|Year : 2015 | Volume
| Issue : 1 | Page : 40-43
Patellar tendon reconstruction with ipsilateral free semi-tendinosus and gracilis autograft for neglected patellar tendon rupture
Appalaraju Sanaboyina, Venkateswara M Rao
Department of Orthopaedics, Maharajah's Institute of Medical Sciences, Nellimarla, Andhra Pradesh, India
|Date of Web Publication||28-Apr-2015|
Department of Orthopaedics, Maharajah's Institute of Medical Sciences, Nellimarla - 535217, Vizianagaram, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Chronic patellar tendon ruptures are rare. Diagnosis is usually made on clinical background. The ideal method of treatment is a matter of debate. The management of neglected, chronic patellar tendon must address four difficulties: The proximally retracted patella, reconstruction of the patellar tendon, temporary protection of repair, patello-femoral tracking, and active full range of knee movement. By presenting a case of chronic patellar tendon rupture, the advantages of reconstruction with a free semi-tendinosus and gracilis autograft from an early rehabilitation are described.
Keywords: Absent active straight leg raising, free hamstring (semitendinosus and gracilis) graft, modified Insall-Salvati ratio, neglected patellar tendon rupture, patella alta, quadriceps expansion rupture
|How to cite this article:|
Sanaboyina A, Rao VM. Patellar tendon reconstruction with ipsilateral free semi-tendinosus and gracilis autograft for neglected patellar tendon rupture. J Orthop Allied Sci 2015;3:40-3
|How to cite this URL:|
Sanaboyina A, Rao VM. Patellar tendon reconstruction with ipsilateral free semi-tendinosus and gracilis autograft for neglected patellar tendon rupture. J Orthop Allied Sci [serial online] 2015 [cited 2019 Aug 19];3:40-3. Available from: http://www.joas.in/text.asp?2015/3/1/40/155927
| Introduction|| |
Patellar tendon ruptures are relatively rare injuries caused by forced flexion of knee against an eccentric quadriceps contraction force. These injuries are most common in patients younger than 40 years of age. 
Patellar tendon ruptures are also seen in patients with systemic diseases that adversely affect the soft tissues such as rheumatoid arthritis or systemic lupus erthymatosis.  Patients with chronic patellar tendon rupture can have significant proximal retraction of patella and sub-optimal tissue for primary repair. These patients benefit from augmentation of patellar tendon repair.  Kelikian et al. have described the use of semi-tendinosis for augmentation of patellar tendon rupture. It is a suitable graft because it is strong and native tissue, does not require an additional surgery for removal, and allows for immediate mobilization.  Larson and Simonian reported excellent results on a series of four knees in three patients utilizing this technique and an aggressive post op physiotherapy protocol. 
| Case Report|| |
The patient was a 26-year-old female, who worked as an agricultural laborer. She had ruptured her left patellar tendon 2 years ago when she had an accidental fall while carrying a pot filled with water and landed on her knee in flexion. She had been walking with a hand to knee gait after the fall and had not received any treatment so far; she landed up in our institute 2 years after the injury to get a disability certificate. She did not have any systemic diseases.
On examination of left knee, no scars were seen, the patella was seen at a higher level and on flexion of knee the shape of distal femoral condyles could be made out [Figure 1]. On contracting the quadriceps by trying to do extension of the knee, the patella was moving upwards. She was using her opposite leg to do a straight leg-raising and there was no active extension of knee possible [Video 1]. The patella was mobile and could be brought down with no pain. Later X-ray imaging of left knee in 30° showed patella alta but by applying downward pressure, the patella could be brought down to maintain a normal modified Insall-Salvati ratio [Figure 2] and [Figure 3]. A surgical intervention was warranted.
|Figure 3: Pre op x-rayof the same knee with patella pushed down by examiner|
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Patient in supine position with tourniquet under control a median parapatellar incision was made over the left knee. Patella was found to be elevated with rupture of extensor apparatus. Using closed tendon strippers which are used for anterior cruciate ligament reconstruction, semi-tendinosus and gracilis-free tendons are harvested. Single bundle length of 220 mm was obtained with graft dimensions of 220 mm × 6 mm.
Steinman pin is passed through patella to provide traction. Tension band wiring of patella in figure of 8 is done. Extensor apparatus is sutured with ethibond no: 5. Knee range of movement from 0° to 95° is obtained. Patellar tracking is well-maintained. Moreover, 7 mm drill holes are made transversely in patella and tibia over a guidewire using cannulated reamers from anterior cruciate ligament (ACL) reconstruction set. Semi-tendon and gracilis-free graft are passed in a rectangular loop and sutured with ethibond no: 5 [Figure 4]. Wound closed in layers after placing drain. Compression bandage applied. Drain removed on day 2. Passive range of knee movement started on day 4 from 0° to 60°. Full weight-bearing walking with walker started on day 6. At the time of discharge, patient was mobilized full weight-bearing with active straight leg raising possible and active knee range of movement from 0° to 85° [Video 2].
|Figure 4: Intra op pic showing patella tension band wiring and semitendinosus and gracilis graft|
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After 6 weeks, removal of Tension band wire done under anesthesia. Intra-operative manipulation of knee was done to get full flexion at knee. Knee closed in layers. From post-operative day 2, patient was started on continuous passive motion. By day 10, she had active straight leg raising positive and knee range of movement from 0° to 120° [Figure 5], [Figure 6] and [Figure 7].
|Figure 6: Post op knee extension showing full extent in comparision to opposite knee|
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After 1 year of follow-up, she had full active knee range of movement from 0° to full flexion [Video 3] with good patellar tracking and X-ray showing normal location of patella [Figure 8].
| Discussion|| |
Patellar tendon is a strong and important structure in the extensor mechanism of the knee. Acute patellar tendon ruptures are relatively uncommon and usually occur when forceful quadriceps muscle contraction is resisted by a flexed knee joint.  The true incidence of patellar tendon rupture is unknown, but it is the third most common injury to the extensor mechanism, after patellar fracture and quadriceps tendon rupture. , Diagnosis is made upon clinical examination, inability to extend knee, a palpable defect distal to patella and patella alta. X-ray can be helpful to distinguish patellar tendon ruptures from patellar fractures. 
Large trials have never been performed and therefore there are no gold standard protocols for treatment or rehabilitation program. Surgical repair is always indicated unfortunately due to quantitative and qualitative impairment of the tendon fibers, simple reinsertion often is not sufficient or not even possible. Furthermore, a chronic rupture usually is accompanied by abundant scar tissue formation and quadriceps muscle contracture. In this scenario, a patellar tendon augmentation usually is required in order to create a stable and functional extensor mechanism. 
Many reconstruction techniques have been proposed: Synthetic material , , autograft using semi-tendinosus alone  or together with the gracilis  and the contra lateral patellar tendon , or allograft using Achilles tendon. ,,, A contra lateral bone-patellar tendon-bone graft consists of a composite quadriceps tendon, patella, patellar tendon and tibia unit, which allows the extensor mechanism to be reconstructed and the patella to be automatically positioned at the proper height. This technique is most useful when the remaining tendon stump is not adequate or in cases of surgical revision. Despite significant morbidity associated with autografts, allograft techniques have a risk of bacterial or viral infection, neoplasia and especially non-conventional transmissible agent transmission. They should only be considered when the extensor mechanism is extensively damaged and an autograft cannot be used. 
The biggest challenge with this surgery is the need to mobilize a non-reducible patella, which was not the case with our patient.
| References|| |
Mihalko WM, Vance M, Fineberg MJ. Patellar tendon repair with hamstring autograft: A cadaveric analysis. Clin Biomech (Bristol, Avon) 2010;25:348-51.
Pritchard CH, Berney S. Patellar tendon rupture in systemic lupus erythematosus. J Rheumatol 1989;16:786-8.
Haas SB, Callaway H. Disruptions of the extensor mechanism. Orthop Clin North Am 1992;23:687-95.
Kelikian H, Riashi E, Gleason J. Restoration of the quadriceps function in neglected tear of the patellar tendon. Surg Gynecol Obstet 1957;104:200-4.
Larson RV, Simonian PT. Semitendinosus augmentation of acute patellar tendon with immediate mobilization. Am J Sports Med 1995;23:82-6.
Van der Zwaal P, Van Arkel ER. Recurrent patellar tendon rupture: Reconstruction using ipsilateral gracilis and semitendinosus tendon autografts. Injury 2007;38:320-3.
Kapoora RK, Malhotrab R, Bhanb S. Traumatic bifocal avulsion of the patellar tendon. Injury 2005;36:115-7.
Milankov MZ, Miljkovic N, Stankovic M. Reconstruction of chronic patellar tendon rupture with contralateral BTB autograft: A case report. Knee Surg Sports Traumatol Arthrosc 2007;15:1445-8.
Kim JR, Park H, Roh SG, Shin SJ. Concurrent bilateral patellar tendon rupture in a preadolescent athelete: A case report and review of the literature. J Pediatr Orthop B 2010;19:511-4.
Naguib AM, Sefton GK. Recurrent bilateral rupture of the patellar tendons: Tendon replacement using polyester connective tissue prosthesis. Injury 2006;37:379-82.
Van der Bracht H, Verdonk R, Stuyts B. Augmentation of a patellar tendon repair with an autologous graft. Acta Orthop Belg 2009;75:417-9.
Dejour H, Denjean S, Neyret P. Treatment of old or recurrent ruptures of the patellar ligament by contralateral autograft. Rev Chir Orthop Reparatrice Appar Mot 1992;78:58-62.
McNally PD, Marcelli EA. Achilles allograft reconstruction of a chronic patellar tendon rupture. Arthroscopy 1998;14:340-4.
Falconiero RP, Pallis MP. Chronic rupture of a patellar tendon: A technique for reconstruction with Achilles allograft. Arthroscopy 1996;12:623-6.
Lewis PB, Rue JP, Bach BR Jr. Chronic patellar tendon rupture: Surgical reconstruction technique using 2 Achilles tendon allografts. J Knee Surg 2008;21:130-5.
Labib SA, Wilczynski MC, Sweitzer BA. Two-layer repair of a chronique patellat tendon rupture: A novel technique and literature review. Am J Orthop (Belle Mead NJ) 2010;39:277-82.
Nguene-Nyemb AG, Huten D, Ropars M. Chronic patellar tendon rupture reconstruction with a semitendinosus autograft. Orthop Traumatol Surg Res 2011;97:447-50.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]