Orthopaedics & Traumatology: Surgery & Research 101 (2015) 307–311

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Original article

Acute traumatic : Early and late results of

surgical treatment of 38 cases

∗

A. Roudet , M. Boudissa , C. Chaussard , B. Rubens-Duval , D. Saragaglia

Clinique Universitaire de Chirurgie Orthopédique et de Traumatologie du Sport, CHU de Grenoble, Hôpital Sud, avenue de Kimberley, BP 338, 38130

Echirolles, France

a r

t

i c l e i n f o

a b s t r a c t

Article history: Introduction: Acute patellar tendon rupture is easy to diagnose but is still often overlooked. The aim of

Received 22 August 2014

this study was to assess early and late results of surgical treatment of acute patellar tendon rupture. Our

Accepted 23 December 2014

hypothesis was that functional outcome is satisfactory.

Methods: A retrospective study included 38 in 37 patients (4 female, 33 male). Mean age was

Keywords:

42.6 ± 9.9 years (range, 23–81 years). Lesions comprised 15 tendon body ruptures, 20 avulsions from the

Patellar tendon

tip of the patella and 3 avulsions from the anterior tibial tuberosity. Tendon repair was protected in

Acute rupture

more than 95% of cases by a reinforcement frame: hamstring (21 cases), synthetic (12 cases)

Surgical repair

or metallic wire (3 cases). Results were evaluated in 2 steps: on patient files at a mean follow-up of

7.1 months (range, 3–24 months) to assess complications and early functional and radiological results;

and by phone at a mean follow-up of 9.3 years (range, 19–229 months) in order to assess long-term

functional outcome on Lysholm score and patient satisfaction.

◦ ◦

Results: Thirty-one knees were assessed at a mean 7.1 months. Mean flexion was 128.5 ± 7.5

◦ ◦ ◦ ◦ ◦

(range, 85 –150 ), extension −1 (range, −15 to 0 ) and Caton-Deschamps index 0.96 (range, 0.57–1.29).

Twenty-three knees were further assessed at a mean 9.3 years. Mean Lysholm score was 93.7 points

(range, 61–100). Ninety-six percent of patients were satisfied or very satisfied with the result. All had

returned to their previous job, and 20 had returned to sports activities, including 8 at pretrauma level.

Conclusion: Patellar tendon rupture has good prognosis if diagnosis and surgical treatment is early.

Level of evidence: IV: retrospective study.

© 2015 Elsevier Masson SAS. All rights reserved.

1. Introduction surgery in this indication [1,4,5]. This is due to its rarity, and resul-

tant lack of statistical power.

Patellar tendon rupture is rare and 6 times less frequent than The present study sought to assess functional and radiological

patellar fracture [1]. Unlike quadriceps tendon rupture, patellar results of surgical repair of acute patellar tendon rupture, testing

tendon rupture mainly occurs in active subjects of about 40 years of the hypothesis that outcome is satisfactory.

age, often following indirect trauma caused by sudden quadriceps

contraction with the knee in moderate flexion: sudden impulsion, 2. Patients and methods

sprinting, avoiding a fall, etc. It is generally agreed that a healthy

patellar tendon will not rupture: rupture usually affects a tendon 2.1. Series

that has degenerated [2] under iterative microtrauma [3] or local

Forty-five of the 98 patients managed for patellar tendon lesions

corticosteroid injection. Diagnosis should be straightforwardly sug-

between 1991 and 2011 were immediately excluded from the

gested when active extension of the knee is impossible, but remains

study (Fig. 1): tendon sectioning by a ski edge (n = 17), anterior

too often overlooked in emergency contexts.

tibial tuberosity (ATT) avulsion in children or adolescents (n = 16),

Although management of acute patellar tendon rupture is now

patellar lesions associated with knee dislocation (n = 1) or ligament

well-codified, there have been few assessments of the results of

surgery or knee replacement (n = 11) and patients not living locally

(n = 16). The series thus comprised 37 patients and 38 knees (1 bilat-

eral case): 33 males (89.2%) and 4 females (10.8%), with a mean age

∗

of 42.6 ± 9.9 years (range, 23–81 years) for a median 44 years. Mean

Corresponding author. Tel.: +33 4 76 76 58 33; fax: +33 4 76 76 58 18.

2

E-mail address: [email protected] (D. Saragaglia). body-mass index (BMI) was 25.7 ± 2.66 kg/m (range, 17.5–32.7);

http://dx.doi.org/10.1016/j.otsr.2014.12.017

1877-0568/© 2015 Elsevier Masson SAS. All rights reserved.

308 A. Roudet et al. / Orthopaedics & Traumatology: Surgery & Research 101 (2015) 307–311

Fig. 1. Series flowchart.

Table 1

a full-body rupture was repaired by end-to-end resorbable suture

Radiologic signs at admission. ® ®

(Vicryl No. 2, Ethicon , Issy-Les-Moulineaux, France). In 20 cases

Number (%) (53%), there was avulsion from the tip of the patella; in 17 of these

cases (85%), transosseous reinsertion was performed after tack-

Patella Alta 34 (90)

®

ing the tendon with two non-resorbable sutures (Ti-Cron No. 4,

Bone avulsion 14 (37) ®

Covidien , Courbevoie, France) introduced via two 2.5-mm diam-

Patellar tip 13

eter vertical patellar tunnels; in the 3 most recent cases (15%),

Tibial tuberosity 1

reinsertion used metal anchors. In the other 3 knees (8%), distal

≥ 1 indirect radiologic sign 37 (97)

tendon avulsion from the ATT was repaired by transosseous rein-

Mean Caton-Deschamps index 1.44 ± 0.19

sertion using either two thick resorbable sutures (n = 2) or metal

anchors (n = 1).

Repair was protected by a reinforcement frame in 36 cases (95%),

≥

21 patients were overweight or obese, including 7 with grade 1 the other 2 cases being the earliest in the series. In the earliest

. Ten patients (27%) presented risk factors: 4 with pre- 3 cases (8%), the reinforcement used metal wire; later, 12 (32%)

existing tendinopathy and 3 with injections during the previous used synthetic ligament; and the 21 most recent cases (55%) used

months (1 case of gout, 1 of diabetes and 1 of long-course cortico- hamstrings (gracilis or semitendinosus) [1,7].

◦

steroids). Intraoperative lateral fluoroscopy in 30 flexion systematically

Trauma etiology was sports accident in 21 cases (57%), domestic checked patellar height versus the contralateral side. If no con-

accident in 8 (21%), road accident in 4 (11%) and work accident in tralateral view was available, patellar height was adjusted to obtain

±

4 (11%). Mean trauma-to-surgery time was 1.4 0.9 days (range, CDI = 1.

0–11 days); in longer intervals, the lesion was deemed chronic and

not included in the present study.

2.3. Postoperative course

◦

Table 1 presents results for AP and lateral radiographs in 20–30

flexion at admission. Only 1 knee showed no indirect radiologi-

The limb was immobilized in a trochanter-malleolus walking

cal signs of patellar tendon rupture. Caton-Deschamps index (CDI)

cast, enabling immediate weight-bearing, for at least 6 weeks, fol-

[6] was normal in only 4 cases. Five patients showed radiological

lowed by a removable brace until complete extension could be

signs of preoperative osteoarthritis of the knee, including 2 with

achieved without pain or deficit (a further 2 weeks to 1 month).

femoropatellar involvement.

2.4. Assessment

2.2. Intraoperative findings and surgical techniques

Patients were systematically followed up at postoperative D15,

The patient was in supine position, with a pneumatic tourni- D45 and 3 months and then according to progress. Early follow-up

◦

quet, and the knee in 45–90 flexion (Table 2). In 15 cases (39.5%), enabled clinical and radiological data to be collected along with

A. Roudet et al. / Orthopaedics & Traumatology: Surgery & Research 101 (2015) 307–311 309

Table 2

Surgical techniques.

Avulsion of patella tip (%) Full-body rupture (%) Avulsion of ATT (%) Total (%)

Number of knees 20 (53) 15 (39) 3 (8) 38 (100)

Type of repair

End-to-end suture 0 15 0 15 (39)

Transosseous reinsertion 17(45) 0 2 (5) 19 (50)

Reinsertion by anchors 3 (8) 0 0 3 (8)

Fixation by staples 0 0 1 (3) 1 (3)

Protection frame

Hamstring 10 (26) 10 (26) 1 (3) 21 (55)

Metal wire 2 (5) 0 1 (3) 3 (8)

Synthetic ligament 6 (16) 5 (13) 1 (3) 12 (32)

No protection 2 (5) 0 0 2 (5)

ATT: anterior tibial tuberosity.

◦

short-term complications. Data collection was performed by an trauma. One of the patients with < 100 flexion had pretraumatic

independent investigator, who also called the patients back to col- stage-2 patellofemoral osteoarthritis, already treated by injections.

lect functional outcome data. The other was a 37-year-old man free of comorbidity, managed by

Assessment focused on ipsi-contralateral symmetry of flexion proximal transosseous reinsertion with hamstring reinforcement

◦ ◦ ◦

and extension, pain, return to work, and return to and level of frame. Mean extension was −1 (range, −15 to 0 ). Three patients

◦

physical activity. Lysholm scores [8] were calculated, and patient (10%) showed lack of active extension. The patient with 15 lack

self-assessment of the result was obtained. of extension had pretraumatic tendinopathy and had undergone

Statistical analysis used R software. The significance threshold full-body suture with synthetic ligament reinforcement frame. No

was set at P < 0.05. patients were in pain at last follow-up.

At the last radiologic assessment found in the patients’ files

◦

(AP + lateral in 30 flexion), there were 3 cases of patellar tunnel

3. Results

widening (10%), without clinical impact: 2 involving semitendi-

nosus reinforcement frames and 1 a metal wire reinforcement.

3.1. Complications (n = 38)

Mean CDI was 0.91 ± 0.13 (range, 0.57–1.29). Two knees showed

patella infera (CDI < 0.6): 1 with metal wire and 1 with syn-

A massive pulmonary embolism occurred in one 25-year-old

thetic ligament reinforcement. Two showed patella alta (CDI > 1.2)

patient free of known risk factors, who died on D15. Three cases of

(both with semitendinosus reinforcement frames). Over follow-up

skin complications (9.6%) were without long-term impact: 1 super-

(3 to 24 months), there was no aggravation of any preoperative

ficial healing failure, managed by simple local treatment; 1 skin

osteoarthritis.

rupture caused by breakage of a metal wire reinforcement frame at

4 months, healed after removal of the frame; and 1 skin necrosis,

resolved by negative pressure. None incurred infection or required 3.3. Long-term results (n = 23)

antibiotherapy. In 1 case, redo surgery for recurrent rupture was

required at 2 months, following a fall, in a case of primary patellar Twenty-three patients had long-term telephone follow-up (7

tip avulsion treated by transosseous reinsertion with synthetic liga- lost to follow-up and 1 death from acute pancreatitis). Mean

±

ment reinforcement frame; the secondary rupture was repaired by follow-up was 111.5 48.2 months (range, 19–229 months) for a

reinsertion with hamstring reinforcement frame, without impaired median 106 months. Mean Lysholm score was 93.7; 20 patients had

outcome. returned to sport (Table 4).

3.2. Short-term results (n = 31) Table 4

Long-term results.

Thirty-one of the 37 patients (38 knees) were followed up by

n = 23 Results at a mean 9.3 years

the surgeon and the other 6 in a different structure. Mean follow-

Flexion symmetry with healthy side 18 (78%)

up was 7.1 ± 2.9 months (range, 3–24 months). Both of the patients

Extension symmetry with healthy side 23 (100%)

with only 3 months’ follow-up showed full recovery of range of

motion and were considered cured. Table 3 presents short-term Pain 2 (9%)

◦

results. The patient with 85 flexion was the oldest in the series

Mean Lysholm score 93.7 points (61–100)

and had suffered from tri-compartmental osteoarthritis before the

Excellent: 98–100 10 (44%)

Very good: 93–97 6 (26%)

Good: 82–92 5 (22%)

Table 3

Moderate: 66–81 1 (4%)

Short-term results.

Poor: < 65 1 (4%)

n = 31 Results at a mean 7.1 months

Return to sport 20 (87%)

◦ ◦ ◦

At previous level 8 (35%)

Mean flexion 128.5 ± 7.5 (85 –150 )

Lower level 12 (52%)

− ◦ ◦ ◦

Mean active extension 1 (−15 to 0 )

Return to work 23 (100%)

Complete active extension 35 (92%)

Subjective satisfaction

Pain 0

Very satisfied 10 (44%)

Satisfied 12 (52%)

Caton-Deschamps index 0.91 ± 0.13 (0.57–1.29)

Moderately satisfied 1 (4%)

Tunnel enlargement 3 (10%) Dissatisfied 0

310 A. Roudet et al. / Orthopaedics & Traumatology: Surgery & Research 101 (2015) 307–311

Table 5

Results in main literature series.

Number FU (years) Flexion Extension Lysholm score Patellar height

◦

Marder and Timmerman [9] (1999) 12 2.6 Mean 5 No extension deficit 95 (66–100) ISI = 1.09 ± 0.68

deficit/healthy side

◦

Kasten et al. [10] (2001) 29 8.1 132 No extension deficit – 55% with > 10% ISI

difference from healthy side

◦

Bhargava et al. [11] (2004) 11 2.2 137 No extension deficit 97 (92–100) ISI = 1 (0.95–1.1)

West et al. [12] (2008) 34 4 – – 92 (84–100) No patella alta or infera at

6 months’ FU

Chen et al. [13] (2009) 7 2.2 – – 94 (91–99) ISI = 0.96

Present series (2014) 23 9.3 78% with flexion No extension deficit 93.7 (61–100) CDI = 0.91 ± 0.13 (0.57–1.29

identical to healthy at 7.1 months’ FU)

side

ISI: Insall-Salvati index; CDI: Caton-Deschamps index; FU: follow up.

There was no significant correlation between Lysholm score and Concerning surgical technique, end-to-end suture appears to be

age (P = 0.34) or BMI (P = 0.32). Age (P = 0.90) and BMI (P = 0.68) had consensual in full-body rupture. On the other hand, consensus is

no impact on return to sport. There was no significant correlation lacking for patellar tip avulsion. Ettinger et al. [16], in a biomet-

between hamstring harvesting for reinforcement frames and return ric cadaver study, reported better results with anchor traction than

to sport (P = 0.72). with classical transosseous fixation, but recommended prospective

randomized clinical trials to confirm their findings. Their technique

was implemented by Bushnell et al. [17,18], who reported 21%

failure (3/14), which does not seem to argue for a superiority of

4. Discussion

anchorage over classical techniques.

Reinforcement frames are a widely used safeguard in patel-

In the present study, at almost 9 years’ follow-up, mean Lysholm

lar tendon repair [1,10]. All biomechanical studies agree on this,

score was 93.7/100, with 96% of patients satisfied or very satisfied

reporting better suture and reinsertion traction resistance with

with their result.

hamstring [19], non-resorbable suture [20] or metal wire reinforce-

The main strong point of the study was the length of follow-up.

ment frames [21] compared to simple reinsertion.

Limitations involve the size of the series, which was, however,

Except in special cases, we prefer a semitendinosus reinforce-

acceptable in the light of the low prevalence of the pathology in

ment frame [1], or using the gracilis if it is not too thin, as

question and the series in the literature. The design was moreover

on the one hand the suture is thus reinforced by biological tis-

retrospective, single-center, non-controlled. Apart from patients

sue and on the other hand the problems incurred by metal wire

followed up in other structures, for whom information was lack-

(tolerance, breakage, iatrogenic patellar infera induced by wire

ing, there was 26% loss at last follow-up. On the other hand, all

tightening, need to ablate material, etc.) are avoided. Our atti-

patients who could be contacted agreed to participate. Finally, as

tude has evolved over time: we first used metal reinforcement

late follow-up was by telephone, there was no long-term radiolog-

frames, and then adopted synthetic ligament; then, when ante-

ical assessment.

rior cruciate ligament reconstruction using the hamstrings was

Epidemiologically, the series included 89% males, comparable

introduced, we shifted to semitendinosus or gracilis reinforcement

to the series of Clayton and Court-Brown [14] analyzing tendon

frames, which we now use systematically, as harvesting is straight-

lesions in 64,926 non-selected patients seen in the Edinburgh

forward.

(UK) traumatology emergency department between 1996 and 2001

Certain studies [9,11,12,22] favor early mobilization after patel-

(Table 5). They found male predominance of 78% in the 18 cases

lar tendon repair. The present study and that by Kasten et al. [10]

of patellar tendon rupture, with a mean age of 53.4 years (ver-

found nearly normal motion in more than 80% of cases, which is

sus 42.6 years in the present series). They reported twice as many

strictly comparable to the findings of Enad and Loomis [22] and

quadriceps as patellar tendon ruptures, whereas Boudissa et al.

West et al. [12]. Immobilization avoids the risk of suture failure,

[15], analyzing data for the same period in the same hospital

which often induces a greater or lesser impairment of active exten-

department as in the present study, reported only 1.5-fold more

sion and quadriceps force; this is especially true for non-compliant

quadriceps tendon ruptures; this difference may be due to the fact

patients.

that our department recruits sport, leisure and daily life trauma

more than road accident cases.

There are risk factors for tendon lesions. Kannus and Jozsa

Disclosure of interest

[2] identified histopathologic factors underlying tendon rupture:

notably, degenerative hypoxic remodeling. The present series

The authors declare that they have no conflicts of interest

included 3 cases of rupture following local corticosteroid injection,

concerning this article.

which is far from rare [13].

Funding: no funding for this article.

The present results were close to those of Kasten et al.’s

[10] series of 68 patients, 28 of whom were followed up for a

mean 8.1 years. Treatment was similar to the present series, with

resorbable suture and metal wire reinforcement frame (22 knees)

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