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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.

No MeSH data available.


Postoperative radiograph after allograft patellar tendon reconstruction of the (A) right and (B) left knees.
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fig4-2325967116672175: Postoperative radiograph after allograft patellar tendon reconstruction of the (A) right and (B) left knees.

Mentions: The distraction proceeded well with the right as well as the left patellae, with the need to speed the rate of distraction on the left side at some point to 3 mm per day where the patella was more proximally migrated and to make up for having to stop the distraction for almost 2 weeks until resolution of the pin tract infection. The correction was achieved after 2 months on the right side and after 3 months on the left side. Once the patellae were in a satisfactory position bilaterally (Figure 3), the decision was made to remove the frames after 3 months and proceed with open bilateral patellar tendon reconstruction (Figure 4). This was done using patellar tendon allograft, and fixation of the tibial tubercle allograft bone plug into a trough in the proximal tibia was accomplished using 4.5-mm cortical screws bilaterally. Proximally, the allograft tendon was secured to the quadriceps tendon using 5.0 Ethibond sutures (Ethicon). Postoperatively, ROM was initiated on the first postoperative day starting at 0° to 40°, progressing to 60° at 2 weeks, and increased gradually to 90° by 4 weeks. The patient was allowed partial weightbearing with crutches and a hinged knee brace set at 0° to 50° for 6 weeks, then continued using the brace for walking for another 4 weeks until regaining quadriceps strength. The patient was followed monthly, and bony healing of the tibial tubercle allograft to the proximal tibia was achieved by 16 weeks. The patient underwent physical therapy postoperatively, was able to gradually achieve full extension and 100° flexion bilaterally, and was able to stand and walk again. 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. The final ROM was full extension to 100° flexion bilaterally. The quadriceps strength was 5 out of 5 bilaterally, and no functional outcome scores were obtained pre- or postoperatively. The patient died of medical problems unrelated to his orthopaedic condition. We were not able to obtain a letter of consent.


Neglected Patellar Tendon Rupture With Massive Proximal Patellar Migration Treated With Patellar Transport and Staged Allograft Reconstruction
Postoperative radiograph after allograft patellar tendon reconstruction of the (A) right and (B) left knees.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

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

fig4-2325967116672175: Postoperative radiograph after allograft patellar tendon reconstruction of the (A) right and (B) left knees.
Mentions: The distraction proceeded well with the right as well as the left patellae, with the need to speed the rate of distraction on the left side at some point to 3 mm per day where the patella was more proximally migrated and to make up for having to stop the distraction for almost 2 weeks until resolution of the pin tract infection. The correction was achieved after 2 months on the right side and after 3 months on the left side. Once the patellae were in a satisfactory position bilaterally (Figure 3), the decision was made to remove the frames after 3 months and proceed with open bilateral patellar tendon reconstruction (Figure 4). This was done using patellar tendon allograft, and fixation of the tibial tubercle allograft bone plug into a trough in the proximal tibia was accomplished using 4.5-mm cortical screws bilaterally. Proximally, the allograft tendon was secured to the quadriceps tendon using 5.0 Ethibond sutures (Ethicon). Postoperatively, ROM was initiated on the first postoperative day starting at 0° to 40°, progressing to 60° at 2 weeks, and increased gradually to 90° by 4 weeks. The patient was allowed partial weightbearing with crutches and a hinged knee brace set at 0° to 50° for 6 weeks, then continued using the brace for walking for another 4 weeks until regaining quadriceps strength. The patient was followed monthly, and bony healing of the tibial tubercle allograft to the proximal tibia was achieved by 16 weeks. The patient underwent physical therapy postoperatively, was able to gradually achieve full extension and 100° flexion bilaterally, and was able to stand and walk again. 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. The final ROM was full extension to 100° flexion bilaterally. The quadriceps strength was 5 out of 5 bilaterally, and no functional outcome scores were obtained pre- or postoperatively. The patient died of medical problems unrelated to his orthopaedic condition. We were not able to obtain a letter of consent.

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.