Recurrent Bilateral Rupture of the Patellar Tendons: Tendon Replacement Using Polyester Connective Tissue Prosthesis
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Injury Extra (2006) 37, 379—382 www.elsevier.com/locate/inext CASE REPORT Recurrent bilateral rupture of the patellar tendons: Tendon replacement using polyester connective tissue prosthesis Ashraf M. Naguib *, Graham K. Sefton Harrogate District Hospital, Lancaster Park Road, Harrogate HG2 7SX, North Yorkshire, United Kingdom Accepted 20 March 2006 Case report which has not been specified in her medical report was used for augmentation. She spent 6 weeks in A 27-year-old woman with 7 years history of sys- plaster following surgery and then underwent temic lupus erythematosus was referred to the extensive physiotherapy. After an year of treat- senior author for management. ment, the lady continued to have severe weakness Shortly after being diagnosed with the disease of active extension. She was unable to walk without she experienced bilateral spontaneous rupture of her knees supported in extension braces. The exten- patellar tendons. Treatment was an end-to-end sion lag on both knees gradually became worse and tendon repair with a heavy non-absorbable suture she needed to use two elbow crutches. according to the technique described by Krackow.11 At presentation to our unit, physical examination Intra-operatively, both tendons were noted to be showed diffuse swelling of both knees. Both the ruptured in their midsubstance. patellae were proximally displaced. There was very Cylindrical casts with the knees in full extension little discomfort during the examination and there were used for 8 weeks to protect the repair; this was was no tenderness around the knee. Full active followed by physiotherapy. The overall post-opera- extension was not possible, but full passive exten- tive progress was described by the patient as good sion was possible. and the patient was able to resume normal mobility. She had an extension lag of 808 on the right knee Four years later, while the lady was going upstairs and 708 on the left knee. she felt sudden pain in the right knee and she fell Radiographs showed bilateral patella alta. MRI down and was unable to stand. The patient was scan showed that parts of the patellar tendon were diagnosed as having bilateral rupture of patellar replaced by cysts filled with fluid. Smaller cysts tendons. She underwent bilateral tendon explora- were also present in the peri patellar region. The tion 3 weeks after injury. Repair and augmentation remaining tendon was very thin and attenuated. was performed on both knees. A synthetic material Findings were similar in both knees (Fig. 1). Two days after presentation, the patient under- * Corresponding author. Tel.: +44 1423 885959; went exploratory surgery of the right knee. The fax: +44 1423 555443. knee was explored through a mid-line longitu- E-mail address: [email protected] (A.M. Naguib). dinal incision with excision of the previous scar. 1572-3461 # 2006 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2006.03.024 380 A.M. Naguib, G.K. Sefton Figure 2 Picture following debridement showing no patellar tendon tissue between the lower pole of patella and the tibial tuberosity. of motion of the right knee at that time was 0—1208. Theleftkneewasapproachedinthesame manner. Findings were similar to the right side. Reconstruction was performed using the same Figure 1 MRI of the right knee showing a large cyst technique. The post-operative management and replacing the proximal part of the patellar tendon. rehabilitation were also similar. At 2 years post- operatively both knees had full extension with no The patellar tendon was ruptured at the lower pole extension lag and range of flexion of 1208 on both of patella and replaced with a cyst filled with green sides. The patient was able to walk normally with thick paste-like substance. Smaller cysts filled with no aid. the same substance were present in both the medial and lateral retinaculae. The articular cartilage of the knee and patella looked healthy. All cysts, scar Discussion tissue and the degenerated remnants of the tendon were excised as part of the debridement procedure. Simultaneous bilateral patella tendon ruptures are This left no patellar tendon tissue between the very rare injuries. No predisposing cause was iden- lower pole of the patella and the tibial tuberosity tified in some cases; however, most reported cases (Fig. 2)80mm 10 mm Leeds Keio polyester con- have been associated with systemic diseases such nective tissue prosthesis (CTP) (Neoligaments, as rheumatoid arthritis, systemic lupus erythroma- Leeds, UK) was used for reconstruction of the patel- tosus, and chronic renal failure.7,9,14,17,22 A few lar tendon according to the technique described by additional reports describe rupture in endocrine the same authors.20 disorders such as hyperparathyroidism and diabetes Histopathology and microbiological examination mellitus.3,15 of the specimen confirmed giant cell foreign body Pritchard and Berney18 investigated the fre- reaction with no evidence of infection. quency of patellar tendon rupture in patients with Two weeks post-operatively, a regimen of quad- systemic lupus erythromatosus. They found that riceps setting exercises was begun under the super- tendon rupture appears to be associated with vision of a physiotherapist. After 6 weeks of extended disease duration, minimal disease activ- immobilisation, the cast was removed, and active ity, the presence of deforming hand arthropathy range-of-motion and quadriceps strengthening exer- and, chronic corticosteroid therapy. cises were started. Renal dysfunction and long-term use of corticos- At 3 months post-operatively, range of motion of teroids were suggested as the aetiological factors the knee was 908 of active flexion with no extension for tendon rupture in patients with lupus erythro- lag. matosus. At 6 months post-operatively, the patient was The effect of steroids remains controversial. admitted for surgery on the left knee. Range Glucocorticoids may inhibit collagen synthesis or Recurrent bilateral rupture of the patellar tendons 381 compromise the blood supply, thus weakening the the anterior surface of the patella and through a tendons; however, no cases of patellar tendon drill hole in the tibial tubercle. The ligament was rupture have been reported in patients taking secured to the tibia using stables or screw and steroids for conditions such as asthma or skin dis- washer. Despite the satisfactory results with this eases.19 technique, post-operative elongation and failure In this report, the patient suffered bilateral of the CTP due to abrasion remained a big con- rupture twice in 4 years and to our knowledge this cern. is the first report of recurrent rupture in association We believe that passing the CTP through bone with systemic lupus erythromatosus. In all the tunnels in the patella improves the purchase and reported cases including this report, it remains allows safe application of traction on the patella to difficult to explain the bilateral and simultaneous bring it down to its anatomical position. It also nature of this injury. reduces the risk of elongation and abrasion of the Early diagnosis of patellar tendon rupture can CTP. be difficult. In a review of 36 patellar tendon Although more studies are needed to evaluate ruptures, Siwek and Rao21 reported that 10 rup- the long-term results, we believe that this techni- tures were misdiagnosed on initial examination que does offer a good option in the treatment of this and that diagnosis was made more than 2 weeks difficult-to-manage problem. after injury in seven patients. In one case, diag- nosis was delayed 6 months while the loss of strength in the legs was attributed to steroid References myopathy. Patients with bilateral spontaneous rupture 1. Casey Jr MT, Tietjens BR. Neglected ruptures of the patellar may have minimal or even no history of trauma. tendon: a case series of four patients. Am J Sports Med 2001; 29:457—60. The symmetrical abnormal findings on clinical 2. Chagar B, Boussouga M, Lazrak KH, Taobane H. Neglected examination in addition to the rarity of the con- spontaneous bilateral rupture of the patellar tendon: a case dition add to the difficulty in making an early report. Rev Chir Orthop Reparatrice Appar Mot 2003;89(8): diagnosis. 733—7. In a delayed diagnosis of more than 6 weeks, 3. Chen CH, Niu CC, Yang WE, Chen WJ, Shih CH. Spontaneous bilateral patellar tendon rupture in primary hyperparathyr- quadriceps contracture, fibrous adhesions and the oidism. Orthopedics 1999;22:1177—9. poor quality of the remaining tendon make surgical 4. Crossett LS, Sinha RK, Sechriest VF, Rubash HE. Reconstruc- repair and restoration of patellar tendon length tion of a ruptured patellar tendon with Achilles tendon more complicated. allograft following total knee arthroplasty. J Bone Joint Surg Different methods of treatment have been (Am) 2002;84-A(8):1354—61. 5. Emmerson Jr RH, Head WC, Malinin TI. Reconstruction of described for this challenging problem. Allograft patellar tendon rupture after total knee arthroplasty with using extensor apparatus or Achilles tendon has an extensor mechanism allograft. Clin Orthop 1990;260: 4,5,13 been used with satisfactory results. 154—61. Chagar et al.2 described augmentation using free 6. Fujikawa K, Ohtani T, Matsumoto H, Seedhom BB. Recon- autograft from the semitendinous tendon or inver- struction of the extensor apparatus of the knee with the 16 Leeds-Keio ligament. J Bone Joint Surg (Br) 1994;76-B: sion of the quadriceps tendon. Peyser and Makley 200—3. described the use of biceps tendon attached to the 7. Jakobsen LP, Knudsen TB, Bloch T. Spontaneous infrapatellar fibular head for reconstruction in a case of tendon rupture in a patient with systemic lupus erythema- neglected rupture. tosus. Ugeskr Laeger 2000;162(38):5088—9. In another series of four neglected ruptures, 8. Kasten P, Schewe B, Maurer F, Gosling T, Krettek C, Weise K.