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Case Report: Chronic Ruptured Patellar Tendon Repair with V-Y Advancement of the Quadriceps Tendon and Semitendinosus Graft

A 66-year-old clergyman presented to the orthopaedic clinic due to having progressive difficulty playing golf. He reports that in 1989 he was diagnosed with a ruptured right patellar tendon after playing basketball. Surgery was recommended, however, he elected to forego the procedure because his golf game was unhindered. He has lived without a right patellar tendon for the past nineteen years.

Physical exam showed that he had a 40-degree lag in extension in his right leg when seated at the edge of the examination table. Examination also showed a reducible right patella. Radiographs confirmed a high-riding right patella that did not engage with the femoral trochlear groove (Figure 1). The diagnosis of a chronic right patellar tendon rupture was made and surgical repair was scheduled.

Figure 1. Preoperative radiograph of right patella showing a high-riding patella.

The patient was brought to the operating room to repair the chronic ruptured right patellar tendon. A midline incision was made exposing the extensor mechanism. As the leg was flexed, the patella traveled proximally with the quadriceps tendon. Approximately six centimeters of the patellar tendon remained attached distally to the tibial tubercle with a large amount of scar tissue attached to the proximal end of the ruptured patellar tendon.

The scar tissue was excised and the patella advanced distally to meet the remnants of the patellar tendon. This afforded a limited amount of mobility because of the shortened patellar tendon and thus a V-Y advancement of the quadriceps tendon was initiated. The quadriceps tendon was cut in a V and then sutured closed in a Y configuration. This V-Y advancement of the quadriceps tendon provided an additional two centimeters of distal advancement of the patella.

Three holes were then created in the patella. One transverse hole was initially made with a guide wire and then drilled with a 4.5-mm drill bit. This hole would receive the semitendinosus tendon. Two vertical holes were made parallel to each other using the guide wire from the cannulated drill system. These two holes would receive the sutures from the patella tendon (Fig. 2).

Figure 2. Intraoperative photograph demonstrating the three holes in the patella. Sutures are placed through each of the canals.

The semitendinosus tendon was then harvested and left attached distally. The tendon was sutured with #2 Ethibond. Two #2 Tycron sutures were then placed in the patellar tendon in Krakow whipstitch fashion and then passed through the two vertical holes in the patella. The patellar tendon was attached to the patella with true traverse sutures and the positioning of the patella was checked with the knee in 90-degree flexion. The semitendinosus tendon was criss-crossed through the transverse hole in the patella to relieve the tension on the repaired patellar tendon. The tendon was sutured down to the lateral aspect of the patella tendon at the level of the tibial tubercle (Fig. 3).

Figure 3. Intraoperative photograph showing the patellar tendon repaired with the criss-crossed semitendinosus tendon overlying it.

The knee was able to be flexed to 75-degrees without excess tension on the repair and the graft. The incision was closed in routine fashion after irrigation. The patient’s knee was placed into full extension and was to be kept in that manner for six weeks.
Discussion:

Chronic patellar tendon ruptures are infrequent injuries that can be approached with any number of different treatments. Patellar tendon injuries can occur due to traumatic injury, secondary to trauma (i.e.: total knee arthroplasty), or after corticosteroid use. (References 1,6) These types of injuries typically present with weakness in extension of the leg, atrophy of the quadriceps muscle, and pain at the inferior pole of the patella.(Reference 6)

Several methods have been utilized to repair chronic patellar tendon ruptures, including: non-operative management, direct repair of the tendon, autogenous grafting, allografting, or xenografting. (References 2,3,6) In this case, a combined direct repair of the tendon and autogenous grafting using the semitendinosus tendon was performed.

The primary concern in this case was that of the extreme time lapse between when the patellar tendon ruptured and when the repair was completed.(References 4,6) As a consequence of the time delay, scar tissue accumulated around the ruptured tendon along with contracture of the quadriceps tendon.(References 5,6) To address these two issues, the abundance of scar tissue was excised before the patella tendon was repaired and a V-Y advancement of the quadriceps tendon was performed to deal with quadriceps contracture. In addition, an autogenous graft of the semitendinosus tendon was used to reinforce the patella tendon repair and to reduce the stress placed on it.

At the conclusion of the operation, a brace was placed on the patient’s right leg to prevent the flexion of the knee. When the patient returned to the office ten days after the operation, physical exam revealed 45-degrees of flexion without any stress on the repair. Radiographs showed the patella had been reduced from its previous position (Fig. 4)

Figure 4. Ten-day post-operative radiograph revealing the patella reduced from its previous position.
References:
1. Falconiero R, Pallis M. Chronic Rupture of a Patellar Tendon: A Technique for Reconstruction with Achilles Allograft.Arthroscopy: The Journal of Arthroscopic and Related Surgery 1996; 12 (5): 293-296.
2. Cadambi A, Engh GA. Use of a Semitendinosus Tendon Autogenous Graft for Rupture of the Patellar Ligament After Total Knee Arthroplasty: A Report of Seven Cases. The Journal of Bone and Joint Surgery 1992; 74 (7): 974-979.
3. Ecker ML, Lotke PA, Glazer RM. Late Reconstruction of the Patellar Tendon. The Journal of Bone and Joint Surgery1979; 61 (6): 884-886.
4. Siwek CW, Rao JP. Ruptures of the Extensor Mechanism of the Knee Joint. The Journal of Bone and Joint Surgery1981; 63 (6): 932-937.
5. Isiklar ZU, Varner KE, Lindsey RW, Bocell JR, Lintner DM. Late Reconstruction of Patellar Ligament Ruptures Using Ilizarov External Fixation. Clinical Orthopaedics and Related Research 1996; 322: 174-178.
6. McNally PD, Marcelli EA. Achilles Allograft Reconstruction of a Chronic Patellar Tendon Rupture. Arthroscopy: The Journal of Arthroscopic and Related Surgery 1998; 14 (3): 340-344.