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IJCRR - 6(17), September, 2014

Pages: 52-54

Date of Publication: 11-Sep-2014

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LATE PATELLAR TENDON RECONSTRUCTION - NOVEL TECHNIQUE

Author: Ravichandran S., Surendher Kumar R., Krishna Bhargava, Krishnagopal R.

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Abstract:Traumatic rupture of the patellar tendon occurs in the young and is caused by sudden contraction of the quadriceps against resistance.
The lesion usually occurs at the point where the patellar tendon is attached to the lower pole of the patella. We present a 26-year-old male patient who presented to our hospital 4 months after history of bike accident. Following which the patient was unable to walk immediately. Patient was treated with native bandage for a month after which patient was able to weight bear. On
walking patient had pain, instability, locking and inability to extend the knee. Clinically, patient had a swelling over infra patellar region with extensor lag of 25-30 degrees. X-ray of the knee showed no bony injury and MRI showed complete tear of the patellar tendon. Patellar tendon rupture repaired with modified Ecker technique using hamstring graft. Post-op operatively, he was
immobilized with above knee slab for 2 weeks after which patient was made to weight bear partially. At 10 weeks, full weight bearing with knee brace was started and at the end of 3 months patient had near normal range of movements.

Keywords: Patellar tendon rupture, Patellar tendon repair, Modified ecker technique, Hamstring

Full Text:

INTRODUCTION
Surgical management of neglected patellar tendon rupture is more challenging than that of acute ruptures, and the results are less promising because of proximal patellar migration and retraction, atrophy of the quadriceps (1-3). Several methods to relocate the patella anatomically have been proposed including preoperative traction, quadricepsplasty and external fixation (1-8). We present a case with a neglected patellar tendon rupture which was treated successfully with a modified Ecker technique (7) and adjustable knee brace postoperatively. Good functional result was achieved with intensive rehabilitation.

CASE REPORT
A 26-year-old male was admitted to our hospital with a complaint of inability to extend his left knee. His history revealed a road-traffic accident 4 months earlier, after which the patient was unable to walk immediately, he went in for native treatment where 2 bandages around knee each for 15 days has been applied. After which the patient was able to walk with pain, instability, locking and inability to extend knee. On examination, swelling seen over infra-patellar region and patella was migrated proximally. Passive range of motion was full with an extension lag of 25-30 degree. Radiographs showed no evidence of any bony injury. MRI of the knee joint revealed complete tear of the patellar tendon. With all the clinical and radiographic findings we diagnosed as patellar tendon rupture. Pre-anesthetic workup was done and planned for surgical reconstruction of patellar tendon using modified ECKER technique. An anterior midline incision was given to expose patella and tibial tuberosity. Then two transverse tunnel was drilled in patella with a thick K wire and another one in tibial tuberosity with 4 mm drill bit. Holding the knee in extension a circular wire was passed from the tunnels and tightened until obtaining an adequate distance between patella and tibial tuberosity, considering Insall-salvati ratio (normal patellar tendon is approximately equal to the length of the patella) (9). Semitendinosus and Gracils tendon grafts were harvested by open end tendon stripper. The semi-tendinous tendon was prepared and passed through the tunnel drilled in the tibial tuberosity and the inferior tunnel drilled in the patella, then sutured. Then, the gracilis tendon was passed through the same tunnel in tibial tuberosity and superior tunnel of patella and sutured to the semitendinosus tendon graft. Circlage wire removed after the repair was completed. With Hip in 45 degree of flexion, the knee could be flexed to 20% with gravity of the leg and the repair was found to be stable. The knee was immobilized by plaster slab in extension post-operatively.

DISCUSSION Fresh patellar tendon ruptures require immediate repair of the extensor mechanism for optimum results. End to end repair with circulage wiring or with non-absorbable suture material and cast immobilization for 6-8 week is recommended (3). Better outcome has been reported in early repair of patellar tendon with no extension lag and quadriceps strength (3). Neglected rupture of the patellar tendon is a rare condition [5–8,10]. Patellar tendon rupture is often missed in patients with multiple injuries, especially in obese population. End to end approximation is difficult in neglected rupture cases. Late the presentation greater the chances of quadriceps retraction and proximal patellar migration. It is difficult to locate the ruptured ends in neglected cases due to fibrosis, in such conditions it is recommended to reconstruct patellar tendon with fascia lata, hamstring tendons (commonest) or Achilles tendon (11-12). Several techniques have been reported for relocation of patella to its anatomical position in cases with severe quadriceps contracture and migrated patella with external fixation using pins and Ilizarov technique(5). Mandelbaum et al. [2] proposed ‘Z’ lengthening for the quadriceps tendon and ‘Z’ shortening for the patellar tendon with augmentation using semitendinosus and gracilis tendon grafts. Postoperatively immobilized in plaster with knee in full extension for 4 weeks followed by 10 degree per week of knee flexion in a hinged knee brace reporting 130 degree flexion at end of 1 year follow up. Even though being a neglected rupture, interoperatively we did not have any difficulty in moving the patella in spite of no preoperative traction. Semitendinosus-gracils graft were used to reconstruct the patellar tendon without any circulage wiring. Postoperatively immobilied in above knee plaster with full extension for 4 weeks followed by 10 degree per week of flexion in a hinged brace. At the end of 12 weeks patient had 120 degree of knee flexion with no extension lag and good strength of quardriceps was acheived.

CONCLUSION
Modified Eckar technique is a good and promising procedure in reconstruction of neglected patellar tendon rupture. Outcome will be better if treated earlier. Still a good result can be obtained in reconstruction of the patellar tendon using an autologus tendon graft along with intensive rehabilitation.

ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

References:

1. Takebe K, Hirohata K (1985) Old rupture of the patellar tendon. Clin Orthop Relat Res 196:253–255.

2. Mandelbaum BR, Bartolozzi A, Carney B (1988) A systematic approach to reconstruction of neglected tears of the patellar tendon. Clin Orthop Relat Res 235:268–271.

3. Siwek CW, Rao JP (1981) Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 63:932–937.

4. Nsouli AZ, Nsouli TA, Haidar R (1991) Late reconstruction of the patellar tendon: case report with a new method of repair. J Orthop Trauma 31:1319–1321.

5. Isiklar ZU, Varner KE, Lindsey RW et al (1996) Late reconstruction of patellar ligament ruptures using Ilizarov external fixation. Clin Orthop Relat Res 322:174–178.

6. Kelikian H, Riashi E, Gleason J (1957) Restoration of quadriceps function in neglected tear of the patellar tendon. Surg Gynecol Obstet 104:200–204.

7. Ecker ML, Lotke PA, Glazer RM (1979) Late reconstruction of the patellar tendon. J Bone Joint Surg Am 61:884–886.

8. Shephard GJ, Christodoulou L, Hegap AIA (1999) Neglected rupture of the patellar tendon. Arch Orthop Trauma Surg 119:241–242.

9. Insall J, Salvati EA (1971) Patella position in the normal knee joint. Radiology 101:101–104.

10. Casey MT, Tietjens BR (2001) Neglected ruptures of the patellar tendon, a case series of four patients. Am J Sports Med 29:457–460.

11. Matava MJ (1996) Patellar tendon ruptures. J Am Acad Orthop Surg 4:287–296.

12. Burks RT, Edelson RH (1994) Allograft reconstruction of the patellar ligament: a case report. J Bone Joint Surg Am 76:1077–1079.

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