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Patellar tendon ossification after anterior cruciate ligament reconstruction using bone--patellar tendon--bone autograft.

Camillieri G, Di Sanzo V, Ferretti M, Calderaro C, Calvisi V - BMC Musculoskelet Disord (2013)

Bottom Line: The clinical diagnosis was confirmed by Ultrasound, X-Ray and Computed Tomography studies, blood tests were performed to exclude metabolic diseases then the surgical removal of the lesion was performed.After three years from surgery, the patient did not report femoro-patellar pain, there was not range of motion limitation and the clinical-radiological examinations resulted negative.The surgical removal of the ossifications followed by anti-inflammatory therapy, seems to be useful in order to relieve pain and to prevent relapses.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedic Surgery, University of L’Aquila, Rome, Italy.

ABSTRACT

Background: Among the various complications described in literature, the patellar tendon ossification is an uncommon occurrence in anterior cruciate ligament (ACL) reconstruction using bone - patellar tendon - bone graft (BPTB). The heterotopic ossification is linked to knee traumatism, intramedullary nailing of the tibia and after partial patellectomy, but only two cases of this event linked to ACL surgery have been reported in literature.

Case presentation: We present a case of a 42-year-old Caucasian man affected by symptomatic extended heterotopic ossification of patellar tendon after 20 months from ACL reconstruction using BPTB. The clinical diagnosis was confirmed by Ultrasound, X-Ray and Computed Tomography studies, blood tests were performed to exclude metabolic diseases then the surgical removal of the lesion was performed. After three years from surgery, the patient did not report femoro-patellar pain, there was not range of motion limitation and the clinical-radiological examinations resulted negative.

Conclusion: The surgical removal of the ossifications followed by anti-inflammatory therapy, seems to be useful in order to relieve pain and to prevent relapses. Moreover, a thorough cleaning of the patellar tendon may reveal useful, in order to prevent bone fragments remain inside it and to reduce patellar tendon heterotopic ossification risk.

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Related in: MedlinePlus

Intraoperative images. (A) Intraoperative image showing the proximal patellar tendon ossification (arrow). (B) Proximal (b1) and distal (b2) removed lesions.
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Figure 2: Intraoperative images. (A) Intraoperative image showing the proximal patellar tendon ossification (arrow). (B) Proximal (b1) and distal (b2) removed lesions.

Mentions: Our patient is a healthy 42-year-old Caucasian man with a history of ACL reconstruction using BPTB performed 20 months before our examination by another surgeon. Ten months from surgery, the patient reported persistent and progressive femoro-patellar pain of the left knee, mainly on the patellar apex, during kneeling, climbing up and down the stairs. He also reported progressive thickening and hard texture of the patellar tendon compared to the contralateral. He did not report other knee injuries after the ACL reconstruction. At clinical examination, we noticed two prominences with hard texture, more evident in 90° knee flection, in lateral profile. One prominence was localized on the proximal portion of the patellar tendon and another smaller on the distal portion. The range of motion was limited by pain at 0°-110°, Lachman test, anterior drawer, Jerk test, Pivot-shift and meniscal tear tests were negative, IKDC score (International Knee Documentation Committee) was 41.1. The ultrasound examination was performed at first and the images showed two bone-like echogenic lesions with acoustic shadowing behind. The radiological images revealed two ossifications localized on proximal and distal portion of the patellar tendon. The Computed Tomography (CT) study (Figure 1A, B) was performed and it showed a 2.8 × 1.5 × 1.2 cm conical ossification of the proximal portion and a 1 × 1 × 0.7 cm ossification of the distal portion of the patellar tendon, well represented in the 3D reconstructions (Figure 1C). A comprehensive metabolic panel (glucose, lipids, albumin, total proteins, creatinine, blood urea nitrogen, alanine amino transferase, aspartate amino transferase, alkaline phosphatase, bilirubin, sodium, potassium, chloride and calcium) was performed to exclude metabolic diseases and the result of all tests was within normal ranges. Our hypothesis was that the ossification was the consequence of the persistence of bone fragments inside the patellar tendon after the closure of the soft tissues. Unfortunately, the patient had not any post-operative radiographs to prove this hypothesis. Two months after the diagnosis of ossification of the patellar tendon, an open surgical treatment was performed to remove the proximal and distal lesions (Figure 2A, B). Two masses of bone texture, localized at the patellar apex and at the distal portion of the tendon, inside the tendon sheat and surrounded by tendon’s fibers, were removed. A rigid orthesis locked in extension was applied and an anti-inflammarory therapy with ibuprofen (200 mg twice a day for a week) was performed. The rehabilitation program consisted in: during the I-II weeks loading according the pain, isometric contraction of the quadriceps three times a day, flection 0°-90° twice a day using a CPM device (Continuous Passive Motion) and flexors stretching; during III-IV weeks were added isotonic contraction of the quadriceps 0°-30° and active/passive flection 0°-120° (III-IV week) and 0°-135° (V-VI week). After six weeks of rehabilitation the patient returned to normal activity. At three years from surgery, the patient did not report femoro-patellar pain, there was not range of motion limitation, IKDC score was 90.8. Both clinical and radiological examinations resulted negative too.


Patellar tendon ossification after anterior cruciate ligament reconstruction using bone--patellar tendon--bone autograft.

Camillieri G, Di Sanzo V, Ferretti M, Calderaro C, Calvisi V - BMC Musculoskelet Disord (2013)

Intraoperative images. (A) Intraoperative image showing the proximal patellar tendon ossification (arrow). (B) Proximal (b1) and distal (b2) removed lesions.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3672061&req=5

Figure 2: Intraoperative images. (A) Intraoperative image showing the proximal patellar tendon ossification (arrow). (B) Proximal (b1) and distal (b2) removed lesions.
Mentions: Our patient is a healthy 42-year-old Caucasian man with a history of ACL reconstruction using BPTB performed 20 months before our examination by another surgeon. Ten months from surgery, the patient reported persistent and progressive femoro-patellar pain of the left knee, mainly on the patellar apex, during kneeling, climbing up and down the stairs. He also reported progressive thickening and hard texture of the patellar tendon compared to the contralateral. He did not report other knee injuries after the ACL reconstruction. At clinical examination, we noticed two prominences with hard texture, more evident in 90° knee flection, in lateral profile. One prominence was localized on the proximal portion of the patellar tendon and another smaller on the distal portion. The range of motion was limited by pain at 0°-110°, Lachman test, anterior drawer, Jerk test, Pivot-shift and meniscal tear tests were negative, IKDC score (International Knee Documentation Committee) was 41.1. The ultrasound examination was performed at first and the images showed two bone-like echogenic lesions with acoustic shadowing behind. The radiological images revealed two ossifications localized on proximal and distal portion of the patellar tendon. The Computed Tomography (CT) study (Figure 1A, B) was performed and it showed a 2.8 × 1.5 × 1.2 cm conical ossification of the proximal portion and a 1 × 1 × 0.7 cm ossification of the distal portion of the patellar tendon, well represented in the 3D reconstructions (Figure 1C). A comprehensive metabolic panel (glucose, lipids, albumin, total proteins, creatinine, blood urea nitrogen, alanine amino transferase, aspartate amino transferase, alkaline phosphatase, bilirubin, sodium, potassium, chloride and calcium) was performed to exclude metabolic diseases and the result of all tests was within normal ranges. Our hypothesis was that the ossification was the consequence of the persistence of bone fragments inside the patellar tendon after the closure of the soft tissues. Unfortunately, the patient had not any post-operative radiographs to prove this hypothesis. Two months after the diagnosis of ossification of the patellar tendon, an open surgical treatment was performed to remove the proximal and distal lesions (Figure 2A, B). Two masses of bone texture, localized at the patellar apex and at the distal portion of the tendon, inside the tendon sheat and surrounded by tendon’s fibers, were removed. A rigid orthesis locked in extension was applied and an anti-inflammarory therapy with ibuprofen (200 mg twice a day for a week) was performed. The rehabilitation program consisted in: during the I-II weeks loading according the pain, isometric contraction of the quadriceps three times a day, flection 0°-90° twice a day using a CPM device (Continuous Passive Motion) and flexors stretching; during III-IV weeks were added isotonic contraction of the quadriceps 0°-30° and active/passive flection 0°-120° (III-IV week) and 0°-135° (V-VI week). After six weeks of rehabilitation the patient returned to normal activity. At three years from surgery, the patient did not report femoro-patellar pain, there was not range of motion limitation, IKDC score was 90.8. Both clinical and radiological examinations resulted negative too.

Bottom Line: The clinical diagnosis was confirmed by Ultrasound, X-Ray and Computed Tomography studies, blood tests were performed to exclude metabolic diseases then the surgical removal of the lesion was performed.After three years from surgery, the patient did not report femoro-patellar pain, there was not range of motion limitation and the clinical-radiological examinations resulted negative.The surgical removal of the ossifications followed by anti-inflammatory therapy, seems to be useful in order to relieve pain and to prevent relapses.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedic Surgery, University of L’Aquila, Rome, Italy.

ABSTRACT

Background: Among the various complications described in literature, the patellar tendon ossification is an uncommon occurrence in anterior cruciate ligament (ACL) reconstruction using bone - patellar tendon - bone graft (BPTB). The heterotopic ossification is linked to knee traumatism, intramedullary nailing of the tibia and after partial patellectomy, but only two cases of this event linked to ACL surgery have been reported in literature.

Case presentation: We present a case of a 42-year-old Caucasian man affected by symptomatic extended heterotopic ossification of patellar tendon after 20 months from ACL reconstruction using BPTB. The clinical diagnosis was confirmed by Ultrasound, X-Ray and Computed Tomography studies, blood tests were performed to exclude metabolic diseases then the surgical removal of the lesion was performed. After three years from surgery, the patient did not report femoro-patellar pain, there was not range of motion limitation and the clinical-radiological examinations resulted negative.

Conclusion: The surgical removal of the ossifications followed by anti-inflammatory therapy, seems to be useful in order to relieve pain and to prevent relapses. Moreover, a thorough cleaning of the patellar tendon may reveal useful, in order to prevent bone fragments remain inside it and to reduce patellar tendon heterotopic ossification risk.

Show MeSH
Related in: MedlinePlus