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Desai VM, DeFrancesco CJ, Yellin JL, Nguyen JC, Williams BA. Patient Characteristics and Postoperative Outcomes of Surgically Treated Inferior Pole Patellar Sleeve Fractures. J Pediatr Orthop 2024:01241398-990000000-00586. [PMID: 38873923 DOI: 10.1097/bpo.0000000000002730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Despite representing over half of all pediatric patella fractures, inferior pole patellar sleeve fractures (PSFs) are a relatively uncommon pediatric injury. As a result, existing literature on PSFs is limited to case reports and small case series. The purpose of this study was to evaluate the radiographic and clinical characteristics of operatively treated PSFs as well as outcomes following surgical management. METHODS A retrospective review of all inferior pole PSFs requiring surgery from 2007 to 2023 was performed at a single urban tertiary care children's hospital. Cases were identified using diagnostic and billing codes. Patient demographics, injury characteristics, surgical techniques, and postoperative rehabilitation practices were recorded. Regional skeletal maturity, fracture characteristics, and postreduction patellar height were recorded. Postoperative complications were recorded and categorized using the modified Clavien-Dindo Classification System (CDS). RESULTS Thirty-eight inferior pole PSFs were identified meeting study criteria. The majority of patients were male (86.8%), and the mean age at injury was 11.0 years (range: 7.2 to 15.0). Mean BMI was 21.1. Radiographically, the majority of patients were Epiphyseal Fusion Stage 0 (nonunion), with a median postreduction Caton-Deschamps index (CDI) of 1.2 (IQR: 1.1 to 1.3). These fractures were predominantly treated with suture-based fixation (84%). Postoperative immobilization varied within the cohort, and the initiation of knee ROM was permitted at a median of 3.5 (IQR: 2.0 to 4.6) weeks. All patients regained full range of motion and straight leg raise without extensor lag, and return-to-sport was achieved by a median of 17.6 weeks (IQR: 12.8 to 30.3). Complications occurred in 10 (26.3%) patients, with 3 (7.9%) requiring a return to the OR (CDS Grade III). CONCLUSIONS Inferior pole PSFs appear to occur most commonly among prepubertal males of normal BMI and normal patellar height. Despite variable rehabilitation protocols, operative management resulted in restoration of extensor mechanism function. Eight percent of patients experienced complications requiring unplanned surgery. This large series improves our understanding of the epidemiology, injury characteristics, and postoperative outcomes of an operatively treated cohort of a rare injury pattern. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Vineet M Desai
- Departments of Orthopaedics
- Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA
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Yellin JL, Feroe AG, Watkins IT, Franco H, Guevel B, Haber DB, Kocher MS. Management and subsequent outcomes of patellar sleeve injuries: A retrospective case series of 90 pediatric and adolescent patients. J Child Orthop 2024; 18:208-215. [PMID: 38567045 PMCID: PMC10984153 DOI: 10.1177/18632521241228167] [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: 08/09/2023] [Accepted: 12/22/2023] [Indexed: 04/04/2024] Open
Abstract
Purpose This study aims to report the epidemiology of patellar sleeve injuries, describe diagnostic findings and treatment, and assess functional outcomes following different treatments. Methods A medical database was queried from 1990 to 2016 to identify patients ≤18 years presenting to a single pediatric institution with a patellar sleeve injury. Patients with significant comorbidities or previously operatively treated for ipsilateral knee injuries were excluded. Standard demographic data, mechanism of injury, skeletal maturity, injury-related radiographic parameters, along with treatment paradigms, post-treatment clinical and radiographic findings, and patient-reported outcomes were collected. Results A total of 90 patients, mean age of 10.7 years (range: 7-17) was included, of which 69 (77%) were male. Seventy-three percent of all injuries occurred while playing sports (particularly football/basketball/soccer), with "direct blow" or "landing" being the most prevalent mechanisms of injury. Twenty-six (29%) underwent operative treatment, with transosseous suture fixation being the most popular surgical technique (73%). Of the 64 (71%) non-operatively treated patients, 18 (39%) were placed in a hinged knee brace locked in extension with the remainder split between casting and standard knee immobilizer. Compared to the non-operative cohort, a higher percentage of the operative group had a pre-treatment extensor lag (p < 0.001) and greater fragment displacement (p < 0.001) with patella alta (p < 0.001) on imaging. There was no difference in outcome scores (Pedi-IKDC/Lysholm) or patella alta on radiographs between groups. Post-treatment surveys indicated no difference in residual pain or ability to return to sport. Conclusion This large case series provides valuable epidemiologic, clinical, and radiographic data describing patellar sleeve fractures, along with outcomes following non-operative and operative treatments. Level of evidence IV.
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Affiliation(s)
- Joseph L Yellin
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aliya G Feroe
- Division of Sports Medicine, Boston Children’s Hospital, Boston, MA, USA
- Department of Orthopaedics, Mayo Clinic, Rochester, MN, USA
| | - Ian T Watkins
- Division of Sports Medicine, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Helena Franco
- Division of Sports Medicine, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Borna Guevel
- Division of Sports Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Daniel B Haber
- Panorama Orthopedics & Spine Center, Westminster, CO, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Aljasim O, Vahabi A, Biçer MEK, Taşkıran E. Synovectomy induced patellar tendon ossification in patient with rheumatoid arthritis: A case report and review of the literature. Int J Surg Case Rep 2023; 110:108574. [PMID: 37574628 PMCID: PMC10448270 DOI: 10.1016/j.ijscr.2023.108574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/19/2023] [Accepted: 07/23/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION Patellar tendon ossification is a rare complication that primarily occurs following a knee injury. This article aims to describe, for the first time, a case of patellar tendon ossification following synovectomy. CASE PRESENTATION A 48-year-old male with a diagnosis of rheumatoid arthritis presented with swelling in his left knee following a synovectomy procedure. After a thorough physical examination, radiographic assessment, and computed tomography, the patient was diagnosed with total patellar tendon ossification. Subsequently, the patient underwent excision of the ossified mass and tendon reconstruction using an Achilles allograft. DISCUSSION The primary causes of patellar tendon ossification are iatrogenic and traumatic injuries. The presence of rheumatoid arthritis, which negatively affects tissue healing, may exacerbate this condition. Smaller lesions can be managed conservatively or through resection and repair. In cases of extensive ossification, resection and reconstruction are necessary. A comprehensive literature review is also provided. CONCLUSION The occurrence of patellar tendon swelling following trauma or surgery should raise suspicion of patellar tendon ossification. Rheumatoid arthritis is a risk factor for the development of patellar tendon ossification. In cases of extensive ossification, successful treatment can be achieved through reconstruction using an Achilles allograft.
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Affiliation(s)
- Omar Aljasim
- Department of Orthopedic Surgery, Gebze Medikal Park Hospital, Kocaeli, Turkey.
| | - Arman Vahabi
- Department of Orthopedic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | | | - Emin Taşkıran
- Department of Orthopedic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
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Perkins CA, Egger AC, Willimon SC. Transosseous Repair of Patellar Sleeve Fractures: A Case Series and Surgical Technique Guide. J Knee Surg 2022; 35:1326-1332. [PMID: 33545727 DOI: 10.1055/s-0041-1723013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to describe the surgical technique and outcomes of transosseous repair of patellar sleeve fractures in a pediatric cohort. A retrospective review was performed on patients younger than 16 years undergoing transosseous repair of distal patellar sleeve fractures. A chart review was performed on demographics, surgical repair technique, and postoperative care. Primary outcomes included intact extensor mechanism function and range of motion (ROM) at final follow-up. In this study, 20 patients, 17 males and 3 females, with a mean age of 11.7 years were included. ROM was initiated at a median of 27.5 days following surgery. All patients had a healed patellar sleeve fracture and intact extensor function at final follow-up. Final mean knee ROM among the 18 patients with minimum 3-month follow-up was 132 degrees. Thirteen patients (72%) achieved full ROM (≥ 130 degrees) and 5 patients (28%) achieved less than 130 degrees knee flexion. Duration of initial immobilization was found to be the only variable strongly associated with final postoperative ROM. Mean duration of immobilization for patients achieving ≥ 130 degrees was 24 days versus 44 days in those patients achieving < 130 degrees, p = 0.009. All patients who began knee ROM within 21 days of surgery obtained full knee ROM. No patients experienced construct failure or extensor lag. Operative management of displaced patellar sleeve fractures with anatomic transosseous suture repair of the sleeve fracture, brief immobilization no more than 21 days, and initiation range of early ROM results in excellent outcomes.
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Affiliation(s)
- Crystal A Perkins
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Anthony C Egger
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - S Clifton Willimon
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, Georgia
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Devana SK, Trivellas A, Bennett A, Jackson N, Beck JJ. Clinical and Radiographic Differentiation of Pediatric Patellar Sleeve Fractures and Other Inferior Pole Pathologies. Am J Sports Med 2022; 50:977-983. [PMID: 35142232 DOI: 10.1177/03635465221073995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Inferior pole patellar sleeve fractures (PSFs) are rare injuries that occur in skeletally immature patients that may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larsen-Johansson syndrome (SLJS). PURPOSE The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF, and SLJS. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Retrospective review of skeletally immature patients diagnosed with PSF, IPF, and SLJS between 2011 and 2019 at a single urban academic center was performed. Chart and radiographic review was completed. Between-group differences were assessed using analysis of variance, Kruskal-Wallis test, and Fisher exact test, as appropriate to variable distributions. RESULTS In total, 125 patients (82% male) were included, with a mean (SD) age of 10.7 (2) years (16 PSF, 51 IPF, 58 SLJS). There were no significant differences in patient characteristics between the 3 groups. One hundred percent of the patients with PSF (P < .001) and IPF (P < .001) had acute trauma, compared with 24% of patients with SLJS. Fewer patients with PSF had an intact straight leg raise (38%) compared with those with IPF (94%; P < .001) and SLJS (98%; P < .001). Fewer patients with SLJS had knee swelling (41%) compared with those with PSF (93%; P < .001) and IPF (94%; P < .001). More patients with PSF had knee effusion (81%) compared with those with IPF (37%; P = 0.011) and SLJS (3%; P < .001). More patients with SLJS were able to bear weight (88%) compared with those with IPF (12%; P < .001) and PSF (0; P < .001). Radiographically, compared with those with IPF and SLJS, patients with PSFs had increased mean prepatellar swelling (6.1 [P < .001] and 6.5 [P < .001] vs 12.9 mm), intra-articular effusion (6.1 [P = .014] and 4.9 [P = .001] vs 9.2 mm), maximum fragment size (26 [P = .004] and 17.7 [P < .001] vs 45.3 mm), and maximum fragment displacement (1.24 [P = .002] and 1.45 [P = .003] vs 13.30 mm), respectively. Compared with those with SLJS (1.10), patients with PSF (1.92; P < .001) and IPF (1.22; P < .001) had patella alta with higher mean Insall-Salvati ratios >1.2. CONCLUSION Differences in clinical features such as ability to straight leg raise, knee swelling, knee effusion, ability to bear weight, and radiographic features, such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location, and patellar height, can all be helpful in recognizing rare pediatric inferior patellar pathology, thus increasing efficiency in indicating for higher-level imaging to reach a prompt diagnosis and provide appropriate treatment.
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Affiliation(s)
- Sai K Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA.,Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, California, USA
| | - Andromahi Trivellas
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA.,Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, California, USA
| | - Abbie Bennett
- Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, California, USA
| | - Nicholas Jackson
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
| | - Jennifer J Beck
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA.,Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, California, USA
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Nadig N, Jaber J, Cameron C, Antosh I. Traumatic Enthesophyte From a Chronic Pectoralis Major Tendon Rupture: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00081. [PMID: 34398839 DOI: 10.2106/jbjs.cc.20.00698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
CASE A 24-year-old active duty soldier with a chronic pectoralis major tendon rupture presented a year later with a bony lesion consistent with an enthesophyte at the humeral insertion. The patient continued to have pain that was affecting his activities of daily living and underwent surgical intervention. CONCLUSION Operative management with enthesophyte excision and pectoralis major tendon repair provided relief to the patient's symptoms and return to preinjury levels of function as evaluated with Tegner, single assessment numeric evaluation, and visual analog scale scores at the 2-year follow-up.
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Affiliation(s)
- Nischal Nadig
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jamil Jaber
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Craig Cameron
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Ivan Antosh
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas
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李 广, 刘 平. [Progress in the surgical treatment of the patellar fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1057-1062. [PMID: 34387438 PMCID: PMC8403998 DOI: 10.7507/1002-1892.202104068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/11/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To review research progress of surgical treatment of patellar fractures. METHODS The domestic and foreign literature about patellar fracture treatment in recent years was extensively consulted, and the advantages, disadvantages, and indications of various surgical treatments were summarized. RESULTS The patella plays an important role in knee flexion and extension activities, and the fracture significantly affects the patient's quality of life. At present, the surgical methods include open reduction and internal fixation and patella resection. The internal fixation methods include ring/binding patella fixation, tension band wiring and improved technology, tension band wiring combined with other methods, screw fixation (including absorbable screws), steel plate fixation, and patella fixator fixation. Each surgical method has different indications, advantages, and disadvantages. Choosing an appropriate treatment plan plays a crucial role in clinical prognosis. CONCLUSION There are many surgical treatments for patellar fractures. In order to improve the effectiveness and reduce postoperative complications, it is necessary to choose the most appropriate treatment strategy for the type of fracture.
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Affiliation(s)
- 广磊 李
- 华中科技大学同济医学院附属梨园医院骨科(武汉 430077)Department of Orthopedics, Liyuan Hospital Affiliated to Tongji Medical School of Huazhong University of Science and Technology, Wuhan Hubei, 430077, P.R.China
| | - 平 刘
- 华中科技大学同济医学院附属梨园医院骨科(武汉 430077)Department of Orthopedics, Liyuan Hospital Affiliated to Tongji Medical School of Huazhong University of Science and Technology, Wuhan Hubei, 430077, P.R.China
- 华中科技大学同济医学院附属梨园医院体检中心(武汉 430077)Physical Examination Center, Liyuan Hospital Affiliated to Tongji Medical School of Huazhong University of Science and Technology, Wuhan Hubei, 430077, P.R.China
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Chronic bilateral sleeve fracture of the patellae in a healthy child: a case report. Chin Med J (Engl) 2020; 133:1744-1746. [PMID: 32649524 PMCID: PMC7401739 DOI: 10.1097/cm9.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Schmidt-Hebbel A, Eggers F, Schütte V, Achtnich A, Imhoff AB. Patellar sleeve avulsion fracture in a patient with Sinding-Larsen-Johansson syndrome: a case report. BMC Musculoskelet Disord 2020; 21:267. [PMID: 32326930 PMCID: PMC7181494 DOI: 10.1186/s12891-020-03297-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/17/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patellar sleeve avulsion (PSA) fractures are rare injuries that occur in in skeletally immature patients. Initial diagnosis is key to a successful outcome, as these injuries are easily overlooked on plain radiographs with poor results well documented from delayed management. High index of suspicion from the mechanism of injury, thorough clinical examination and Magnetic Resonance Imaging (MRI) help to avoid misdiagnosis. CASE PRESENTATION The case of a 12-year-old male athlete with an acute PSA after a conservative treatment of a SLJ syndrome is described. The patient was referred to our clinic due to severe pain and loss of function after performing a high jump. Plain radiographs (X-ray) and MRI confirmed an inferior pole PSA which was fixed with double trans osseous ultra-high strength tapes. At the 3-month follow- up visit the patient was able to ambulate brace free. At 2-years follow up the patient was able to play soccer and ice hockey. To our knowledge, there are no case reports of inferior pole PSA with prior SLJ syndrome described in literature. CONCLUSIONS Early clinical suspicion and distinguishing this PSA from other enchondral ossification disorders around the knee is critical to avoid misdiagnosis. Whether SLJ syndrome increases the risk of sustaining a PSA is still not clear. Trans osseous fixation with suture tapes leads to good functional results in a young athlete with inferior pole PSA.
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Affiliation(s)
- Andrés Schmidt-Hebbel
- Clínica Alemana de Santiago, Departamento de Ortopedia y Traumatología, Av. Vitacura 5951, Santiago de, Chile
| | - Felipe Eggers
- Technical University of Munich. Klinikum rechts der Isar, Abt. f. Sportorthopädie- Ismaninger Str. 22, 81675 Munich, Germany
| | - Vincent Schütte
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost, Marseburger Str. 165, 06112 Halle/Saale, Germany
| | - Andrea Achtnich
- Technical University of Munich. Klinikum rechts der Isar, Abt. f. Sportorthopädie- Ismaninger Str. 22, 81675 Munich, Germany
| | - Andreas B. Imhoff
- Technical University of Munich. Klinikum rechts der Isar, Abt. f. Sportorthopädie- Ismaninger Str. 22, 81675 Munich, Germany
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Schütte V, Schmidt-Hebbel A, Imhoff AB, Achtnich A. [Patellar sleeve fractures : Bracing and augmentation technique with suture tape]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 31:56-62. [PMID: 30539194 DOI: 10.1007/s00064-018-0581-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Transosseous augmentation of patellar sleeve fractures (PSF) with suture tape in young athletes. INDICATIONS Acute avulsions of the proximal or distal patellar pol with clinical relevant deficit of knee extension. CONTRAINDICATIONS Local infections, severe soft tissue damage (relative contraindication), fractures of the patella or tibial tuberosity. SURGICAL TECHNIQUE Direct longitudinal anterior approach to the patella. Debridement of the proximal patellar tendon insertion. Anatomic reduction of any osteochondral fragments. Transosseous augmentation of the tendon with FiberTapes® (Arthrex, Naples, FL, USA). POSTOPERATIVE MANAGEMENT Passive motion exercise to 30° of flexion from day 1; increase to 60° from week 3; 90° from week 5. Partial load-bearing of 20 kg with knee in locked full extension brace during first 2 weeks. Isometric exercises from week 3. Free active ROM and full weight bearing from week 7. RESULTS If diagnosis and treatment is early and sufficient augmentation of the tendon and periosteum is provided, good to excellent functional outcome can be expected.
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Affiliation(s)
- V Schütte
- Tech. Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, 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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