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Neglected Patellar Tendon Rupture With Massive Proximal Patellar Migration Treated With Patellar Transport and Staged Allograft Reconstruction

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Several methods had been reported to relocate the proximally migrated patella distally to its anatomic location, including preoperative traction, intraoperative traction, quadricepsplasty, and external fixation... Over the course of 2 years, the patient developed progressive scarring of the quadriceps tendon on the left side and had an extensor lag of 25°... He was operated upon successfully with open quadricepsplasty and was able to again achieve full extension... In their case report of 2 cases, the final ROM was 0° to 90° and 0° to 120°, with no extensor lag... Synthetic materials have also been used with satisfactory results... In cases with severe quadriceps tendon contracture and fixed proximal patellar migration, numerous techniques have been reported to adequately mobilize the patella and relocate it distally to its anatomic position and to reconstruct the patellar tendon; however, there is no widely accepted method... Levin used a Dacron graft to replace the tendon followed by cast immobilization for 6 weeks... Casey and Tietjens reported on 4 cases where they successfully used direct repair augmented by cerclage... The use of external fixation has been reported for patients with severe quadriceps contractures and fixed elevated patella... Isiklar et al reported on 2 patients with chronic patellar tendon ruptures due to failed primary repairs in which the authors used ring and wire external fixation, applying the distraction principles of Ilizarov preoperatively to mobilize the patella distally and postoperatively to protect the reconstruction while maintaining ROM and full weightbearing... In their case report, Isiklar et al reported on successful use of external fixation to treat 2 patients with chronic patellar tendon ruptures with failed primary repair, presenting 3.5 years and 8 months after the initial injury, the final ROM achieved was 0° to 130° in 1 patient and 0° to 110° in the second patient, with no extensor lag, normal Insall-Salvati ratio, and 5 out of 5 quadriceps strength in both patients... Those results were most similar to the results we achieved... The wires were pulled axially through a small wire site at the skin minimizing skin trauma... Despite the high rate of complications encountered, specifically the pin tract infection in the first patient and deep vein thrombosis in the second patient, those complications were managed conservatively and appropriately without the need to reoperate and without any effect on the final outcome of the procedure.

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Intraoperative view showing bilateral Ilizarov frame application. Note the distal ring holding the patella will be pushed distally (arrow), transporting the patella to the outlined circle.
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fig2-2325967116672175: Intraoperative view showing bilateral Ilizarov frame application. Note the distal ring holding the patella will be pushed distally (arrow), transporting the patella to the outlined circle.

Mentions: A 2-ring circular external fixator frame was used (Figure 2). The proximal ring was a 180-mm two-thirds ring fixed to the femur using two 6-mm half pins. The distal ring was a 155-mm half ring fixed to the patella using 2 tension wires placed within the patella from lateral to medial with an angle spread of about 20°. Three distraction rods were then placed between the femoral and patellar rings, with hinges adjacent to the patella half ring. Postoperatively, the patient was allowed weightbearing as tolerated and knee ROM exercises. The adjustments were started on the first postoperative day, with a target of 1.5-mm distraction per day divided into 3 adjustments. The patient was followed up every 2 weeks with radiographs of both knees to follow the progression of distal transfer of the patella. The target was to pull the right patella distally 6 cm and the left 9 cm. We used the Insall-Salvati ratio14 for assessment of patellar height to follow the progression of distal patellar transport, and the goal was to achieve a ratio of 1.


Neglected Patellar Tendon Rupture With Massive Proximal Patellar Migration Treated With Patellar Transport and Staged Allograft Reconstruction
Intraoperative view showing bilateral Ilizarov frame application. Note the distal ring holding the patella will be pushed distally (arrow), transporting the patella to the outlined circle.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2 - License 3
Show All Figures
getmorefigures.php?uid=PMC5120681&req=5

fig2-2325967116672175: Intraoperative view showing bilateral Ilizarov frame application. Note the distal ring holding the patella will be pushed distally (arrow), transporting the patella to the outlined circle.
Mentions: A 2-ring circular external fixator frame was used (Figure 2). The proximal ring was a 180-mm two-thirds ring fixed to the femur using two 6-mm half pins. The distal ring was a 155-mm half ring fixed to the patella using 2 tension wires placed within the patella from lateral to medial with an angle spread of about 20°. Three distraction rods were then placed between the femoral and patellar rings, with hinges adjacent to the patella half ring. Postoperatively, the patient was allowed weightbearing as tolerated and knee ROM exercises. The adjustments were started on the first postoperative day, with a target of 1.5-mm distraction per day divided into 3 adjustments. The patient was followed up every 2 weeks with radiographs of both knees to follow the progression of distal transfer of the patella. The target was to pull the right patella distally 6 cm and the left 9 cm. We used the Insall-Salvati ratio14 for assessment of patellar height to follow the progression of distal patellar transport, and the goal was to achieve a ratio of 1.

View Article: PubMed Central - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Several methods had been reported to relocate the proximally migrated patella distally to its anatomic location, including preoperative traction, intraoperative traction, quadricepsplasty, and external fixation... Over the course of 2 years, the patient developed progressive scarring of the quadriceps tendon on the left side and had an extensor lag of 25°... He was operated upon successfully with open quadricepsplasty and was able to again achieve full extension... In their case report of 2 cases, the final ROM was 0° to 90° and 0° to 120°, with no extensor lag... Synthetic materials have also been used with satisfactory results... In cases with severe quadriceps tendon contracture and fixed proximal patellar migration, numerous techniques have been reported to adequately mobilize the patella and relocate it distally to its anatomic position and to reconstruct the patellar tendon; however, there is no widely accepted method... Levin used a Dacron graft to replace the tendon followed by cast immobilization for 6 weeks... Casey and Tietjens reported on 4 cases where they successfully used direct repair augmented by cerclage... The use of external fixation has been reported for patients with severe quadriceps contractures and fixed elevated patella... Isiklar et al reported on 2 patients with chronic patellar tendon ruptures due to failed primary repairs in which the authors used ring and wire external fixation, applying the distraction principles of Ilizarov preoperatively to mobilize the patella distally and postoperatively to protect the reconstruction while maintaining ROM and full weightbearing... In their case report, Isiklar et al reported on successful use of external fixation to treat 2 patients with chronic patellar tendon ruptures with failed primary repair, presenting 3.5 years and 8 months after the initial injury, the final ROM achieved was 0° to 130° in 1 patient and 0° to 110° in the second patient, with no extensor lag, normal Insall-Salvati ratio, and 5 out of 5 quadriceps strength in both patients... Those results were most similar to the results we achieved... The wires were pulled axially through a small wire site at the skin minimizing skin trauma... Despite the high rate of complications encountered, specifically the pin tract infection in the first patient and deep vein thrombosis in the second patient, those complications were managed conservatively and appropriately without the need to reoperate and without any effect on the final outcome of the procedure.

No MeSH data available.