Reconstruction of a ruptured patellar tendon using ipsilateral semitendinosus and gracilis tendons with preserved distal insertions: two case reports

Surgical treatment of patellar tendon rupture after total knee arthroplasty with a double-row repair method using the hamstring tendons: A novel technique with functional results

BACKGROUND

Patellar tendon rupture (PTR) is extremely rare but serious complication after primary or revision total knee arthroplasty. Due to the serious failure rates of end-to-end repair techniques, various augmentation techniques have been described. In this study, the results of patients with PTR after reconstruction using our own technique with semitendinosus (ST) and gracilis tendons taken from the affected side were evaluated retrospectively.

METHODS

A total of 14 patients, whose diagnosis was made based on physical examination and clinical findings, and supported radiologically (ultrasonography), were included in the study. In these patients, reconstruction was performed using double-row repair technique with the ST and gracilis tendons. Active-passive knee joint range of motion, active knee extension loss, and the Caton-Deschamps index at preoperative and final follow-up visits were compared. Tegner-Lysholm knee score and Kujala score were used to evaluate functional results.

RESULTS

In 14 patients (8 women and 6 men) with a mean age of 68.1 years, the median time between injury and surgery was 6.6 weeks. In all patients, the rupture was in the distal part of the patellar tendon. While the median preoperative Caton-Deschamps index was 1.8, the postoperative median value was found to be 1.25 after an average follow-up of 3.8 years (P = .014). The median preoperative knee extension loss decreased from 25° to 5° postoperatively. Tegner-Lysholm knee score and Kujala score of the patients at their last follow-up were significantly increased (P < .01).

CONCLUSION

For PTR developing after total knee arthroplasty, the double-row reconstruction technique with ST and gracilis tendons is effective.

Interest of longitudinal patellar tunnels in reconstructing chronic patellar tendon rupture with semitendinosus autograft: A case report

Treatment of chronic patellar tendon ruptures represents a real challenge for orthopaedic surgeons. The superior patellar migration and the pathological aspect of the tendon are the two conditions that aggravate the situation. Several reconstruction methods have been described in the literature. Hamstring tendon augmentation using horizontal patellar tunnel is widely used in such cases. However, underuse of longitudinal patellar tunnels, although they reproduce the native footprint of the patellar tendon insertion, highlights a missed opportunity in chronic patellar tendon rupture reconstruction. In the current article, we describe a semitendinosus tendon autograft reconstruction technique where the patellar tunnels are drilled longitudinally instead of being drilled transversely from medial to lateral. At 34 months follow-up, our patient claimed full active knee mobility with good quadriceps strength. Reproducing the native footprint of the patellar tendon insertion, through longitudinal patellar tunnels, leads to optimal outcomes after chronic patellar tendon rupture reconstruction with Semitendinosus Autograft.

Augmentation in the repair of traumatic patellar tendon ruptures. A novel mechanical and biological construct: Technical note

Patellar tendon ruptures are infrequent and potentially disabling injuries. These injuries are usually repaired with transosseous suture tunnels. However, this technique can produce a significant gap formation and prolonged postoperative immobilization. Although several techniques have been described to improve the integrity of the repair, the surgical technique of choice is a matter of debate especially when there is tissue loss due to high-energy trauma. This study aims to evaluate the clinical outcomes of patients with acute patellar tendon ruptures due to high-energy trauma treated with a novel construct configuration that includes a suture anchor and a figure-of-eight augmentation with hamstring autograft with medial and lateral reinforcement. To determine the clinical outcomes the International Knee Documentation Committee (IKDC) score was obtained pre-surgery and at 12 months of follow-up. A total of six patients were recruited, with a median age of 27.5 years, five of these were male. Three lesions were in the proximal pole of the tendon, two were mid-substance and one was in the junction with tibial tuberosity. The IKDC clinical score significantly increased from pre-surgery to the 12-month follow-up with a median difference of 32.8 (95% CI, 19.5-42.6, p = 0.0313). Likewise, the patients presented a post-surgery quadriceps strength level with a median of 5/5. All patients had full active knee extension with a median of 0-120°. There was no statistical difference in the range of motion comparing the surgical knee to the contralateral knee (p = 0.6883). No patient presented any type of reintervention or complication during the follow-up period. The configuration of the construct presented in the technique had not been reported before in the literature and combines the advantages of the use of suture anchors and biological augmentation with lateral and medial reinforcement. This technique may be useful in patients with traumatic injuries with and without loss of tissue. Although it is a small series with concomitant injuries, satisfactory clinical results were presented during follow-up.

Revision Patella Tendon Repair With Hamstring Tendon Autograft Augmentation Following Failed Inferior Pole Patella Fracture Open Reduction and Internal Fixation

A 46-year-old man presents with left knee bucking 3 months after open reduction and internal fixation of a left knee inferior pole patella fracture. Radiograph and magnetic resonance imaging evaluation reveal displacement and comminution of the inferior pole of the patella confirming failure of the repair. The purpose of this video is to demonstrate the surgical management of failed inferior pole patella fractures using suture anchors for repair of the patella tendon and augmentation with ipsilateral autologous hamstring grafts.

Clinical Outcomes are Similar Between Graft Types Used in Chronic Patellar Tendon Reconstruction: A Systematic Review

Purpose

To compare clinical outcomes between graft types and techniques used to repair chronic patellar tendon injuries to help surgeons make evidence-based decisions.

Methods

Medline, Embase, and Cochrane libraries were searched through January 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Inclusion criteria were surgical treatment of chronic patellar tendon injury (defined as >6 weeks old), article available in English, and human subjects, minimum 1-year follow-up, and level of evidence I-IV. Studies describing chronic patellar tendon ruptures in the setting of total knee arthroplasty were excluded. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal tools for case reports and case series.

Results

A total of 642 studies were identified through the initial search with 9 studies meeting all inclusion criteria. All studies included were case series encompassing 96 patients with follow-up ranging from 21 months to 7.2 years. Reconstruction techniques included the use of semitendinosus and/or gracilis tendon(s), Achilles tendon, bone-patellar tendon-bone (BTB), or direct repair. The most common graft choice was semitendinosus and/or gracilis tendon(s). Each reconstruction method yielded improvement in respect to range of motion (ROM), extensor lag, quadriceps strength, and patient-reported outcome measures (PROMs). Commonly reported complications were pain and numbness with only one reported instance of graft failure.

Conclusions

In this study, we found that all reconstructive methods described in the literature can produce satisfactory outcomes with improved function, strength, and minimal complications after chronic patellar tendon ruptures. Because of study heterogeneity and low levels of evidence, consensus cannot be reached on a single superior reconstruction method.

Level of Evidence

Level IV, systematic review of level IV studies.

Neglected Rupture of the Patellar Tendon After Fixation of Tibial Tubercle Avulsion in an Adolescent Male Managed With Ipsilateral Semitendinosus Autograft Reconstruction

The combination of a tibial tubercle fracture with patellar tendon avulsion in adolescents is an extremely rare injury that needs to be managed properly. Herein, we report the case of a 15-year-old boy who presented to our department two months after sustaining a tibial tubercle fracture that had been managed with mini-open reduction and internal fixation in another hospital; he had restricted range of motion and complete inability to extend his knee. Clinical and radiological investigations revealed a neglected avulsion of the patellar tendon with marked scarring and severe retraction. The patient underwent patellar tendon reconstruction using the ipsilateral semitendinosus tendon that passed through separate tunnels in the patella and proximal tibia. The postoperative course was uneventful, and one year later the patient had a satisfactory range of motion and a Lysholm score of 90. To our knowledge, a neglected patellar tendon avulsion after tibial tubercle fracture fixation has been reported only once in the literature. The reconstruction of the patellar tendon using an ipsilateral semitendinosus autograft is an excellent surgical technique, especially when severe tendon retraction has occurred.

Reconstruction of massive knee defects with extensor mechanism deficiency through concurrent anterolateral thigh flap and autogenous hamstring tendon: A report of two cases

Reconstruction of an infected knee joint with a large defect and extensor mechanism deficiency is challenging. In this study, we aim to describe a one-stage reconstruction surgery and provide its surgical outcome. Two patients had patellar open fracture and subsequent septic arthritis; in addition, a large soft tissue defect, loss of patella, and shortening of the patellar tendon were observed. The semitendinosus-gracilis tendon formed a loop to stabilize the patella. A free or supercharged reverse pedicle myocutaneous anterolateral thigh flap with fascial extension is designed to fill the defect and eradicate the infection. Mean clinical follow-up was 18 months. Although some limitation in the knee range of motion was observed, the dynamometer showed only partial loss in peak concentric power and eccentric power. We developed an innovative surgical procedure to alleviate infection and reconstruct a complex knee defect with extensor mechanism deficiency; this procedure resulted in favorable clinical outcomes.

Extensor mechanism failure in total knee arthroplasty

Extensor mechanism failure in total knee arthroplasty (TKA) can present as quadriceps tendon rupture, patella fracture or patella tendon rupture.Component malrotation, excessive joint line elevation and previous lateral release are some of the risk factors contributing to extensor mechanism failure in TKA.Partial quadriceps tendon rupture and undisplaced patella fracture with intact extensor mechanism function can be treated conservatively.Extensor mechanism failure in TKA with disruption of the extensor mechanism function should be treated operatively as it is associated with poor function and extensor lag.It is recommended that acute repair of patella or quadriceps tendon rupture are augmented due to the high risk of re-rupture.Chronic ruptures of the extensor mechanism must be reconstructed as repair has a high failure rate. Reconstruction can be performed using autograft, allograft or synthetic graft. Cite this article: EFORT Open Rev 2021;6:181-188. DOI: 10.1302/2058-5241.6.200119.

[Effectiveness of modified patellar tendon reconstruction using hamstring autograft in the treatment of chronic patellar tendon ruptures and defects]

Objective

To investigate the effectiveness of modified patellar tendon reconstruction using hamstring autograft in the treatment of chronic patellar tendon rupture and defects.

Methods

The clinical data of 11 patients with chronic patellar tendon rupture and defects admitted between January 2015 and August 2018 were retrospectively analyzed. The patient were treated with inverted U-shaped reconstruction technique using hamstring autografts, in which 2 bone tunnels were created at the level of 1/2 and lower 3/4 of the patella, and 1 bone tunnel was created beneath the tibial tuberosity. There were 8 males and 3 females with an average age of 30.1 years (range, 10-61 years). The average interval from the primary injury to the operation was 9.5 months (range, 2-36 months). According to Yousef classification, there were 7 cases of type A2, 3 cases of type B2, and 1 case of type C2. The length of the patella tendon defect was measured when the patella was reducted intraoperatively with an average of 4.5 cm (range, 2.7-7.1 cm). Subjective function scores [including International Knee Documentation Committee (IKDC) subjective score, Tegner activity level, and Lysholm score] were evaluated before operation and at last follow-up. The loss of knee extension, Caton index, and thigh circumference difference at 15 cm above the patella between bilateral limbs were also measured.

Results

All patients were followed up 24-66 months (mean, 34.2 months). All incisions were primary healing, and there were no complications such as wound infection, venous thrombosis of the lower extremities, stiffness of the knee joint, graft failure, neurovascular injury, etc. No second revision surgery was performed during the follow-up. At last follow-up, the subjective function scores (IKDC subjective score, Tegner activity level, Lysholm score), loss of knee extension, thigh circumference difference, and Caton index were significantly improved when compared with those before operation ( P<0.05). Two patients still had patella alta, with Caton indexes of 1.29 and 1.32, respectively.

Conclusion

In the treatment of chronic patellar tendon ruptures and defects, the modified patellar tendon reconstruction using hamstring autograft can significantly improve the postoperative knee function, restore the normal range of knee extension, enhance the extensor and correct the patella alta.

Technique for Fixation of Semitendinosus to the Patella in Patellar Tendon Reconstruction

Chronic patellar tendon injuries are rare yet challenging to treat. Timing of surgery and graft choices are debatable. Many techniques and methods of fixation have been described with pros and cons. Functional impairment of the extensor mechanism and postoperative complications triggers the quest for finding the ideal technique. In this Technical Note, we use distally based semitendinosus (ST) looped over 2 ETHIBOND sutures. The ETHIBOND is passed through 2 vertical tunnels in the patella and retrieved proximally, docking the ST in a blind tunnel created in the lower pole of the patella. The whip-stitched free ST end is passed through a tunnel behind the tibial tubercle and sutured back to its base. A polyester tape is used to augment the repair in a circumferential manner. Postoperatively full weight bearing is allowed as tolerated in a hinged knee brace locked in extension with only passive range of motion of 0-90° allowed for 6 weeks.

Intra-operative patellar fracture during chronic patellar tendon rupture reconstruction: salvage and prophylactic modified techniques

Management of chronic neglected patellar tendon rupture represents a challenging condition for the orthopedic surgeons to deal with due to many factors such as quadriceps muscle atrophy, superior migration of the patella, e.g., patella alta, peri-patellar adhesions and patellar tendon atrophy. Such difficulties might be further complicated by intra-operative patellar fracture during patellar tendon reconstruction. In the current article, the authors report (1) a salvage procedure for such devastating intra-operative complication, based on bypassing the patella and gaining the advantage of the quadriceps tendon for structural and functional restoration of the knee extensor mechanism, and (2) prophylactically a technical modification of patellar tendon reconstruction guarding against such inadvertent patellar fracture.

Modified adductor sling technique: A surgical therapy for patellar instability in skeletally immature patients

BACKGROUND

Due to open femoral physis the therapy of patellar instability in skeletally immature patients is challenging. We developed a modified surgical technique of the 'Adductor-Sling-Approach' by Sillanpää. The purpose of this study was to evaluate the clinical outcome of the operative technique and to analyse the reasons for failure.

METHODS

Thirty 'modified adductor sling' reconstructions in 28 patients were included in the study. From 2010 to 2016 modified adductor sling reconstruction was performed by looping the gracilis or semitendinosus tendon around the adductor magnus tendon and attaching it at the medial facet of the patella. Clinical outcome was retrospectively evaluated at a mean follow up of 25.6months (range 12-43). The evaluation also included subjective International Knee Documentation Committee (IKDC), Lysholm Score, Kujala Score and Tegner Activity Score.

RESULTS

The average age at the time of operation was 15.10years (range 11-17). Eighty-seven percent of the patients, who underwent the modified adductor sling technique, gained a stable patella and excellent results in postoperative scores. Recurrent dislocation occurred in four of 30 cases (13%). Analysis showed that possible reasons for failure of the tendon graft could be maltracking of the patella due to patella alta, trochlear dysplasia or an elevated tibial tuberosity to trochlear groove distance.

CONCLUSION

The modified adductor sling technique for MPFL reconstruction in children and adolescents showed elevated redislocation rates. Only in absence of additional patellofemoral maltracking, caused by elevated tibial tubercle to trochlear groove distance (>15mm), patella alta or especially severe trochlear dysplasia, the modified adductor sling technique could be recommended.

Augmentation of Patellar Tendon Repair With Autologous Semitendinosus Graft-Porto Technique

Patellar tendon ruptures can lead to significant functional deficiency of the extensor mechanism of the knee. These injuries, because of their inherent nature and associated complications, may require a complex treatment and remains a challenge for orthopaedic surgeons. Current surgical techniques present significant complications, including patellar fracture, damage to patellar articular cartilage, and abnormal patella height. This note describes a surgical technique to provide an additional reinforcement to the patellar tendon repair with a semitendinous autograft, without the necessity to perform any transosseous tunnels at the patella bone. First, the patellar tendon is repaired with an end-to-end technique and the semitendinous tendon is harvested. A transosseous tunnel at the tibial tubercle is drilled and 2 rents are made, both medial and lateral to the retinaculum at the level of the intermedial segment of the patella close to the patellar margin. The graft is passed through the tunnel and rents in a U-shaped form. The graft is sutured along the length of the patellar tendon on both margins in tension at 30° of knee flexion. Fluoroscopy imaging is performed to assess the patella height. This technique provides a significant augmentation of patellar tendon, avoiding the potential patella bone tunnel complications.

Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft

PURPOSE

To evaluate the clinical and functional outcome following the reconstruction of chronic patellar tendon ruptures using the contralateral bone-tendon-bone (BTB) autograft.

METHODS

The records of seven patients who underwent reconstruction of chronic patellar tendon rupture with contralateral patellar BTB were retrospectively reviewed. Chronic tears were defined as a minimum of 3 months from injury to initial clinical evaluation. Clinical assessments included range of motion of the knee, Tegner, Lysholm and International Knee Documentation Committee (IKDC) score and a radiographic analysis of patellar height (Caton-Deschamps index). Postoperative complications and quadriceps strength at last follow-up were reported.

RESULTS

The mean age of the patients undergoing surgery was 33 (±10.5) years with a mean follow-up of 41.3 (±29.7) months. Reconstruction surgery was performed at an average of 16 months (3-60 months) after the injury. 86 % of the patients had a normal patella height with mean of patellar height of 1.5 (±0.2) in preoperative radiographs and of 1.2 (±0.07) on postoperative evaluation (p = 0.0136). The mean IKDC was 45.5 (±10.8) before surgery and 64.5 (±12.4) at the last follow-up (p = 0.0001), and Lysholm score was 45.4 (±11.3) and 79 (±11.8), respectively (p = 0.0001). The median Tegner activity scale preinjury was 6 (range 5-7), preoperatively was 1 (range 1-2) and 4 (range 2-5) postoperatively (p = 0.0001). All patients had quadriceps wasting with a difference in thigh girth between the injured side and healthy side of 3.6 ± 0.7 cm (ns). No surgical complications were encountered.

CONCLUSIONS

In this limited cohort, surgical reconstruction of chronic patellar tendon ruptures using contralateral bone-tendon-bone graft was a safe and viable option that improves clinical and functional outcomes compared to presurgical function. However, despite the restoration of a normal patellar height, function did not return to preinjury level.

Bilateral patellar tendon reconstruction using LARS ligaments: case report and review of the literature

Background

Acute bilateral patellar tendon rupture is a rare occurrence, with only 1 case reported in the English literature of a young, fit athlete with no regular medications. To our knowledge this is the first such case reported using a LARS reconstruction.

Case presentation

A 26-year-old otherwise well ex-olympic gymnast with bilateral acute on chronic patellar tendon rupture underwent reconstruction using LARS ligaments. At four years post-operatively he has maintained full range of motion and strength, without re-rupture or any evidence of synovitis.

Conclusion

The use of LARS ligament for reconstruction of the patellar tendon is a viable and effective option for rupture. It avoids donor site morbidity associated with autograft. Reconstruction of both patellar tendons simultaneously in a young, elite-level athlete has not previously been reported in the English-language literature.