suture tape augmentation between 03/2014 and 11/2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Visual Analog Scale (VAS) for pain, Tegner Activity Scale (TAS) and return to sport rates, Lysholm score, International Knee Documentation Committee subjective knee form (IKDC) as well as Knee Injury and Osteoarthritis Outcome Score (KOOS). Additionally, a standardized clinical examination and an isometric strength evaluation of knee extension and flexion were performed. It was hypothesized that high return to sport rates and good functional outcome would be observed and that the majority of patients would not present with a severe (> 20%) knee extension strength deficit when compared to the contralateral side. RESULTS A total of 7 patients (mean age 37.0 ± SD 13.5 years; 6 male/1 female) were available for final assessment at a median follow-up of 17.0 (25-75% IQR 16.0-77.0) months. Three injuries occurred during ball sports, two injuries occurred during winter sports, and one injury each occurred during a motorcycling and skateboarding accident. The average time between trauma and surgery was 4.7 ± 2.6 days. At follow-up, patients reported little pain (VAS: 0 [0-0.4]). Return to sport was possible for all patients 8.9 ± 4.0 months postoperatively at a high level (TAS: 7.0 [6.0-7.0]). Five patients (71.4%) returned to the preinjury level of play, and 2 (28.6%) did not return to the preinjury level of play. Patient-reported outcome measures were moderate to good (Lysholm score: 80.4 ± 14.5; IKDC: 84.2 ± 10.6; KOOS subscales: pain 95.6 ± 6.0, symptoms 81.1 [64.9-89.1], activities of daily living 98.5 [94.1-100], sport and recreation function 82.9 ± 14.1 and knee-related quality of life 75.9 ± 16.3). All patients were very satisfied (57.1%) or satisfied (42.9%) with the postoperative result. No postoperative complications were reported. Strength measurements revealed a severe knee extension deficit in 3 patients (42.9%), but no significant deficit of isometric knee extension or flexion strength in comparison with the contralateral side was observed overall (p > 0.05). CONCLUSION Suture tape augmentation in acute PTR repair leads to good functional outcome without major complications. Although a severe knee extension strength deficit may occur in some patients postoperatively, an excellent return to sports rate and high patient satisfaction can be expected nonetheless. LEVEL OF EVIDENCE Retrospective cohort study; III.
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Affiliation(s)
- Maximilian Hinz
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Stephanie Geyer
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Felix Winden
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Alexander Braunsperger
- Department of Sport and Health Sciences, Prevention Center, Technical University of Munich, Munich, Germany
| | - Florian Kreuzpointner
- Department of Sport and Health Sciences, Prevention Center, Technical University of Munich, Munich, Germany
| | - Markus Irger
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Julian Mehl
- Department of Sports Orthopaedics, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
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4
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Qi H, Li Z, Ma T, Ren C, Xu Y, Huang Q, Zhang K, Li M. Treatment of proximal patellar tendon rupture with custom-made anchor-like plate and suture: cases report and literature review. Front Surg 2023; 10:1170760. [PMID: 37228760 PMCID: PMC10203210 DOI: 10.3389/fsurg.2023.1170760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/12/2023] [Indexed: 05/27/2023] Open
Abstract
We reported 2 cases of patellar tendon rupture at the lower pole of the patella. For patellar tendon rupture, simple suture fixation has been proved to be inadequate in strength. Our center uses custom-made anchor-like plate and suture to treat proximal patellar fracture. The fixation strength is reliable, no additional bone tunnel is required, and the fixation of the lower patellar fracture can be achieved at the same time. After the operation, the patient starts functional exercise of the knee joint at an early stage, The function of the knee joint of the patient recovered well after 1 year, without other complications.
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Affiliation(s)
- Hongfei Qi
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Zhong Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Teng Ma
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Cheng Ren
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Yibo Xu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Qiang Huang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Kun Zhang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Ming Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
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5
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Otlans P, Heimur J, Sonnier JH, Gibby D, Freedman KB. The Utility of MRI in Evaluating Ruptures of the Patellar Tendon. Orthop J Sports Med 2023; 11:23259671221144980. [PMID: 36655018 PMCID: PMC9841853 DOI: 10.1177/23259671221144980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/13/2022] [Indexed: 01/15/2023] Open
Abstract
Background Although the identification of patellar tendon rupture is a clinical diagnosis aided by standard radiography, magnetic resonance imaging (MRI) may aid in identifying the location of the rupture and concomitant pathology. Purpose To evaluate the characteristics of patellar tendon tears needing surgical repair and to determine whether patient or injury factors were predictive of tear location. Study Design Case series; Level of evidence, 4. Methods Consecutive patients who underwent primary patellar tendon repair for rupture between May 15, 2017, and April 10, 2020, were reviewed retrospectively. Exclusion criteria included age <18 years, surgical treatment of multiligamentous knee injury, laceration injury, and knee arthroplasty. Radiographs, MRI scans, MRI reports, clinic notes, and operative notes were evaluated. Statistical analysis was performed to determine factors associated with tear location, complications, and reoperation. Results In total, 147 patients and 156 tendon tears were included; 82.1% of the tears were patellar avulsions, 14.7% were midsubstance or complex tears, and 3.2% were tibial avulsions. Patient and injury characteristics (body mass index, race, medical comorbidities, presence of patellar tendinitis, mechanism of injury, Insall-Salvati ratio, and the presence of infrapatellar bone fragments) were not predictive of tear location (P > .05). Patellar tendon ruptures were able to be clinically diagnosed correctly in >99% of cases. MRI was used to evaluate 77 (49.4%) knees. Patients who underwent MRI before surgery were more likely to have a history of preexisting tendinitis (P = .015) and a lower preoperative Insall-Salvati ratio (1.68 vs 1.52; P = .017). Conclusion Patient and injury factors were not predictive of tear location. The majority of patellar tendon tears were avulsion-type injuries from the inferior patella. MRI was not necessary to aid in the diagnosis of patellar tendon rupture, as 99.4% of tears were able to be diagnosed clinically without advanced imaging.
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Affiliation(s)
- Peters Otlans
- Proliance SW Seattle Orthopedics, Burien, Washington, USA
| | - Juliana Heimur
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | | | - Devyn Gibby
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin B. Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
- Kevin B. Freedman, MD, Rothman Orthopaedics at Thomas Jefferson University, 825 Old Lancaster Road, Suite 200, Bryn Mawr, PA 19010, USA () (Twitter: @RothmanOrtho)
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6
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Lewis DC, Athoff AD, Kamalapathy P, Yarboro SR, Miller MD, Werner BC. Risk Factors for Infection and Revision Surgery following Patellar Tendon and Quadriceps Tendon Repairs: An Analysis of 3,442 Patients. J Knee Surg 2022; 35:1495-1502. [PMID: 33853152 DOI: 10.1055/s-0041-1727113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Disruption of the extensor mechanism is debilitating with surgical repair being the accepted treatment. The incidence of infection and reoperation after extensor mechanism repair are not well reported in the literature. Thus, the objective of the current study was to (1) determine the incidence of surgical site infection and reoperation within 1 year of primary extensor mechanism repair and (2) identify independent risk factors for infection and reoperation following patellar and quadriceps tendon repair. A retrospective review of the 100% Medicare Standard Analytic files from 2005 to 2014 was performed to identify patients undergoing isolated patellar tendon repair and quadriceps tendon repair. Diagnosis of infection within 1 year of operative intervention and revision repair were assessed. Extensor mechanism injuries in the setting of total knee arthroplasty and polytrauma were excluded. Multivariate logistic regression analysis was performed to evaluate risk factors for postoperative infection and reoperation within 1 year. Infection occurred in 6.3% of patients undergoing patellar tendon repair and 2.6% of patients undergoing quadriceps tendon repair. Diabetes mellitus (odds ratio [OR] = 1.89, p = 0.005) was found to be an independent risk factor for infection following patellar tendon repair. Reoperation within 1 year occurred in 1.3 and 3.9% following patellar tendon and quadriceps tendon repair, respectively. Age less than 65 years (OR = 2.77, p = 0.024) and obesity (OR = 3.66, p = 0.046) were significant risk factors for reoperation after patellar tendon repair. Hypertension (OR = 2.13, p = 0.034), hypothyroidism (OR = 2.01, p = 0.010), and depression (OR = 2.41, p = 0.005) were significant risk factors for reoperation after quadriceps tendon repair. Diabetes mellitus was identified as a risk factor for infection after patellar tendon repair. Age less than 65 years, peripheral vascular disease, and congestive heart failure were risk factors for infection after quadriceps tendon repair. The current findings can be utilized to counsel patients regarding preoperative risk factors for postoperative complications prior to surgical intervention for extensor mechanism injuries.
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Affiliation(s)
- Daniel C Lewis
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Alyssa D Athoff
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
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7
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Murphy TP, Mescher PK, Tucker CJ. Patellar Stress Fracture After Suture Anchor Patellar Tendon Repair in an Active Duty Military Member: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00075. [PMID: 35320134 DOI: 10.2106/jbjs.cc.21.00765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 31-year-old US service member presented with a patellar tendon tear that was repaired acutely with 2 biocomposite suture anchors. He presented more than 2 years later with a stress fracture through a suture anchor drill hole and was treated with partially threaded screw fixation. CONCLUSION Stress fracture through a suture anchor drill hole after patellar tendon repair is a previously unreported complication. Surgeons should have a high index of suspicion and low threshold to obtain advanced imaging in cases of unexplained pain after patellar tendon repair.
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Affiliation(s)
- Timothy P Murphy
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Patrick K Mescher
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Christopher J Tucker
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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8
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Nakashima H, Takahara Y, Uchida Y, Kato H, Itani S, Iwasaki Y. Patellar Tendon Repair With Suture Tape Augmentation for Proximal Patellar Tendon Rupture. Arthrosc Tech 2022; 11:e115-e119. [PMID: 35155101 PMCID: PMC8820993 DOI: 10.1016/j.eats.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/27/2021] [Indexed: 02/03/2023] Open
Abstract
Patellar tendon ruptures are severe but uncommon injuries that require surgical treatment. Primary repair for acute patellar tendon ruptures using augmentation techniques has shown good results in terms of biomechanical and clinical outcomes. This Technical Note details patellar tendon repair with suture tape augmentation for proximal patellar tendon rupture. Because this surgical technique does not require harvesting of the hamstring tendon and hardware removal, it is minimally invasive. In addition, it is simple and quick to perform.
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Affiliation(s)
- Hirotaka Nakashima
- Address correspondence to Hirotaka Nakashima, M.D., Ph.D., Department of Orthopedic Surgery, Nippon Kokan Fukuyama Hospital, 1844 Tsunoshita Daimon-cho, Fukuyama City, Hiroshima 721-0927, Japan.
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9
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Fredericks DR, Slaven SE, McCarthy CF, Dingle ME, Brooks DI, Steelman TJ, Donohue MA, Griffin DW, Giuliani JR, Dickens JF. Incidence and Risk Factors of Acute Patellar Tendon Rupture, Repair Failure, and Return to Activity in the Active-Duty Military Population. Am J Sports Med 2021; 49:2916-2923. [PMID: 34313493 DOI: 10.1177/03635465211026963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patellar tendon ruptures have a reported incidence of 0.68 per 100,000 person-years in the general population. The epidemiology of surgically treated patellar tendon ruptures in the US military has yet to be reported, which would provide opportunity for identification of risk factors for these otherwise healthy and active patients. PURPOSE To determine the incidence of patellar tendon rupture in the Military Health System (MHS) population and to analyze demographic patterns, surgical fixation methods, and rerupture rates. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS We utilized the MHS Data Repository (MDR) to identity active-duty military servicemembers surgically treated for patellar tendon rupture between 2010 and 2015. Records were reviewed for demographic information, injury characteristics, fixation technique, and occurrence of rerupture. Risk factors for rupture were calculated using Poisson regression based on population counts and demographic data obtained in the MDR. Risk factors for rerupture and return to duty were analyzed via univariate analysis and multivariate regression. RESULTS A total of 504 operatively treated primary patellar tendon repairs in 483 patients were identified, with an overall incidence of 6 per 100,000 person-years. Mean age was 33.6 years (range, 17-54 years) and 98% of patients were male. Fixation method was 81% bone tunnels and 7% suture anchors, and 12% were unknown. Black race had a higher relative rate ratio for rupture compared with the race categories White (9.21; P < .0001) and Other (3.27; P < .0001). The rupture rate was higher in 35- to 44-year-old patients compared with those aged 18 to 24 years (P < .0001), 25 to 34 years (P < .0001), and 45 to 64 years (P = .004). Return to full previous level of activity occurred in 75.8% of patients, 14.6% returned to activity with limitations, and 9.5% were medically separated. The rerupture rate was 3%. Fixation method, tobacco usage, body mass index, and race were not significant risk factors for rerupture. CONCLUSION The incidence of patellar tendon rupture in the US military population is substantially higher than has been reported in the civilian population. Among military personnel, men, Black servicemembers, and those aged 35 to 44 years were at highest risk for patellar tendon rupture. Three-quarters of patients were able to return to full activity without limitations. The rerupture rate was low and unaffected by fixation method.
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Affiliation(s)
- Donald R Fredericks
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sean E Slaven
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Conor F McCarthy
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Marvin E Dingle
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Daniel I Brooks
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA
| | - Theodore J Steelman
- Fort Belvoir Community Hospital, Department of Orthopaedic Surgery, Fort Belvoir, Virginia, USA
| | - Michael A Donohue
- John A. Feagin Jr. Sports Medicine Fellowship at West Point, West Point, New York, USA
| | - Daniel W Griffin
- Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois, USA
| | | | - Jonathan F Dickens
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,John A. Feagin Jr. Sports Medicine Fellowship at West Point, West Point, New York, USA
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10
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Haskel JD, Fried JW, Hurley ET, Mojica ES, Alaia MJ, Strauss EJ, Campbell KA. High rates of return to play and work follow knee extensor tendon ruptures but low rate of return to pre-injury level of play. Knee Surg Sports Traumatol Arthrosc 2021; 29:2695-2700. [PMID: 33760963 DOI: 10.1007/s00167-021-06537-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Extensor mechanism ruptures (EMR) of the knee are rare but debilitating injuries that always require surgery to restore knee function. The purpose of this study was to systematically review the literature to ascertain the rate of return to play following patellar or quadriceps tendon ruptures. METHODS A systematic literature search was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using the EMBASE, MEDLINE, and Cochrane Library databases. Inclusion criteria consisted of clinical studies reporting on return to play after patellar or quadriceps tendon repair. Statistical analysis was performed with the use of SPSS. RESULTS Our review found 48 studies including 1135 cases meeting our inclusion criteria. There were 33 studies including 757 patellar tendon (PT) repairs, and 18 studies including 378 quadriceps tendon (QT) repairs. The overall rate of return to play for PT repairs was 88.9%, with 80.8% returning to the same level of play. The overall rate of return to play for QT repairs was 89.8%, with 70.0% returning to the same level of play. Among professional athletes, the overall rate of return to play after PT repair and QT repair was 76.9% and 70.9%, respectively. Following PT repair, 95.8% were able to return to work, and following QT repair, 95.9% were able to return to work. CONCLUSION The overall rate of return to play was high following both PT and QT repairs. Moreover, a high percentage of those patients were able to return to their pre-operative level of sport with a low risk for re-rupture. LEVEL OF EVIDENCE Level IV.
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11
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Rosteius T, Jettkant B, Brinkemper A, Rausch V, Lotzien S, Geßmann J, Schildhauer TA, Königshausen M. Long-term follow up of extensor tendon ruptures of the knee using electromyography and three-dimensional gait analysis. Knee 2021; 29:251-261. [PMID: 33676320 DOI: 10.1016/j.knee.2021.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/09/2021] [Accepted: 02/08/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to analyze the long-term outcomes of extensor tendon ruptures of the knee using exact measuring tools. METHODS The results of patients treated for extensor tendon rupture with a minimum follow up of 10 years were reviewed. Electromyography (EMG) and three-dimensional (3D) gait analyses were performed and compared with the healthy side of each patient and with the gait patterns of 20 healthy controls. Functional outcome scores were assessed using the Lysholm score and Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS After a mean of 13.4 ± 3 years, 23 patients were available for follow up. The mean Lysholm score was 86.6, and the KOOS averaged 78.1. Gait analysis showed no major kinematic differences between these patients compared with healthy controls. In the squat test, the mean peak amplitude of the rectus femoris muscle was significantly smaller on the injured side than on the healthy side (140.21 ± 66.13 μV vs. 168.25 ± 91.77 μV; P = 0.01). The mean peaks of the vastus lateralis and medialis EMG signals were also lower on the injured side (P = 0.63; P = 0.08). Correspondingly, the thigh girth at 20 cm and 10 cm above the knee was significantly lower on the injured side. One patient had re-rupture after patella tendon repair. CONCLUSION At long-term follow up the patients reached good clinical outcomes and exhibited mainly physiological gait patterns after rupture of knee extensor tendons. However, the thigh muscles showed hypotrophy and a significantly smaller EMG signal amplitude during a high-intensity task on the formerly injured side.
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Affiliation(s)
- Thomas Rosteius
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Birger Jettkant
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Alexis Brinkemper
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Valentin Rausch
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Sebastian Lotzien
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Jan Geßmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | | | - Matthias Königshausen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
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Bulaïd Y, Fabre M, Parratte S, Argenson JN, Ollivier M. Patella Distal Pole Fracture Treated Using Ipsilateral Hamstring Autograft Augmentation and No Additional Hardware. Arthrosc Tech 2020; 10:e61-e65. [PMID: 33532209 PMCID: PMC7823080 DOI: 10.1016/j.eats.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/11/2020] [Indexed: 02/03/2023] Open
Abstract
Patellar lower-pole fractures occur in relatively young patients after eccentric contraction of the quadriceps or direct trauma. Early diagnosis and adequate treatment lead to excellent outcomes and prevent tendon retraction and scarring. The aim of surgical treatment is to restore articular congruence and reestablish the extensor mechanism of the knee. All surgical treatments (sutures and tension band wiring, separate vertical wiring or augmented with Krackow sutures, wiring through screws, basket plate, hook plate) use additional hardware. We propose a hardware-free technique using ipsilateral hamstring augmentation.
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Affiliation(s)
- Yassine Bulaïd
- Caportho, Centre de Chirurgie Orthopédique et Sportive, Béthune, France,Clinique Anne d’Artois, Béthune, France,Address correspondence to Yassine Bulaïd, MD, Caportho, Centre de Chirurgie Orthopédique et Sportive, Clinique Anne d’Artois, 100 Rue Emile Basly, 62400 Béthune, France.
| | - Maxime Fabre
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Sébastien Parratte
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Jean-Noël Argenson
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Matthieu Ollivier
- l’Assistance Publique des Hôpitaux de Marseille, Institut du Mouvement et de L'appareil Locomoteur, Department of Orthopaedic Surgery, Sainte-Marguerite Hospital, Marseille, France,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
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13
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Massey PA, Myers M, McClary K, Brown J, Barton RS, Solitro GF. Biomechanical Analysis of Patellar Tendon Repair With Knotless Suture Anchor Tape Versus Transosseous Suture. Orthop J Sports Med 2020; 8:2325967120954808. [PMID: 33062760 PMCID: PMC7536376 DOI: 10.1177/2325967120954808] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022] Open
Abstract
Background Patellar tendon ruptures have routinely been repaired with transosseous suture tunnels. The use of knotless suture anchors for repair has been suggested as an alternative. Purpose To compare the load to failure and gap formation of patellar tendon repair at the inferior pole of the patella with knotless suture anchor tape versus transosseous sutures. A secondary objective was to investigate whether either technique shows an association between bone density and load to failure. Study Design Controlled laboratory study. Methods A total of 20 human tibias with attached patellar and quadriceps tendons were sharply incised at the bone-tendon junction at the inferior pole of the patella. A total of 10 tendons were repaired using 2 knotless suture anchors in the inferior pole of the patella and a single suture tape with 2 core sutures. The other 10 tendons were repaired using No. 2 suture passed through 3 transosseous tunnels. A distracting force was then applied through the suture in the quadriceps tendon. Gap distance through load cycling at the repair site and maximum load at repair failure were then measured. Bone density was measured using computed tomography scanning. Results No difference was found in the mean load to failure of knotless patellar tendon repair versus transosseous suture repair (367.6 ± 112.2 vs 433.9 ± 99 N, respectively; P = .12). After 250 cycles, the mean repair site gap distance was 0.85 ± 0.45 mm for the knotless patellar tendon repair versus 2.94 ± 2.03 mm for the transosseous suture repair (P = .03). A small correlation, although not statistically significant, was found between bone density and load to failure for the knotless tape repair (R 2 = 0.228; P = .66). No correlation was found between bone density and load to failure for the transosseous repair (R 2 = 0.086; P = .83). Conclusion Suture tape repair with knotless anchors for repair of patellar tendon rupture has comparable load to failure with less gap formation than transosseous suture repair. There is a small correlation between bone density and failure load for knotless anchor repair, which may benefit from further investigation. Clinical Relevance Using knotless suture anchors for patellar tendon rupture repair would allow for a smaller incision, less dissection, and likely shorter operating time.
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Affiliation(s)
- Patrick A Massey
- Department of Orthopaedic Surgery, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Mitchell Myers
- Department of Orthopaedic Surgery, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Kaylan McClary
- Department of Orthopaedic Surgery, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Jimmy Brown
- Department of Orthopaedic Surgery, Louisiana State University Health, Shreveport, Louisiana, USA
| | - R Shane Barton
- Department of Orthopaedic Surgery, Louisiana State University Health, Shreveport, Louisiana, USA
| | - Giovanni F Solitro
- Department of Orthopaedic Surgery, Louisiana State University Health, Shreveport, Louisiana, USA
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Beranger JS, Kajetanek C, Bayoud W, Pascal-Mousselard H, Khiami F. Return to sport after early surgical repair of acute patellar tendon ruptures. Orthop Traumatol Surg Res 2020; 106:503-507. [PMID: 32179020 DOI: 10.1016/j.otsr.2020.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 12/16/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patellar tendon ruptures make up about 5% of all extensor mechanism injuries. They mainly occur in young, athletic men who have contributing risk factors such as chronic tendinopathy. The aim of this study was to evaluate the return to sport after repair of an acute patellar tendon rupture. We hypothesized that surgical repair yields good functional outcomes with a high rate of return to competitive sports in patients treated with the same surgical technique. METHODS This retrospective study involved 23 cases of patellar tendon rupture in 20 patients (2 women, 18 men). The average age was 42.0±13.8 years (24-68). Eighteen ruptures occurred at the patellar attachment and five were mid-substance. Either transosseous reattachment or direct suture repair was carried out within 21 days; all tendons were augmented with a non-metallic tibiopatellar suture. At the final assessment, a clinical examination was carried out (extensor mechanism testing and range of motion) with collection of functional scores (pain, VISA-P, Lysholm and satisfaction), date of return to sport and final radiographs. RESULTS At a mean follow-up of 47.7 months (15-120), there were no cases of significant knee stiffness. Seventeen patients (94.4%) had returned to sport, 15 at their pre-injury level (83%). The mean time before running could be restarted was 9 months (6-15 months) and 17 months for sports at the same pre-injury level (8-18 months). The mean VISA score and the mean Lysholm score were 85.5 (62-99) and 67.3 (35-97) respectively; 85% of patients were satisfied or very satisfied. The prognosis was worse when the patient was older than 40 and had a BMI above 25. Early surgical repair of patellar tendon rupture yields good functional outcomes with return to sport possible at high levels. LEVEL OF EVIDENCE IV, Retrospective cohort study.
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Affiliation(s)
- Jean-Sébastien Beranger
- Service d'orthopédie et de traumatologie du sport, université Sorbonne, CHU Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France
| | - Charles Kajetanek
- Service d'orthopédie et de traumatologie du sport, université Sorbonne, CHU Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France.
| | - Wael Bayoud
- Service d'orthopédie et de traumatologie du sport, université Sorbonne, CHU Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France
| | - Hugues Pascal-Mousselard
- Service d'orthopédie et de traumatologie du sport, université Sorbonne, CHU Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France
| | - Frédéric Khiami
- Service d'orthopédie et de traumatologie du sport, université Sorbonne, CHU Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France
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Althoff AD, Reeves RA, Traven SA, Byrd M, Leddy LR, Slone HS. Smoking is associated with increased complications and readmission following extensor mechanism repair. Knee Surg Sports Traumatol Arthrosc 2019; 27:3048-3053. [PMID: 30612164 DOI: 10.1007/s00167-018-5339-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Extensor mechanism injuries are disabling injuries that require prompt evaluation and treatment and complications are often devastating. While smoking has been shown to increase complications following total joint arthroplasty, this relationship has not yet been established in those undergoing extensor mechanism repair. The purpose of this study was to evaluate the risk of smoking on postoperative complications following extensor mechanism repair. METHODS The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent an extensor mechanism repair from 2005 to 2016. Patients were stratified by tobacco use, as either "current" or "nonsmokers." A multivariate logistic regression was used to control for demographic and comorbid factors while assessing perioperative complications. RESULTS 5208 patients were identified, and of these, 843 (16.2%) were current smokers. Smokers were younger, male, and with lower BMIs compared to nonsmokers (p = 0.001, p = 0.003, p = 0.002, respectively). They had a higher rate of surgical complications (OR 1.61, CI 1.02-2.52), including deep surgical site infections (OR 3.27, CI 1.03-10.43) and unplanned return to the operating room (OR 2.001, 1.24-3.23). Smokers were more likely to be readmitted within 30 days of surgery (OR 1.78, OR 1.09-2.90). CONCLUSION Tobacco use is associated with a 1-2% increase in surgical, but not medical, complications following repair of extensor mechanism injuries. Smokers are at higher risk for deep infections, unplanned return to the OR, and hospital readmission. Identifying these patients preoperatively will allow surgeons to accurately counsel patients on perioperative risks. Counseling in preoperative smoking cessation is valuable for optimizing patient outcomes following extensor mechanism repair. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Alyssa D Althoff
- College of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA.
| | - Russell A Reeves
- Department of Orthopaedic Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC, 29425, USA
| | - Sophia A Traven
- Department of Orthopaedic Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC, 29425, USA
| | - Michael Byrd
- College of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Lee R Leddy
- Department of Orthopaedic Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC, 29425, USA
| | - Harris S Slone
- Department of Orthopaedic Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, MSC 622, Charleston, SC, 29425, USA
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Tandberg AN, Grindem H, Wiig C, Figved W. Knee sliced open by skate blade: complete patellar tendon rupture in an elite long track speed skater. BMJ Case Rep 2019; 12:12/4/e228611. [PMID: 30988109 DOI: 10.1136/bcr-2018-228611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A long track speed skater sustained a deep horizontal cut to the right knee just distally to the patella, after he got hit by the skate blade of the pair mate. The injury included a complete patellar tendon rupture from the apex of the patella, a 1 mm deep transverse cut in the femoral condyle and a partial rupture of the anterior cruciate ligament. The tendon rupture was repaired with transosseous suture repair without augmentation. A knee brace was used for 8 weeks, with a gradual decrease in flexion restraints. A rehabilitation programme was overseen by a dedicated physiotherapist. At 6 months, he started a gradual return to skating sessions. After 1 year, he had symmetrical single-legged hop performance, but quadriceps weakness due to pain. The patient returned to competition speed skating at national levels after 11 months, and within the first postoperative year, he was breaking new personal records on the ice.
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Affiliation(s)
| | - Hege Grindem
- Department of Sports Medicine, Oslo Sport Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Christian Wiig
- Department of Physiotherapy, Vest helse og trening AS, Akershus, Norway
| | - Wender Figved
- Orthopaedic Department, Baerum Hospital, Vestre Viken Hospital Trust, Akershus, Norway
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Hantes ME, Mathews R, Raoulis V, Varitimidis S, Karachalios T, Malizos KN. Better knee function after surgical repair of acute quadriceps tendon rupture in comparison to acute patellar tendon rupture. Orthop Traumatol Surg Res 2019; 105:119-123. [PMID: 30455100 DOI: 10.1016/j.otsr.2018.09.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/05/2018] [Accepted: 09/18/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to determine if there is a difference in knee function between patients with quadriceps tendon rupture and patellar tendon rupture after acute surgical repair. Our hypothesis was that knee function would be similar between the two groups. METHODS The study population included 24 patients; 13 patients suffered from quadriceps tendon rupture and 11 patients from patellar tendon rupture. All patients underwent acute surgical repair using heavy non-absorbable trans-osseous sutures; another non-absorbable suture, passed through both retinaculum and around the repaired tendon to augment the repair. Clinical evaluation was performed using the Lysholm, Kujala, and VAS scoring systems. In addition, radiographic evaluation to evaluate patellar height and patello-femoral joint arthritis using Iwano's classification was performed. RESULTS The average follow-up time was 70.5 months. All patients in the quadriceps tendon group had full range of knee motion while 3 patients (27%) in the patellar tendon group had reduced knee flexion. Patients in the quadriceps tendon group had a significantly higher Kujala score in comparison to the patellar tendon group (88 vs. 73 p=0.033). No significant differences were identified between the two groups according to the Lysholm scoring system. Patients in the quadriceps tendon group had significantly less pain according to VAS scale (1.2 vs. 3.5 p=0.012). Radiographic evaluation revealed that two patients from each group showed signs of grade II patello-femoral joint arthritis according to Iwano's classification. CONCLUSION Acute surgical repair of quadriceps tendon ruptures provides better knee function, in comparison to the surgical restoration of patellar tendon rupture. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Michael E Hantes
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, Mezourlo, 41110 Larissa, Greece.
| | - Rejith Mathews
- Department of Orthopedic Surgery, Sri Narayani hospital and research centre, Vellore, Tamil Nadu, India
| | - Vasilios Raoulis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, Mezourlo, 41110 Larissa, Greece
| | - Sokratis Varitimidis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, Mezourlo, 41110 Larissa, Greece
| | - Theophilos Karachalios
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, Mezourlo, 41110 Larissa, Greece
| | - Konstantinos N Malizos
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, Mezourlo, 41110 Larissa, Greece
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18
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Schütte V, Schmidt-Hebbel A, Imhoff AB, Achtnich A. [Patellar tendon ruptures : Internal bracing and augmentation technique]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:45-55. [PMID: 30683978 DOI: 10.1007/s00064-018-0585-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/20/2018] [Accepted: 09/23/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report a surgical technique for the treatment of patellar tendon ruptures augmented with an internal brace suture tape. INDICATIONS Acute patellar tendon ruptures, fractures of the distal patellar pole, chronic insufficiency of the patellar tendon or revision surgery for failed repairs. CONTRAINDICATIONS Severe damage to the surrounding soft tissue. Local infection. Life-threatening conditions. SURGICAL TECHNIQUE Direct longitudinal anterior approach to the patellar tendon. Two parallel transosseous bone tunnels are drilled in the patella and tibial tuberosity with a 2.4 mm drill bit. Two separate FiberTapes® (Arthrex, Naples, FL; USA) are shuttled through the proximal and distal bone tunnels around the tendon in "X" and "O" type configuration. Patellar height is reestablished under fluoroscopic control and both FiberTapes are tied down. Both tendon ends are debrided and readapted with absorbable sutures. POSTOPERATIVE MANAGEMENT Passive motion exercise to 90° of flexion from day 1. Partial load to 20 kg of body weight with knee in locked full extension brace during first 2 weeks. Isometric exercises from week 3. Passive flexion to 110° from week 4 (adapted to pain). Free active range of motion and weight bearing from week 7. RESULTS In more than 10 years of clinical application, positive results were continuously found in acute as well as chronic patellar tendon ruptures. These results are consistent with those in the current literature.
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Affiliation(s)
- V Schütte
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost, Halle/Saale, Deutschland
| | | | - A B Imhoff
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.
| | - A Achtnich
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland
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Nguyen MV, Nguyen JV, Taormina DP, Pham H, Alaia MJ. A Comprehensive Return-to-Play Analysis of National Basketball Association Players With Operative Patellar Tendon Tears. Orthop J Sports Med 2018; 6:2325967118800479. [PMID: 30345321 PMCID: PMC6187427 DOI: 10.1177/2325967118800479] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Patellar tendon tears impart potentially debilitating sequelae among professional basketball athletes. Hypothesis: Professional basketball athletes with patellar tendon tears have decreased return-to-play performance in seasons after injury compared with preinjury statistics. Study Design: Case series; Level of evidence, 4. Methods: Patellar tendon tears among National Basketball Association (NBA) athletes from the 1999-2000 to 2014-2015 seasons were identified. Player performance statistics for players who underwent operative patellar tendon repair were compared from 1 season before injury to 1 season after injury and 2 seasons before injury to 2 seasons after injury using the primary outcome of player efficiency rating (PER). Secondary performance outcomes were also analyzed. Results: A total of 13 patellar tendon tears (10 complete, 3 partial) were identified among 12 NBA athletes. Three players (25%) did not return to play in the NBA. No significant differences were found in PER in comparisons of 1 season before and after injury (16.6 ± 1.5 vs 14.3 ± 1.7; P = .20) or in comparisons of 2 seasons before and after injury (15.8 ± 0.8 vs 6.3 ± 2.3; P = .49). Diminished performance outcomes were noted for total minutes played (2598 ± 100 vs 1695 ± 78; P = .01), games played (74.8 ± 1.9 vs 60.5 ± 1.4; P = .04), and minutes per game (34.8 ± 1.5 vs 28.2 ± 1.8; P = .02) in comparisons of 1 season before and after injury. Total minutes played per season (2491 ± 190 vs 799 ± 280; P = .045) decreased in comparisons of 2 seasons before and after injury. Conclusion: Patellar tendon tears were not associated with diminished efficiency-adjusted performance, as measured by PER, games played, minutes per game played, points per 36 minutes, and rebounds per 36 minutes. However, decreases in total minutes played were observed following patellar tendon tear. Orthopaedic surgeons may be better prepared to counsel basketball athlete patients with patellar tendon tear given these findings.
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Affiliation(s)
| | - John V Nguyen
- Department of Electrical Engineering and Computer Science, University of Michigan College of Engineering, Ann Arbor, Michigan, USA
| | - David P Taormina
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York, USA
| | - Hien Pham
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York, USA
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Patellar Tendon Excision and Repair for Residual Patella Alta after Prior Failed Patellar Tendon Repair: Surgical Decision Making and Outcome. Case Rep Orthop 2018; 2018:7964732. [PMID: 30151290 PMCID: PMC6087580 DOI: 10.1155/2018/7964732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/27/2018] [Accepted: 05/30/2018] [Indexed: 11/18/2022] Open
Abstract
Presented in this report is a complex revision case of a patellar tendon repair preceded by excess tendon excision to correct for recurrent patella alta deformity, in a workers' compensation patient. The goal of this procedure was to alleviate this patient's pain, to preserve his ability to function in his activities of daily living, and to allow him to return to work at some capacity. On postoperative radiographs, the revision procedure appeared to have successfully corrected this patient's patella alta deformity. After an extended rehabilitation process, this patient had reached maximal medical improvement at 1-year follow-up. He displayed modest improvements in all PROs, including a clinically significant improvement in his short-form mental component score. Despite his functional capacity being still somewhat limited, this patient reported subjective satisfaction after this complicated salvage procedure.
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21
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Reconstruction of Acute Patellar Tendon Rupture after Patellectomy. Case Rep Orthop 2018; 2018:7549476. [PMID: 29808145 PMCID: PMC5902117 DOI: 10.1155/2018/7549476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/06/2018] [Accepted: 03/17/2018] [Indexed: 11/17/2022] Open
Abstract
Acute rupture of the knee extensor mechanism after patellectomy is extremely rare. We present the case of a patient with acute patellar tendon rupture who had undergone patellectomy 53 years before. Twelve days after the injury, the ruptured patellar tendon was repaired with end-to-end suture. Postoperatively, we splinted the knee for 6 weeks but permitted the patient to walk without limiting weight bearing at 1 week postoperatively. At one-year follow-up, the patient is able to move his knee almost full range of motion and the Lysholm knee score is 81. The patient is satisfied with the outcome. This is the first report to treat acute rupture of the patellar tendon in a patient who had undergone patellectomy. Although careful rehabilitation is required, end-to-end suture might be an adequate surgical procedure for acute rupture of the knee extensor mechanism after patellectomy.
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22
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Woodmass JM, Johnson JD, Wu IT, Krych AJ, Stuart MJ. Patellar Tendon Repair With Ipsilateral Semitendinosus Autograft Augmentation. Arthrosc Tech 2017; 6:e2177-e2181. [PMID: 29349015 PMCID: PMC5765631 DOI: 10.1016/j.eats.2017.08.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/07/2017] [Indexed: 02/06/2023] Open
Abstract
Patellar tendon ruptures are rare but potentially devastating injuries. Acute repair after patellar tendon rupture affords the best opportunity for tension-free restoration of the extensor mechanism. Biological augmentation of primary repair is believed to decrease strain across the repair site and reduce the risk of rerupture. We present a technique for primary patellar tendon repair with bidirectional fixation using transosseous tunnels, suture anchor fixation, and ipsilateral hamstring autograft augmentation in a distal patellar pole socket.
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Affiliation(s)
| | | | | | - Aaron J. Krych
- Address correspondence to Aaron J. Krych, M.D., Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, U.S.A.Department of Orthopedic SurgeryMayo ClinicRochesterMN55905U.S.A.
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Sanchez G, Ferrari MB, Sanchez A, Moatshe G, Chahla J, DePhillipo N, Provencher MT. Proximal Patellar Tendon Repair: Internal Brace Technique With Unicortical Buttons and Suture Tape. Arthrosc Tech 2017; 6:e491-e497. [PMID: 28580272 PMCID: PMC5443655 DOI: 10.1016/j.eats.2016.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/21/2016] [Indexed: 02/03/2023] Open
Abstract
Patellar tendon ruptures may be considerably limiting, especially in younger and highly active patients. These injuries ultimately result in a complete inability to maintain extension of the knee, thereby placing strict impediment on physical activity. As a result, a durable repair construct via surgery is necessary to allow patients to return to their preinjury activity level. Because of the inherent difficulty in maintaining patellar tendon position after repair, and to avoid failure of the tendon healing to the patella, we recommend using an internal brace construct. The construct uses bone tunnels in the patella and also cortical buttons on the tibia with suture tape whipstitched through the tendon. We feel that this provides an enhanced fixation construct. The purpose of this Technical Note is to describe our preferred method for proximal patellar tendon repair via an internal brace construct with unicortical buttons and suture tape.
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Affiliation(s)
- George Sanchez
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | | | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Matthew T. Provencher
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
- The Steadman Clinic, Vail, Colorado, U.S.A
- Address correspondence to Matthew T. Provencher, M.D., Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657, U.S.A.Steadman Philippon Research Institute181 West Meadow DriveSuite 1000VailCO81657U.S.A.
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Bouget P, Breque C, Beranger JS, Faure JP, Khiami F, Vendeuvre T. Biomechanical cadaveric comparison of patellar ligament suture protected by a steel cable versus a synthetic cable. J Exp Orthop 2017; 4:9. [PMID: 28332149 PMCID: PMC5362567 DOI: 10.1186/s40634-017-0084-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/17/2017] [Indexed: 11/16/2022] Open
Abstract
Background Purpose and hypothesis: Patellar ligament rupture is a rare disabling pathology requiring a surgical ligament suture protected by a frame. The gold standard is the steel cable, but its rigidity and the necessity of a surgical re-intervention for its removal render it unsatisfactory. The objective of this paper is to quantify the mechanical protection provided by the terylene® in comparison with steel. Methods Twenty-four knees of 12 fresh frozen cadaveric subjects were divided into 2 homogeneous groups (terylene and steel) of 12 knees (mean age = 69.3 years). Proximal ligament repair was performed according to a three-tunnel transosseous reinsertion technique. Mechanical tests were performed in flexion to simulate movement of the knee. The interligament gap and the amplitude angulation of the knee were measured by a system of extensometer and optical goniometer. Mechanical analysis permitted calculation of flexion amplitude for a ligament gap of 1 and 2 mm taking as initial angle the adjusting angle of pretension of the protection frame. Study of deformations of frames was performed. Statistical analysis was performed with a Wilcoxon Mann Whitney test. Results There is no significant difference in protection of the ligament suture between the “terylene” and “steel” groups. Mean flexion amplitudes (mΔF) show no significant differences between the 2 groups for a distension of the suture of 1 mm (m ΔF terylene1 = 4.74 °; mΔF steel1 = 5.91°; p = 0.198) and 2 mm (mΔF terylene2 = 8.71°; mΔF steel2 = 10.41°; p = 0.114). Elastic deformation of terylene was significantly greater than that of steel (p = 0.0004). Conclusion Suture protection of the patellar ligament by a terylene wire is not significantly different from that provided by steel frame. The elastic properties of terylene and absence of a need for re intervention to secure its removal lead us towards its use in acute ruptures of the patellar ligament. The main limits involve the properties of the chain extenders with no contraction/muscle shortening and partial dehydration of tendons and ligaments and the mean age of 69.3 years. Level 5. Electronic supplementary material The online version of this article (doi:10.1186/s40634-017-0084-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- P Bouget
- Department of Orthopedics and Traumatology, University Hospital Center of Poitiers, Poitiers, France.
| | - C Breque
- ABS Lab, University School of Medicine of Poitiers, Poitiers, France
| | - J S Beranger
- Department of Orthopedics and Traumatology, André Mignot Hospital, Hospital Center of Versailles, Versailles, France
| | - J P Faure
- ABS Lab, University School of Medicine of Poitiers, Poitiers, France.,Department of Visceral Surgery, University Hospital Center of Poitiers, Poitiers, France
| | - F Khiami
- Department of Orthopedics and Traumatology, La Pitié Salpêtrière Hospital, Public Hospital of Paris, Paris, France
| | - T Vendeuvre
- Department of Orthopedics and Traumatology, University Hospital Center of Poitiers, Poitiers, France
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Belhaj K, El Hyaoui H, Tahir A, Meftah S, Mahir L, Rafaoui A, Lmidmani F, Arsi M, Rahmi M, Rafai M, Garch A, Fadili M, Nechad M, El Fatimi A. Long-term functional outcomes after primary surgical repair of acute and chronic patellar tendon rupture: Series of 25 patients. Ann Phys Rehabil Med 2016; 60:244-248. [PMID: 27894876 DOI: 10.1016/j.rehab.2016.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/29/2016] [Accepted: 10/03/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aimed to evaluate the clinical outcomes after surgical repair of patellar tendon rupture (PTR) and compare the evolution of 2 types of rupture (acute and chronic) after the same rehabilitation protocol. METHODS This was a prospective cohort study of patients with PTR treated between January 2006 and January 2014 in the department of trauma surgery, Ibn Rochd university hospital, Casablanca. RESULTS We evaluated 25 patients (21 men) after a median follow-up of 75 months (range 29-120). The mean age was 34.7±8.59 years. Overall, 17 patients had acute rupture and 8 chronic rupture. Fifteen healthy volunteers (13 men) were recruited as a control group. Mean Knee Society Score (KSS) knee score was significantly higher after than before surgery (82.28±12.297 vs 20.64±7.6; P<0.0001) as was KSS function score (88.40±17.483 vs 23.40±8.98; P<0.0001). Pain measured on a visual analog scale was significantly lower after than before surgery (1.96±1.24 vs 6.60±1.26; P<0.0001). ROM and KSS knee and function scores were significantly lower on the operated than non-operated side after surgery. For both types of PTR, only knee extensor muscle strength was significantly lower on the operated than non-operated side and as compared with healthy volunteer knees. CONCLUSIONS Surgical repair of PTR with reinforcement and an early rehabilitation program demonstrate good results after a long follow-up. However, chronic PTR may need longer or a different rehabilitation protocol of the knee-extensor apparatus.
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Affiliation(s)
- K Belhaj
- Department of physical medicine and rehabilitation, Ibn Rochd university hospital, Casablanca, Morocco.
| | - H El Hyaoui
- Department of orthopedics and traumatology (P32), Ibn Rochd university hospital, Casablanca, Morocco
| | - A Tahir
- Department of orthopedics and traumatology (P4), Ibn Rochd university hospital, Casablanca, Morocco
| | - S Meftah
- Department of physical medicine and rehabilitation, Ibn Rochd university hospital, Casablanca, Morocco
| | - L Mahir
- Department of physical medicine and rehabilitation, Ibn Rochd university hospital, Casablanca, Morocco
| | - A Rafaoui
- Department of orthopedics and traumatology (P32), Ibn Rochd university hospital, Casablanca, Morocco
| | - F Lmidmani
- Department of physical medicine and rehabilitation, Ibn Rochd university hospital, Casablanca, Morocco
| | - M Arsi
- Department of orthopedics and traumatology (P32), Ibn Rochd university hospital, Casablanca, Morocco
| | - M Rahmi
- Department of orthopedics and traumatology (P32), Ibn Rochd university hospital, Casablanca, Morocco
| | - M Rafai
- Department of orthopedics and traumatology (P32), Ibn Rochd university hospital, Casablanca, Morocco
| | - A Garch
- Department of orthopedics and traumatology (P32), Ibn Rochd university hospital, Casablanca, Morocco
| | - M Fadili
- Department of orthopedics and traumatology (P4), Ibn Rochd university hospital, Casablanca, Morocco
| | - M Nechad
- Department of orthopedics and traumatology (P4), Ibn Rochd university hospital, Casablanca, Morocco
| | - A El Fatimi
- Department of physical medicine and rehabilitation, Ibn Rochd university hospital, Casablanca, Morocco
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Hohmann E, Wansbrough G, Senewiratne S, Tetsworth K. Medial Gastrocnemius Flap for Reconstruction of the Extensor Mechanism of the Knee Following High-Energy Trauma. A minimum 5 year follow-up. Injury 2016; 47:1750-5. [PMID: 27297707 DOI: 10.1016/j.injury.2016.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/02/2016] [Accepted: 05/16/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to assess the medium-term results of reconstruction of the extensor mechanism using the medial gastrocnemius while also providing soft tissue coverage. MATERIALS AND METHODS This retrospective review consisted of a consecutive series of four patients (age 28-40 years) with complex high energy traumatic injuries to lower extremity including both soft tissue loss and disruption of the knee extensor mechanism. The medial gastrocnemius rotational flap was used to reconstruct the patellar tendon and restore soft tissue coverage simultaneously. Range of motion and extensor lag; functional recovery was judged by return to work and sports activity. Validated measures included the Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, and the modified Cincinnati Score. RESULTS At the final follow up was 61.5 (57-66) months after reconstruction, the mean SF 12 physical component score ranged from 21.7 to 56.8 with a median of 55.3; the mental component from 42.8 to 60.7 with a median of 58.6. The KSS knee score ranged from 50 to 78 with a median of 68; the function score from 65 to 90 with a median of 85. The Oxford knee score ranged from 22 to 45 with a median of 33.5. The KOOS ranged from 28 to 82.7 with a median of 73.7 and the modified Cincinnati score from 38 to 82 with a median of 76.5. Knee range of motion ranged from 0 to 120°. Of the four patients three returned to working fulltime in their profession and returned to sports, including mountain biking and fitness training. CONCLUSIONS For severe traumatic knee injuries with the combination of soft tissue defects and disruption of the extensor mechanism, the medial gastrocnemius flap provides an excellent reconstructive option to address both problems simultaneously. The results of this small case series support the use of this limb salvage technique.
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Affiliation(s)
- Erik Hohmann
- Musculoskeletal Research Unit, CQ University, Rockhampton, Australia.
| | - Guy Wansbrough
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia
| | - Serene Senewiratne
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Department of Surgery, School of Medicine, University of Queensland, Australia
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Ng JP, Cawley DT, Beecher SM, Lee MJ, Bergin D, Shannon FJ. Focal intratendinous radiolucency: A new radiographic method for diagnosing patellar tendon ruptures. Knee 2016; 23:482-6. [PMID: 26746043 DOI: 10.1016/j.knee.2015.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/10/2015] [Accepted: 09/30/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Diagnosis of patellar tendon rupture is usually based on clinical history and examination. In equivocal cases, imaging may be required. Lateral radiograph is a simple and cost-effective method for prompt diagnosis. However, no specific radiological sign has been described. Rather than utilising patella alta as an indirect measure of patellar tendon rupture, we hypothesise that a focal intratendinous radiolucency is another reliable and accurate radiological sign for diagnosis. Sensitivity and specificity analysis was undertaken to evaluate the diagnostic value of this radiographic sign. METHODS Lateral radiographs of mid-substance patellar tendon ruptures from 19 patients were analysed. These were then randomised with another 19 normal knee radiographs from age-matched patients to create a pool of 38 radiographs for interpretation. Six independent interpreters who were blinded to the diagnosis were requested to indicate whether rupture was present or absent based on the visualisation of a focal intratendinous radiolucency in the patellar tendon. The Insall-Salvati (IS), Caton-Deschamps (CD) and Blackburne-Peel (BP) ratios were measured in the same radiographs. Sensitivity and specificity for each of the radiographic measurements were calculated. Inter- and intraobserver correlations were reported in kappa statistics. RESULTS The average sensitivity and specificity for focal radiolucency in the patellar tendon substance were 82.5% and 95.2%, respectively. Sensitivity and specificity for the IS ratio were 84.2% and 78.9%, for CD was 68.4% and 84.2% and for BP was 68.4% and 89.4% respectively. CONCLUSION The presence of a focal intratendinous radiolucency in the patellar tendon is both accurate and reliable in diagnosing patellar tendon ruptures.
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Affiliation(s)
- Jonathan P Ng
- Dept of Trauma & Orthopaedic Surgery, Galway University Hospitals, Ireland.
| | - Derek T Cawley
- Dept of Trauma & Orthopaedic Surgery, Galway University Hospitals, Ireland
| | - Suzanne M Beecher
- Dept of Trauma & Orthopaedic Surgery, Galway University Hospitals, Ireland
| | - Matthew J Lee
- Dept of Trauma & Orthopaedic Surgery, Galway University Hospitals, Ireland
| | - Diane Bergin
- Dept of Radiology, Galway University Hospitals, Ireland
| | - Fintan J Shannon
- Dept of Trauma & Orthopaedic Surgery, Galway University Hospitals, Ireland
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