Primary Repair of Patellar Tendon Rupture Without Augmentation
Primary Repair of Patellar Tendon Rupture Without Augmentation
Abstract & Commentary
Synopsis: Primary repair and ensuring knee flexion to at least 60° on the operating table minimizes the chance of complications such as arthrofibrosis, limited knee extension, and patella baja occurring without risking rerupture.
Source: Marder RA, Timmerman LA. Primary repair of patellar tendon rupture without augmentation. Am J Sports Med 1999;27(3):304-307.
Marder and timmerman present a series of 15 consecutive patients with rupture of the patellar tendon, treated by primary repair without cerclage protective augmentation and with an active rehabilitation program. All the patients were male and their average age was 33 years, with a range from 19 to 41 years. All were athletically active, at least to the recreational level. The injuries usually occurred as the result of jumping in athletic events or from a motor vehicle accident.
Acute surgical repair was performed in all cases. The exact method of repair depended upon how the tendon was torn. When it was avulsed from the patella, no. 5 nonabsorbable sutures were placed using a Krackow whip-stitch into the tendon and then through drill holes in the patella. When the tendon was torn in its midsubstance, whip-stitch sutures generally were used to oppose the disrupted tendon ends. In all cases, on the operating table, overtightening of the patellar tendon was prevented by being sure that the knee could be easily flexed to 60° following the repair.
Postoperatively, the patients were treated with a hinged knee brace for at least six weeks. Active flexion to 45° was allowed for the first three weeks and then gradually increased to 90° by six weeks in the brace.
Fourteen of the 15 patients were available for evaluation. None had sustained a rerupture by the 2½-year follow-up point. Twelve of the 14 patients had resumed all of their previous activities but two were restricted in their activity level because of knee pain. In all, five patients had some residual anterior knee pain. Functional testing on the Lysholm-Gillquist scale showed an average score of 95.
Overall, Marder and Timmerman found these results to be more than satisfactory and concluded that protection of the repair, either with cerclage wiring or prolonged immobilization of the knee in full extension, was not necessary. They cite other articles in the literature that indicate that these protective mechanisms can lead to problems with arthrofibrosis, limited knee extension, and patella baja. They believe that their technique of primary repair and ensuring knee flexion to at least 60° on the operating table minimizes the chance of these complications occurring without risking rerupture. Using this technique, they had no patients who had radiographic evidence of patella alta.
Comment by James D. Heckman, MD
This consecutive series of 15 patients presents an adequate follow-up of 2½ years in 14 of them. Marder and Timmerman stress the importance of an anatomic repair of the patellar tendon with strong, nonabsorbable suture using the reliable Krackow whip-stitch technique. Using this method, they had no reruptures and, thus, were able to allow the patients to engage in an active rehabilitation program early, thus avoiding prolonged immobilization in full knee extension. While a few of the patients had some residual anterior knee pain, this method of treatment allowed the patients to return to their previous level of activity by about 10 months, a shorter time frame than with some of the reports of repair followed by immobilization in full extension for 6-8 weeks.
Marder and Timmerman present an interesting and strongly functional method of repairing the acutely ruptured patellar tendon. The numbers are fairly small and because the study represents different types of tendon injury, ranging from avulsion from the patella to midsubstance tears to avulsions from the tibial tubercle, all three of which were repaired in somewhat different ways, it is difficult to be certain that this methodology will work in a larger series of patients. Probably the most important point is the emphasis placed upon the balancing act that is necessary to restore normal patellar tendon length on the operating table so that at least 60° of knee flexion can be achieved passively. Surgeons should always try to avoid either creating a patella baja or patella alta because both of these conditions will lead to significant impairment of the extensor mechanism function. The security of the repair in this series allowed the patients to undergo a vigorous, early active rehabilitation program that further facilitated return to function. The knees remained protected in a brace for at least six weeks but active flexion was allowed, first to 45° and then on to 90°, so that the repairing patellar tendon was stimulated to heal along the lines of stress, probably facilitating the good outcome that most of the patients experienced.
This technique seems to be a useful one that should simplify surgical treatment and enhance the rehabilitation and long-term function of the injured knee, much as is now being pursued in the aggressive postoperative management of anterior cruciate ligament reconstruction.
The most common complication following primary repair of patellar tendon rupture is:
a. rerupture.
b. patella alta.
c. patella baja.
d. anterior knee pain.
Which of the following is not correct about drilling, abrasion, or microfracture techniques to penetrate subchondral bone?
a. Results in formation of fibrocartilage
b. Takes advantage of the healing potential of the chondrocytes at the defect margins
c. Early motion but delayed weightbearing have been beneficial in animal models
d. Ideal for small lesions less than 2 cm2
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