Quadrizeps- und Patellasehnenrupturen

Ruptures of the quadriceps or patellar tendon are uncommon but extremely relevant injuries. Early diagnosis and surgical treatment with a stable suture construction are mandatory for a good postoperative clinical outcome. The standard methods of repair for quadriceps and patellar tendon injuries include the placement of suture loops through transpatellar tunnels. Reinforcement with either a wire cerclage or a PDS cord is used in patellar tendon repair. The PDS cord can also be applied as augmentation in quadriceps tendon repair. In secondary patellar tendon repair an autologous semitendinosus graft can be used. For chronic quadriceps tendon defects a V-shaped tendon flap with a distal footing is recommended. The different methods of repair should lead to early functional postoperative treatment. The clinical outcome after surgical treatment of patellar and quadriceps tendon ruptures is mainly good.     

Intra-operative patellar fracture during chronic patellar tendon rupture reconstruction: salvage and prophylactic modified techniques

Management of chronic neglected patellar tendon rupture represents a challenging condition for the orthopedic surgeons to deal with due to many factors such as quadriceps muscle atrophy, superior migration of the patella, e.g., patella alta, peri-patellar adhesions and patellar tendon atrophy. Such difficulties might be further complicated by intra-operative patellar fracture during patellar tendon reconstruction. In the current article, the authors report (1) a salvage procedure for such devastating intra-operative complication, based on bypassing the patella and gaining the advantage of the quadriceps tendon for structural and functional restoration of the knee extensor mechanism, and (2) prophylactically a technical modification of patellar tendon reconstruction guarding against such inadvertent patellar fracture.

     

Medial Patellofemoral Reconstruction Techniques for Patellar Instability

The medial patellofemoral complex (MPFC) is the term used to describe the primary soft tissue stabilizer of the patella, which consists of fibers that attach to the patella (medial patellofemoral ligament, or MPFL), and the quadriceps tendon (medial quadriceps tendon femoral ligament, or MQTFL). Despite the variability of its attachment on the extensor mechanism, the midpoint of this complex is consistently at the junction of the medial quadriceps tendon with the articular surface of the patella, indicating that either patellar or quadriceps tendon fixation can be used for anatomic reconstruction. Multiple techniques exist to reconstruct the MPFC, including graft fixation on the patella, quadriceps tendon, or both structures. Various techniques using several graft types and fixation devices have all reported good outcomes. Regardless of the location of fixation on the extensor mechanism, elements critical to the success of the procedure include anatomic femoral tunnel placement, avoiding placing undue tension on the graft, and addressing concurrent morphological risk factors when present. This infographic reviews the anatomy and techniques for the reconstruction of the MPFC, including graft configuration, type, and fixation, while addressing common pearls and pitfalls in the surgical treatment of patellar instability.     

Die Rupturen der Sehnen am Streckapparat des Kniegelenkes

Ruptures of the quadriceps and patellar tendon are comparatively rare lesions. From the number of cases from 1973 till 1983 17 ruptures of the femoral extensor tenson and 8 ruptures of the patellar tendon were controlled diagnostically, therapeutically and in view of their long-term results. Causally in the group of quadriceps tendons 13 spontaneous ruptures were facing 4 traumatically caused ruptures. In case of traumatic ruptures 3 of them were adolescents after extreme traumatic violence by rapid traumata. Degeneratively conditioned subcutaneous quadriceps tendon ruptures we only found in case of men who were on an average older than 50 years. In spite of physiologically extreme resistance to ruptures 6 of 8 ruptures of the ligamentum patellae were ascribed to the fact that by the progressing degeneration the temaining strain capacity of the tendon was reduced below the measure of normal load. In each individual case the aspects of expert opinion were traced-above all in case of tendon ruptures with osseous patella lesions. For the first time a temporally staggered bilateral spontaneous rupture of the patella was described. The operative approach has been discussed just as much as the necessity to examine the internal knee-joint structures arthroscopically in case of the plurality of accompanying retinaculum lesions.     

钢丝环形加“8”字内固定治疗髌骨骨折

为对髌骨骨折钢丝环形加“８”字内固定进行生物力学评价，本实验采用截肢获得的６个髌骨标本进行研究。保留股四头肌腱和髌韧带。于髌骨纵向中点横形锯开，造成横形骨折。髌骨骨折四种内固定方法即：钢丝环形加“８”字、钢丝“８”字、钢丝环形和克氏针加钢丝“８”字内固定。使固定的髌骨韧带标本屈曲９０°，应用电测法对固定性能进行测试。载荷—应变评价结果表明，钢丝环形加“８”字固定效果最好。因此，从１９８８年３月～１９９１年７月应用此法治疗１２７例髌骨骨折，获得随访９６例，优、良结果占９５．８％。     

Neglected bilateral rupture of the patellar tendon: A case report

Simultaneous bilateral rupture of the patellar tendon (PT) is extremely rare and is generally associated to some chronic diseases. When the rupture becomes chronic, it is more difficult to repair that as it remained untreated.The diagnosis, which is clinical, is often delayed, guided by standard radiography and confirmed by ultrasound or MRI.The management of a bilateral neglected, chronic patellar tendon rupture must address some serious difficulties: the proximally retracted patella, the reconstruction of the patellar tendon, finally, the temporary protection of this repair.We report a case of neglected bilateral rupture of the patellar tendon in a chronic hemodialysis patient, treated with a plastic surgery of the ipsilateral quadriceps tendon.     

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.     

Rupture of the quadriceps tendon: an association with a patellar spur

We reviewed the records of 107 consecutive patients who had undergone surgery for disruption of the knee extensor mechanism to test whether an association existed between rupture of the quadriceps tendon and the presence of a patellar spur. The available standard pre-operative lateral radiographs were examined to see if a patellar spur was an indicator for rupture of the quadriceps tendon in this group of patients. Of the 107 patients, 12 underwent repair of a ruptured patellar tendon, 59 had an open reduction and internal fixation of a patellar fracture and 36 repair of a ruptured quadriceps tendon. In the 88 available lateral radiographs, patellar spurs were present significantly more commonly (p < 0.0005) in patients operated on for rupture of the quadriceps tendon (79%) than in patients with rupture of the patellar tendon (27%) or fracture of the patella (15%). In patients presenting with failure of the extensor mechanism of the knee in the presence of a patellar spur, rupture of the quadriceps tendon should be considered as a possible diagnosis.     

Neglected spontaneous bilateral rupture of the patellar tendon: a case report

A patient taking corticosteroids for rheumatoid arthritis experienced a spontaneous bilateral rupture of the patellar tendon. Initially neglected, the rupture was repaired surgically by tendinoplasty using the semitendinous tendon for the right knee and inversion of the quadriceps tendon for the left. Functional results were similar. On the right knee, the wire cerclage loosened leading to posterior sagittal displacement of the patella, pointing out the difficulties encountered when repairing neglected rupture of the patellar tendon. Due to the small number of cases and difficulties in assessing the techniques proposed, no large-scale series has been reported in the literature.     

Ruptures of the extensor mechanism of the knee joint. Clinical results and patellofemoral articulation

The functional results of 28 cases of rupture of the quadriceps and patellar tendons are reported. Excellent or good results were noted in 15 of 18 quadriceps and 7 of 10 patellar tendons. Radiographic comparison with the opposite knee disclosed incongruences between the patella and the femoral groove in the tangential view and/or cranial-caudal position of the patella in the lateral view in 13 of the quadriceps tendon ruptures and seven of the patellar tendon ruptures. Patients with residual pain had patellofemoral incongruity but since two-thirds of the patients with incongruity were asymptomatic, incongruity alone may not be the cause of the symptoms. There was no positive correlation to muscular strength or range of movement. Nevertheless, exact adaptation of the patellar tendon and periarticular tissue seems necessary to obtain correct patello-femoral articulation. Reinforcement of the tendon with a wire cerclage is recommended to decrease the tension on the suture line and the consequent risk of a secondary rupture. In acute ruptures of the quadriceps tendon end-to-end sutures are sufficient.     

髌骨骨折不同改良方式张力带钢丝固定的生物力学研究及临床应用

【摘要】目的 为临床选择有效的骸骨骨折内固定方式提供实验依据。方法 取4具外伤截肢后下肢,保留股四头肌健、骸骨、骸韧带及关节囊,将股骨、腔骨固定在材料试验机上,维持腔股关节屈曲36”位,通过牵拉肌腥产生张力,用线性运动传感器测定骨折移位,移位3rum为固定失效,测AO张力带钢丝、昏氏张力带钢丝、“8”字张力带钢丝和Magnt,&x)tl钢丝4种固定法。结果“8”字张力带钢丝和肯氏张力带钢丝固定效果最好,AO张力带钢丝次之,三者均能承受294N以上牵张力,允许术后早期活动,M哪——钢丝不能承受294N以上牵张力,固定欠可靠。临床应用“8”字张力带钢丝固定治疗骸骨骨折42例,其中横断骨折36例,粉碎性骨折6例,随访6~26个月,优良率达95.2%。结论 克氏针“8”字张力带钢丝固定是治疗骸骨骨折首选方法,其固定效果可靠,疗效高。     

改良髌骨部分切除术生物力学实验与初步临床报道

作者通过５条下肢的体外力学测试，研究了髌骨部分切除、髌韧带重新附丽的部位对膝关节完全伸直时所需股四头肌力的影响，并测试了钢丝（直径０．４ｍｍ、双股）附丽髌韧带的最大固定力量。实验结果证明髌骨下１／４切除，髌韧带附丽贴近髌骨前面骨皮质对膝关节完全伸直时所需股四头肌力无显著影响（ｐ＞０．０５）髌骨下１／４切除、髌韧带附丽贴近关节软骨面将显著增大膝关节完全伸直时所需股四头肌力（ｐ＜０．００１）；钢丝附丽髌韧带的最大固定力量为６７．４ｋｇ（６０．９～７２．５ｋｇ）。我科自１９９２年１０月以来，采用髌骨部分切除、钢丝重新附丽髌韧带贴近髌骨前面骨皮质的改良方法治疗髌骨上、下极骨折１３例，按陆裕朴的评定标准，优良率达１００％。文中讨论了该术式的手术方法、手术时机、指征及术后处理。     

Quadriceps and patellar tendon rupture

Ruptures of the patellar and/or quadriceps tendon are rare injuries that require immediate repair to re-establish knee extensor continuity and to allow early motion. We evaluated 36 consecutive patients with quadriceps or patellar tendon rupture between 1993 and 2000. There were 37 primary ruptures, 3 reruptures, 21 quadriceps and 19 patellar tendon ruptures. Follow up examination (>24 months postoperatively) included the patient's history, assessment of risk factors, clinical examination of both knees, isometric muscle strength measurements and three specific knee scores, Hospital for Special Surgery Score, Knee Society Score and Turba Score, and a short form SF-36. We evaluated 29 patients (26 men) with 33 ruptures (16 patellar tendon, 17 quadriceps tendon). Seven patients were lost to follow up. We found no difference between the range of motion and muscle strength when the injured leg was compared to the non-injured leg. Risk factors did not influence the four scores, patient satisfaction, pain, muscle strength or range of motion. Multiple injured patients had a significant reduction in muscle strength and circumference, however patient satisfaction did not differ to the non-multiple injured patient group.     

Tendon rupture of the extensor muscles of the knee

Five cases of rupture of the quadriceps tendon and two cases of rupture of the patellar ligament form the authors' own patient material (1975-1984) are reviewed. It seems we must differentiate between rupture of the quadriceps tendon (namely, rupture in an elderly patient with degeneratively changed tendon in trivial traumas) on the one hand, and rupture of the patellar ligament (rupture in the young patient with considerable trauma, as in sports) and hence a more or less purely traumatically caused rupture, on the other. Except for one case of spontaneous rupture associated with cortison treatment for several years, the four remaining quadriceps tendon ruptures were based on the same accident mechanism, the average age of these patients being 65 years: on trying to stabilize themselves while stumbling, the quadriceps muscle was suddenly tensed. In both cases of rupture of the patellar tendon, rupture occurred while jumping off a springboard during sports activities. The authors advocate protecting the tendon suture in quadriceps tendon rupture via a walking cast of the femur; in rupture of the patellar ligament, it is recommended to effect wire cerclage between patella and tuberositas tibiae. In each case, functional exercise should be initiated as early as possible.     

Editorial Commentary: The Medial Patellofemoral Complex Is Composed of the Medial Patellofemoral Ligament and the Medial Quadriceps Tendon–Femoral Ligament: Do We Need to Reconstruct Both?

The medial patellofemoral ligament (MPFL) has been known as the primary soft-tissue restraint to lateral patellar translation. More recent anatomic studies have identified additional fibers that extend to the quadriceps tendon (medial quadriceps tendon–femoral ligament [MQTFL]), leading to the use of the term “medial patellofemoral complex” (MPFC) to describe the broad and variable attachment of this complex on the patella and quadriceps tendon. Whereas many techniques and outcomes of traditional MPFL reconstruction have been described, fewer reports exist on anatomic MPFC reconstruction to recreate both bundles of this complex. To date, the specific biomechanical roles of, and indications for, reconstruction of the MPFL versus MQTFL fibers have not been defined. One primary benefit of MQTFL reconstruction has been to avoid the risk of patella fracture, which is not obviated in the setting of concurrent patellar fixation when reconstructing both components of the MPFC. The risks and benefits comparing fixation on the patella, quadriceps tendon, or both with anatomic double-bundle reconstruction remain to be determined. Additional studies are needed to understand the differences between reconstructing the proximal and distal fibers of the MPFC with regard to graft length changes and femoral attachment sites, in order to optimally recreate the function of each graft bundle in the surgical treatment of patellar instability.     

Neglected patellar tendon rupture: a case of reconstruction without quadriceps lengthening

Neglected rupture of the patellar tendon is a rare, can be easily missed in a group of patients. We present a 24 year old, male patient who sustained right femoral diaphyseal and tibial plateau fractures and a patellar tendon rupture following a motor vehicle accident. The fractures were treated by open reduction internal fixation but the patellar tendon rupture was missed and the diagnosis was delayed by 7 months. Patella was migrated proximally. It was moved distally to the original location and neglected patellar tendon rupture treated successfully with modified Ecker technique. Neither preoperative traction nor additional intraoperative procedures were performed to relocate the patella to its anatomic position in the extended knee and good functional result was achieved with intensive rehabilitation.     

The patellofemoral component of total knee arthroplasty

Patellofemoral complications continue to form a large proportion (up to 50%) of total knee arthroplasty (TKA) complications. If adequate attention is paid intraoperatively to patellar tracking and component position, the incidence of subluxation, component loosening, and fracture should decrease. When treating patellar subluxation and dislocation, tibial tubercle transfer should be avoided because there is an unacceptably high incidence of complications. Care should be taken to treat the underlying cause of dislocation with either a soft tissue procedure or component revision. Fracture of the patella may be treated nonoperatively in 50% and 80% of patients. Cysts, if large, may be bone-grafted to avoid the potential complications of stress fracture and component loosening. Loosening of the patellar component is likely to be symptomatic and to require surgery in up to 75% of cases. A displaced patellar component may cause attritional wear of the quadriceps tendon or patellar ligament. All rheumatoid patellae should be resurfaced. The present trend in the osteoarthritic patella is toward resurfacing more often. With improved implant design and a predicted decrease in complications, resurfacing in the osteoarthritic patella may become routine. Osteoarthritic patellae that maintain good cartilage, normal anatomic shape, and congruent tracking need not be resurfaced.     

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.     

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.