Proximal tibia--extensor mechanism composite allograft for revision TKA with chronic patellar tendon rupture

Rupture of the patellar tendon following TKA is fortunately an uncommon complication with an incidence of 0.2-4% (Abril et al. 1995). Numerous options have been reported for treating this complication, including primary suture into a bone trough (Abril et al. 1995), autogenous tendon transfer (Cadambi and Engh 1992), and use of an artificial ligament (Fujikawa et al. 1994). Allograft patellar tendon has also been utilized either retaining the host patella and using a bone-tendon-bone graft or excising the host patella and using a quadriceps tendon-patella-patellar tendon-tibial tubercle graft (Emerson et al. 1990, Emerson et al. 1994, Zanotti et al. 1995, Booth et al. 1999). All of these techniques require structural integrity of the proximal tibia in the area of the tibial tubercle in order to attach the repair or graft to restore continuity of the extensor mechanism. When there is massive osteolysis and bone loss involving the proximal tibia, the situation becomes more complex and the previously described techniques are not advisable. In such cases, function can be obtained with a composite allograft of proximal tibia-patellar tendon-patella-quadriceps tendon. We describe a technique for dealing with this difficult clinical situation.     

Proximal tibia--extensor mechanism composite allograft for revision TKA with chronic patellar tendon rupture

Rupture of the patellar tendon following TKA is fortunately an uncommon complication with an incidence of 0.2-4% (Abril et al. 1995). Numerous options have been reported for treating this complication, including primary suture into a bone trough (Abril et al. 1995), autogenous tendon transfer (Cadambi and Engh 1992), and use of an artificial ligament (Fujikawa et al. 1994). Allograft patellar tendon has also been utilized either retaining the host patella and using a bone-tendon-bone graft or excising the host patella and using a quadriceps tendon-patella-patellar tendon-tibial tubercle graft (Emerson et al. 1990, Emerson et al. 1994, Zanotti et al. 1995, Booth et al. 1999). All of these techniques require structural integrity of the proximal tibia in the area of the tibial tubercle in order to attach the repair or graft to restore continuity of the extensor mechanism. When there is massive osteolysis and bone loss involving the proximal tibia, the situation becomes more complex and the previously described techniques are not advisable. In such cases, function can be obtained with a composite allograft of proximal tibia-patellar tendon-patella-quadriceps tendon. We describe a technique for dealing with this difficult clinical situation.     

The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation

Osgood-Schlatter disease (OSD) is a well-described clinical condition, although its origin remains controversial. Mechanical, growth or traumatic factors are suggested as causes of this lesion. Thirty-five patients were included in this study. Twenty of them had OSD (study group) and the remaining 15 adolescents constituted the control group. Magnetic resonance imaging of the knees was performed in all patients. The distance between the distal pole of the patella and the proximal margin of patellar tendon attachment to the tibial apophysis (A), the distance between the distal pole of the patella and the tibial tubercle epiphysis (B), the distance between the proximal margin of the patellar tendon attachment to the tibia and the tibial tubercle epiphysis (C) and the distance between the knee joint level and the tibial tubercle epiphysis (D) were measured. The ratio of the distance between the distal pole of the patella and the proximal margin of the patellar tendon attachment to the tibia to the distance between the distal pole of the patella and the tibial tubercle epiphysis (A : B) was lower in the study group. The ratio of the distance between the proximal margin of the patellar tendon attachment point to the tibia and the tibial tubercle epiphysis to the distance between the knee joint level and the tibial tubercle epiphysis (C : D) was higher in the control group. We conclude that if the patellar tendon attaches more proximally and in a broader area to the tibia, this might probably cause OSD.     

The management of patella infera in current practice

Patella infera described by Caton et al.The measurement is made in 1982 is an accompanying symptom in certain knee affections secondary to the abnormal situation of the patella. The measurement is made on the X-ray with sagittal view after measuring the patellar height, using the original technique described by the author, when the ratio between the articular surface of the patella and the distance form the patellar tip to the tibial tubercle. Indications of surgery may be when this ration is inferior or equals 0.6. The origin of the patella infera can be mechanical or inflammatory. The operative technique addresses the etiology. In current practice, the patellar height and the patellar tendon length may be evaluated using a sagittal section MRI. In the authors’ experience, when the Caton ratio is lower or equals 0.6 and when the length of the patellar tendon is over 25 mm, the indication of surgery includes proximal transfer of the tibial tubercle. If the length of the patellar tendon is less than 25 mm, it is often necessary to perform a patellar tendon lengthening (PTL). This type of surgery is contraindicated in the authors’ experience in depressive or pusillanimous subjects. The two surgical techniques are described. Both techniques use an anterior and medial approach. The proximal transfer of the tibial tubercle (PTT) includes medial and lateral retinaculum release. The tibial tubercle is detached and transferred upwards according to the pre-operative planning generally 1 or 2 cm and is fixed with 2 screws. PTL includes a medial and lateral retinaculum release often with the fat pad. The patellar tendon is dissociated in the middle over its whole length, and the medial pad is detached of the tibial tubercle and the lateral of the patella. After lengthening, the edges of the tendon are sutured, and this suturing reinforced. Alternative procedures may be used when PTT or PTL are not possible, using transplantation with an allograft of the extensor system or a plasty with hamstring muscles.     

Open-wedge retro-tubercular tibial osteotomy: an innovating technique

Open-wedge tibial osteotomy for varus correction is a common orthopedic procedure. The rate of complications remains significant: loss of correction, nonunion, patellar infera... We propose a new open-wedge technique for tibial osteotomy which has several advantages: less risk of patella infera, improved bone healing, excellent mechanical stability. The osteotomy involves two cuts with an anterior portion ending distally to the tibial tubercle. This preserves the integrity of the patellar tendon and maintains contact between the proximal tibia and the tibial tubercle. Adjunction of an anteroposterior screw adds stability. The anterior plane of the osteotomy provides an excellent surface contact favoring bone healing. The posterior plane is the same as with a "classical" open-wedge osteotomy. The lateral cortical must always remain intact (hinge). The technique described here does not require any specific instrumentation and is compatible with most of the available osteosynthesis implants.     

Patellofemoral disorders and instability

Originally the main idea was to obtain a stable patella, i.e., to stabilize the "slipping patella". In the past many conditions like patella alta, ligamentous laxity, PF bone hypoplasia, weakness of the quadriceps muscle, genu valgum or genu recurvatum were thought to predispose to patellar instability. For a long period muscle exercises were instituted to strengthen the weak m.vastus medialis and to make vastus lateralis stronger. This pulls the patella laterally, especially during running or jumping, when lateral luxation of the patella occurs. Muscle imbalance as well as anatomical abnormalities are the basis both for patellar instabilities and reasonable surgical procedures were: proximal extensor mechanism realignment, proximal capsular reefing, patellar tendon splitting and its medial transfer. On the other hand bone procedures on the hypoplastic lateral femoral condyle were also performed by Albee, as well as tibial tubercle transfer and trochleoplasty by deepening of the trochlea (Dejour). An understanding of the pathoanatomic basis is the corner stone for     

An alternative cruciate reconstruction graft: The central quadriceps tendon

The central quadriceps tendon, above the patella, is thicker and wider than the patella tendon. Using precise technique, one can obtain a tendon graft for cruciate reconstruction with 50% greater mass than a patellar tendon bone-tendonbone graft of similar width. The central quadriceps tendon graft may be harvested by a second surgeon while the first surgeon is simultaneously accomplishing notchplasty and tunnel placement for cruciate ligament reconstruction. Consequently, this cruciate ligament reconstruction graft offers time savings as well as greater tendon volume. The central quadriceps tendon graft is difficult to harvest, with significant risk of entering the suprapatellar pouch and losing knee distension during ACL reconstruction. By careful adherence to the technique described in this article, the surgeon can obtain this reconstruction graft safely. It is important to recognize the anatomic subtleties of the proximal patella, which include a curved proximal surface, dense cortical bone, and closely adherent suprapatellar pouch. Proper technique is of utmost importance in obtaining this tendon graft safely and efficiently.     

Total knee replacement for osteoarthritis of the knee with congenital dislocation of the patella

We carried out three total knee replacements with proximal realignment in two patients with severe osteoarthritis of the knee and congenital dislocation of the patella. During the operation, the femur and the tibia were cut according to the recommendations of the manufacturer of the implant. The femoral component was placed in external rotation and the centre of the tibial component aligned in relation to the tibial tuberosity with regard to rotation and translation. After making the bone cuts, the iliotibial tract was detached from Gerdy's tubercle, the popliteus tendon divided, and the biceps femoris tendon elongated by Z-plasty. After the trial implants were positioned, a proximal re-alignment procedure was performed. One knee had deep infection. There was one dislocated patella which was repositioned, and walking ability was improved in all knees. We believe that the rotational alignment of a prosthesis is as important as the soft-tissue surgery.     

Neglected patellar tendon rupture: preserve the fat pad

Management of neglected patellar tendon ruptures remains a difficult therapeutic endeavor, as complications such as adhesions, proximal patellar migration, and quadriceps contracture occur. Treatment goals include restoration of extensor mechanism, both structurally and functionally, which allows active knee extension. Few cases of neglected patellar tendon rupture have been reported in the literature, however, all have used preoperative or additional intraoperative procedures to relocate the patella or to provide additional support to the reconstructed tendon. This article presents a case of a 25-year-old man whose diagnosis of patellar tendon rupture was delayed by 1 year. The patella was mobile and could be brought down to its original position manually. The patellar tendon was successfully reconstructed with autogenous semitendinosus and gracilis tendon graft. No preoperative or intraoperative traction was used on the patella. Quadriceps lengthening was not performed and no hardware was used between the patella and the tibia to augment the reconstruction. Scar tissue was not excised and was used to cover the hamstring tendons. The patient achieved a good functional result after 5 months of rehabilitation. At 14-month follow-up, the patient had returned to his pre-injury level of work with no deterioration of knee function.     

Anatomical reconstruction of the patellar tendon: a new technique with hamstring tendons and iliotibial tract.

A new technique of patellar tendon reconstruction was performed in a patient who lost tendon and tibial tuberosity during wide excision surgery for a malignancy. In this procedure, the tendon was anatomically replaced by a graft composed of ipsilateral hamstring tendons and iliotibial tract, with the biomechanical conditions considered. Both ends of the graft were secured in the size-matched bone tunnels in the patella and tibia by screw post fixation, which is a technique established in ligament reconstruction surgery in the knee joint. At the twenty-month follow-up, the result was deemed successful.     

Anterior approach to the knee with osteotomy of the tibial tubercle for bicondylar tibial fractures

Eight patients--six who had a bicondylar fracture of the tibia and two who had a complex fracture-dislocation--were treated by open reduction and internal fixation that was achieved through an anterior approach to the knee. The approach included elevation of the tibial tubercle, proximal retraction of the extensor mechanism (patellar tendon, retropatellar fat pad, and patella), and transection and detachment of the anterior horn of one or both menisci. The extent of the approach depended on the specific need for exposure. The quality of reduction was better and the rate of complications was lower, compared with conventional approaches. The main advantage of this approach is that the tibial plateau and the intercondylar notch are exposed clearly and completely; this is a prerequisite for the rapid reconstruction of the joint surface and, in some patients, for the reattachment or primary suture of the cruciate ligaments. I recommend the anterior approach with osteotomy of the tibial tubercle in the treatment of patients who have a severe displaced bicondylar fracture of the proximal end of the tibia.     

进展性下位髌骨综合征

目的：报道临床所见的进展性下位髌骨综合征,探讨其病因、诊断,并介绍一种新的治疗方法。方法：本组病人共11例,均由膝关节手术或创伤引起。以膝关节僵硬和髌骨高度降低为主要特征。髌骨垂直高度系数（Linclau法）平均较对侧减少50．4％,Lysholm膝关节功能评分平均47．5分。采用健侧中1／3骨－髌腱－骨移植延长髌腱。结果：髌骨高度恢复正常,膝关节伸屈功能及Lysholm评分较术前显著改善。结论：膝关节手术及创伤是引起该综合征的直接原因,髌骨垂直高度系数较对侧显著减少是诊断该病的主要依据。以中1／3骨－髌腱－骨移植延长髌腱,可准确恢复髌骨原来高度,改善膝关节的功能。     

A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report

The quadriceps tendon and patellar tendon (ligament) were repaired with a Dacron vascular graft used as a tension suture material. In cases of quadriceps tendon ruptures, the Dacron graft is passed transversely through the patellar ligament just below the patella and crossed transversely at the level of the musculotendinous junction with two loops applying tension to the tendon, which brings the tendon ends together by creating a solid structure. In cases of patellar ligament ruptures, the Dacron graft is passed through a hole in the tibia posteriorly to the tibial tuberosity instead of through the patellar ligament below the patella. This technique enables early mobilization on the first day after surgery. The technique was first tested on six dogs with severed quadriceps tendons and patellar ligaments that were repaired with this suture method. All of the animals recovered from surgery and walked and ran normally on the repaired legs within 27 days and with only mild limping after 17 days. The technique was then used on six patients, four with complete quadriceps tendon rupture and two with complete tear (avulsion) of the patellar ligament (tendon). In all of the patients, excellent surgical results were obtained and leg immobilization was virtually eliminated. Physical therapy was prescribed the first day after surgery. The rehabilitation period was significantly reduced.     

A technique for reconstruction of the medial patellofemoral ligament

Additional medial patellofemoral ligament reconstruction was performed successfully on six consecutive patients with recurrent dislocation of the patella because of residual patellar instability after medial transfer of the tibial tubercle. A technique for medial patellofemoral ligament reconstruction is described, and complications and postoperative management are discussed. The reconstruction was performed using a double strand hamstring tendon graft in five patients and iliotibial allograft in one. Good stabilization of the patella was achieved in all six patients, resulting in improved confidence in higher levels of activity. The satisfactory outcome of additional medial patellofemoral ligament reconstruction suggests the possibility that the procedure may be part of the optional procedure in proximal realignment for recurrent dislocation of the patella.     

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.     

One-incision endoscopic technique for posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft

Quadriceps tendon–patellar bone autograft is an alternative graft choice for posterior cruciate ligament (PCL) reconstruction. A 2-incision technique with outside-in fixation at the femoral condyle is generally used. In this article, we describe a 1-incision endoscopic technique for PCL reconstruction with quadriceps tendon–patellar bone autograft. The graft consists of a proximal patellar bone plug and central quadriceps tendon. The bone plug is trapezoidal, 20 mm long, 10 mm wide, and 8 mm thick. The tendon portion is 80 mm long, 10 mm wide, and 6 mm thick, including the full-thickness of the rectus femoris and partial thickness of the vastus intermedius. Three arthroscopic portals, including anteromedial, anterolateral, and posteromedial, are used. All procedures are performed in an endoscopic manner with only 1 incision at the proximal tibia. At the femoral side, the bone plug is fixed by an interference screw. At the tibial side, the tendon portion is fixed by a suture to a screw on the anterior cortex and an interference bioscrew in the posterior tibial tunnel opening. Quadriceps tendon autograft has the advantages of being self-available, allowing for easier arthroscopic technique, and providing comparable graft size. The 1-incision technique provides a simple reconstruction method for PCL insufficiency without a second incision at the medial femoral condyle.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 329–332     

Medial patellofemoral ligament reconstruction with gracilis autograft for patellar instability

We describe a technique for patellar stabilization by reconstruction of the medial patellofemoral ligament with the gracilis tendon. The tendon is anchored posteriorly on the soft tissue of the medial femoral epicondyle and anteriorly on the medial border of the patella. The plasty is completed by suture of the medial patellar wing. Inferior or medial transposition of the tibial tubercle may be associated. We have used this technique since 1995 for 145 knees with patellar instability. The small incisions have the advantages of minimally invasive surgery, particularly for the postoperative period and the cosmetic effect.     

Editorial Commentary: You Have Some (Infrapatellar Branch of the Saphenous) Nerve!

Infrapatellar branches of the saphenous nerve are always present at the anteromedial aspect of proximal tibia. Iatrogenic injury to these branches is a known consequence of knee surgery, be it an arthroscopic portal, harvesting of a hamstring or bone–patellar tendon–bone anterior cruciate ligament graft, or opening wedge opening high tibial osteotomy. Their anatomic course can be variable. High-resolution ultrasound may provide an improved diagnostic tool for better identification.     

Le fratture articolari ed extra-articolari del ginocchio

Joint fractures of the knee include epiphyseal detachments of the distal femur and proximal tibia (types 3 and 4 according to Salter-Harris). Extra-articular fractures include: avulsion of the tibial spines, detachment of the anterior tuberosity and patellar fractures. Fractures involving the distal femoral and proximal tibial epiphysis are relatively infrequent but may lead to long-term complications owing to the formation of post-traumatic bone bridges. Unless the fracture is composed, surgical treatment is always indicated. Avulsion fractures of the tibial spines occur as a result of a chondro-epiphyseal detachment of the insertion of the cruciate ligaments (predominantly the anterior one). They are infrequent injuries (3 per 100,000 cases per year, 2% of all knee injuries). Accurate diagnosis and appropriate treatment prevent unfortunate outcomes. Adolescent tibial tubercle fractures are uncommon, high-energy injuries sometimes combined with patellar tendon rupture; they represent a frequently missed diagnosis. Open reduction/internal fixation is generally required. Patellar fractures are caused by direct trauma (primary osseous fractures) or by an eccentric load during extension of the knee (sleeve and avulsion fractures). Most fractures require open reduction/internal fixation. The complication rate is low but late reconstruction of missed injuries may result in an extensor deficit.

     

Quadriceps and patellar tendon ruptures

Ruptures of the quadriceps as well as the patellar tendon occur in low frequency, but cause major functional deficits of the leg. These injuries usually require operative treatment. Acute quadriceps tendon ruptures are treated by suture repair, using heavy sutures guided through bone tunnels in the patella. Chronic defects and neglected cases require a local tendon transfer, either by a quadriceps tendon turn-down or by a V-Y-plasty of the quadriceps tendon. Ruptures of the patellar tendon are treated by suture of the tendon stumps plus an reinforcement procedure protecting the tendon and avoiding secondary patella alta. Patello-tibial fixation may be achieved by a cerclage technique using wire or an autologous tendon strip, alternatively a patello-tibial external fixator can be applied. In chronic and neglected cases, patellar tendon reconstruction is performed with autologous tendon grafts or with soft tissue allografts. The graft must be protected by a patello-tibial fixation for the first weeks.