Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty

BACKGROUND: Rupture of the patellar tendon after total knee arthroplasty is a rare and debilitating complication. Proper surgical management of this condition remains controversial. The purpose of this study was to review the results of reconstruction of a ruptured patellar tendon with an Achilles tendon allograft following total knee arthroplasty. METHODS: We reviewed our experience with the use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to restore extensor function in nine patients with patellar tendon rupture following total knee arthroplasty (five primary and four revision). All patients were examined clinically and radiographically at an average of twenty-eight months. RESULTS: The average knee and functional scores improved from 26 and 14 points, respectively, before the surgery to 81 and 53 points after the surgery. The average extensor lag decreased from 44 degrees preoperatively to 3 degrees postoperatively, and the average range of motion of the knee increased from 88 degrees to 107 degrees. Two grafts failed in the early postoperative period. Both were repaired successfully. Radiographs showed an average proximal patellar migration of 17.8 mm, which did not appear to affect extensor function. CONCLUSIONS: This short-term follow-up study showed that once an Achilles allograft has healed, it can serve as a reliable reconstruction of a ruptured patellar tendon following total knee arthroplasty. This technique may be particularly suited for patients in whom the extensor mechanism was compromised by multiple prior operations. Continued follow-up is necessary to determine the long-term durability of these results.     

Achilles allograft reconstruction of a chronic patellar tendon rupture

Chronic ruptures of the patellar tendon are uncommon injuries. They are technically difficult to repair because of scar formation, poor quality of the remaining tendon, and quadriceps muscle atrophy and contracture. We report the reconstruction of a chronic patellar tendon rupture with an interesting complication, a tibial stress fracture. The reconstruction was performed 3 months after the injury using an Achilles tendon-bone allograft and reinforcing suprapatellar wire. At 2 weeks postoperatively, the patient had attained full extension and 90 degrees of flexion. Ten months after the index procedure, the patient had range of motion 0 degrees to 120 degrees and was diagnosed with a healing tibial stress fracture. At 17 months postoperatively, the patient had attained full extension, 120 degrees of flexion, and 85% quadriceps strength. The preoperative goals of attaining full range of motion, improving quadriceps strength, obtaining anatomic patellar alignment, and restoring function were obtained despite the complication of a tibial stress fracture. Although this reconstructive procedure is technically demanding, with potential complications, the functional results obtained can be excellent.Arthroscopy 1998 Apr;14(3):340-4     

Reconstruction of patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft

Although patellar tendon rupture after total knee arthroplasty (TKA) is a rare complication, the consistently poor outcome of conventional tendon repair has convinced some to abandon such reconstruction in favor of a prospective protocol using an allograft distal extensor mechanism. The graft consists of a quadriceps tendon, a patella with a cemented prosthesis, a patellar tendon, and a tibial tubercle. Since December 1985, 13 knees in 12 patients were reconstructed using this method. Ten knees were followed for six to 51 months; five of these knees were followed for more than 24 months. Knee extension power and improved function were ultimately attained in all cases, although minimal extensor lags were present in three cases. Preoperative motion returned in all but one knee. Healing of the allograft to the host tissue was attained primarily at all of the tibial junctions. Two graft complications occurred, both in the first three months after surgery: one quadriceps junction treated by resuture failed at the one-month mark, and the other graft had to be revised for extensor weakness from rupture of the graft at the patella-patellar tendon junction, which was attributed to surgical damage to the tendon. After completion of healing to the host and rehabilitation of the knee joint, no grafts in the series failed during the course of normal daily activities. One patient fractured the allograft patella in a severe fall. The long-term durability of this construct needs to be studied further.     

Patellotibial fusion for patellar tendon rupture after total knee arthroplasty

Patellar tendon rupture is a rare but recognized complication of total knee arthroplasty. Multiple repair methods have been described in the literature. This unique case involved a patient with an underlying metabolic disorder and poor soft tissue quality. A patellotibial fusion was used to achieve a more definitive reestablishment of the extensor mechanism and to improve the patient's level of activity.     

Arthroscopic treatment of popliteus tendon dysfunction following total knee arthroplasty

Following total knee arthoplasty, the popliteus tendon may cause a “snap” when it rolls over a retained lateral femoral condylar osteophyte or when it subluxates over the posterior condyle of the femoral component. When this condition is painful and fails to respond to conservative treatment, arthroscopic release of the popliteus tendon has been beneficial     

Popliteus tendon dysfunction following total knee arthroplasty

The popliteus tendon can be a potential source of internal derangement after total knee arthroplasty. It can subluxate anteriorly and posteriorly over a retained lateral femoral condylar osteophyte or over the overhanging edge of the metallic posterior femoral condyle. Surgical release of the tendon from its femoral insertion relieves the problem.     

Surgical treatment of Achilles tendon ruptures

A total of 75 patients with surgically repaired Achilles tendon ruptures were evaluated with special reference to the status at the end of a standardized short period of cast immobilization (6 weeks). There were 3 (4%) reruptures caused by new adequate trauma, but no other major complications. The final functional result was evaluated with reference to the patients' return to social and recreational activities. Objective measurements reflecting the final functional result are discussed.     

Alteration of the patellar height following total knee arthroplasty

Introduction

Patellofemoral related complications after total knee arthroplasty (TKA) remain clinically relevant. The hypothesis of the present study was that the patellar height changes more than 10 % of its preoperative height after TKA. Possible influences of age, gender, side and navigation system on patellar height were evaluated separately in subgroups.

Materials and methods

A total of 107 knees were enrolled after primary TKA. The patellar height was determined for each patient preoperatively, 1 week and 1 year postoperatively on routinely performed standing lateral view radiographs at 30° knee flexion. Insall–Salvati index (ISI), modified Insall–Salvati index (MIS) as well as Miura–Kawamura index (MKI) were determined for the whole cohort.

Results

One week after TKA the ISI, MIS and MKI changed by more than 10 % in 24 (22 %), 33 (30 %) and 54 (50 %) cases, respectively. Moreover, the 1 year follow-up revealed a decrease or increase of ISI in 30 (28 %), MIS in 47 (44 %) and MK in 65 (61 %) knees. The frequency of patella alta, norma and baja preoperatively as well as 1 week and 1 year postoperatively were not significantly different. Significant differences of patellar height changes were not noted between the defined subgroups.

Conclusions

The present study demonstrates that TKA leads, at 1 week and 1 year follow-up, to patellar height alteration more than 10 % in a significant number of knee joints. However, with the use of ISI and MIS the changes of patellar height did not exceed the defined thresholds to be classified as patella alta or baja.     

Use of patellar allograft to reconstruct a patellar tendon-deficient knee after total joint arthroplasty

A catastrophic complication after total knee arthroplasty (TKA) is rupture of the patellar tendon. Several techniques for treatment have been described, including cast immobilization with or without operative repair, the use of a semitendinosus, fascia lata, or hamstring tendon autogenous graft, the use of a Dacron 4-mm vascular graft (U.S. Catheter and Instrument, Glen Falls, NY), the use of bovine xenograft and even transplantation of an entire allograft extensor mechanism. Treatment results of patellar tendon rupture after TKA can be discouraging. Altered tissue quality secondary to connective tissue diseases, diabetes, rheumatoid arthritis, lupus erythematosus, secondary hyperparathyroidism, or concurrent steroid medications contributes to poor results. Additionally, no one treatment has provided consistent clinical success. Successful treatment of a patient with a ruptured patellar tendon after TKA using the bone-patellar tendon-bone allograft commonly used for anterior cruciate ligament reconstruction is reported.     

Management of chronic ruptures of the Achilles tendon

Chronic ruptures of Achilles tendons are those that present four to six weeks after the original injury. They have become more common as acute Achilles tendon injuries have become more frequent, and they are associated with considerable functional morbidity. Most surgeons agree that chronic ruptures should be managed operatively. Diagnosis is based predominantly on history and clinical examination. Real-time, high-resolution ultrasound and magnetic resonance imaging are helpful in preoperative planning or as a diagnostic aid. Local tissue, local tendons, and allografts can be used to reconstruct the tendon, and end-to-end repair is possible if the gap is <2.5 cm. Compared with acute injuries, chronic injuries are associated with a higher rate of postoperative infection and more prolonged recovery.     

The efficacy of patellar decompression for improving anterior knee pain following total knee arthroplasty without patellar resurfacing

Background

Anterior knee pain remains common following total knee arthroplasty (TKA). In this study, we evaluated the efficacy of patellar decompression via drilling for the treatment of anterior knee pain following TKA without patellar resurfacing.

Methods

A prospective cohort study was performed in 271 consecutive patients who underwent primary total knee replacement with patellar decompression (study group, n = 131) or without decompression (control group, n = 140). The patients were assessed according to the Knee Society rating, clinical anterior knee pain score, and British Orthopaedic Association patient-satisfaction score in each group. Each assessment was performed without the examiner knowing whether the patella had been decompressed. Radiographic evaluations were also performed according to the Knee Society scoring system for functional activity and our own severity grade system for patellofemoral articular change.

Results

There were no adverse events following patellar decompression. The overall prevalence of anterior knee pain was not significantly different between groups (p = 0.71). However, patients presenting pain over grade II after the operation in the study group were statistically low (p = 0.01). The overall postoperative knee scores were higher in the study group, but there were no significant differences between groups (p = 0.0731). Analyses of the radiographs revealed similar postoperative outcomes in both groups of knees.

Conclusions

As we observed significantly lower rates of anterior knee pain and no patellar complications following patellar decompression via drilling in TKA without patellar resurfacing, we recommend performing patellar decompression in cases of total knee replacement without patellar resurfacing.     

Advanced osteoarthritic knee with neglected patellar tendon rupture treated with total patellectomy and total knee arthroplasty

Loss of the knee extensor mechanism results in a change of normal knee joint alignment and functional anteroposterior instability. In patients with neglected or chronic patellar tendon rupture, advanced degenerative change of the knee joints may develop at the later stage. We present a case of a 64-year-old man with chronic left patellar tendon rupture and 10-cm proximal patella migration associated with advanced osteoarthritis of the knee. Total patellectomy and simultaneous total knee arthroplasty (TKA) relieved his symptoms and disability successfully. His left knee still did well at 7-year follow-up.     

Acute and chronic Achilles tendon ruptures in athletes

The Achilles tendon is the most injured tendon of athletes in the lower extremities and is the most common tendon to rupture spontaneously. Operative repair provides earlier return to sporting activities and lesser rate of rerupture. The general goal is to attempt anastomosis of the acute ruptured ends; however, delayed ruptures may require more extensive procedures. New surgical approaches, including percutaneous and mini-open techniques, are being introduced to potentially diminish perioperative complications. Advent of early protective range of motion and rehabilitation has shown a potential for earlier return to sporting activities for Achilles ruptures.     

Lateral patellar burnishing in total knee arthroplasty following medialization of the patellar button

This case report describes a total knee revision necessitated by painful contact between the exposed lateral facet of the patella and the femoral component. Pain was resolved following repositioning and enlarging the patellar component. The clinical significance of this report is that the contemporary practice of medializing the patellar component to improve patellar tracking should be performed in moderation to avoid overexposure of the lateral patella. In the setting of persistent anterior knee pain following total knee arthroplasty, the etiology of the pain may be identified as contact between the patellar and femoral component on the sunrise radiograph.     

Excisional arthroplasty for patellar loosening in total knee arthroplasty

Four thousand two hundred eighty-seven cases of Anatomic Graduated Components total knee replacements with a cemented, single-peg, all-polyethylene patellar component were performed at our institution over the past 15 years. One hundred eighty cases of patellar component loosening were found. Eleven knees (0.3%) in 11 patients required isolated patellar component reoperation. In all cases, the patellar component was excised and not reimplanted. The average follow-up for the 11 patients was 2.2 years. Five had a complete minimum follow-up of 2 years following reoperation. Pain and function were improved. Complications included infection in 3 knees and extensor lag in 1 knee. Because of the complication rate associated with isolated patellar component excision caused by a loose patellar component, we recommend surgical removal of the patellar component only in cases of severe pain and/or prominence of the component.     

Endoscopic reconstruction for chronic Achilles tendon ruptures using a hamstring tendon autograft

BackgroundTo determine the safety and efficacy of endoscopic reconstruction of chronic Achilles tendon ruptures using a hamstring tendon autograft at mid-term follow-up.MethodsWe reviewed the medical records of patients with chronic Achilles tendon rupture treated surgically by endoscopic reconstruction using a hamstring tendon autograft at our institution between March 2010 and October 2015. Radiologic outcomes were assessed using pre- and postoperative magnetic resonance imaging (MRI). Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot Scale, the Plantar Flexion Strength (PFS), the Victorian Institute of Sport Assessment-Achilles (VISA-A) scale, the Visual Analogue Scale (VAS) pain score, and the Arner-Lindholm standard. All patients achieved primary healing with no lengthening of the Achilles tendon, skin necrosis, infection, deep vein thrombosis or other complications.ResultsMean follow-up period was 15 ± 3 months (range, 12–18 months). There was no Achilles tendon re-rupture. MRI examination revealed that Achilles tendon continuity was restored. Patients’ mean AOFAS, PFS, and VISA-A scores were significantly higher and mean VAS pain score was significantly lower after surgery compared to before (P < 0.05). According to Arner-Lindholm standards, there were twenty (76.9%) excellent, six (23.1%) good, and zero bad outcomes.ConclusionEndoscopic reconstruction utilizing a hamstring tendon autograft is a safe and efficacious option for repair of chronic Achilles tendon ruptures. Studies with larger sample sizes and a longer follow-up are required to confirm the advantage of this technique compared to open surgery.     

人工全膝关节置换术后单纯金属底座髌骨假体的翻修

目的分析带金属底座髌骨假体失败的原因,并观察单纯髌骨假体翻修的临床疗效。方法对 22例 (30膝 )人工全膝关节置换术后因金属底座髌骨假体失败而行单纯髌骨假体翻修者进行回顾性分析。假体均为同一类型的后十字韧带保留型假体,以金属底座髌骨假体置换髌骨。应用膝关节 KSS评分标准评价翻修术后的临床转归。结果髌骨假体失败时间在人工全膝关节置换术后的 26～ 96个月,平均 62.3个月,主要症状有金属摩擦感 (80％ )和膝关节疼痛 (70％ )。术中发现 23膝 (76.7％ )聚乙烯完全磨损、金属底座外露; 9膝髌骨倾斜或半脱位; 2膝完全脱位。 30膝均成功施行骨水泥全聚乙烯髌骨翻修术,随访时间 24～ 81个月,平均 42.5个月。所有患者主诉症状消失,可独立行走活动,膝关节评分从术前的平均 73分（ 27～ 88分）增加至 87分（ 60～ 100分）;膝关节屈曲度由术前的平均 91°增加至 99.5°。结论 (1)金属底座髌骨假体早期失败率较高; (2)髌骨位线不良和异常滑动轨迹是导致带金属底座髌骨假体失败的诱发因素; (3)单纯髌骨假体翻修可获满意的临床结果,其发生并发症的潜在危险和人工全膝关节翻修术相似,应予以重视。     

Use of a turndown quadriceps tendon flap for rupture of the patellar tendon after total knee arthroplasty

Patellar tendon rupture is a devastating complication after total knee arthroplasty. The results of surgical treatment of this complication were discouraging in most of the reports. We describe a case of rupture of patellar tendon 7 weeks after total knee arthroplasty treated with a turndown quadriceps flap and circumferential wiring. Two years and 6 months after operation, the patient had no extension lag of the knee and knee flexion to 110 degrees .     

Intraoperative patellar tendon strain: predicting the range of knee flexion after total knee arthroplasty

Background  The preoperative range of motion is an important factor that influences the range of motion after total knee arthroplasty. Because the length and tightness of the extensor mechanism are extracapsular elements with an influence on knee flexion, it is reasonable to assume that the tension of the knee extensor mechanism during surgery has a considerable impact on the postoperative range of motion. The purpose of this study was to determine the influence of the tightness of knee extensor mechanism on postoperative knee flexion. Methods  In 18 knees undergoing posterior-stabilized type total knee arthroplasty, we measured the longitudinal strain on the patellar tendon with all the components in position during passive knee flexion up to 135°. The patellar tendon strains measured during surgery were compared with the preoperative maximum knee flexion angle and postoperative maximum knee flexion angle at 1 year. Results  There was a significant inverse correlation between the patellar tendon strain during surgery at 60° (r = -0.54, P < 0.05), 90° (r = -0.55, P < 0.05), or 135° of flexion (r = -0.65, P < 0.05) and postoperative knee flexion. Conclusions  The results indicated that subjects with high intraoperative patellar tendon strain during passive flexion of the knee had more restricted postoperative knee flexion. Therefore, the tightness of the knee extensor mechanism measured at total knee arthroplasty is a good predictor of maximum postoperative range of flexion.