Anatomical reconstruction of the patellar tendon: a new technique with hamstring tendons and iliotibial tract

Patellar Tendon Rupture During Postoperative Physiotherapy for Crouch Gait: A Case Report

INTRODUCTION

A 14-year-old adolescent girl with spastic diplegic cerebral palsy underwent bilateral distal femur extension osteotomy and patellar tendon plication. Two and a half months after surgery, during physiotherapy, she sustained mid-substance tear of the left patellar tendon. The girl was successfully managed with patellar tendon repair and augmentation with tensor fascia lata autograft.

CONCLUSION

Patellar tendon rupture during rehabilitative physiotherapy after patellar tendon plication surgery is rare. Postoperative protocols in patients with cerebral palsy are crucial and should progress gradually to improve knee range of motion. This report highlights that patellar tendon repair with fascia lata augmentation yields good outcome.

Allogeneic Tendon Transplantation for the Treatment of Pathological Patellar Ligament Defect in Children: Technical Note and 4-Year Follow-Up

OBJECTIVE

The absence of patellar ligament will bring about a severe negative impact on daily life. Many reconstruction techniques have been described in adults. However, there is a lack of technical introduction regarding the reconstruction of the patellar ligament in children. The purpose of this study was to report a surgical technique for reconstructing the patellar ligament in children.

METHOD

A retrospective analysis of the clinical data on a patellar ligament (tendon sheath fibroma) patient with allogeneic tendon reconstruction. An 8-year-old child with postoperative recurrence of left patellar ligament tumor was enrolled in our study. Anterior tibialis tendon allograft was used to reconstruct the patellar ligament after complete resection of the patellar ligament for the tumor. The tunnels were constructed on the deep surface of the tibial tubercle and the root of the quadriceps tendon (to decrease the harmful impact on patella development), respectively. The allogeneic tendon was passed through the tunnels above in the shape of "8," and the two ends of the tendon were attached to the bleeding bone bed at the inferior edge of the patella with suture anchors to achieve better bone-tendon healing. During the follow-up, the knee's range of motion and imaging manifestations were recorded.

RESULT

Postoperative pathology suggests chondromesenchymal hamartoma, a rare benign soft tissue tumor different from the previous operation (tendon sheath fibroma). During the 4-year follow-up, the patient's active range of motion of the knee achieved 0° to 120°; and the patient could walk normally without any external help. Physical examinations (the apprehension sign and J sign) showed no ligamentous instability or patellar ligament tenderness. Imaging analysis showed that the ratio length of the patellar ligament to the patella was almost normal. The integrity, continuity, and shape of the allogeneic ligament showed excellent results in MRI. Combined with clinical and imaging findings, allogeneic tendon patellar ligament reconstruction was deemed successful.

CONCLUSION

Allogeneic ligament reconstruction technique can provide a treatment option by reconstructing the extensor mechanism, minimizing the impact on patellar development, and augmenting biological healing for children with the absence of the patellar ligament.

Extensor Mechanism Allograft in Osteosarcoma of the Patella: A Case Report

CASE

A 24-year-old female diagnosed with fibroblastic osteosarcoma of the patella underwent a total patellectomy and surgical reconstruction with a large bone-tendon allograft of the extensor mechanism and adjuvant chemotherapy. At 5 years' postoperative, the patient has adequate disease control and excellent joint function.

CONCLUSIONS

Reconstruction with an extensor mechanism allograft is an appropriate alternative for patients with malignant patella tumors without tumor contamination of the joint, allowing for satisfactory knee function and disease control.

Allograft Reconstruction of the Extensor Mechanism after Resection of Soft Tissue Sarcoma

INTRODUCTION

Soft tissue tumors around the knee joint still pose problems for the excision and subsequent reconstruction.

METHODS

In the 6 included patients the soft tissue sarcoma has its base on the anterior surface of the extensor mechanism and expands towards the skin. The entire extensor apparatus (quadriceps tendon, patella, and patellar tendon) was resected and replaced by a fresh-frozen allograft.

RESULTS

The mean follow-up was 6.7 years (range: 2-12.4 years). In two patients a local recurrence occurred, resulting in a 5-year local recurrence-free rate of 66.7% (95% CI: 19.5%-90.4%). Distant metastases were found in 4 patients resulting in a 5-year metastasis-free rate of 33.3% (95% CI: 4.6%-67.5%). Two patients underwent at least one revision surgery, including one patient in whom the allograft had to be removed. According to the ISOLS function score 24.7 points (range: 19-28 points) were achieved at the last follow-up. The mean active flexion of the knee joint was 82.5° (range: 25-120°) and a mean extension lag of 10° (range: 0-30°) was observed.

CONCLUSIONS

The replacement of the extensor mechanism by an allograft is a reasonable option, allowing wide margins and restoration of active extension in most patients.

TRIAL REGISTRATION

The presented study is listed on the ISRCTN registry with trial number ISRCTN63060594.

Bone-patellar tendon-bone allograft reconstruction for peri-patellar tendon sarcomas: case series

INTRODUCTION

Reconstruction after wide resection for a sarcoma involving the knee extensor mechanism is challenging even if the tumor is small.

CASE DESCRIPTION

We report on four consecutive peri-patellar tendon sarcomas treated similarly at a single institution. Histological diagnoses were synovial sarcoma (two cases), clear cell sarcoma and extraskeletal Ewing's sarcoma (one case each). Follow-up periods after surgery were 18-67 months. All cases underwent pre-operative radiotherapy and subsequent surgery. After preoperative radiotherapy and wide resection including the patellar tendon, bone-patellar tendon-bone allograft was fixed to the residual patella and tibial tuberosity with screws and a cable wire. Soft tissue and skin defect over allograft was covered by free antero-lateral thigh flap. Post-operatively, the operated knee was splinted straight for at least 6 weeks, and then range-of-motion exercise was gradually introduced. Except for one case with a proximal tibial stress fracture 5 months post-operatively, no complication was observed. Both bone-bone junctions between allograft and residual bones were united within 1 year after surgery. At the latest clinical follow-up, all the patients had satisfactory functions with Musculoskeletal Tumor Society score of 28-30 out of 30 points and virtually full range of motion.

DISCUSSION AND EVALUATION

This case series is the first to report bone-patellar tendon-bone allograft for reconstruction after tumor resection with joint preservation and with satisfactory clinical outcomes.

CONCLUSIONS

Bone-patellar tendon-bone allograft reconstruction with vascularized flap reconstruction is a viable option for peri-patella tendon sarcomas.

Anatomical reconstruction of the patellar tendon using the fascia lata attached to the iliac bone following resection for soft tissue sarcoma: a case report

A new reconstruction of the patellar tendon was performed in a 43-year-old patient who lost tendon and tibial tuberosity after a wide tumor resection for low-grade myofibroblastic sarcoma of the parapatellar tendon. In this technique, the patellar tendon was anatomically reconstructed using a fascia lata attached to the iliac bone. The iliac bone was fixed to the tibial bony trough with absorbable screws, and the fascia lata was fashioned into three branches: the central branch was folded through the tunnel in the patella, and the medial and lateral branches were tagged to the medial and lateral retinaculum, respectively, around the patella. The skin defect was covered by the bilateral head of the gastrocnemius flap and a split-thickness skin graft. At the 3-year follow-up, the active range of motion of the knee joint was 0 to 110 degrees. The functional result according to the Musculoskeletal Tumor Society scoring system was 97%. Radiographs showed that the grafted bone was united well to the tibial bone, and the grafted fascia was confirmed as a dark band on MRI. There was no evidence of disease and no complaint of the donor site. This procedure allows for the reconstruction of the patellar tendon in the original location. To our knowledge, this reconstructive procedure of the patellar tendon using the fascia lata attached to the iliac bone has never been reported in English literature.

Anatomical reconstruction of the knee extensor apparatus for prepatellar myxofibrosarcoma

A novel reconstruction of the knee extensor apparatus was attempted in a 69-year-old patient with prepatellar myxoid fibrosarcoma. The skin (35×25 cm), subcutaneous tumor, quadriceps tendon, patella, anterior capsule, and patella tendon were widely resected en-bloc. Following wide resection, the excised quadriceps tendon, patella, and patella tendon were anatomically reimplanted into the original site after being devitalized in liquid nitrogen. These complexes were covered by a free vascularized latissimus dorsi myocutaneous flap. At 18-month follow-up, the strength of active knee extension was 4+ of 5 in the muscle manual test. The active range of motion was 110° in flexion and -10° in extension. The tumor showed no evidence of disease. The patella and femur joint showed no osteoarthritis on plain radiographs. This procedure is the only way to achieve anatomical reconstruction. Reattachment of patella tendon to the tibial tuberosity was possible. The use of liquid nitrogen to devitalize is straightforward and the operation time can be shortened. To our knowledge, this type of reconstructive procedure has never been reported in the English literature.