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Iatrogenic patellar tendon deficiency treated with rectus femoris tendon turndown autograft Iatrogenic rupture of the patellar tendon is a rare injury. Arthroscopic debridement of the deep infrapatellar bursa and fat pad may cause unrecognized damage to the patella tendon. Primary tendon repair is often not possible if there is a segmental defect. Options for treatment of segmental defects are limited. We believe that reconstruction with rectus femoris turndown autograft combined with a semitendinosus augmentation is an effective form of treatment for this challenging condition. A 39-year-old male, with an 18-month history of chronic deep infrapatellar bursitis and patellar tendonitis of right knee, presented to our institution with difficulty ambulating and weakness. The patient underwent an arthroscopic excision of the deep infrapatellar bursa 2 months prior at another institution. There was no history of trauma or corticosteroid injection. On examination, the patient had grade 3 knee extension power and a palpable defect in the midsubstance of the patella tendon. The active range of motion was 5 to 110 degrees of flexion. Plain radiographs were unremarkable except for a subtle soft tissue defect at the mid-substance of the patella tendon. Magnetic resonance imaging confirmed the diagnosis of patella tendon rupture with a 1.5 cm defect. The medial and lateral retinaculi were intact, which supported the iatrogenic nature of the rupture. Open surgical reconstruction of the patella tendon was performed 12 days after presentation and 72 days after the initial procedure. The patella tendon rupture was confirmed at the midsubstance via a standard midline incision. The fat pad was intact and there was no direct communication with the knee joint. The intact retinaculi prevented gross retraction of the patella and allowed for easy approximation of patella ligament length. The rectus femoris tendon was identified on the superficial aspect of the quadriceps tendon, and carefully mobilized. It was left intact at its distal insertion onto the patella and turned down over the patella tendon defect. The semitendinosus tendon was harvested and left intact distally. The semitendinosus graft was then passed through a 6.5-mm transverse patellar tunnel, in a medial to lateral direction. The turned-down rectus femoris tendon and semitendinosus tendon were sutured to the distal patella tendon stump with the knee in hyperextension to allow for eventual stretch of the reconstruction. The semitendinosus was also sutured to the intact medial and lateral retinaculi (Fig. 1). The limb was placed in an extension splint for 6 weeks and kept non-weightbearing. Isometric quadriceps exercises were started immediately. At 18 months follow-up, the patient regained grade 5 knee extension power, with active range of motion of 0 to 140 degrees of flexion (Fig. 2). He was able to return to preoperative daily activities, including jogging, and resume work as an engineer in the Australian Defence Force. © 2015 Royal Australasian College of Surgeons
Endoscopic resection of the deep infrapatellar bursa is indicated for bursitis, painful impingement of the infrapatellar fat pad (Hoffa’s disease)1 and infrapatellar tendinopathy, as well as for removal of ossicle formation in Osgood Schlatter’s disease.2 The potential danger of this procedure is iatrogenic damage of the patella tendon insertion. Several different autograft materials have been described to treat chronic patella tendon rupture, including semitendinosus and gracilis tendons, contralateral patellar tendon, patellar retinaculum, fascia lata and vastus lateralis fascia, as well as an Achilles tendon allograft.3–5 To our knowledge, the use of the rectus femoris tendon as a means of reconstruction of the patella tendon has not been described. We feel that this technique is particularly useful for chronic ruptures where tendon ends cannot be primarily opposed, and for iatrogenic ruptures where there is segmental loss of tendon substance. Donor site morbidity with this technique is minimal as the quadriceps tendon is trilaminar, with the tendons of vastus lateralis and
Fig. 1. Photograph of the anterior aspect of the right knee. The rectus femoris turndown autograft has been sutured to the patella tendon stump. The semitendinosus tendon has been passed through a tunnel in the patella and sutured to the patella tendon stump to augment the reconstruction.
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
Fig. 2. Photograph of the patella tendon reconstruction at 18 months follow-up. (a) The patient is straight-leg raising. The bed where the rectus femoris tendon was harvested (arrow) and the semitendinosus graft (arrow head) can be appreciated. (b) Almost full flexion of 140 degrees was achieved.
intermedius deep to the bed of the rectus femoris graft (Fig. 3).6 It is unknown whether the good result in our patient was due to the combination of the rectus femoris turndown and semitendinosus augmentation, with no literature available on the rectus femoris tendon turndown technique, and good results reported with the use of hamstrings autograft alone.7 We feel that the chronic and segmental nature of tendon deficiency in our patient warranted a combination of techniques. Our case demonstrates use of the rectus femoris tendon turndown, augmented with the semitendinosus tendon, to effectively reconstruct an iatrogenic patella tendon segmental defect.
References 1. von Engelhardt LV, Tokmakidis E, Lahner M et al. Hoffa’s fat pad impingement treated arthroscopically: related findings on preoperative MRI in a case series of 62 patients. Arch. Orthop. Trauma Surg. 2010; 130: 1041–51. 2. Klein W. Endoscopy of the deep infrapatellar bursa. Arthroscopy 1996; 12: 127–31. 3. Gokce A, Ekici H, Erdogan F. Arthroscopic reconstruction of a ruptured patellar tendon: a technical note. Knee Surg. Sports Traumatol. Arthrosc. 2008; 16: 581–4.
Fig. 3. Diagram of rectus femoris semitendinosus tendon augmentation.
turndown
autograft
and
4. Nguene-Nyemb AG, Huten D, Ropars M. Chronic patellar tendon rupture reconstruction with a semitendinosus autograft. Orthop Traumatol Surg Res 2011; 97: 447–50. 5. Wiegand N, Maumov I, Vamhidy L, Warta V, Than P. Reconstruction of the patellar tendon using a Y-shaped flap folded back from the vastus lateralis fascia. Knee 2013; 20: 139–43. 6. Sinnatamby CS. Last’s Anatomy: Regional and Applied, 9th edn. Edinburgh: Churchill Livingston, 1999; 157. 7. Maffulli N, Del Buono A, Loppini M, Denaro V. Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures: average 5.8-year follow-up. J. Bone Joint Surg. Am. 2013; 95: 1231–6.
Andrew James Kanawati, MBBS Michael Stening, MBBS, FRACS Department of Orthopaedics, Hawkesbury District Health Service, Sydney, New South Wales, Australia doi: 10.1111/ans.13012
© 2015 Royal Australasian College of Surgeons
Iatrogenic patellar tendon deficiency treated with rectus femoris tendon turndown autograft Iatrogenic rupture of the patellar tendon is a rare injury. Arthroscopic debridement of the deep infrapatellar bursa and fat pad may cause unrecognized damage to the patella tendon. Primary tendon repair is often not possible if there is a segmental defect. Options for treatment of segmental defects are limited. We believe that reconstruction with rectus femoris turndown autograft combined with a semitendinosus augmentation is an effective form of treatment for this challenging condition. A 39-year-old male, with an 18-month history of chronic deep infrapatellar bursitis and patellar tendonitis of right knee, presented to our institution with difficulty ambulating and weakness. The patient underwent an arthroscopic excision of the deep infrapatellar bursa 2 months prior at another institution. There was no history of trauma or corticosteroid injection. On examination, the patient had grade 3 knee extension power and a palpable defect in the midsubstance of the patella tendon. The active range of motion was 5 to 110 degrees of flexion. Plain radiographs were unremarkable except for a subtle soft tissue defect at the mid-substance of the patella tendon. Magnetic resonance imaging confirmed the diagnosis of patella tendon rupture with a 1.5 cm defect. The medial and lateral retinaculi were intact, which supported the iatrogenic nature of the rupture. Open surgical reconstruction of the patella tendon was performed 12 days after presentation and 72 days after the initial procedure. The patella tendon rupture was confirmed at the midsubstance via a standard midline incision. The fat pad was intact and there was no direct communication with the knee joint. The intact retinaculi prevented gross retraction of the patella and allowed for easy approximation of patella ligament length. The rectus femoris tendon was identified on the superficial aspect of the quadriceps tendon, and carefully mobilized. It was left intact at its distal insertion onto the patella and turned down over the patella tendon defect. The semitendinosus tendon was harvested and left intact distally. The semitendinosus graft was then passed through a 6.5-mm transverse patellar tunnel, in a medial to lateral direction. The turned-down rectus femoris tendon and semitendinosus tendon were sutured to the distal patella tendon stump with the knee in hyperextension to allow for eventual stretch of the reconstruction. The semitendinosus was also sutured to the intact medial and lateral retinaculi (Fig. 1). The limb was placed in an extension splint for 6 weeks and kept non-weightbearing. Isometric quadriceps exercises were started immediately. At 18 months follow-up, the patient regained grade 5 knee extension power, with active range of motion of 0 to 140 degrees of flexion (Fig. 2). He was able to return to preoperative daily activities, including jogging, and resume work as an engineer in the Australian Defence Force. © 2015 Royal Australasian College of Surgeons
Endoscopic resection of the deep infrapatellar bursa is indicated for bursitis, painful impingement of the infrapatellar fat pad (Hoffa’s disease)1 and infrapatellar tendinopathy, as well as for removal of ossicle formation in Osgood Schlatter’s disease.2 The potential danger of this procedure is iatrogenic damage of the patella tendon insertion. Several different autograft materials have been described to treat chronic patella tendon rupture, including semitendinosus and gracilis tendons, contralateral patellar tendon, patellar retinaculum, fascia lata and vastus lateralis fascia, as well as an Achilles tendon allograft.3–5 To our knowledge, the use of the rectus femoris tendon as a means of reconstruction of the patella tendon has not been described. We feel that this technique is particularly useful for chronic ruptures where tendon ends cannot be primarily opposed, and for iatrogenic ruptures where there is segmental loss of tendon substance. Donor site morbidity with this technique is minimal as the quadriceps tendon is trilaminar, with the tendons of vastus lateralis and
Fig. 1. Photograph of the anterior aspect of the right knee. The rectus femoris turndown autograft has been sutured to the patella tendon stump. The semitendinosus tendon has been passed through a tunnel in the patella and sutured to the patella tendon stump to augment the reconstruction.
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
Fig. 2. Photograph of the patella tendon reconstruction at 18 months follow-up. (a) The patient is straight-leg raising. The bed where the rectus femoris tendon was harvested (arrow) and the semitendinosus graft (arrow head) can be appreciated. (b) Almost full flexion of 140 degrees was achieved.
intermedius deep to the bed of the rectus femoris graft (Fig. 3).6 It is unknown whether the good result in our patient was due to the combination of the rectus femoris turndown and semitendinosus augmentation, with no literature available on the rectus femoris tendon turndown technique, and good results reported with the use of hamstrings autograft alone.7 We feel that the chronic and segmental nature of tendon deficiency in our patient warranted a combination of techniques. Our case demonstrates use of the rectus femoris tendon turndown, augmented with the semitendinosus tendon, to effectively reconstruct an iatrogenic patella tendon segmental defect.
References 1. von Engelhardt LV, Tokmakidis E, Lahner M et al. Hoffa’s fat pad impingement treated arthroscopically: related findings on preoperative MRI in a case series of 62 patients. Arch. Orthop. Trauma Surg. 2010; 130: 1041–51. 2. Klein W. Endoscopy of the deep infrapatellar bursa. Arthroscopy 1996; 12: 127–31. 3. Gokce A, Ekici H, Erdogan F. Arthroscopic reconstruction of a ruptured patellar tendon: a technical note. Knee Surg. Sports Traumatol. Arthrosc. 2008; 16: 581–4.
Fig. 3. Diagram of rectus femoris semitendinosus tendon augmentation.
turndown
autograft
and
4. Nguene-Nyemb AG, Huten D, Ropars M. Chronic patellar tendon rupture reconstruction with a semitendinosus autograft. Orthop Traumatol Surg Res 2011; 97: 447–50. 5. Wiegand N, Maumov I, Vamhidy L, Warta V, Than P. Reconstruction of the patellar tendon using a Y-shaped flap folded back from the vastus lateralis fascia. Knee 2013; 20: 139–43. 6. Sinnatamby CS. Last’s Anatomy: Regional and Applied, 9th edn. Edinburgh: Churchill Livingston, 1999; 157. 7. Maffulli N, Del Buono A, Loppini M, Denaro V. Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures: average 5.8-year follow-up. J. Bone Joint Surg. Am. 2013; 95: 1231–6.
Andrew James Kanawati, MBBS Michael Stening, MBBS, FRACS Department of Orthopaedics, Hawkesbury District Health Service, Sydney, New South Wales, Australia doi: 10.1111/ans.13012
© 2015 Royal Australasian College of Surgeons
