ARTHROSCOPY AND SPORTS MEDICINE

Reconstruction of a chronic patellar tendon rupturewith semitendinosus autograft

Yasser E. Abdou

Received: 9 May 2014 / Published online: 2 September 2014

� Springer-Verlag Berlin Heidelberg 2014

Abstract

Introduction Successful outcome following patellar ten-

don rupture requires robust restoration of the extensor

mechanism continuity. Rupture of the patellar tendon

occurs most commonly in patients younger than 40 years

and is the result of an indirect large force generated by

contraction of the quadriceps, which is estimated to be at

least 17.5 times of body weight.

Patients and methods Seventeen patients suffered from

chronic rupture of the patellar tendon, underwent recon-

struction with hamstring tendon autograft and were enrol-

led in this prospective study. Average age at time of

surgery was 30 years (range, 22–36 years). Average fol-

low-up period was 21 months (range, 12–30 months).

Patients underwent regular follow-up after clinical and

radiographic preoperative and postoperative evaluation.

Results Analytical results showed satisfactory function

after patellar tendon reconstruction with the use of ham-

string tendon autografts.

Conclusion We suggest that the hamstring tendon auto-

graft is a safe, effective, and acceptable choice for patellar

tendon reconstruction, and that it affords good ligament

reconstruction.

Keywords Knee � Patellar tendon hamstring autograft

Introduction

Rupture of the patellar tendon occurs most commonly in

patients younger than 40 years and is the result of an

indirect large force generated by contraction of the quad-

riceps, which is estimated to be at least 17.5 times of body

weight [1].

Loss of function of the extensor mechanism may be a

result of trauma, multiple operations or tumor resection and

results in significant disability. If primary repair is not

possible, reconstruction requires the use of tendon grafts

[2]. Autologous tendon (e.g., hamstrings) grafting is a well-

established technique and was described more than

50 years ago as a two-stage procedure [3]. More recent

publications describe one-stage techniques using ham-

strings tendons to reconstruct the extensor mechanism [4].

Late reconstruction of the patellar tendon ruptures usu-

ally yields less favorable results than does immediate

reconstruction [5]. This disparity has been attributed to

proximal patellar migration, poor tissue quality, and

quadriceps atrophy. Growing experience with soft tissue

manipulation through the use of autograft tissue has

enabled results for the reconstruction of the chronic rup-

tures to approach those seen with immediate repair [6–10].

The aim of this study is to present a prospective analysis

of seventeen patients with chronic rupture of the patellar

tendon treated late reconstruction using Semitendinosus

tendon autograft.

Patients and methods

Demographics

During the period January 2003 to September 2010, a pro-

spective study was done. Seventeen patients were seen with

clinical signs and symptoms consistent with chronic rupture

of the patellar tendon. As the condition is uncommon, the

patients included in this study had been needed long time to

Y. E. Abdou (&)

Orthopedic Department, Faculty of Medicine, Tanta University,

25 St Elsebai ElZanfali, Zefta, Gharbeyia, Egypt

e-mail: yasserabdou@yahoo.com

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Arch Orthop Trauma Surg (2014) 134:1717–1721

DOI 10.1007/s00402-014-2080-y

collect a number of patients and finish the follow-up period.

All cases had been managed by the author in Tanta Uni-

versity Hospitals without any financial involvement. The

ethical approval was provided for all patients.

Mechanism of injury

All patients were heavy workers. Ten patients were injured

in accidental falls and seven were injured while down-

loading a heavy weight from a truck. All patients reported

what seems to be the classic presentation; a history of

stumbling, followed by immediate severe pain in the knee

and inability to weight bear. All patients refused the sur-

gical interference and managed by only medication to go as

early as possible to their work.

Clinical picture

The diagnosis was proofed clinically with a palpable gab

the patellar tendon (Fig. 1), a high patella, and an inability

to straight leg raise.

Imaging studies

Plain X-rays confirmed patella alta and excluded bony

injuries (Fig. 2). Magnetic resonance imaging showed a

chronic rupture of the patellar tendon.

Preoperative evaluation

Preoperatively, lateral plain radiographs of both the injured

and uninjured knees were obtained. The radiograph of the

contralateral knee was used for appropriate measuring and

for determining normal height alignment of the extensor

mechanism reconstruction. A reconstruction that is too

long will compromise the mechanical advantage of the

extensor mechanism, and a reconstruction that is too short

will limit flexion and may be more likely to re-rupture.

Patient positioning

The patient was positioned supine with the operative leg

draped at the proximal thigh in the standard fashion. A

sterile tourniquet was applied and used as needed. General

anesthesia was required to achieve muscle relaxation.

Surgical technique

A midline longitudinal incision was made and with careful

subcutaneous dissection, the area of rupture was exposed

and the infrapatellar branch of the saphenous nerve iden-

tified and retracted. Care was taken to avoid damage to

infrapatellar fat pad because it is the source of blood supply

to the graft (Fig. 3).

Fig. 1 A palpable gab the patellar tendon

Fig. 2 Plain X-rays confirmed patella alta

Fig. 3 Care of infrapatellar pad fat

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All scars in the remnants of the patellar tendon are

excised and the patella is mobilized until its distal pole lies

just proximal to the joint line when the knee is in slight

flexion (Fig. 4).

Two tunnels were made by 4.5 mm drill bit. The first

was made transverse near to the proximal pole of the

patella and the second was made also transverse just behind

the tibial tuberosity.

The Semitendinosus tendon was harvested freely and

prepared with #2 vicryl sutures to pass easily through the

tunnels.

The Semitendinosus autograft was passed through the

two tunnels in the form of figure eight. A box of stainless

steel wire was made to secure the graft and tensioned while

the patella was maintained in its normal position. Both

ends of the autograft were sutured to each other under

tension (Fig. 5).

Postoperative management

Our regime was more conservative when compared to early

repair. Bivalved cylinder cast was made for 6 weeks; then

the passive range of motion begun. Active range of motion

is started at 9 weeks after removal of wires.

Follow-up

Patients were reviewed at 6 weeks, 9 weeks and 3 months

and then at 6 months, 1 year and 2 years.

Follow-up symptoms and signs of knee function were

assessed according to the guidelines of the International

Knee Documentation Committee (IKDC). The level of

sporting activity was assessed according to the IKDC levels

1–4, which correspond, respectively, to strenuous (football,

basketball), moderate (skiing, tennis, heavy manual labor),

light (jogging), and sedentary activities. The subjective

symptoms were evaluated using the Lysholm knee score. It

evaluates specific symptoms such as limp, lack of support,

locking, instability, pain swelling and difficulty in stair-

climbing and squatting.

Results

One year after reconstruction, twelve patients (70.6 %)

were able to return back to their previous activities. Five

patients (29.4 %) did not return back to their previous

activities as before injury due to anterior knee pain. The

difference in the activity level before injury, preoperative,

and after reconstruction was statistically significant

(p \ 0.001).

The total end results of postoperative IKDC score were

graded into normal five patients (29.4 %), nearly normal in

seven patients (41.2 %), abnormal in two patients

(17.6 %), and severely abnormal in one patient (11.8 %)

(Table 1).

Patient subjective assessment

The patient was asked to rate the involved knee compared

to the normal knee or what was perceived as normal. Five

patients (29.4 %) stated that the knee became normal; 7

patients (41.2 %) stated that it is nearly normal; 3 patients

(17.6 %) stated that it is abnormal, and 2 patients (11.8 %)

stated that it is severely abnormal.

Fig. 4 The patella is mobilized

Fig. 5 Stainless steel wire to secure the graft

Table 1 The total end results of postoperative IKDC score

Score No % Male Female Main age

Normal 5 29.4 4 1 20.5

Nearly normal 7 41.2 5 2 23.4

Abnormal 3 17.6 3 0 33

Severely abnormal 2 11.8 2 0 41

Total 17 100 14 3 29.5

Arch Orthop Trauma Surg (2014) 134:1717–1721 1719

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Symptom evaluation

Pain

Five patients (29.4 %) had no pain during heavy work, while

seven patients (41.2 %) have mild inconstant pain during

strenuous activities. three patients (17.6 %) had mild

inconstant pain during moderate activities; two patients

(11.8 %) had mild inconstant pain with light activities.

Knee swelling

Fourteen patients (82.4 %) did not complain of any knee

swelling. However, two patients (11.8 %) had mild swell-

ing that occurs with strenuous activities. One patient

(5.8 %) had swelling that occurs with moderate activities.

None had constant or tense swelling.

Range of knee motion

Extension range

Sixteen patients (94.2 %) had loss of less than 5� of

extension compared to the healthy side, while one patient

(5.8 %) suffered from loss of 6–10� of extension.

Flexion range

Fifteen patients (88.2 %) had no lack of flexion compared

to the healthy side, while two patients (11.8 %) had lack of

up to 15� of flexion.

Main Lysholm Score

There was a continuous improvement in the score of each

individual patient; the mean score at final follow-up was 85

(Table 2).

Radiological evaluation

Fourteen patients (82.4 %) were graded radiologically

normal knee as there was no postoperative X-ray showed

patella alta, three patients (17.6 %) had a patella with

1–3 cm more proximally placed than on the normal side.

Discussion

Our prospective study included seventeen patients with

chronic ruptured patellar tendon. Subjectively, we have

70.6 % of patients who were satisfied but objectively, we

have 88.2 % of patients who were excellent as regards

range of motion and radiographic evaluation.

Several alternative techniques have been reported.

Lanzetta [11] reviewed several methods of repair with

fascial strips, but such strips lack the strength of intact

tendons and their undisturbed attachments to bone. Levin

[12] described the use of Dacron graft to repair the gap. He

stated that the fibrous-tissue invasion of the graft will

provide long-term strength.

In our study, the Semitendinosus graft was passed

through the two tunnels in the form of figure eight to

strengthen the graft and the graft was sutured to the rem-

nant stump of the patellar tendon.

There was little to be found in the literature for guidance

regarding the issues faced with this patient. Specifically,

there were no reports detailing the treatment of such a

chronically neglected patellar tendon rupture with proximal

patella migration in a patient of this size [10].

Lewis et al. [10] reported that there was persistent

quadriceps atrophy in three of the four cases and extensor

lag in one case; but all of their patients returned to prein-

jury functional levels.

Burks and Edelson [5] repaired a patellar tendon rupture

that occurred 6 weeks previously. One year postopera-

tively, the patient demonstrated dramatic results, with

0–130� flexion, no extensor lag, and full strength with no

pain.

Case reports by Falconiero and Pallis [7] and McNally

and Marcelli [9] demonstrated similar success. In this

study, the extensor lag was reported in one patient (5.8 %)

who suffered from loss of 6–10� of extension.

In all of these reports; like this study, the reconstructions

included reinforcing suprapatellar wires to distribute

loading stresses on the graft, and in each reconstruction,

this hardware later required removal.

Twelve patients (70.6 %) of this study were satisfied as

they were graded normal and nearly normal, but five patients

(29.4 %) were unsatisfied as they were graded abnormal and

severely abnormal mainly due to the anterior knee pain.

Conclusion

Our results showed that patellar tendon reconstruction

using hamstrings autograft for neglected patellar tendon

injuries provides good stability and excellent outcome.

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Table 2 Main Lysholm Score Preoperative Postoperative

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