Introduction Disruption of the tendon attaching the patella to the tibial tubercle (the patella is a sesamoid bone making this a tendon, not a ligament) Epidemiology incidence < 0.5% of the US population per year demographic most commonly in 3rd and 4th decade male > female location quadriceps tendon rupture > patella tendon rupture risk factors weakening of collagen structure systemic systemic lupus erythematous rheumatoid arthritis chronic renal disease diabetes mellitus local patellar degeneration (most common) previous injury patellar tendinopathy other corticosteroid injection Pathophysiology mechanism tensile overload of the extensor mechanism most ruptures occur with knee in flexed position greatest forces on tendon when knee flexion > 60 degrees ratio of patellar tendon force to quads tendon force >1 at <45° and <1 at >45° at smaller flexion angle, patellofemoral contact point is at distal pole of patella, giving quads tendon a mechanical advantage pathoanatomy 3 patterns of injury avulsion with or without bone from the proximal insertion/inferior pole of patella (most common) strain at tendon-bone interface is 3-4x strain at midsubstance midsubstance distal avulsion from the tibial tubercle biology rupture is usually the result of end stage or long-standing chronic tendon degeneration Outcome most important factor is timing of repair Anatomy Extensor mechanism of the knee quadriceps femoris muscles quadriceps tendon patella patellar tendon tibial tubercle Forces in patellar tendon ascending stairs is 3x body weight to rupture a normal tendon is 17x body weight Blood supply infrapatellar fat pad retinacular structures (medial and lateral inferior geniculate arteries) Presentation History sudden quadriceps contraction with knee in a flexed position (e.g., jumping sports, missing step on stairs) Symptoms infrapatellar pain popping sensation difficulty weight-bearing Physical exam inspection elevation of patella height usually associated with a large hemarthrosis and ecchymosis localized tenderness palpable gap below the inferior pole of the patella motion unable to perform active straight leg raise or maintain passively extended knee reduced ROM of knee (and difficulty bearing weight) due to pain if only tendon is ruptured and retinaculum is intact, active extension will be possible but will have extensor lag of a few degrees Imaging Radiographs recommended views AP and lateral of the knee optional views merchant or skyline findings patella alta seen in complete rupture knee in flexion (ideally 30 degrees), the Insall-Salvati ratio is > 1.2 Ultrasound indications suspected acute and chronic injuries findings effective at detecting and localizing disruption operator and user-dependent MRI indications differentiate partial from complete tendon rupture most sensitive imaging modality findings site of disruption, tendon degeneration, patellar position, and associated soft tissue injuries Treatment Nonoperative immobilization in full extension with a progressive weight-bearing exercise program indications partial tears with intact extensor mechanism modalities application of a removable knee splint early knee range of motion Operative primary repair indications complete patellar tendon ruptures ability to approximate tendon at site of disruption techniques end-to-end repair transosseous tendon repair suture anchor tendon repair tendon reconstruction indications severely disrupted or degenerative patella tendon techniques semitendinosus or gracilis tendon autograft free ends of the tendons are passed through transosseous hole of the patella, and then through a transosseous hole within the tibial tubercle to make a complete circle graft. other options central quadriceps tendon-patellar bone autograft contralateral bone-patellar tendon-bone autograft allograft rehabilitation may weight bear early with protected knee extension brace exercises to optimize range of motion and minimizes stress on the repair include passive extension and active closed chain flexion (heel slides) prone open chain knee flexion Techniques Direct primary repair approach longitudinal midline incision expose rupture and adjacent retinacula debride the ends of the rupture end-to-end technique approximate tendon at site of rupture nonabsorbable sutures are woven with locking stitch transosseous tendon repair suture the patellar tendon to the patella with a no.5 nonabsorbable transosseous suture can be protected with a cerclage wire or nonabsorbable tape between patella and tibial tuberosity postoperative care immediate immobilization weight-bearing status rehabilitation following acute primary repair with suture augmentation - immediate immobilization with full weight-bearing and controlled initiation of knee ROM at 7-10 days, goal of brace free ambulation, full knee extension, and 120 degrees of knee flexion by 6 weeks, and full return to sport at 6 months Complications Stiffness (loss of knee flexion) prevent this by starting early ROM and quads strengthening treat this with MUA if flexion is <120° at 6-8wks Decreased quadriceps strength Quadriceps atrophy (does not compromise return of strength)
Technique Guide 10/18/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Patellar Tendon Rupture Repair Neil Duplantier Knee & Sports - Patella Tendon Rupture
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.251) A 24-year-old basketball player feels a painful "pop" in his knee when landing from a rebound. He develops immediate swelling, pain, and inability to extend his knee. A lateral radiograph is shown in Figure A. Proper management should include which of the following Review Topic QID: 637 FIGURES: A 1 Physical therapy for range of motion followed by surgical reconstruction with patellar tendon autograft 2% (48/2271) 2 Hinged knee brace locked at 30-degrees of flexion for 6 weeks followed by physical therapy for range of motion 1% (12/2271) 3 Medializing tibial tubercle osteotomy with lateral retinacular release 0% (5/2271) 4 Primary surgical repair 97% (2192/2271) 5 Arthroscopy for debridement versus repair 0% (9/2271) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ06.122) Which of the following rehabilitation exercises provides for restoration of range of motion while limiting stress on the repair of a ruptured patellar tendon? Review Topic QID: 308 1 Active open chain flexion, active closed chain extension 3% (48/1401) 2 Passive flexion, active closed chain extension 22% (303/1401) 3 Active closed chain flexion, active open chain extension 4% (51/1401) 4 Active flexion, passive extension 68% (953/1401) 5 Passive flexion, active open chain extension 3% (42/1401) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.28) A 35-year-old male slips on a patch of ice and falls on a hyperflexed knee. He reports hearing a "pop" during the fall and was unable to bear weight on the knee immediately after the injury. He has a large knee effusion on examination. A radiograph is shown in Figure A. He undergoes operative repair of the injury with standard technique. Which of the active range of motion exercises is MOST appropriate in the immediate postoperative period? Review Topic QID: 3451 FIGURES: A 1 Leg extensions 10% (296/3054) 2 Heel slides 83% (2548/3054) 3 Standing squats 2% (55/3054) 4 Rear lunges 1% (25/3054) 5 Seated leg press 4% (112/3054) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ07.152) A 40-year-old recreational basketball player injured his knee while jumping for a rebound. He felt a pop and developed immediate swelling. His radiographs are shown in Figures A and B. What is the recommended management? Review Topic QID: 813 FIGURES: A B 1 Obtain an MRI 4% (46/1218) 2 Ice, rest, and observation 1% (8/1218) 3 Physical therapy to regain motion 0% (4/1218) 4 Knee arthroscopy and repair 1% (7/1218) 5 Open surgical repair 94% (1150/1218) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
KEYNOTE: Extensor Mechanism Rupture: Repair or Augmentation? - Michael Stuart, MD (4.10, 2018 Winter SKS) Knee & Sports - Patella Tendon Rupture - All WINTER SKS: 2018 SHOULDER, KNEE, & SPORTS MEETINGKEYNOTE: Extensor Mechanism Rup... 8/15/2018 306 views heel slides Knee & Sports - Patella Tendon Rupture - Surgical Cases tutorial on performing a heel slide 1/26/2012 2845 views
Partial patellar tendon tear in 18M (C2823) Knee & Sports - Patella Tendon Rupture HPI - Bad landing on right knee How would you treat this injury? (Patient has a very promising sports career in front of him) 6/2/2017 353 14 4 Patella tendon tear (C2067) Knee & Sports - Patella Tendon Rupture HPI - Unclear history of present illness. Fell down 6 weeks ago, pt presented in the hospital 3 weeks after the injury with severe knee effusion. Had a wash out of the knee with the possible diagnosis of knee septic arthritis. He has been d/c home with oral AB. No other details are known from this admission. Admitted again in our Hospital with ascites and severe knee effusion. Arthroscopic wash out performed again, due to suspicion of a septic knee. Cultures and fluid analysis were negative for infection. How would you treat this patient? 11/19/2014 609 4 8 Chronic left patellar tendon rupture (C1104) Knee & Sports - Patella Tendon Rupture HPI - Left patellar tendon tear during pickup basketball 22 years ago. s/p patellar tendon repair right after injury (primary repair). Complains of instability of the anterior knee and difficulty walking (can't run/jog). What would you do with this patient? 12/7/2011 61 2 11