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Patellar Tendon Rupture: Treatment
Updated: Sep 25, 2009
Treatment
Medical Therapy
Nonoperative treatment has a limited role in the care of patellar tendon ruptures. For the rare person with a partial patellar tendon tear with maintenance of patellar height, cast or brace immobilization in full extension for 6 weeks followed by a therapy program to regain motion and strength may be appropriate. Progress must be slow to allow for tendon-to-bone healing. Strengthening exercises should be delayed for at least 3 months.
Surgical Therapy
Complete tears of the patellar tendon are best addressed with early surgical intervention. This allows the best opportunity for anatomic repair of all the injured structures within the extensor mechanism.
Several techniques have been described for the immediate repair of the acutely ruptured patellar tendon. In general, repair involves suturing the torn tendon through bone tunnels within the patella or tibial tubercle, depending on the location of the disruption. Additionally, retinacular tears are repaired anatomically.
In the unusual case of chronic patellar tendon tears, direct repair may be challenging or impossible. Surgical correction may be performed in stages, depending on the degree of patella alta and peripatellar scarring. Typically, the repair needs augmentation. Alternatively, the patellar tendon can be replaced with allograft or autograft tissue.25,26,27
Preoperative Details
As with any procedure, both the tissues and the patient must be ready for surgical intervention. The ultimate outcome depends not only on the anatomic repair of the extensor mechanism, but also on the rehabilitative efforts of the patient. It is important to stress in the preoperative period the importance of participating in the postoperative rehabilitative protocol so that maximal range of motion and strength can be achieved.
Patellar tendon ruptures with concomitant retinacular tears (Image 3) commonly result in diffuse swelling and ecchymosis along the anterior knee. Therefore, delaying surgical intervention until the inflammation begins to diminish may be safer. This 4-7 day delay may decrease the risk of wound complications.
Additional issues that should be considered are the extent of pathology within the ruptured tendon, the degree of patella alta, and the possibility of concomitant injuries within the knee. Extensive tendinosis or calcification within the ruptured tendon may compromise the repair. While no study has focused on this issue, the surgeon may choose to excise this pathologic tissue and may subsequently need to supplement the repair with additional tissue. Therefore, the patient and the surgeon must be ready to accept this alternative.
Since anatomic repair is the goal, the surgeon must identify the appropriate patellar height for the injured patient. A radiograph of the contralateral knee can serve as a template intraoperatively to assist in recreating the normal patellar position.
Concomitant injuries to the menisci, articular cartilage, or supporting ligamentous structures may be present. Depending on the location and extent of injury to these structures, additional intervention may be necessary. Therefore, the surgeon must consider this in the preoperative period so that surgical incisions are well planned and material needed for repair or reconstruction is available.28
Intraoperative Details
Patellar tendon rupture. This intraoperative picture depicts a rupture of the patellar tendon from the inferior pole of the patella with associated medial and lateral retinacular tears.
Patellar tendon rupture. Two Krackow stitches with number 5 nonabsorbable sutures are sewn through the patellar tendon.
Patellar tendon rupture. The inferior pole of the patella is debrided of soft tissue, then decorticated.
Patellar tendon rupture. An anterior cruciate ligament tibial tunnel guide is positioned along the anterior half of inferior pole and angled such that the drill exits along the superior pole of the patella. A total of 3 parallel tunnels are created. Note the contralateral knee within the operative field, which later serves as the guide in recreating normal patellar height.
Patellar tendon rupture. The Beath pin replaces the drill bit. The suture is then placed through the eyelet.
Patellar tendon rupture. All of the suture ends are now along the superior pole of the patella. The inner limbs of the stitches are within the central tunnel while the outer limbs are within the corresponding outer tunnels.
Patellar tendon rupture. A cerclage stitch was passed along the superior pole of the patella and through a tunnel within the tibial tubercle. This is now being tensioned to maintain normal patellar height so that the repair sutures can now be tied.
Patellar tendon rupture. The repair is now complete with recreation of normal patellar height. The retinacular tears were repaired with absorbable suture with the knee positioned in 30° of flexion.
The patient is positioned supine on the operating table after a regional or general anesthetic is administered. A first-generation cephalosporin typically is administered, since nonabsorbable material is used. The procedure begins with an examination of both knees. Range-of-motion and ligamentous examination is performed to determine whether any motion deficits or concomitant ligamentous injuries are present.
A tourniquet is placed on the involved leg, and typically both legs are cleansed and draped free. After exsanguinating the limb and starting the tourniquet, a straight midline longitudinal incision is made, extending from the superior pole of the patella to the medial aspect of the tibial tubercle. Thick medial and lateral subcutaneous flaps are created to the extent of the retinacular tears.
The torn end of the patellar tendon is then mobilized and minimally debrided of friable tissue. Depending on the location of the tear, the tibial tubercle, inferior pole of the patella, or both are debrided of soft tissue and subsequently decorticated with a curette or bur (Image 5). Troughs are not created. Two No. 5 nonabsorbable sutures are then inserted using a Krackow stitch into each half of the tendon (Image 4).3 Three parallel tunnels are placed through the patella or tibial tubercle.
The authors advocate the technique recently described by Ong and Sherman of using an ACL tibial tunnel guide during this aspect of the procedure to maneuver the drill more accurately to the desired endpoint (Image 6).29 Using the tunnel guide decreases the risk of violating the articular surface, reduces the number of passes required to obtain an optimal position, minimizes injury to the quadriceps tendon, and eliminates the additional step of retrieving sutures through drill holes.
The drill is then replaced with a Beath pin (Image 7). The inner limbs of each stitch are passed through the central tunnel, and then the outer limbs are passed through the outer tunnels (Image 8). In certain situations, the authors have used suture anchors in both the patella and the tibial tubercle with good results but still favor the use of tunnels at this time.
A drill hole is then created transversely through the tibial tubercle through which an additional No. 5 nonabsorbable suture is passed. This suture is then passed superiorly within the quadriceps tendon along the superior pole of the patella (Image 9). This is accomplished by passing a 16-gauge spinal needle along the superior pole and then threading the suture through.
Both knees are then positioned in 30° of flexion. The patellar height is measured from the tibial tubercle to the inferior pole of the patella on the noninvolved leg and recreated in the involved leg by increasing tension in the cerclage suture. Once the correct position is obtained, the repair sutures are tied and the knee is reexamined to assess the degree of knee flexion that can be obtained without causing excessive tension on the repair. Alternatively, an intraoperative radiograph can be obtained on the involved knee, prior to tying the repair sutures, and compared with the radiograph of the contralateral knee obtained in the preoperative period.
The repair site is then oversewn with No. 0 absorbable suture to bring the loose ends remaining on the avulsed side over the repair. The retinacular tears are closed with the same suture material but with the knee held in 30 º of flexion to limit the possibility of capturing the knee and, thus, limiting motion (Image 10). The wound is then closed in standard fashion, with effort to minimize the amount of grasping of the skin edges. This hopefully further diminishes the risk of wound breakdown in this inflamed tissue. A standard dressing is applied, followed by a self-contained cooling device and hinged knee brace locked in extension.
Situations exist in which acute repair with only sutures is not adequate. This can occur when the patient has a midsubstance tear, has a chronic rupture, or has undergone a previous resection of chronic patellar tendinitis or a recent ACL reconstruction with the use of patellar tendon autograft. In these cases, augmentation or reconstruction may be necessary. Described techniques involve the use of both autograft (hamstrings, fascia lata, central quadriceps tendon) and allograft (Achilles tendon) tissue as well as synthetic material.25,26,27,30,31,32,33,34,35,36 Regardless of the material used, these techniques generally involve weaving the supplemental tissue through the native patellar tendon or through bone tunnels within the patella, tibial tubercle, or both.
In the individual with a chronic tear, other factors are involved. Since the patella has been retracted for an extended period, significant scarring may develop, which limits the surgeon's ability to recreate normal patellar height and the ability to regain full knee motion. Adequate mobility can usually be obtained after thorough debridement of the medial and lateral gutters and subperiosteal elevation of the vastus intermedius from the anterior femur. If this is inadequate, a 2-staged reconstruction with preoperative traction with the use of a transverse Steinmann pin placed in the patella can be performed. When the remaining tendon is scarred and attenuated, a Z-lengthening of the quadriceps and Z-shortening of the patellar tendon can be performed. This allows for the sliding of the patella back to the anatomic position. A reconstructive technique as mentioned above then should follow.30,31,32,37
Allograft reconstructive techniques have also been described for care of the chronic patellar tendon rupture.33,38 The procedure involves placement of the bone-block end of the graft into a trough created in the tibial tubercle. The tendinous end is then split and passed through one or more tunnels within the patella and/or encircling the patella medially and laterally.
Postoperative Details
The ultimate goal of the surgical repair is the return of normal knee mechanics and strength. To achieve this goal, it is important for the repair to be stable enough to allow for early, controlled range of motion as described by Marder and Timmerman.6
Provided that a stable repair has been achieved, the authors' standard postoperative protocol is described below (see Table).
Table Standard Postoperative Protocol
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Table
| Time After Surgery | Weightbearing | Immobilization | Therapy |
| 0-3 d | None, with use of crutches | Hinged knee brace locked in extension | 1. Motion - None 2. Modalities and/or exercises - None |
| 4-13 d | Toe touch with crutches | Hinged knee brace locked in extension | 1. Motion - Active flexion to 45° and passive extension to 0° (no active extension) 3 times a day 2. Modalities and/or exercises - Swelling control with ice, gentle medial and lateral patellar mobilization, gentle isometric hamstring exercises, contralateral isometric quadriceps exercises 3 times a day |
| 2-4 wk | Partial (25-50%) with crutches | Hinged knee brace locked in extension | 1. Motion - Active flexion to progress to 90° and passive extension to 0° (no active extension) 3 times a day 2. Modalities and/or exercises - Swelling control with ice, gentle medial and lateral patellar mobilization, gentle (~25%) isometric quadriceps exercises (sets, no straight leg raises), continue with ipsilateral hamstring exercises and contralateral quadriceps exercises 3 times a day |
| 4-6 wk | Progress to weightbearing as tolerated, crutches discontinued when good quadriceps control is obtained | Hinged knee brace locked in extension | 1. Motion - Active flexion to progress as tolerated and passive extension to 0° (no active extension) 3 times a day 2. Modalities and/or exercises - Swelling control with ice, gentle medial and lateral patellar mobilization, gentle (~25%) isometric quadriceps exercises (sets, no straight leg raises), continue with ipsilateral hamstring exercises and contralateral quadriceps exercises 3 times a day |
| 6-12 wk | Weightbearing as tolerated | Hinged knee brace locked in extension until good active quadriceps control and normal gait are obtained | 1. Motion - Progress to full 3 times a day 2. Modalities and/or exercises - Swelling control with ice, more aggressive medial and lateral patellar mobilization, begin straight leg raises without resistance, continue with ipsilateral hamstring exercises and contralateral quadriceps exercises 3 times a day; start stationary cycling at 8 weeks |
| 12-16 wk | Complete weightbearing | No immobilization | Progress with quadriceps strengthening (isokinetic) exercises and start neuromuscular retraining |
| 16-24 wk | Complete weightbearing | No immobilization | May start running and sport-specific training |
| >6 mo | Complete weightbearing | No immobilization | May return to jumping and contact sports when obtain 85-90% of strength of contralateral extremity on isokinetic strength testing |
| Time After Surgery | Weightbearing | Immobilization | Therapy |
| 0-3 d | None, with use of crutches | Hinged knee brace locked in extension | 1. Motion - None 2. Modalities and/or exercises - None |
| 4-13 d | Toe touch with crutches | Hinged knee brace locked in extension | 1. Motion - Active flexion to 45° and passive extension to 0° (no active extension) 3 times a day 2. Modalities and/or exercises - Swelling control with ice, gentle medial and lateral patellar mobilization, gentle isometric hamstring exercises, contralateral isometric quadriceps exercises 3 times a day |
| 2-4 wk | Partial (25-50%) with crutches | Hinged knee brace locked in extension | 1. Motion - Active flexion to progress to 90° and passive extension to 0° (no active extension) 3 times a day 2. Modalities and/or exercises - Swelling control with ice, gentle medial and lateral patellar mobilization, gentle (~25%) isometric quadriceps exercises (sets, no straight leg raises), continue with ipsilateral hamstring exercises and contralateral quadriceps exercises 3 times a day |
| 4-6 wk | Progress to weightbearing as tolerated, crutches discontinued when good quadriceps control is obtained | Hinged knee brace locked in extension | 1. Motion - Active flexion to progress as tolerated and passive extension to 0° (no active extension) 3 times a day 2. Modalities and/or exercises - Swelling control with ice, gentle medial and lateral patellar mobilization, gentle (~25%) isometric quadriceps exercises (sets, no straight leg raises), continue with ipsilateral hamstring exercises and contralateral quadriceps exercises 3 times a day |
| 6-12 wk | Weightbearing as tolerated | Hinged knee brace locked in extension until good active quadriceps control and normal gait are obtained | 1. Motion - Progress to full 3 times a day 2. Modalities and/or exercises - Swelling control with ice, more aggressive medial and lateral patellar mobilization, begin straight leg raises without resistance, continue with ipsilateral hamstring exercises and contralateral quadriceps exercises 3 times a day; start stationary cycling at 8 weeks |
| 12-16 wk | Complete weightbearing | No immobilization | Progress with quadriceps strengthening (isokinetic) exercises and start neuromuscular retraining |
| 16-24 wk | Complete weightbearing | No immobilization | May start running and sport-specific training |
| >6 mo | Complete weightbearing | No immobilization | May return to jumping and contact sports when obtain 85-90% of strength of contralateral extremity on isokinetic strength testing |
For tenuous repairs, whether for acute or chronic tears, a more conservative program is used and tailored to the situation. Generally, strict immobilization is recommended for 6 weeks, followed by range-of-motion exercises. Strengthening exercises are then started approximately 3 months after the repair, followed shortly thereafter by neuromuscular retraining. Return of quadriceps bulk and strength usually is delayed, and return to premorbid athletic activities may take approximately 9-12 months.
Follow-up
After an adequate repair allowing for an aggressive postoperative rehabilitative program, the follow-up care goals, with intervals dated as time after surgery, are as follows:
- 3-5 days - Adequate pain control, decrease in swelling and wound check
- 2 weeks - Active flexion to 45°, full passive extension
- 4 weeks - Active flexion to 90°, maintenance of full passive extension
- 6-8 weeks - Full active flexion
- 3 months - Straight leg raise with no extension lag
- 6 months - Symmetric quadriceps size and strength
Complications
Not infrequently, decreased quadriceps strength and loss of full knee flexion can complicate the overall success of a repair. Prolonged immobilization leads to stiffness. Manipulation under anesthesia or arthroscopic lysis of adhesions may be necessary to improve motion. Occasionally, the decreased range of motion can be attributed to patella baja. This is when the patella lies more distal than normal, which can result when the tendon is relatively shortened by the repair.
Rerupture, failure of fixation, or both also can occur, especially in patients who return to athletic endeavors before the tendon is completely healed. The repeat injury may require a revision of the repair.39 Inadequate placement of the suture repair or failure to recreate the appropriate patellar height can cause patellofemoral pain.
Wound breakdown and infections can occur, as with any other surgical intervention. These complications may be slightly more common in this region because of limited soft tissue along the anterior knee and operating through inflamed tissue. To diminish these potential wound complications, perioperative antibiotics and closed-suction drains can be used, the initial incision can be made through uncompromised skin, and grasping of the skin edges can be kept to a minimum.
More on Patellar Tendon Rupture |
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| Workup: Patellar Tendon Rupture |
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Further Reading
Related eMedicine topics
Total Knee Arthroplasty
Complications of Total Knee Arthroplasty
Anterior Cruciate Ligament Pathology
Clinical studies
Acute Patella Tendon Rupture
Keywords
patellar tendon rupture, patellar ligament tear, knee tendon rupture, tendonitis, tendinitis, quadriceps tendon rupture, ruptured patella tendon
