Patellar tendon ruptures.

BACKGROUND: Isolated rupture of the patellar tendon is a rare injury. Often occurring during a fall in 20- and 30-year olds, patients may have a preexisting medical condition (eg, history of steroid use) or a history of repetitive microtrauma to the knee. A high-riding patella on physical examination and radiographs is pathognomonic. METHODS: Immediate orthopaedic referral for surgical repair is necessary to reestablish knee extension. Delay in diagnosis can make surgical treatment more difficult. Current methods of postoperative rehabilitation are evolving. RESULTS: Evaluative studies based on rating scales show satisfactory clinical and functional results after surgery. However, time lost from work and recreation may be protracted, and quadriceps atrophy is often evident. CONCLUSIONS: Ruptures of the patellar tendon should be diagnosed acutely and immediately referred to an orthopaedic surgeon. The impact of the injury to the patient may be long-standing even after operative treatment. Contemporary surgical and rehabilitative techniques give the best opportunity for restoration of functional activity.     

Atraumatic bilateral Achilles tendon rupture: an association of systemic steroid treatment.

A case of bilateral Achilles tendon rupture associated with steroid use is reported. This case illustrates the importance of taking a thorough drug history in cases of tendon rupture. In lower limb tendon rupture all patients, especially those on steroids, should be warned of the increased risk of contralateral injury.     

Atraumatic bilateral Achilles tendon rupture: an association of systemic steroid treatment.

A case of bilateral Achilles tendon rupture associated with steroid use is reported. This case illustrates the importance of taking a thorough drug history in cases of tendon rupture. In lower limb tendon rupture all patients, especially those on steroids, should be warned of the increased risk of contralateral injury.     

Bilateral patellar tendon ruptures without predisposing systemic disease or steroid use: a case report and review of the literature

Simultaneous bilateral patellar tendon rupture occurs rarely and is even rarer in patients without systemic disease or predisposing conditions. We present a case of bilateral, midsubstance patellar tendon ruptures along with a partial anterior cruciate ligament tear from a fall from a standing height in an otherwise healthy adult without any predisposing conditions. Most patients that sustain a tendon rupture have risk factors for tendonopathy including chronic renal disease, systemic lupus erythematosus, rheumatoid arthritis, or exposure to medications (such as corticosteroids or fluoroquinolones). Currently, there are approximately 50 reported cases of bilateral patellar tendon rupture in the scientific literature; however, only a small minority occurred in patients without any predisposing factors. Most of the reports of a bilateral tendon rupture without systemic disease occurred in the inferior pole of the tendon, with only a few of these occurring in the midsubstance. Because of the rarity of this event in a patient without systemic disease, this condition is often misdiagnosed. Emergency physicians should maintain a high degree of suspicion in those patients with concerning clinical and/or radiographic findings.     

Reconstruction of chronic patellar tendon rupture with semitendinosus tendon: case report

Chronic patellar tendon rupture is a rare injury whose treatment poses technical difficulties. Surgical repair is mandatory to restore the extensor mechanism of the knee. Many different surgical methods of patellar tendon reconstruction have been described. We present the case of a 48-year-old male patient who sustained patellar tendon rupture 8 months before surgery. A semitendinosus tendon graft and the modified Ecker technique were used for the reconstruction of the patellar tendon. Full extension was achieved alongside high patient satisfaction. However, the patient required prolonged intensive rehabilitation.     

Patellar Tendon Rupture with Underlying Systemic Lupus Erythematosus: A Case Report

Background: There have been few case reports of patellar tendon rupture in patients with underlying systemic lupus erythematosus (SLE). Objectives: We present a unique case to discuss the importance of recognizing patellar tendon rupture in the emergency department (ED). Case Report: An 18-year-old man with SLE presented to the ED with pain, swelling, and inability to extend his left knee after a fall. Physical examination demonstrated a palpable defect over the patellar tendon, and plain radiographs showed patella alta. Patellar tendon rupture was diagnosed, and the patient underwent open surgical repair. Conclusion: In low-energy patellar tendon rupture, the effects of the pathophysiology and the treatment for SLE, which includes systemic corticosteroids, are currently unclear. However, it is important to establish prompt diagnosis and appropriate treatment in the ED to maximize recovery and minimize long-term disability.     

Ligament augmentation reconstruction system artificial ligaments in patellar tendon reconstruction-a chronic patellar tendon rupture after multiple operations: A case report

BACKGROUND Patellar tendon rupture is a rare disease,and reports regarding patellar tendon reconstruction with ligament augmentation reconstruction system(LARS)ligaments are limited,with only three reports available in the literature.LARS ligaments are made of polyethylene terephthalate and have been certified as a more favorable option than other tendon transplants.To our knowledge,this is the first report of patellar tendon reconstruction with LARS for suture fixation due to poor quality of the tendon after multiple operations to enable early mobilization and quick rehabilitation.CASE SUMMARY A 65-year-old woman had limited ability in extending her leg and an inability to perform a straight leg raise after multiple operations due to patella fracture.The patient underwent patellar tendon reconstruction with LARS artificial ligaments.After 12 mo of follow-up,the patient was able to perform a straight leg raise,and the incision healed well without complications.The Lysholmscore was 95 and the range of motion of the knee was 0-130°.CONCLUSION This study revealed that patellar tendon reconstruction with LARS artificial ligaments is possible in a patient with a patellar tendon rupture who required rapid postoperative recovery.     

Verschiedene Techniken zur Ersatzplastik des vorderen Kreuzbands

A wide variety of proven methods for anterior cruciate ligament (ACL) surgery is known for treating a very mixed group of patients. The gold standard for ACL replacement today is anatomic single bundle reconstruction using hamstring tendon, patellar tendon or quadriceps tendon as autologous graft. An indication for ACL double bundle reconstruction is seen in patients with large insertion zones. The double bundle concept also includes replacement of a partial rupture or remnant augmentation. Graft choice should be adapted to the individual patient. For specific graft choice age, gender, activity, sports, professional and religious habits should be considered.     

Strain Ratio Measurements of Patellar and Achilles Tendons With Different Reference Regions in Healthy Volunteers

Strain ratio measurements of tendons vary because of the reference tissue selection. The main purpose of this study is to highlight, in detail, the numeric variability attributable to the use of various reference materials on strain ratio measurements of patellar and Achilles tendons. Measurements were performed at the proximal, middle and distal thirds of the patellar and Achilles tendons on the dominant site of healthy volunteers. A total of 3 references were used: the Hoffa's fat pad for the patellar tendon, the Kager's fat pad for the Achilles tendon, subcutaneous tissue and Aquaflex gel pads (Parker Laboratories, Fairfield, NJ, USA) for both tendons. Although the same methods were used by the same physician for each tendon site on repeated measurements, strain ratio values had numeric variability with various reference materials in each measurement. Therefore, comparison of numeric strain ratio results of various studies with various reference materials could confuse the clinical interpretations of these numeric data, and, using a reference material with standard stiffness like Aquaflex ultrasound gel pads, should be considered by verifying these results with further studies.     

Bilateral Achilles tendon rupture: an unusual occurrence.

Bilateral Achilles tendon rupture is an unusual injury. This rare entity usually occurs in patients on chronic steroid therapy or with underlying disease. Bilateral Achilles tendon rupture is extremely rare in a previously healthy individual. A case involving traumatic Achilles tendon rupture as a result of a sky diving accident is reported. Evaluation of patients with suspected Achilles tendon rupture is briefly reviewed.     

Mechanical properties of the human patellar tendon, in vivo

BACKGROUND: Mechanical properties of the human patellar tendon are largely based on cadaver studies, which may not necessarily be applicable to the human patellar tendon, in vivo. While ultrasonography is an attractive non-invasive method for studying human, in vivo, muscle-tendon behaviour, it has mostly been used to examine Achilles tendon properties. We examine the accuracy of human patellar tendon elongation, in vivo, and its within-day and between-day reproducibility. METHODS: Subjects performed four maximal 10-s ramp isometric knee extension trials to examine within-day reproducibility, and the procedure was repeated on a separate day to assess between-day reproducibility. Continuous and simultaneous ultrasonography based measurement of both tibial and patellar movement together with patellar tendon force yielded mechanical estimates. RESULTS: Longitudinal tibial displacement corresponded to 45 (SEM 8) % of the overall tibia-patella displacement. For within-day reproducibility there was no difference between trials for stiffness [trial a, 4334 (SEM 562) N/mm; trial b, 4273 (SEM 533) N/mm], strain [trial a, 6.9 (SEM 0.6) %; trial b, 6.8 (SEM 0.7) %] or elastic modulus [trial a, 1.09 (SEM 0.12) GPa; trial b, 1.09 (SEM 0.10) GPa]. The within day correlation coefficient and typical error were 0.95 and 9.9% for stiffness, 0.97 and 5.5% for strain, and 0.94 and 9.4% for elastic modulus. The corresponding values for between days were 0.94 and 8.7% for stiffness, 0.98 and 3.7% for strain, and 0.86 and 9.6% for elastic modulus. INTERPRETATION: The present methodology of assessing human patellar tendon elongation, strain and stiffness, in vivo, is accurate and reproducible which permits its use in future investigations of patellar tendon biomechanics and the potential effects of various interventions.     

An interview with Per Renstrom on his personal perspective of the changes and developments in the sports medicine field over the last 40 years

Kettlebell exercises are more efficient for an athlete to increase his or her muscle strength. However it carries the risk of injury especially in the beginners. A 39 year old gentleman came to our clinic with radial sided wrist pain following kettlebell exercises. Clinically patient had swelling and tenderness over the tendons in the first dorsal wrist compartment, besides Finklesten test was positive. Patient had a decreased excursion of the thumb when compared to the opposite side. Ultrasound/MRI scan revealed asymmetric thickening of the 1st compartment extensors extending from the base of the thumb to the wrist joint. Besides injury to the Extensor Pollicis Brevis (EPB) tendon by repetitive impact from kettlebell, leading to its split was identified. Detailed history showed that the injury might be due to off-centre handle holding during triceps strengthening exercises. Our report stresses the fact that kettlebell users should be taught about problems of off-center handle holding to avoid wrist injuries. Also, in Kettlebell users with De Quervains disease clinical and radiological evaluation should be done before steroid injection as this might lead to complete tendon rupture.     

Distal biceps ruptures: open and endoscopic techniques

Distal biceps tendon ruptures are relatively rare. Patients are usually middle-aged men involved in heavy labor. Patients usually present with the history of a pop and a proximal migration of the biceps muscle belly. Clinical exam should be sufficient to diagnose a complete rupture. Several specific tests have been described. Ultrasound scanning or MRI can help confirm the diagnosis. Radiographs are not needed to diagnose distal biceps tendon rupture but may show typical findings. Imaging, more specifically the flexion-abduction-supination (FABS) view MRI, is particularly helpful in the case of a partial rupture or chronic rupture of the distal biceps tendon. Results of surgical reinsertion of the distal biceps have been shown to be superior to conservative treatment. Different techniques and approaches have been described with specific advantages and disadvantages. Primary repair of the tendon is preferred. If this is no longer possible in chronic tears, an augmentation can be done using tendon graft. Results of surgical treatment are good in the vast majority of patients. Reruptures are rare but minor complications are common. Major complications may include posterior interosseous nerve palsy or radioulnar synostosis, but the risk of these complications may be decreased by meticulous attention to detail during surgery.     

Levofloxacin-associated Achilles tendon rupture

OBJECTIVE: To describe a case of levofloxacin-induced partial Achilles tendon rupture; this occurred in the presence of known risk factors and acute renal failure. CASE SUMMARY: A 79-year-old white man received levofloxacin for presumed pneumonia, developed acute renal failure in the setting of dehydration, and began having ankle pain on the 12th day of admission. Levofloxacin was discontinued, and magnetic resonance imaging revealed a 6-cm partial tear and degenerative changes. DISCUSSION: The Naranjo probability scale indicates a possible association between levofloxacin and tendon rupture because the event occurred in the setting of known risk factors such as steroid use, renal failure, older age, and male gender. CONCLUSIONS: Levofloxacin, like other fluoroquinolones, may cause Achilles tendon rupture, and this may be particularly likely with known risk factors.     

Fluoroscopically Guided Supraglenoid Tubercle Steroid Injections for the Management of Biceps Tendonitis

Background: The management of bicipital tendonitis can be challenging to the clinician. Traditionally, blind injections near the bicipital groove have been performed by clinicians with risk of bicipital tendon rupture or atrophy. Because of the inaccuracy and risk associated with blind bicipital tendon steroid injections, we sought to ascertain whether a fluoroscopically guided steroid injection into the region of the origin of the long head of the bicipital tendon (supraglenoid tubercle) was efficacious. Methods: A retrospective chart review of 6 consecutive patients with a diagnosis of bicipital tendonitis was performed. All patients underwent a fluoroscopically guided steroid/anesthetic injection into the supraglenoid tubercle of the shoulder. The main outcome measure was post‐procedure change in visual analog pain scale; the secondary outcome was the physical examination (presence of a Speed's test). Results: Ten cases were identified, but only 6 had complete data and were included in the analysis. Five of the 6 patients experienced a reduction in pain by 50% at follow‐up. Discussion: A fluoroscopically guided block injected into the supraglenoid tubercle may be effective in the management of bicipital tendonitis.     

自体肌腱移植双束解剖重建内侧髌股韧带治疗髌骨脱位

背景:对于髌骨不稳的治疗,临床上一般分为保守和手术治疗,其中手术治疗方法众多,每种方法各有侧重,对于使用何种方法治疗髌骨不稳,目前仍没有形成统一的共识.目的:探讨应用自体移植肌腱双束解剖重建内侧髌股韧带治疗髌骨脱位.方法:选择安徽医科大学第一附属医院骨科行膝关节镜辅助下内侧髌股韧带重建髌骨脱位患者46例,所有患者均采用自体移植肌腱双束解剖重建.结果与结论:重建后随访2~16个月,观察患者关节稳定性及灵活度.46例患者随访期间未见严重并发症,患膝轻度伸直受限1例,重建后均未见髌骨复发脱位.重建后随访Lysholm膝关节评分和Kujala评分均高于重建前(P < 0.01).结果证实,采用膝关节镜辅助下自体移植肌腱双束解剖重建内侧髌股韧带治疗髌骨脱位效果较好.     

Anatomie et tendinopathie patellaire : un malentendu

The anatomical structure linking the patella and the tibia is called the “patellar ligament” in the international nomenclature. This term is well accepted yet can be a source of confusion for non-specialists. This is because the priority role of this structure is not to maintain joint stability, the primary role of the cruciate ligaments and the collateral ligaments, but rather to prolong the mechanical action of the quadriceps muscle onto the leg skeleton beyond the “patellar sesmoid”. Patellar tendon injuries are a common observation in sports medicine. The proximal third of the tendon below the patella is most generally involved. This highly frequent tendinopathy sometimes termed an “insertion” tendiopathy. Based on 100 consecutive magnetic resonance imaging studies and cadaveric dissection, we confirm that the insertion of the patellar tendon is situated on the anterior aspect of the patella and not the tip. We describe two anatomical variants of the healthy patellar tendon (type 1 and 2) that should not be confused with a site of tendinopathy. The anatomical limits between tendinous tissue and infrapatellar adipose body (the Hoffa adipose ligament), notably on the upper third is still debated and merits further work.     

Mechanics of cadaveric anterior cruciate ligament reconstructions during simulated jump landing tasks: Lessons learned from a pilot investigation

BackgroundAround half of anterior cruciate ligament (ACL) injuries are treated through reconstruction, but the literature lacks mechanical investigation of reconstructions in a dynamic athletic task and rupture environment. The current objective was to ascertain the feasibility of investigating ACL reconstructions in a rupture environment during simulated landing tasks in a validated mechanical impact simulator.MethodsFour cadaveric lower extremities were subjected to simulated landing in a mechanical impact simulator. External joint loads that mimicked magnitudes recorded from an in vivo population were applied to each joint in a stepwise manner. Simulations were repeated until ACL failure was achieved. Repeated measures design was used to test each specimen in the native ACL and hamstrings, quadriceps, and patellar tendon reconstructed states.FindingsACL injuries were generated in 100% of specimens. Graft substance damage occurred in 58% of ACLRs, and in 75% of bone tendon bone grafts. Bone tendon bone and quadriceps grafts survived greater simulated loading than hamstrings grafts, but smaller simulated loading than the native ACL. Median peak strain prior to failure was 20.3% (11.6, 24.5) for the native ACL and 17.4% (9.5, 23.3) across all graft types.InterpretationThe simulator was a viable construct for mechanical examination of ACLR grafts in rupture environments. Post-surgery, ACL reconstruction complexes are weaker than the native ACL when subjected to equivalent loading. Bone tendon bone grafts most closely resembled the native ligament and provided the most consistently relevant rupture results. This model advocated reconstruction graft capacity to sustain forces generated from immediate gait and weightbearing during rehabilitation from an ACL injury.     

The effect of transforming growth factor-beta on mechanical properties of the fibrous tissue regenerated in the patellar tendon after resecting the central portion

BACKGROUND: No investigators have studied the effects of an application of growth factors on the in vivo tissue regeneration in the tendon after resecting the central portion. The purpose of this study is to clarify whether an application of transforming growth factor (TGF)-beta1 increases the mechanical properties of the regenerated tissue in the patellar tendon after resecting the central portion. METHODS: Thirty female rabbits were divided into three groups, after a 3 mm wide and 10 mm long tendon substance was resected from the central portion in the patellar tendon. In Group I, 5-ng TGF-beta1 dissolved in 0.1-ml saline was injected into the resected portion in the patellar tendon. In Group II, only 0.1-ml saline was injected into the resected portion. In Group III, nothing was injected. All animals were sacrificed at 6 weeks after surgery. Mechanical and histological evaluations were made concerning the regenerated tissue and the unresected tendon tissue in the patellar tendon. FINDINGS: Concerning the regenerated tissue, the tangent modulus and the tensile strength of Group I were significantly greater than those of Groups II and III, while there were no significant differences in these parameters between Groups II and III. INTERPRETATION: The application of TGF-beta1 significantly increases the tangent modulus and the tensile strength of the fibrous tissue regenerated in the patellar tendon after resecting the central portion. This study has provided basic important information on the utility of TGF-beta1 in the in vivo tendon regeneration.     

The changes in mechanical properties of regenerated and residual tissues in the patellar tendon after removal of its central portion

OBJECTIVE: To know the temporal changes of the mechanical properties of the regenerated and the residual tissues in the patellar tendon after removal of the central portion.Design. The regenerated and the residual tissues were compared to sham-operated tendons. BACKGROUND: Although the structural properties of the whole patellar tendon after removal of the central portion have been investigated, no studies have distinguished between the regenerated and the residual tissues.Methods. For 52 skeletally mature rabbits, a full-thick, segmental defect was made at the central portion of the right patellar tendon, while a sham operation performed in the left tendon. At 3, 6, 12, and 24 weeks, we evaluated the mechanical properties and fibroblast density of the regenerated and the residual tissues as well as the blood flow and tissue dimensions of the patellar tendon. In addition, non-treated patellar tendons from six rabbits were served as the control for mechanical testing. RESULTS: The tangent modulus and the tensile strength of the regenerated tissue progressively increased with time. On the other hand, these parameters of the residual tendinous portion decreased until 6 weeks, although they gradually increased thereafter. The tensile strength of the regenerated and the residual tissues at 24 weeks were approximately 80% and 75%, respectively, of the non-treated, control tendon. Abundant blood flow and cell proliferation were observed in the regenerative tissue until 6 weeks. CONCLUSION: The mechanical properties of the regenerated and the residual tissues after removal of the central portion in the patellar tendon are much different from those of the original tendon. RELEVANCE: The present study showed inferior mechanical properties of the residual and the regenerated tissues for up to 24 weeks after removal of the central portion in the patellar tendon. Therefore, the aggressive rehabilitation that applies excessive load to the patellar tendon should be avoided at an early stage after harvesting the tendon for ligament reconstruction.