Bilateral Patellar Rupture ARTICLE BY RONALD ALSTON, CST

am a 34-year-old Radiologic Examination and Two years prior to this injury, I black male who con- Immediate Treatment had been diagnosed with Osgood- siders myself to be X-rays films were taken and read Schlatter disease or "jumper's ." in the best of health, by the on-call radiologist who Treatment included ice and rest, a very active partici- reported both with which seemed to alleviate the prob- pant in most recre- alta with some bony deposits and lem. Partial rupture of the patellar I ational sports, and a no bony fragments. Despite the , known as jumper's knee, competitive bodybuilder. At this unremarkable x-ray film, there was is a repetitive overload lesion at the time, I am not taking any medica- severe injury to both of my knees. bone-tendon junction at the lower tion and have no prior knee injuries. Both of the patellar had patellar pole. Found mainly in ath- In an instant, my life changed. ruptured, making active knee letes, it is caused either by microrup- On Thursday, September 16,1993, extension impossible. The treat- ture or partial macrorupture of the during a recreational touch football ment for bilateral proximal part of the tendon with game, I attempted to jump for a ball rupture is surgical repair of the degeneration and devitalized tissue thrown to an opposing player and patellar tendon disruption with at the insertion of the patellar ten- felt immediate pain in both knees bilateral application of plaster don. Peripatellar tendinitis affecting before hitting the ground. This pain splints. Full-leg Robert Jones dress- either the cluadricevs tendon or the lasted approximately 20 minutes ings were applied to both legs to patellar teidon inkrtion onto the and was localized in both knees just keep them immobile. Surgery was patella is most commonly seen in below the patella. I was unable to scheduled for the next morning and athletes involved in jumping-related ambulate but could move both feet medication was given for pain. sports. Patellar and quadriceps ten- and had numbness in both of my knees. I was removed from the playing field about 25 minutes later 1 by four teammates and waited to be I transferred by ambulance to a near-

$ by emergency room, not knowing the extent of my injury. The pain had now subsided. After being seen by the physician on-call for orthope- dic trauma, the admitting showed bilateral pa- tella alta (high riding kneecap) with palpable infrapatellar defect and localized swelling (Figure 1). There was no active knee extension and no other of the knee. Both my legs were neurovascularly intact. This article will aquaint the read- er with the surgical procedure of bilateral patellar tendon repair as well as postoperative responses and rehabilitation from the unique per- spective of a patient as well as a CST. Figure 1. Anterior view of both knees showing defects inferior to both patellae. don ruptures from indirect injury in athletes may represent the end stage of jumper's knee and result from repetitive microtrauma. Many ath- letes involved in sport activities place repetitive stress on the exten- sor mechanism of the knee, causing microtrauma concentrated at the superior or inferior pole of the patella. Volleyball seems to be the most common sport involved, as well as basketball, a sport in which I frequently participate. As a result of patellar trauma, a critical degree of tendon degeneration may have occurred prior to rupture. The over- loading of the knees leads to degen- eration of the patellar tendons, plus decreased elasticity, degenerative changes in collagen fibrils, and decreased vascular supply. In this case, the major factor leading to the tendon ruptures was degeneration from repetitive microtrauma that Figure 2. Anterior view of both knees showing disruption of both patellae ten- represents end stage jumper's knee. dons. My age was also a factor since the tendons had undergone more wear and tear than would be found in a restore normal patellar tendon significant stump on the inferior younger athlete. length. Delayed surgery may cause pole (Figure 2). Both sides had com- Bilateral patellar tendon rupture technical problems in repair. If not plete disruption of the patellar reti- is a very rare injury seen in approxi- repaired soon after injury, patellar nacula, both medially and laterally. mately five patients a year in the tendon shortening may occur. The were inspected and the United States with approximately cartilage was found to be free of 20 reported cases in English litera- Operative Procedure damage. The medial and lateral ture. Mine was only the second On September 17,1993, I was menisci of both knees were intact as such procedure ever performed at brought to the orthopedic anesthe- were the anterior cruciate . the Mayo Clinic. The majority of sia block room and placed under Attention was then turned to the these cases occurred in patients epidural . I was then repair, which was performed with a with systemic diseases such as sys- taken to the operating room where No. 1 polybutilate (Ethibond) suture temic lupus erythematosus, my lower extremities were prepared in a Krakow stitch in each patellar rheumatoid arthritis, or renal fail- and draped in the usual fashion. tendon medially and laterally. A ure. Rupture of the infrapatellar ten- Tourniquets were applied to the Krakow stitch is a weaving stitch don in healthy athletes, as well as . The limbs were exsanguinat- that makes it easier to obtain better those diagnosed with jumper's ed and the tourniquets were inflat- fixation of the tissue. Three drill knee, is extremely rare. In this case, ed to 300 mm of mercury. The holes were placed in the patella the injury occurred as the tendons repair of the patellar tendons was after the bed was prepared using a snapped at the lower pole of the carried out simultaneously as fol- burr. The No. 1 polybutilate suture patella by the strong force of jump- lows. An incision was made cen- was then carried up through these ing, thus causing the quadriceps to tered over the patella from the drill holes. A drill hole was placed contract and fire with an extreme superior pole to the medial aspect in each just above the level of amount of force causing both patel- of the tibial tuberosity and approxi- the tibial tuberosity through which lae to retract superiorly into the mately 1 cm distal to this point. a No. 5 uncoated polyester fiber region of the . Bilateral patellar This incision was carried down (Mersilene) suture was passed. The tendon rupture precludes the through the suprapatellar bursa and sutures were then carried circumfer- patient from ambulation or exten- the tendon sheath was incised and entially through the retinaculum sion of either leg. Rupture of the the patellar tendon exposed. and quadriceps tendon and tied patellar tendon requires immediate Immediately upon reaching the tightly with the knee in 30" flexion. surgical attention. Excellent func- level of patellar tendon, it was Following this, the No. 1 polybuti- tion usually follows repair of patel- noted that both patellar tendons late suture was carried through the lar tendon ruptures when surgery is were disrupted completely from the patella and tied tightly (Figure 3). performed early and care is taken to inferior pole of the patella with no Good apposition of the patella to

THE SURGICAL TECHNOLOGIST home with pain medication. scheduled for (PT) 9/24/93: I was brought back to the to start October 22, 1993, in the cast room for removal of the Robert Sports Medicine Department. I Jones dressings. My wounds were would be assessed in 3 weeks. intact even though I had been hav- 10/29/93: My knee motion was ing some fever previously. The inci- increased to 60°, but I still had to sions were nontender and had remain non-weight-bearing as I had absolutely no drainage or erythema, been since I entered the hospital. thus my sutures were removed and 11/15/93: I was seen by my physi- 1/2 in adhesive strips were placed cian as an outpatient to check the over the wounds. I was then placed motion as well as the strength of my in Ortho-Tech Rehab I11 braces with repair. The ability to actively extend the knees locked in full extension. my legs was intact. During the first 2 weeks after surgery, I went through both mental Rehabilitation and physical changes despite the 10122193: 45-minute therapeutic fact that I knew what was ahead. exercise (TE) and measured for a During my recovery period, the platform walker with height of 45 seriousness of my injury and extent in. Increased the Ortho-Tech hinge of my surgery had not yet set in. brace from 0" to 30' to 0' to 60' Being as active as I had been and bilaterally and then progress to 90' never experiencing any injury that and crutches within 3 weeks. don showing sutures. had disabled me for a significant 11/10/93:30 minutes TE. Doing time period, losing the use of both well, easily achieved 60" range of lowe; extremities was devastating motion (ROM). The brace was to say the least. The rupture of a increased to 90" and crutches were the patellar tendon was achieved single patellar tendon is rare and I added using a four-point gait for and my knees were able to be flexed felt it would never happen to me. walking. Next session in 2 weeks 90" without disruption of the The possibility of bilateral patellar and increase brace to 120'. repairs. The retinacula were closed tendon rupture is merely impossi- 11/19/93: 30 minutes TE. Now using interrupted 0 polybutilate ble, at least that is what I kept have 0' to 70' ROM. Will proceed sutures and the remaining frayed telling myself despite the fact that with daily PT to increase ROM and edges of the patellar tendons were such surgery had been performed. increase brace to 120'. tacked down using 0 uncoated Both legs were in braces and the 11/22/93: 45 minutes TE. Passive monofilament polyglactin 910 only mobility I had was through the motion now at 0" to 80'. Will sutures. The tourniquets were use of a wheelchair with the help of attempt to use Biodex machine, released and hemostasis obtained my wife. Depression really set in as which is used to flex and manipu- with electrocautery. The wounds I went from a very active, indepen- late the knee to increase available were irrigated and closed over a dent young man to a totally depen- passive motion. Continue on a daily drain with interrupted 2-0 uncoated dent one. The days during this heal- basis. monofilament polyglactin 910 ing process grew longer. I was 11/23/93: 45 minutes TE. Used sutures subcutaneously and inter- unable to walk or play with my 3- hot packs. Biodex used for ROM rupted 2-0 polypropylene sutures in month-old daughter and, for a short passive mode using 12.5 in on leg the skin. Sterile dressings were period of time, 1stopped eating. Yet, extension and 4 in on the seat. Was applied, followed by long-leg able to achieve 73" flexion bilateral- I reallv didn't believe it was hav-I Robert Jones dressings with medial pening to me. Before my injury, I ly using Biodex scale. and lateral plaster splints. was I spent much of my free time in the 11/24/93: 45 minutes TE. Hot taken to the recovery room in good gym lifting weights. I worked very packs and Biodex machine for pas- condition. hard at developing my body. But sive motion not at 80' bilateral pas- despite all my efforts, I saw my legs sive motion parameters as above. Postoperative Care atrophying before my eyes. Continue on a daily basis. 9120193: Three days after surgery, Time helped me work through 11/26/93: 45 minutes TE. Hot I was taken to the cast room. My the pain though it was not always packs and Biodex machine for pas- dressings were removed, exposing easy to keep a positive attitude. I sive motion to 85'. Ice was applied intact wounds without erythema or dug deeply into myself and once following exercise. drainage. Long-leg Robert Jones my acceptance was put into per- 11/29/93: 45 minutes TE. Hot dressings with medial and lateral spective, the real healing began. packs, passive motion to 90'. plaster splints were placed and I 10/22/93: I returned to the cast 11/30/93: 45 minutes TE. Hot was returned to my room. On room where my wounds were packs, PT as above. Ten minutes September 21,1993, I was released clean, dry, and intact. I began upper body ergometer (UBE) from the hospital and was sent motion from 0' to 30' and was machine approved by physician to begin strengthening. bilaterally 130" to 135". I should be once they enter the operating room 12/1/93: 45 minutes TE. Hot able to resume all activities with no until the time they leave will never packs and Biodex for passive complications. be enough. I have experienced their motion. Continue daily. pain and frustration and from the 12/2/93:45 minutes TE. Hot Summary time they leave the operating room, packs and Biodex for passive As CSTs, we are integral members it is the start of a new beginning for motion to 92". Continue daily. of the surgical team working with most of them. A 12/6/93: 45 minutes TE. Hot the surgeons, nurses, and anesthesia packs and Biodex for passive providers, as well as the patient. Acknowledgements motion. UBE for 10 minutes. The Our job duties require us to perform I would like to thank Robert UBE is being used for cardiovascu- a number of tasks, the most impor- Trousdale, MD, Department of lar work. tant being to provide the best , Mayo Clinic, 12/7/93:45 minutes TE. Hot patient care possible. In order to for performing my surgery and for packs and Biodex for passive perform these responsibilities, we his assistance with this manuscript motion 0" to 93". attend accredited surgical technolo- and Michael J. Stuart, MD, head of 12/9/93:Same as 12/7/93. gy programs. These programs the Sports Medicine Center, 12/10/93:30 minutes TE. Bilateral assure us of the essentials needed to Department of Orthopedic Surgery, flexion 90" to 95". carry out these responsibilities. As a Mayo Clinic, for his help during my 12/14/93: 45 minutes TE. Passive CST, I feel my training has been the recuperation. Special thanks to motion bilaterally to 100". best. We CSTs work hard to uphold Peter Lohman, my physical thera- 12/15/93:Added leg press, three our position. We sharpen our skills pist, for putting up with me during sets of 15 repetitions, level six to each day we work in the operating the tough times, and for his contin- continue 3 to 4 times a week. room. We are truly professionals. In ued help and support on a regular 12/17/93:45 minutes TE and the article, I shared a personal expe- basis, and to my wife, Jane, for her Biodex and will proceed with leg rience with you and, with this expe- support and care during this diffi- press at the YMCA. Three sets of 10 rience, I learned some things that cult time. to 15 repetitions. we do not and can not see through 12/21/93: Doing well. Biodex to the eyes of the patients to whom we Bibliography 105" bilaterally. Will increase leg provide surgical care each day. This Delee JC, Craviotto DF. Rupture of the press to level 8 doing three sets, 2 to lesson can not be taught in the quadriceps tendon after a central third 3 times a week. patellar tendon anterior cruciate liga- classroom, during our clinicals, or ment reconstruction. Am J Sports Med. 12/22/93:45 minutes TE. Hot in our everyday practice. This is the August 1991;19;4:415. packs and Biodex up to 105" on the traumatic effect &at major surgery Karlsson J, Lundin 0,Wigerstad-Lossing I, left and 107" on the right. Add ham- has on our patients after they leave Peterson L. Partial rupture of the patel- string curls and toe raises. the operating room. Most are faced la. Am J Sports Med. August 12/27/93: 45 minutes TE. 108" on with days and weeks of pain, uncer- 1991;19;4:402. the left and 105" on the right. Rupture of the patellar tendon. South Med tainty, and unanswered questions. J. March 1988;81;3:376. 12/28/93: 45 minutes TE. Same as My misfortune has given me an Webb LX, Toby EB. Bilateral rupture of the previous day. unwanted opportunity to experi- patella tendon in an otherwise healthy 12/29/93:45 minutes TE. 110" ence the most difficult part of a male patient following minor trauma. J bilaterally. Add leg press, hamstring patient's surgical experience. As a Trauma. November 1986;26;11:1045. curls, toe raises, added hamstring patient, I endured what I would Kelly DW, Carter VS, Jobe FW, Kerlan RK. stretching due to discomfort in the Patellar and quadriceps tendon rup- consider the worst. Surgery was tures: Jumper's knee. Am J Sports Med. medial distal hamstring. Continue easy and painless-postoperatively Sept-Oct 1984;12;5:375. as able. is when the debt is finally paid. I 1/5/94: 45 minutes TE. 110" on the have lost a lot as a result of my left and 105" on the right. Ice post- injury and my surgical experience exercise. Continue with Biodex until as a patient resulted in inactivity, maxed out. Proceed with total gym. mental imbalance, and the uphill 1/6/94: 45 minutes TE. 110" on the battle of fighting each day to feel left, 108" on the right. Continue normal again. My pain has endured with leg press, hamstring curls, toe through the course of my rehabilita- raises on own time, as well as three tion. Learning to walk again has not times a week in Sports Medicine been easy. I thought that through Ronald Alston, Department. rehabilitation it would become easi- CST, /rn.i btwr cvrployrd us u irrrgi- 1/7/94: 45 minutes TE. 111" on the er. I was wrong; it becomes harder LV/ tt~~-/~rr~~l~~~~islwith left, 110" on the right. Continue as and continues until you are whole /lr~Mnya Cli~riiirr able. Total gym trial next week. again. Rehabilitation will continue Roc-lrrsll~,Mirrrlewfu, Rehabilitation continues on a for many months. Through it all, a for 8 ylwrs. Ht* cur- re~rt(vrc1ork.i rlr yen- daily basis and will throughout the valuable lesson has been learned; as era1 surycy uitl~a11 next 3 to 4 months. Expected ROM a CST, the care I give to a patient rrtrp/rasiso11 iol011 arrd rccfnl proctdurci.