Orthopaedics & Traumatology: Surgery & Research (2011) 97, 447—450

CLINICAL REPORT Chronic patellar rupture reconstruction with a semitendinosus autograft

A.G. Nguene-Nyemb, D. Huten, M. Ropars ∗

Department of Orthopaedic Surgery, Pontchaillou Hospital, Rennes Teaching Hospital Center, 2, rue Henri-Le-Guilloux, 35033 Rennes, France

Accepted: 11 January 2011

KEYWORDS Summary Chronic ruptures are somewhat rare, thus little work has been done Patellar tendon; in this area and their true incidence is not known. The management of a neglected, chronic Neglected rupture; patellar tendon rupture must address three difficulties: the proximally retracted , the Semitendinosus reconstruction of the patellar tendon, finally, the temporary protection of this repair. By pre- tendon autograft senting a case of a chronic patellar tendon rupture, the advantages of reconstruction with an isolated semitendinosus tendon autograft, especially from an early rehabilitation perspective, are described. © 2011 Elsevier Masson SAS. All rights reserved.

Introduction with an isolated semitendinosus tendon autograft followed by early rehabilitation are described. Patellar tendon ruptures mostly occur in persons under 40 years of age [1—3], typically during a sporting activity [4—6]. The tendon is usually completely ruptured at the Case report proximal insertion [7]. Treatment of acute patellar ten- don ruptures involves direct tendon to tendon repair or The patient was a 49-year-old male carpenter, who routinely transosseous sutures, usually combined with an additional works on his and averages 3 h/week of sports partic- procedure to temporarily protect the repair [1]. A rupture ipation. He ruptured his left patellar tendon at 28 years of becomes chronic or neglected if not diagnosed. This is not a age; the rupture was repaired by end-to-end suturing and common injury [9]. No extensive case series have been pub- protected with cerlage; the outcome was favorable. The lished. Through a case report of a chronic patellar tendon patient did not have any systemic diseases or concurrent rupture, the challenges and advantages of reconstruction treatments that would have weakened the tendon. While playing football, the patient felt a buckling of his right leg when landing from a jump, followed by pain in the anterior aspect and functional disability. At the emergency ∗ Corresponding author. ward, the clinical examination revealed prominent pain in E-mail address: [email protected] (M. Ropars). the medial patellar retinaculum and lateral radiographs

1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.otsr.2011.01.015 448 A.G. Nguene-Nyemb et al.

Figure 1 a: lateral X-ray after the initial injury shows a patella alta (Caton Deschamps index: 1.5); b: postoperative lateral view of the operated : patellar height is normal. showed a patella alta (Caton Deschamps index = 1.5) with intact. A second tunnel was drilled horizontally with a 6- the patella having the typical overuse appearance for an mm auger into the upper half of the patella. The harvested athlete (Fig. 1a). A diagnosis of patellar instability was tendon was passed through this tunnel from medial to lat- made. A splint was used to immobilize the injury site. After eral and then sutured to both sides of the patellar tendon in 1 month, rehabilitation sessions were initiated and there was 30◦ of flexion. In this position, the length of the patellar a good progression. Four months after the injury, the patient tendon was equal to the height of the patella, accord- described experiencing weakness and being unable to lock ing to the Insall-Salvati index. The autograft tension was his knee when going down stairs over the previous 5 weeks set so that the length of the reconstructed tendon was and had the impression that the patella was moving upward, approximately equal to the height of the patella, with- especially when seated. Clinical evaluation confirmed this out requiring an intraoperative radiograph. No tibial tunnel proximal migration along with an infrapatellar void. How- was made. A cross mattress suture pattern was performed ever, the patient could actively extend his leg. Pushing down with a 4-metric, non-braided, resorbable suture (PDS®1). on the patella caused pain and the patellar femoral grinding To obtain good patella to patellar tendon continuity and test was positive. Ultrasonography confirmed the diagno- solidify the assembly, the quadriceps expansion was folded sis of a chronic patellar tendon rupture with a background over to a 1.5-cm width and sutured to the patellar tendon of chronic . A surgical intervention was war- using the same type of suture. An intraoperative flexion ranted. of 90◦ could be attained easily, without tension. Stan- Using a mid-line incision, full exposure of the patellar dard postoperative radiographs showed good restoration of tendon revealed that the tendon was not inserted on the the patellar height with a Caton Deschamps index of 1 pole of the patella. However, there was a continuum of (Fig. 1b). fibres, which were sufficient to support active extension. Full weight bearing was allowed at Day 1 and protected After debridement and freshening of the pole of the patella, with an extension splint between physiotherapy sessions. distal mobilization of the patella was performed. A hori- The initial rehabilitation aimed at restoring passive range zontal tunnel was drilled with a 4.5-mm bit in the lower of motion up to 90◦ of flexion during the first 45 days; no half of the patella, through which three non-resorbable active extension was allowed. Starting in week 6, the range Mersuture® 3/0 strands were passed; these were used to of motion was gradually increased and quadriceps strength- reinsert the patellar tendon on the patella. The semitendi- ening initiated. nosus tendon was harvested through a small incision over At a 2-year follow-up, full flexion could be achieved the pes anserinus. A tendon stripper was used to harvest and was comparable to the contralateral side, quadriceps the tendon, which was pulled through the main incision. strength was marked as 5/5 and girth at 10 cm above The tibial insertion of the semitendinosus tendon was kept the patella was comparable to the left side (Fig. 2). The Reconstruction of chronic patellar tendon rupture with semitendinosus tendon 449

traction was performed with a transverse pin in the patella for about 15 days or intraoperative traction was performed [1,4,12]. The current approach consists of lowering the prox- imally migrated patella through intraoperative sectioning of the patellar retinaculum and release of the suprapatellar bursa by arthrolysis [1]. If this is not sufficient, the proximal tendon of the rectus femoris can be sectioned, through a Hueter approach, to provide additional lowering [1]. Multiple authors combine the reconstruction with wire cerlage or metalwork to reduce the load on the recon- structed tendon. This device allows for early rehabilitation, but requires a second intervention of remove the implanted material. We used a turn-over flap of the quadriceps exten- Figure 2 Full active extension is present at 2 years follow-up. sion as a protective technique recommended by Dejour et al. [1], which allowed for 90◦ of flexion without tension and patient was able to resume his sports activities. He had no did not require a second intervention to remove implanted pain and no difficulty during day-to-day activities. material.

Discussion Conclusion

Ruptures to the extensor mechanism of the knee are rare Chronic patellar tendon ruptures are rare. Surgical repair [2,6,11]. The true incidence of patellar tendon rupture is is based on tendon augmentation with an autograft, allo- unknown, but it is the third most common injury to the graft or synthetic material, but no consensus has emerged. extensor mechanism, after and quadriceps Many of these reconstruction techniques provide satisfac- tendon rupture [10,12]. tory results. The use of a semitendinosus autograft reduces The diagnosis is not always made during the initial post- donor site morbidity, avoid specific risks related to allografts injury phase. In a retrospective series, Siwek and Rao [10] and does not require surgical revision to remove materials found chronic injuries in 27% of cases. A complete patellar used to protect the reconstructed tendon. tendon rupture occurs in 97% of cases reported in the litera- ture, and like ours, usually occurs at the pole of the patella Disclosure of interest [7]. Many reconstruction techniques have been proposed: The authors declare that they have no conflicts of interest synthetic material [13,14], autograft using the semitendi- concerning this article. nosus alone [15] or together with the gracilis [8] and the contralateral patellar tendon [1,12], or allograft using the Achilles tendon [3,4,9,16]. A contralateral bone-patellar References tendon-bone graft consists of a composite ‘‘quadriceps ten- don, patella, patellar tendon and ’’ unit, which allows [1] Dejour H, Denjean S, Neyret P. Traitement des ruptures anci- the extensor mechanism to be reconstructed and the patella ennes ou itératives du patellaire par autogreffe to be automatically positioned at the proper height. This controlatérale. Rev Chir Orthop 1992;78:58—62. technique is most useful when the remaining tendon stump is [2] Kannus P, Natri A. Etiology and pathophysiology of tendon rup- not adequate or in cases of surgical revision. This is an essen- tures in sports. Scand J Med Sci Sports 1997;7:107—12. tial technique, particularly in terms of graft fixation. Despite [3] McNally PD, Marcelli EA. Achilles allograft reconstruction of a significant morbidity associated with autografts, allograft chronic patellar tendon rupture. Arthroscopy 1998;14:340—4. techniques have a risk of bacterial or viral infection, neo- [4] Falconiero RP, Pallis MP. Chronic rupture of a patellar ten- don: a technique for reconstruction with Achilles allograft. plasia and especially non-conventional transmissible agent Arthroscopy 1996;12:623—6. transmission. They should only be considered when the [5] Järvelä T, Halonenc P, Järvelä K, Moilanena T. Reconstruction extensor mechanism is extensively damaged and an auto- of ruptured patellar tendon after total knee arthroplasty: a graft cannot be used. case report and a description of an alternative fixation method. A semitendinosus autograft is often used in knee liga- Knee 2005;12:139—43. ment and tendon repair. This robust autograft can restore [6] Savaresse E, Bisicchia S, Amendola A. Bilateral spontaneous the strength and stability of the extensor mechanism with concurrent rupture of the patellar tendon in healthy man: minimal donor site morbidity [15,17]. Reconstruction with- case report and review of the literature. Musculoskelet Surg out a tibial bone tunnel could be used in preadolescent 2010;94:81—8. athletes suffering from this injury, if they are not yet skele- [7] Kapoora RK, Malhotrab R, Bhanb S. Traumatic bifocal avulsion of the patellar tendon. Injury 2005;36:115—7. tally mature [13]. In addition, tibial tunnel positioning and [8] Van der Zwaal P, Van Arkel ERA. Recurrent patellar tendon graft length are not a concern. However, this technique has rupture: Reconstruction using ipsilateral gracilis and semi- risks, such as the fracture of a small patella [1]. tendinosus tendon autografts. Injury 2007;38:320—3. The biggest challenge with this surgery is the need [9] Lewis PB, Rue JP, Bach Jr BR. Chronic patellar tendon rupture: to mobilize a non-reducible patella, which was not the surgical reconstruction technique using two Achilles tendon case with our patient. Previously, continuous preoperative allografts. J Knee Surg 2008;21:130—5. 450 A.G. Nguene-Nyemb et al.

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