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Hamstring Tendon Autograft for Chronic Patellar Tendon Rupture- A Series of Ten Cases |
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Imran Sajid, Ashish Kumar, Radhika Sahni, Utkarsh Ravi Kant, Sabeel Ahmad 1. Associate Professor, Department of Orthopaedics, FH Medical College and Hospital, Agra, Uttar Pradesh, India. 2. Junior Resident, Department of Orthopaedics, FH Medical College and Hospital, Agra, Uttar Pradesh, India. 3. Junior Resident, Department of General Surgery, FH Medical College and Hospital, Agra, Uttar Pradesh, India. 4. Junior Resident, Department of Orthopaedics, FH Medical College and Hospital, Agra, Uttar Pradesh, India. 5. Fellow (Adult Joint Reconstruction Surgery), Department of Orthopaedics, L H Hiranandani Hospital, Mumbai, Maharashtra, India. |
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Correspondence Address : Sabeel Ahmad, 529D/308 Kalyanpur, West Ring Road, Lucknow-226022, Uttar Pradesh, India. E-mail: drsabeel5@gmail.com |
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ABSTRACT | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patellar Tendon (PT) rupture is an uncommon injury of the knee extensors. Majority of the PT ruptures occur at the insertion site, on the inferior pole of the patella as an avulsion injury, mostly in males of <40 years of age and involving sports persons or accidental cases. A case series of 10 cases of neglected PT rupture were managed with primary repair along with augmentation with semitendinosus and gracilis (Hamstring tendons) graft. Patient follow-up was done postoperatively at 2nd week, 6th week, 3 months, 6 months, and then yearly. A knee brace was given to the patient postoperatively to immobilise the knee for two weeks. Static quadriceps strengthening exercises were started from postoperative day two. Assisted quadriceps strengthening exercises were allowed after two weeks postoperatively. Active quadriceps strengthening exercises were initiated after four weeks postoperatively. Partial weight bearing was allowed after four weeks and full weight bearing was allowed after eight weeks postoperatively. Postoperatively functional scoring was done using the International Knee Documentation Committee (IKDC) and Lysholm scores, simultaneously checking the knee range of motion, Insaal-Salvati ratio and quadriceps girth. Total of 8 males and 2 females were present with the mean age 43.9 years ranging from 38-53 years. The average period of follow-up was 25.5 months (range 12-39 months). Results were excellent with faster recovery and regain their normal physically active life around 8 months after reconstruction. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Keywords : Injury, Graft, International Knee Documentation Committee, Patella, Tendon | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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INTRODUCTION | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The PT rupture is an uncommon injury of the knee extensors. Most PT ruptures occur at the insertion site as an avulsion injury, mostly in males of <40 years of age and involving sports persons or accidental cases (1),(2),(3). An acute injury is from road traffic accidents while chronic cases are due to diabetes mellitus (4),(5). For acute injuries, the primary repair is the treatment of choice but for chronic cases, the primary repair is often challenging and does not produce desired results due to poor tissue quality and quadriceps atrophy (6),(7). After PT injury, patella migrates proximally due to quadriceps contracture with poor quality remnant of PT leading to scar formation and knee stiffness, which are the main problems with delayed reconstruction [8-10]. In neglected cases surgical intervention is quite challenging, various reconstruction techniques were proposed ranging from the use of semitendinosus auto grafts with or without gracilis tendon, quadriceps tendon autograft, achilles tendon allografts, implants, and synthetic materials (11),(12),(13),(14). Here a case series of 10 patients is presented, diagnosed clinically and radiographically with chronic PT rupture and treated with a reconstruction technique using hamstrings tendon auto graft while keeping their distal insertions intact. This unique technique has an advantage of being simple and cost-effective in addition to providing early knee mobilisation without foreign body sensation. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CASE REPORT | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
A case series of 10 patients diagnosed with chronic neglected PT rupture (neglected defined as > 6 weeks after ruptures) and operated with Hamstrings tendon autograft reconstruction technique, from January 2017 to January 2021. Before proceeding with surgery written and informed consent were taken after explaining the pros and cons of the surgery to the patients. Generally, patients were presented with an inability to extend the knee (mostly between 0-40 degrees), weakness in the knee, difficulty while standing from a sitting position, difficulty while climbing upstairs, and frequent fall and buckling of the knees. Extensor lag (mostly between 0-40 degree) and passive range of motion (mostly between 0-130 degree) were measured by goniometer. Medical Research Council (MRC) grading of power was used (in all patients it was <3/5) to assess the strength of quadriceps, and quadriceps wasting was measured by inch tape using mid-thigh girth (15). The diagnosis of patellar rupture was made clinically with a palpable gap noted below the patella, high riding patella, and inability to extend the knee in almost all cases. Confirmation of PT rupture was made radiologically with plain X-rays showing patella alta (Insall-Salvati ratio (Table/Fig 1)) and Ultrasonography (USG) of the affected knee showing chronic patellar rupture and clinically with high riding patella (Table/Fig 2). Surgical Technique Surgery was performed under spinal anaesthesia with the patient in supine position on a standard operating table. An anterior midline longitudinal incision was made, just proximal to the patella and extending distally up to the medial flare of tibia. Quadriceps tendon, patella bone, ruptured PT, and tibial tuberosity was exposed. Step 1: Primary repair of the PT. It was imperative to repair the tendon primarily, however, the tissue condition was very poor with scar tissue. The scar tissue was removed and the tendon edges were freshened. The remnants were approximated and repaired with ethibond sutures without tension. Step 2: Harvesting the semitendinosus and gracilis tendon (Table/Fig 3). Through the same anterior midline incision, the ends of the semitendinosus and gracilis tendons were identified and exposed. Using an open-ended tendon strip the grafts were harvested, keeping their distal insertion intact. Step 3: Preparing the patellar and tibial tunnel (Table/Fig 3). A) Tibial tunnel: A horizontal tunnel was made at a level of 1cm posterior to the tibial tuberosity. Initially, an anterior cruciate ligament tibial guide was placed and used to drill a horizontal eyelet pin from medial to lateral through the tubercle and then over-reamed with a 4.5-mm endo-button reamer. B) Patellar tunnel: After identifying the medial and lateral edges of the patella, at the upper one-third of the patella, about a cm anterior to the articular cartilage, the tibial anterior cruciate ligament guide was placed to drill a horizontal eyelet pin through the patella followed by over reaming with a 4.5 mm endo-button reamer. Step 4: Tunnelling of the semitendinosus and gracilis tendon (Table/Fig 4), both the tendons were cleaned of any residual muscle or fat tissue. A) Gracilis tendon: The gracilis tendon was passed first from the patellar tunnel from medial to lateral. All throughout, it courses along the primarily repaired PT. B) Semitendinosus (ST) tendon: The ST tendon follows the opposite path as that of the gracilis tendon. It was passed first from 2the tibial tunnel from medial to lateral and then passed through the patellar tunnel lateral to medially. All throughout, it courses along the primarily repaired PT. Step 5: Tensioning the ST and Gracilis tendon. The ST and gracilis tendon were sutured to one another followed by suturing to the PT in a circumferential manner (Table/Fig 4). It is imperative that the semitendinosus and gracilis tendons are sutured to the PT at the appropriate tension. Any excessive tension will lead to stiffness of the knee and decreased range of motion and simultaneously laxity will lead to extensor lag. Postoperative protocol and follow-up: Patient follow-up was done postoperatively at 2nd week, 6th week, 3 months, 6 months, and then yearly. A knee brace was given to the patient postoperatively to immobilise the knee for two weeks. Static quadriceps strengthening exercises were started from postoperativee day two. Assisted quadriceps strengthening exercises were allowed after two weeks postoperatively. Active quadriceps strengthening exercises were initiated after four weeks postoperatively. Partial weight bearing was allowed after 4 weeks and full weight bearing was allowed after 8 weeks postoperatively. Postoperatively functional scoring was done using IKDC and Lysholm scores, simultaneously checking the knee range of motion, Insaal-Salvati ratio and quadriceps girth (16),(17),(18). The mean age of subjects was 43.9 years with ages ranging from 38 years to 53 years. Out of 10 patients, eight patients were males, and two females. The mean duration of injury was 8.5 months ranging from 4 months to 13 months with road traffic accidents being the most common cause of the rupture. There was no associated injury seen in any of the patients (Table/Fig 5). The reason behind the delayed treatment was a sedentary life style and showing to the local practitioners or quacks. The average period of follow-up was 25.5 months (range 12-39 months). They regain the average active knee range of motion of 128 degrees (120-135 degrees), and they regain almost normal power compare to the opposite knee (5/5 MRC grading) without any extension lag (Table/Fig 6). Pre-operative and postoperative findings are given in the (Table/Fig 7),(Table/Fig 8), respectively. Excellent improvement of IKDC 78-92 (average-85) and Lysholm 82-97 (average-89.5) scores (Table/Fig 8), Insaal-Salvati ratio also reduced from average 1.7 to 1. Quadriceps bulk took time to regain in most of the patients and at the end of 1 to 1.5 years almost all the patients have regained normal girth, except one who had a sedentary lifestyle and did not follow the proper physiotherapy settings. Overall outcomes was excellent (was based on near normal mean IKDC scores, Lysholm scores and around full range of motion of the knee) in eight patients and good in two, without any pre and postoperative significant complications. Postoperative radiographs were within the normal limit at 1-2 year follow-up without any patella femoral arthritis and they regained their normal occupational life within one year even though they were labourers by occupation. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
DISCUSSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
In this series, 10 patients with chronic PT rupture were included and mostly male with mode of injury was road traffic accident. Mostly PT rupture is unilateral and seen in athletics or in road traffic accidents [1,2]. Chronic patellar rupture is due to delayed reporting to the health center, misdiagnosis, early treatment with quacks or a sedentary life style. Acute PT can be repaired with good results but in the chronic case, due to poor tissue quality reconstruction is mandatory. Vadala A et al., reviewed several methods of repair with facial strips, but they lack the strength of intact tendons (19). Levin PD described the use of dacron graft to repair the PT rupture gap, and he stated that fibrous tissue invasion will provide the long-term strength (20). Ecker ML et al., reported a case series of four patients in which he described the reconstruction of the PT by using hamstring (gracilis and semitendinosus) tendons (9). Each tendon passed through a separate horizontal tunnel made in the patella and tibial tuberosity through which tendons passed and sutured with each other, he used cerclage wire to add stability which may require removing later on. Dejour H et al., reported contralateral block of the tibial bone auto graft to treat PT rupture but in this series, limitation was producing morbidity in the contralateral knee (21). In 2007 Van der Zwaal P and Van Arkel ERA reported two cases using hamstring graft with augmentation by bio-screws and staples for PT ruptures (22). Similarly in 2012, Chen B et al., reported two cases using hamstrings tendon for reconstructions of PT rupture by retaining distal insertion of tendons proposing the preservation of vascularity of tendons as in our series (23). Other similar studies have been reported using various techniques with different grafts, that include auto grafts {contralateral PT (24), semitendinosus [2,25], allograft extensor mechanism graft (26), achilles tendon (27)}. In this series, hamstring tendons (semitendinosus and gracilis) were used and passed through the patellar and tibial tunnel (Table/Fig 4), then they were sutured in a circumferential manner on the opposite side of the tendon insertion (Table/Fig 9) with the help of ethibond, simultaneously after trimming the edge of the remnant PT to repair. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CONCLUSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Excellent outcome with faster recovery was observed and patients regained their normal physically active life around eight months after reconstruction. This is a unique technique of circumferential reconstruction of the hamstring which did not give any foreign body sensation while kneeling. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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