- Email: [email protected]
Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction (using a tendoachilles allograft) in a case of chronic patellar tendon rupture: A case report
THEKNE-02972; No of Pages 9 The Knee xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Knee
Novel techniques
Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction (using a tendoachilles allograft) in a case of chronic patellar tendon rupture: A case report Abhijeet Kumar a,⁎, Jill Rutherford-Davies a, Philippa Thorpe b, Annalisa Newson a a b
Salford Royal NHS Foundation Trust, Salford, UK Royal Liverpool and Broadgreen NHS Trust, UK
a r t i c l e
i n f o
Article history: Received 20 September 2019 Received in revised form 14 December 2019 Accepted 19 December 2019 Available online xxxx Keywords: Patella alta Extensor mechanism reconstruction Quadriceps contracture Achilles tendon allograft Chronic patellar tendon rupture External fixator
a b s t r a c t Background: Patellar tendon rupture is an infrequent and debilitating condition, which if left untreated, is complicated by quadriceps contracture and patella alta. This results in reduced function of the knee extensor mechanism including extension lag, reduced range of motion (ROM), chronic knee pain, and frequent falls. Early primary repair has good results in most cases and is performed by opposing and suturing the tendon ends. However, when there is a delay between rupture and repair or in case of a re-rupture, primary repair techniques may not work due to retraction of the extensor mechanism. Several treatment modalities have been proposed in such cases, but there is no clear consensus. Methodology: We present the case of a 39-year-old male with chronic rupture of patellar tendon that was reconstructed with a two-stage technique. In the first stage, a ring-fixator was applied to stretch the quadriceps muscle and the second stage consisted of reconstruction of the patellar tendon with a tendoachilles allograft. This procedure was performed in two stages five weeks apart and almost four years after the initial injury. Results: Results were excellent at three years' follow-up with the patient achieving full extension, a ROM of 0–110° and 85% quadriceps strength. There was significant improvement in his pain, mobility and quadriceps bulk. Conclusion: To our knowledge, this treatment has not previously been described in the literature. We present this case as a proven treatment option for treatment of chronic patellar tendon injuries with extensor mechanism shortening. © 2019 Elsevier B.V. All rights reserved.
1. Introduction Patellar tendon ruptures mostly occur in people under 40 years of age [1], typically during a sporting activity [2]. Treatment of acute patellar tendon ruptures involves direct tendon-to-tendon repair or trans-osseous sutures, usually combined with an additional procedure to temporarily protect the repair [3]. The type of repair depends upon the site of injury of the patellar tendon.
⁎ Corresponding author. E-mail address: [email protected]. (A. Kumar).
https://doi.org/10.1016/j.knee.2019.12.014 0968-0160/© 2019 Elsevier B.V. All rights reserved.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
2
A. Kumar et al. / The Knee xxx (xxxx) xxx
A rupture becomes chronic or neglected if not diagnosed or left untreated or if a primary repair re-ruptures. Chronic patellar tendon rupture is an uncommon and disabling injury. Impairment of the extensor mechanism results in great functional disability, thus, advocating the use of surgical modality of treatment as a gold standard [4], and, if left untreated, further complicates the problems by chronic contraction and shortening of the quadriceps tendon. The management of a neglected, chronic patellar tendon rupture must address three difficulties: the proximally retracted patella, the reconstruction of the patellar tendon, and finally, the temporary protection of this repair with appropriate rehabilitation [5]. As it is a rare condition with many described treatment techniques, there is no consensus on the optimal management. We present a case report of a patient with a chronic rupture of the patellar tendon (as a result of re-rupture after an acute repair) with significant quadriceps retraction. This patient was treated with a ring fixator to lengthen the contracted quadriceps tendon that was followed by reconstruction of the patellar tendon with the help of a tendoachilles (TA) allograft. We did not find any similar procedures described in the literature to date.
2. Case report A 39-year-old male patient with a chronic patellar tendon rupture was referred to our hospital with the inability to straighten his right leg at the knee joint, inability to get up and down the stairs and progressive loss of range of movements in his right knee and a poor gait that interfered with his work and day to day function. On examination, he had 0° passive extension and 80° of passive knee flexion. His active range of movement was 40–70°, which meant he had 40° of active extension lag. He had a palpable gap between the patella (which was high riding) and the tibial tuberosity. He was unable to straighten his knee or straighten leg raise. His quadriceps on the affected side was markedly wasted. He had multiple healed scars consistent with primary repair and attempted reconstruction. The patient gave a history of a simple fall four years earlier that resulted in patellar tendon rupture for which he had an early appropriate primary repair with bone anchors and protected using circlage wiring through a midline incision. Subsequently, he had a further fall on to his knee four weeks following primary repair whilst still recovering from the initial surgery that halted his progress. His clinical examination and a fresh ultrasound confirmed the findings of a re-rupture of the patellar tendon. Patellar tendon reconstruction was attempted with a re-repair and a hamstring autograft from the same leg was used to reinforce the reconstruction. The patient reported that he did not regain the ability to a straight leg raise following his second procedure and his quadriceps strength and knee range of motion (ROM) continued to deteriorate. Radiological examination showed a high riding patella with a Blackburne–Peel index [6] of 2.1, as compared with 0.8 on his uninjured side (Figure 1). Imaging of his extensor mechanism using magnetic resonance imaging (MRI), ultrasound and plain films revealed a complete attenuation of the patellar tendon and a gap of 8.9 cm between the inferior pole of patella and tibial tuberosity.
Figure 1. Preoperative radiographs. (a) Anteroposterior view of the affected side; (b) lateral view of the affected side (Blackburne–Peele Index of 2.1), with a high riding patella.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
3
2.1. Preoperative plan We identified that the key barriers to reconstruction were the retracted quadriceps muscle and subsequent significant patella alta. Hence, we realised that without lengthening the quadriceps and lowering the position of the patella, we would not regain satisfactory extensor mechanism function. We needed to regain the normal lever arm function of the extensor mechanism before trying to plan for any kind of reconstruction, or else the lever arm of the extensor mechanism would change and it would never be able to function correctly. We could surmise that whilst the quadriceps on the affected leg was weak and retracted, it had not been injured and had a functioning nerve supply. Quadriceps plasty is one method of lengthening the quadriceps muscle but is associated with poor results and is known to have significant morbidity attached to the procedure. We proposed that we could use the patella as a bony anchor with which to stretch out the quadriceps muscle. A concept was designed of an external ring fixator frame within a ring, within a frame, whereby the internal ring would be anchored across the patella and this ring could be moved within the frame to lengthen the quadriceps muscle. 2.2. Operative procedure Before undertaking the procedure, the patient was counselled at length in clinic about the plan of a two-staged procedure with a period of lengthening of the quadriceps followed by the second stage consisting of reconstruction of the patellar tendon with a TA allograft. Both the procedures were carried out under general anaesthesia, in supine position with antibiotic prophylaxis as per trust policy. 2.2.1. First stage — extensor tendon reconstruction right knee with circular frame application Intra-operatively, the patient was placed in a supine position under general anaesthesia with a sandbag under the ipsilateral buttock. A circular frame under image intensifier was applied as follows: 2 × 180-mm half rings in the distal femur and 1 × 180mm full ring in the proximal tibia as an outer frame. The inner frame consisted of 2 × 160-mm half rings, one anchored in the proximal tibia and one anchored through the patella. A mixture of olive wires and half pins were used to apply the ‘frame in a frame’ construct to the leg. All the wires and half-pins were inserted under image intensifier using cooling techniques and were dressed according to the Liverpool pin site protocol. All wires were tensioned with a lower tension in the patella due to the nature of the sesamoid bone. Images under fluoroscopy were found to be satisfactory. Postoperative images (first stage) after the application of circular frame are shown in Figure 2. Following discharge, the patient was asked to undertake four quarter-turns three times per day as pain allowed. Initially, it was planned to continue the turns for a two-week period but following 10 days of turns, the patient returned to the clinic describing significant discomfort in the quadriceps muscle as a result of the tension applied to the muscle. Radiographs illustrated good progress, showing that the patella had moved more inferiorly in relation to the distal femur compared with preoperative films. Due to the patient's discomfort, we reduced the number of turns and frequency of turns to move the patella within the outer frame. The patient did not undertake any further turns for two weeks before his second stage. He merely maintained the tension in the quadriceps muscle with the hope that when released from the frame, the quadriceps would maintain its length. Throughout the lengthening, the patient was reviewed by our dedicated knee physiotherapist who worked with the patient to
Figure 2. Postoperative images (first stage) after the application of circular frame.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
4
A. Kumar et al. / The Knee xxx (xxxx) xxx
Figure 3. Postoperative radiographs (first stage): anteroposterior and lateral view, after the application of the circular frame.
gain strength and function within the quadriceps muscle. Postoperative radiographs (first stage), after the application of the circular frame, are shown in Figure 3.
2.2.2. Second stage: removal of Ilizarov frame and reconstruction of the extensor tendon mechanism with neoligament and cadaveric TA allograft with a bone block The second stage of the surgery was performed five weeks following the application of the frame construct. The frame was removed in full and the leg was prepped for the reconstruction. Patient was operated in a supine position under general anaesthesia with a tourniquet inflated to 300 mm Hg for part of the operation and antibiotics given at induction. At the beginning of the second stage, the position of the patella on the unaffected leg was imaged to illustrate to the surgeon the ‘normal’ position of the patella in this patient at 0 and 90°. Both legs were kept parallel intra-operatively to measure and compare the distance between the inferior pole of patella and tibial tuberosity at 0 and 90° of flexion. The previous midline incision was used and extended proximally. The tibial tubercle was exposed and a rectangular defect was made in the tibial tubercle into which the bone block on the allograft was shaped for a tight fit. The block was secured in situ with a four-hole1/3 tubular plate and 3 × 3.5-mm cortical screws. The use of the previous midline incision to expose the knee is shown in Figure 4. The defect in the tibial tubercle to receive the allograft bone block is shown in Figure 5. The cadaveric tendon was then divided into three limbs and each limb was whip stitched with fibre loop. Three separate tunnels were drilled through the patella from inferiorly to superiorly and the three whip stitched ends of the TA were passed through these tunnels.
Figure 4. Use of previous midline incision to expose the knee.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
5
Figure 5. Defect in the tibial tubercle to receive the allograft bone block.
The central part of the tendon was stitched back on itself using an absorbable suture with appropriate tension guided by the position of patella on image intensifier at 0 and 90°. The medial and lateral ends of the tendon were fixed in situ to the patella with appropriate tension. The remaining whip stitched ends were weaved through the quadriceps tendon. The neoligament was used as a circlage and an overlay reinforcement. It was anchored through a tunnel in the tibia below the tibial tubercle and weaved through the cadaveric tendon and passed around the sides of the patella and secured above the patella. It was tied under tension adding an additional force to help maintain the patella in its new lower position. When tensioning the reconstructed extensor mechanism, the leg was parallel to the other side and with direct measurement of the tibial tubercle and inferior pole of patella at 0 and 90° of flexion. The patella was found to be tracking centrally in the trochlear groove and the patella height was found to be acceptable. The three tunnels drilled inferiorly to superiorly through the patella and the three whip-stitched ends passed through the tunnels are shown in Figure 6. Figure 7 shows the attachment of the TA allograft and securing the bone block into the tibial tubercle defect. Figure 8 shows the neoligament secured to the tibial crest and weaved through the cadaveric tendon. 2.3. Postoperative period The postoperative period was uneventful. The rehabilitation protocol reduced the patient to partial weight bearing for six weeks and advised against active quadriceps exercises. The patient's knee was placed in a hinged sports knee brace and the knee was kept in extension for the first two weeks. This was increased to 0–60° from weeks two to four, and 0–90° from weeks four to six. The patient was then allowed free range of movements but within the brace for a further two weeks before the brace was removed. The patient was allowed to fully weight bear as able from six weeks postoperatively. The patient reached 90° of active flexion at three months and by the end of the sixth month, his passive ROM was 0–100° and active ROM was 0–90°. He was able to actively extend his knee to 0° of extension with no extension lag compared to 40° preoperatively. Figure 9 shows the postoperative radiographs. At three years' follow-up, the patient's ROM was 0–120° with no restriction to active extension (Figure 10). The International Knee Documentation Committee (IKDC) subjective knee evaluation score at three years was 90. He described his knee function as optimal compared with preoperative state where he was unable to perform activities of daily living. Radiographs (Figure 11) showed complete incorporation of the bone parts of the allograft. The patellar height was within normal limits. Blackburne–Peel ratio was 1.2.
Figure 6. Three tunnels drilled inferiorly to superiorly through the patella and the three whip-stitched ends passed through the tunnels.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
6
A. Kumar et al. / The Knee xxx (xxxx) xxx
Figure 7. Attachment of the tendoachilles (TA) allograft and securing the bone block into the tibial tubercle defect.
3. Conclusion Chronic patellar tendon ruptures are rare. Surgical repair is based on tendon augmentation with an autograft, allograft or synthetic material, but no consensus has emerged. This particular case was complicated by the significant retraction of the quadriceps muscle and a subsequent patella alta. Recognition of this and the need to correct this problem initially enabled subsequent successful reconstruction of the extensor mechanism. The use of a TA allograft reduces donor site morbidity and does not require surgical revision to remove any metalwork. This combined technique of quadriceps lengthening by a novel technique of using an external fixator with a frame-in-a-frame construct and patellar tendon reconstruction using TA allograft can be a reliable treatment option for chronic patellar tendon ruptures or re-ruptures. 4. Discussion We represent a case of a primary patellar tendon repair with a subsequent early re-injury followed by a failed reconstruction who presented to us almost four years after the initial injury. Surgical intervention to repair a patellar tendon rupture is essential to restore the continuity and function of the extensor mechanism [7]. Non-surgical options such as locking knee braces and assisted ambulatory devices rarely yield acceptable outcomes and the only time they may be considered are in elderly and sedentary patients. In early cases, where the ends of patellar tendon can be reasonably well approximated, most surgeons prefer to perform a repair with or without an augmentation with a graft (natural/synthetic). In chronic cases, the patella is retracted proximally and may require extensive surgical release to draw it distally to the appropriate level. Surgical releases, for example, quadriceps plasty, have shown mixed results over time and are associated with a lot of morbidity, thus are not very popular options among many knee surgeons. Preoperative assessment of patellar height is essential for proper planning of the procedure. In this case, we lengthened the quadriceps by stretching it using an external fixator with a frame-in-frame construct. This stretched the muscle and corrected the patella alta enough before the second stage of reconstruction using the TA autograft could be carried out. If the rupture is several months old or if the tendon is destroyed, different authors have presented their findings on the choice of graft they have used for reconstruction. There are various options in the form of autografts, allografts and synthetic grafts. Gillmore et al. [8] in their research suggested that using autografts for reconstruction in these cases is associated with a significantly lower failure rate. Dejour et al. [9] in 1992 described the use of contralateral bone–patellar-tendon–bone graft for reconstruction in these cases with a good overall success rate. Ecker et al. [10] and Mandelbaum et al. [11] in their studies dealing with chronic patellar tendon injuries used semitendinosis and gracilis autografts with good clinical results and functional outcomes. Falconiero and Pallis used the tendo-calcaneal allografts with some success in this situation in the past [12]. Naguib and
Figure 8. Neoligament secured to the tibial crest and weaved through the cadaveric tendon.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
7
Figure 9. Postoperative radiographs anteroposterior and lateral view.
Sefton, in 2006 in their study used synthetic material in the form of polyester tissue prosthesis to treat a case of bilateral chronic patellar tendon injury with good postoperative results [13]. However, TA allograft compared with the less substantial hamstring tendons allows earlier more vigorous rehabilitation [14]. The use of Achilles allograft is not new and has been described in the literature previously for the treatment of chronic patellar tendon injuries [12,15]. In their technique, Crossett et al. described the use of a TA allograft with a calcaneal bone block [15]. The bone block was anchored into the proximal tibial defect and the Achilles tendon was sutured to the underlying extensor mechanism over a closed joint capsule. Bermudez et al., in their study, used a very similar technique to Crossett and reported good functional scores [16]. Barrack et al. also used Achilles tendon allografts for the purpose of reconstruction of an attenuated patellar tendon following chronic patellar tendon injuries in patients with a total knee arthroplasty with encouraging clinical and functional outcomes postoperatively [17]. The risk of disease transmission is an important consideration and has been thoroughly discussed in the literature as a disastrous complication of allograft surgery. A recent study by Katz et al. [18] on anterior cruciate ligament reconstructed knees
Figure 10. Clinical function at three years.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
8
A. Kumar et al. / The Knee xxx (xxxx) xxx
Figure 11. Three years postoperative radiographs: anteroposterior and lateral views.
compared infection rates when using autografts and allografts and failed to find a higher rate of deep bacterial infection in anterior cruciate ligament reconstructions when allograft tissue was used. Also of note is that our institution uses BioCleanse to prepare the allografts that have been shown to be an effective means of graft preparation and sterilization without compromising the mechanical integrity of the graft [19]. The patient returned to his re-injury level of activity and was very satisfied. Rupture of the extensor mechanism is a major disabling injury which is further complicated if there is contracture of the quadriceps muscle. To our knowledge, the use of a frame-in-frame construct external fixator to lengthen the contracted quadriceps preceding a ligament reconstruction with a TA allograft has not been reported in the literature to treat this condition and due to our positive experience, we can recommend this technique. Declaration of competing interest None. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Kannus P. Etiology and pathophysiology of chronic tendon disorders in sports. Scand J Med Sci Sports 2007;7:78–85. https://doi.org/10.1111/j.1600-0838.1997. tb00123.x. [2] Järvelä T, Halonen P, Järvelä K, Moilanen T. Reconstruction of ruptured patellar tendon after total knee arthroplasty: a case report and a description of an alternative fixation method. Knee 2005;12:139–43. https://doi.org/10.1016/j.knee.2004.05.005. [3] McNally P, Marcelli E. Achilles allograft reconstruction of a chronic patellar tendon rupture. Arthroscopy 1998;14:340–4. https://doi.org/10.1016/s0749-8063(98) 70154-9. [4] Greis P, Lahaw A, Holmstrom M. Surgical treatment options for patella tendon rupture, part II: chronic. Orthopedics 2005;28:765–9. https://doi.org/10.3928/ 0147-7447-20050801-13. [5] Lewis P, Rue J, Bach B. Chronic patellar tendon rupture – surgical reconstruction technique using 2 achilles tendon allografts. J Knee Surg 2010;21:130–5. https:// doi.org/10.1055/s-0030-1247807. [6] Blackburne J, Peel T. A new method of measuring patellar height. J Bone Joint Surg Br 1977;59-B:241–2. https://doi.org/10.1302/0301-620x.59b2.873986. [7] Schindler O. Insall & Scott surgery of the knee. J Bone Joint Surg Br 2006;88-B:1678. https://doi.org/10.1302/0301-620x.88b9.18858. [8] Gilmore J, Clayton-Smith Z, Aguilar M, Pneumaticos S, Giannoudis P. Reconstruction techniques and clinical results of patellar tendon ruptures: evidence today. Knee 2015;22:148–55. https://doi.org/10.1016/j.knee.2014.10.007. [9] Dejour H, Denjean S, Neyret P. Treatment of old or recurrent ruptures of the patellar ligament by contralateral autograft. Rev Chir Orthop Reparatrice Appar Mot 1992;78(1):58–62.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
9
[10] Ecker M, Lotke P, Glazer R. Late reconstruction of the patellar tendon. J Bone Joint Surg 1979;61:884–6. https://doi.org/10.2106/00004623-197961060-00013. [11] Mandelbaum B, Bartolozzi A, Carney B. A systematic approach to reconstruction of neglected tears of the patellar tendon. Clin Orthop Relat Res 1988(235):26871. [12] Falconiero R, Pallis M. Chronic rupture of a patellar tendon: a technique for reconstruction with achilles allograft. Arthroscopy 1996;12:623–6. https://doi.org/10. 1016/s0749-8063(96)90204-2. [13] Naguib A, Sefton G. Recurrent bilateral rupture of the patellar tendons: tendon replacement using polyester connective tissue prosthesis. Injury Extra 2006;37: 379–82. https://doi.org/10.1016/j.injury.2006.03.024. [14] Äärimaa V, Ranne J, Mattila K, Rahi K, Virolainen P, Hiltunen A. Patellar tendon shortening after treatment of patellar instability with a patellar tendon medialization procedure. Scand J Med Sci Sports 2007;18:442–6. https://doi.org/10.1111/j.1600-0838.2007.00730.x. [15] Crossett L, Sinha R, Sechriest V, Rubash H. Reconstruction of a ruptured patellar tendon with Achilles tendon allograft following total knee arthroplasty. J Bone Joint Surg 2002;84:1354–61. https://doi.org/10.2106/00004623-200208000-00011. [16] Bermudez C, Ziran B, Barrette-Grischow M. Use of Achilles tendon-bone allograft for reconstruction of the patellar tendon in patients with severe disruption of the extensor mechanism of the knee: a case report. J Trauma Injury, Infect Crit Care 2007;63:211–6. https://doi.org/10.1097/01.ta.0000241293.03907.ae. [17] Barrack R, Stanley T, Allen Butler R. Treating extensor mechanism disruption after total knee arthroplasty. Clin Orthop Relat Res 2003;416:98–104. https://doi. org/10.1097/01.blo.0000092993.90435.69. [18] Katz L, Battaglia T, Patino P, Reichmann W, Hunter D, Richmond J. A retrospective comparison of the incidence of bacterial infection following anterior cruciate ligament reconstruction with autograft versus allograft. Arthroscopy 2008;24:1330–5. https://doi.org/10.1016/j.arthro.2008.07.015. [19] Conrad B, Rappé M, Horodyski M, Farmer K, Indelicato P. The effect of sterilization on mechanical properties of soft tissue allografts. Cell Tiss Banking 2012;14: 359–66. https://doi.org/10.1007/s10561-012-9340-2.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
Contents lists available at ScienceDirect
The Knee
Novel techniques
Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction (using a tendoachilles allograft) in a case of chronic patellar tendon rupture: A case report Abhijeet Kumar a,⁎, Jill Rutherford-Davies a, Philippa Thorpe b, Annalisa Newson a a b
Salford Royal NHS Foundation Trust, Salford, UK Royal Liverpool and Broadgreen NHS Trust, UK
a r t i c l e
i n f o
Article history: Received 20 September 2019 Received in revised form 14 December 2019 Accepted 19 December 2019 Available online xxxx Keywords: Patella alta Extensor mechanism reconstruction Quadriceps contracture Achilles tendon allograft Chronic patellar tendon rupture External fixator
a b s t r a c t Background: Patellar tendon rupture is an infrequent and debilitating condition, which if left untreated, is complicated by quadriceps contracture and patella alta. This results in reduced function of the knee extensor mechanism including extension lag, reduced range of motion (ROM), chronic knee pain, and frequent falls. Early primary repair has good results in most cases and is performed by opposing and suturing the tendon ends. However, when there is a delay between rupture and repair or in case of a re-rupture, primary repair techniques may not work due to retraction of the extensor mechanism. Several treatment modalities have been proposed in such cases, but there is no clear consensus. Methodology: We present the case of a 39-year-old male with chronic rupture of patellar tendon that was reconstructed with a two-stage technique. In the first stage, a ring-fixator was applied to stretch the quadriceps muscle and the second stage consisted of reconstruction of the patellar tendon with a tendoachilles allograft. This procedure was performed in two stages five weeks apart and almost four years after the initial injury. Results: Results were excellent at three years' follow-up with the patient achieving full extension, a ROM of 0–110° and 85% quadriceps strength. There was significant improvement in his pain, mobility and quadriceps bulk. Conclusion: To our knowledge, this treatment has not previously been described in the literature. We present this case as a proven treatment option for treatment of chronic patellar tendon injuries with extensor mechanism shortening. © 2019 Elsevier B.V. All rights reserved.
1. Introduction Patellar tendon ruptures mostly occur in people under 40 years of age [1], typically during a sporting activity [2]. Treatment of acute patellar tendon ruptures involves direct tendon-to-tendon repair or trans-osseous sutures, usually combined with an additional procedure to temporarily protect the repair [3]. The type of repair depends upon the site of injury of the patellar tendon.
⁎ Corresponding author. E-mail address: [email protected]. (A. Kumar).
https://doi.org/10.1016/j.knee.2019.12.014 0968-0160/© 2019 Elsevier B.V. All rights reserved.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
2
A. Kumar et al. / The Knee xxx (xxxx) xxx
A rupture becomes chronic or neglected if not diagnosed or left untreated or if a primary repair re-ruptures. Chronic patellar tendon rupture is an uncommon and disabling injury. Impairment of the extensor mechanism results in great functional disability, thus, advocating the use of surgical modality of treatment as a gold standard [4], and, if left untreated, further complicates the problems by chronic contraction and shortening of the quadriceps tendon. The management of a neglected, chronic patellar tendon rupture must address three difficulties: the proximally retracted patella, the reconstruction of the patellar tendon, and finally, the temporary protection of this repair with appropriate rehabilitation [5]. As it is a rare condition with many described treatment techniques, there is no consensus on the optimal management. We present a case report of a patient with a chronic rupture of the patellar tendon (as a result of re-rupture after an acute repair) with significant quadriceps retraction. This patient was treated with a ring fixator to lengthen the contracted quadriceps tendon that was followed by reconstruction of the patellar tendon with the help of a tendoachilles (TA) allograft. We did not find any similar procedures described in the literature to date.
2. Case report A 39-year-old male patient with a chronic patellar tendon rupture was referred to our hospital with the inability to straighten his right leg at the knee joint, inability to get up and down the stairs and progressive loss of range of movements in his right knee and a poor gait that interfered with his work and day to day function. On examination, he had 0° passive extension and 80° of passive knee flexion. His active range of movement was 40–70°, which meant he had 40° of active extension lag. He had a palpable gap between the patella (which was high riding) and the tibial tuberosity. He was unable to straighten his knee or straighten leg raise. His quadriceps on the affected side was markedly wasted. He had multiple healed scars consistent with primary repair and attempted reconstruction. The patient gave a history of a simple fall four years earlier that resulted in patellar tendon rupture for which he had an early appropriate primary repair with bone anchors and protected using circlage wiring through a midline incision. Subsequently, he had a further fall on to his knee four weeks following primary repair whilst still recovering from the initial surgery that halted his progress. His clinical examination and a fresh ultrasound confirmed the findings of a re-rupture of the patellar tendon. Patellar tendon reconstruction was attempted with a re-repair and a hamstring autograft from the same leg was used to reinforce the reconstruction. The patient reported that he did not regain the ability to a straight leg raise following his second procedure and his quadriceps strength and knee range of motion (ROM) continued to deteriorate. Radiological examination showed a high riding patella with a Blackburne–Peel index [6] of 2.1, as compared with 0.8 on his uninjured side (Figure 1). Imaging of his extensor mechanism using magnetic resonance imaging (MRI), ultrasound and plain films revealed a complete attenuation of the patellar tendon and a gap of 8.9 cm between the inferior pole of patella and tibial tuberosity.
Figure 1. Preoperative radiographs. (a) Anteroposterior view of the affected side; (b) lateral view of the affected side (Blackburne–Peele Index of 2.1), with a high riding patella.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
3
2.1. Preoperative plan We identified that the key barriers to reconstruction were the retracted quadriceps muscle and subsequent significant patella alta. Hence, we realised that without lengthening the quadriceps and lowering the position of the patella, we would not regain satisfactory extensor mechanism function. We needed to regain the normal lever arm function of the extensor mechanism before trying to plan for any kind of reconstruction, or else the lever arm of the extensor mechanism would change and it would never be able to function correctly. We could surmise that whilst the quadriceps on the affected leg was weak and retracted, it had not been injured and had a functioning nerve supply. Quadriceps plasty is one method of lengthening the quadriceps muscle but is associated with poor results and is known to have significant morbidity attached to the procedure. We proposed that we could use the patella as a bony anchor with which to stretch out the quadriceps muscle. A concept was designed of an external ring fixator frame within a ring, within a frame, whereby the internal ring would be anchored across the patella and this ring could be moved within the frame to lengthen the quadriceps muscle. 2.2. Operative procedure Before undertaking the procedure, the patient was counselled at length in clinic about the plan of a two-staged procedure with a period of lengthening of the quadriceps followed by the second stage consisting of reconstruction of the patellar tendon with a TA allograft. Both the procedures were carried out under general anaesthesia, in supine position with antibiotic prophylaxis as per trust policy. 2.2.1. First stage — extensor tendon reconstruction right knee with circular frame application Intra-operatively, the patient was placed in a supine position under general anaesthesia with a sandbag under the ipsilateral buttock. A circular frame under image intensifier was applied as follows: 2 × 180-mm half rings in the distal femur and 1 × 180mm full ring in the proximal tibia as an outer frame. The inner frame consisted of 2 × 160-mm half rings, one anchored in the proximal tibia and one anchored through the patella. A mixture of olive wires and half pins were used to apply the ‘frame in a frame’ construct to the leg. All the wires and half-pins were inserted under image intensifier using cooling techniques and were dressed according to the Liverpool pin site protocol. All wires were tensioned with a lower tension in the patella due to the nature of the sesamoid bone. Images under fluoroscopy were found to be satisfactory. Postoperative images (first stage) after the application of circular frame are shown in Figure 2. Following discharge, the patient was asked to undertake four quarter-turns three times per day as pain allowed. Initially, it was planned to continue the turns for a two-week period but following 10 days of turns, the patient returned to the clinic describing significant discomfort in the quadriceps muscle as a result of the tension applied to the muscle. Radiographs illustrated good progress, showing that the patella had moved more inferiorly in relation to the distal femur compared with preoperative films. Due to the patient's discomfort, we reduced the number of turns and frequency of turns to move the patella within the outer frame. The patient did not undertake any further turns for two weeks before his second stage. He merely maintained the tension in the quadriceps muscle with the hope that when released from the frame, the quadriceps would maintain its length. Throughout the lengthening, the patient was reviewed by our dedicated knee physiotherapist who worked with the patient to
Figure 2. Postoperative images (first stage) after the application of circular frame.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
4
A. Kumar et al. / The Knee xxx (xxxx) xxx
Figure 3. Postoperative radiographs (first stage): anteroposterior and lateral view, after the application of the circular frame.
gain strength and function within the quadriceps muscle. Postoperative radiographs (first stage), after the application of the circular frame, are shown in Figure 3.
2.2.2. Second stage: removal of Ilizarov frame and reconstruction of the extensor tendon mechanism with neoligament and cadaveric TA allograft with a bone block The second stage of the surgery was performed five weeks following the application of the frame construct. The frame was removed in full and the leg was prepped for the reconstruction. Patient was operated in a supine position under general anaesthesia with a tourniquet inflated to 300 mm Hg for part of the operation and antibiotics given at induction. At the beginning of the second stage, the position of the patella on the unaffected leg was imaged to illustrate to the surgeon the ‘normal’ position of the patella in this patient at 0 and 90°. Both legs were kept parallel intra-operatively to measure and compare the distance between the inferior pole of patella and tibial tuberosity at 0 and 90° of flexion. The previous midline incision was used and extended proximally. The tibial tubercle was exposed and a rectangular defect was made in the tibial tubercle into which the bone block on the allograft was shaped for a tight fit. The block was secured in situ with a four-hole1/3 tubular plate and 3 × 3.5-mm cortical screws. The use of the previous midline incision to expose the knee is shown in Figure 4. The defect in the tibial tubercle to receive the allograft bone block is shown in Figure 5. The cadaveric tendon was then divided into three limbs and each limb was whip stitched with fibre loop. Three separate tunnels were drilled through the patella from inferiorly to superiorly and the three whip stitched ends of the TA were passed through these tunnels.
Figure 4. Use of previous midline incision to expose the knee.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
5
Figure 5. Defect in the tibial tubercle to receive the allograft bone block.
The central part of the tendon was stitched back on itself using an absorbable suture with appropriate tension guided by the position of patella on image intensifier at 0 and 90°. The medial and lateral ends of the tendon were fixed in situ to the patella with appropriate tension. The remaining whip stitched ends were weaved through the quadriceps tendon. The neoligament was used as a circlage and an overlay reinforcement. It was anchored through a tunnel in the tibia below the tibial tubercle and weaved through the cadaveric tendon and passed around the sides of the patella and secured above the patella. It was tied under tension adding an additional force to help maintain the patella in its new lower position. When tensioning the reconstructed extensor mechanism, the leg was parallel to the other side and with direct measurement of the tibial tubercle and inferior pole of patella at 0 and 90° of flexion. The patella was found to be tracking centrally in the trochlear groove and the patella height was found to be acceptable. The three tunnels drilled inferiorly to superiorly through the patella and the three whip-stitched ends passed through the tunnels are shown in Figure 6. Figure 7 shows the attachment of the TA allograft and securing the bone block into the tibial tubercle defect. Figure 8 shows the neoligament secured to the tibial crest and weaved through the cadaveric tendon. 2.3. Postoperative period The postoperative period was uneventful. The rehabilitation protocol reduced the patient to partial weight bearing for six weeks and advised against active quadriceps exercises. The patient's knee was placed in a hinged sports knee brace and the knee was kept in extension for the first two weeks. This was increased to 0–60° from weeks two to four, and 0–90° from weeks four to six. The patient was then allowed free range of movements but within the brace for a further two weeks before the brace was removed. The patient was allowed to fully weight bear as able from six weeks postoperatively. The patient reached 90° of active flexion at three months and by the end of the sixth month, his passive ROM was 0–100° and active ROM was 0–90°. He was able to actively extend his knee to 0° of extension with no extension lag compared to 40° preoperatively. Figure 9 shows the postoperative radiographs. At three years' follow-up, the patient's ROM was 0–120° with no restriction to active extension (Figure 10). The International Knee Documentation Committee (IKDC) subjective knee evaluation score at three years was 90. He described his knee function as optimal compared with preoperative state where he was unable to perform activities of daily living. Radiographs (Figure 11) showed complete incorporation of the bone parts of the allograft. The patellar height was within normal limits. Blackburne–Peel ratio was 1.2.
Figure 6. Three tunnels drilled inferiorly to superiorly through the patella and the three whip-stitched ends passed through the tunnels.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
6
A. Kumar et al. / The Knee xxx (xxxx) xxx
Figure 7. Attachment of the tendoachilles (TA) allograft and securing the bone block into the tibial tubercle defect.
3. Conclusion Chronic patellar tendon ruptures are rare. Surgical repair is based on tendon augmentation with an autograft, allograft or synthetic material, but no consensus has emerged. This particular case was complicated by the significant retraction of the quadriceps muscle and a subsequent patella alta. Recognition of this and the need to correct this problem initially enabled subsequent successful reconstruction of the extensor mechanism. The use of a TA allograft reduces donor site morbidity and does not require surgical revision to remove any metalwork. This combined technique of quadriceps lengthening by a novel technique of using an external fixator with a frame-in-a-frame construct and patellar tendon reconstruction using TA allograft can be a reliable treatment option for chronic patellar tendon ruptures or re-ruptures. 4. Discussion We represent a case of a primary patellar tendon repair with a subsequent early re-injury followed by a failed reconstruction who presented to us almost four years after the initial injury. Surgical intervention to repair a patellar tendon rupture is essential to restore the continuity and function of the extensor mechanism [7]. Non-surgical options such as locking knee braces and assisted ambulatory devices rarely yield acceptable outcomes and the only time they may be considered are in elderly and sedentary patients. In early cases, where the ends of patellar tendon can be reasonably well approximated, most surgeons prefer to perform a repair with or without an augmentation with a graft (natural/synthetic). In chronic cases, the patella is retracted proximally and may require extensive surgical release to draw it distally to the appropriate level. Surgical releases, for example, quadriceps plasty, have shown mixed results over time and are associated with a lot of morbidity, thus are not very popular options among many knee surgeons. Preoperative assessment of patellar height is essential for proper planning of the procedure. In this case, we lengthened the quadriceps by stretching it using an external fixator with a frame-in-frame construct. This stretched the muscle and corrected the patella alta enough before the second stage of reconstruction using the TA autograft could be carried out. If the rupture is several months old or if the tendon is destroyed, different authors have presented their findings on the choice of graft they have used for reconstruction. There are various options in the form of autografts, allografts and synthetic grafts. Gillmore et al. [8] in their research suggested that using autografts for reconstruction in these cases is associated with a significantly lower failure rate. Dejour et al. [9] in 1992 described the use of contralateral bone–patellar-tendon–bone graft for reconstruction in these cases with a good overall success rate. Ecker et al. [10] and Mandelbaum et al. [11] in their studies dealing with chronic patellar tendon injuries used semitendinosis and gracilis autografts with good clinical results and functional outcomes. Falconiero and Pallis used the tendo-calcaneal allografts with some success in this situation in the past [12]. Naguib and
Figure 8. Neoligament secured to the tibial crest and weaved through the cadaveric tendon.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
7
Figure 9. Postoperative radiographs anteroposterior and lateral view.
Sefton, in 2006 in their study used synthetic material in the form of polyester tissue prosthesis to treat a case of bilateral chronic patellar tendon injury with good postoperative results [13]. However, TA allograft compared with the less substantial hamstring tendons allows earlier more vigorous rehabilitation [14]. The use of Achilles allograft is not new and has been described in the literature previously for the treatment of chronic patellar tendon injuries [12,15]. In their technique, Crossett et al. described the use of a TA allograft with a calcaneal bone block [15]. The bone block was anchored into the proximal tibial defect and the Achilles tendon was sutured to the underlying extensor mechanism over a closed joint capsule. Bermudez et al., in their study, used a very similar technique to Crossett and reported good functional scores [16]. Barrack et al. also used Achilles tendon allografts for the purpose of reconstruction of an attenuated patellar tendon following chronic patellar tendon injuries in patients with a total knee arthroplasty with encouraging clinical and functional outcomes postoperatively [17]. The risk of disease transmission is an important consideration and has been thoroughly discussed in the literature as a disastrous complication of allograft surgery. A recent study by Katz et al. [18] on anterior cruciate ligament reconstructed knees
Figure 10. Clinical function at three years.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
8
A. Kumar et al. / The Knee xxx (xxxx) xxx
Figure 11. Three years postoperative radiographs: anteroposterior and lateral views.
compared infection rates when using autografts and allografts and failed to find a higher rate of deep bacterial infection in anterior cruciate ligament reconstructions when allograft tissue was used. Also of note is that our institution uses BioCleanse to prepare the allografts that have been shown to be an effective means of graft preparation and sterilization without compromising the mechanical integrity of the graft [19]. The patient returned to his re-injury level of activity and was very satisfied. Rupture of the extensor mechanism is a major disabling injury which is further complicated if there is contracture of the quadriceps muscle. To our knowledge, the use of a frame-in-frame construct external fixator to lengthen the contracted quadriceps preceding a ligament reconstruction with a TA allograft has not been reported in the literature to treat this condition and due to our positive experience, we can recommend this technique. Declaration of competing interest None. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Kannus P. Etiology and pathophysiology of chronic tendon disorders in sports. Scand J Med Sci Sports 2007;7:78–85. https://doi.org/10.1111/j.1600-0838.1997. tb00123.x. [2] Järvelä T, Halonen P, Järvelä K, Moilanen T. Reconstruction of ruptured patellar tendon after total knee arthroplasty: a case report and a description of an alternative fixation method. Knee 2005;12:139–43. https://doi.org/10.1016/j.knee.2004.05.005. [3] McNally P, Marcelli E. Achilles allograft reconstruction of a chronic patellar tendon rupture. Arthroscopy 1998;14:340–4. https://doi.org/10.1016/s0749-8063(98) 70154-9. [4] Greis P, Lahaw A, Holmstrom M. Surgical treatment options for patella tendon rupture, part II: chronic. Orthopedics 2005;28:765–9. https://doi.org/10.3928/ 0147-7447-20050801-13. [5] Lewis P, Rue J, Bach B. Chronic patellar tendon rupture – surgical reconstruction technique using 2 achilles tendon allografts. J Knee Surg 2010;21:130–5. https:// doi.org/10.1055/s-0030-1247807. [6] Blackburne J, Peel T. A new method of measuring patellar height. J Bone Joint Surg Br 1977;59-B:241–2. https://doi.org/10.1302/0301-620x.59b2.873986. [7] Schindler O. Insall & Scott surgery of the knee. J Bone Joint Surg Br 2006;88-B:1678. https://doi.org/10.1302/0301-620x.88b9.18858. [8] Gilmore J, Clayton-Smith Z, Aguilar M, Pneumaticos S, Giannoudis P. Reconstruction techniques and clinical results of patellar tendon ruptures: evidence today. Knee 2015;22:148–55. https://doi.org/10.1016/j.knee.2014.10.007. [9] Dejour H, Denjean S, Neyret P. Treatment of old or recurrent ruptures of the patellar ligament by contralateral autograft. Rev Chir Orthop Reparatrice Appar Mot 1992;78(1):58–62.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014
A. Kumar et al. / The Knee xxx (xxxx) xxx
9
[10] Ecker M, Lotke P, Glazer R. Late reconstruction of the patellar tendon. J Bone Joint Surg 1979;61:884–6. https://doi.org/10.2106/00004623-197961060-00013. [11] Mandelbaum B, Bartolozzi A, Carney B. A systematic approach to reconstruction of neglected tears of the patellar tendon. Clin Orthop Relat Res 1988(235):26871. [12] Falconiero R, Pallis M. Chronic rupture of a patellar tendon: a technique for reconstruction with achilles allograft. Arthroscopy 1996;12:623–6. https://doi.org/10. 1016/s0749-8063(96)90204-2. [13] Naguib A, Sefton G. Recurrent bilateral rupture of the patellar tendons: tendon replacement using polyester connective tissue prosthesis. Injury Extra 2006;37: 379–82. https://doi.org/10.1016/j.injury.2006.03.024. [14] Äärimaa V, Ranne J, Mattila K, Rahi K, Virolainen P, Hiltunen A. Patellar tendon shortening after treatment of patellar instability with a patellar tendon medialization procedure. Scand J Med Sci Sports 2007;18:442–6. https://doi.org/10.1111/j.1600-0838.2007.00730.x. [15] Crossett L, Sinha R, Sechriest V, Rubash H. Reconstruction of a ruptured patellar tendon with Achilles tendon allograft following total knee arthroplasty. J Bone Joint Surg 2002;84:1354–61. https://doi.org/10.2106/00004623-200208000-00011. [16] Bermudez C, Ziran B, Barrette-Grischow M. Use of Achilles tendon-bone allograft for reconstruction of the patellar tendon in patients with severe disruption of the extensor mechanism of the knee: a case report. J Trauma Injury, Infect Crit Care 2007;63:211–6. https://doi.org/10.1097/01.ta.0000241293.03907.ae. [17] Barrack R, Stanley T, Allen Butler R. Treating extensor mechanism disruption after total knee arthroplasty. Clin Orthop Relat Res 2003;416:98–104. https://doi. org/10.1097/01.blo.0000092993.90435.69. [18] Katz L, Battaglia T, Patino P, Reichmann W, Hunter D, Richmond J. A retrospective comparison of the incidence of bacterial infection following anterior cruciate ligament reconstruction with autograft versus allograft. Arthroscopy 2008;24:1330–5. https://doi.org/10.1016/j.arthro.2008.07.015. [19] Conrad B, Rappé M, Horodyski M, Farmer K, Indelicato P. The effect of sterilization on mechanical properties of soft tissue allografts. Cell Tiss Banking 2012;14: 359–66. https://doi.org/10.1007/s10561-012-9340-2.
Please cite this article as: A. Kumar, J. Rutherford-Davies, P. Thorpe, et al., Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction ..., The Knee, https://doi.org/10.1016/j.knee.2019.12.014