Content uploaded by Bertrand Sonnery-Cottet
Author content
All content in this area was uploaded by Bertrand Sonnery-Cottet on Dec 30, 2015
Content may be subject to copyright.
1 3
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-015-3951-7
KNEE
Reconstruction of chronic patellar tendon rupture
with contralateral bone‑tendon‑bone autograft
Eduardo Frois Temponi1 · Nuno Camelo2 · Sanesh Tuteja2 · Mathieu Thaunat2 ·
Matt Daggett3 · Jean Marie Fayard2 · Lúcio Honório de Carvalho Júnior1 ·
Bertrand Sonnery‑Cottet2
Received: 28 August 2015 / Accepted: 15 December 2015
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
an average of 16 months (3–60 months) after the injury.
86 % of the patients had a normal patella height with
mean of patellar height of 1.5 (±0.2) in preoperative
radiographs and of 1.2 (±0.07) on postoperative evalu-
ation (p = 0.0136). The mean IKDC was 45.5 (±10.8)
before surgery and 64.5 (±12.4) at the last follow-up
(p = 0.0001), and Lysholm score was 45.4 (±11.3) and
79 (±11.8), respectively (p = 0.0001). The median Teg-
ner activity scale preinjury was 6 (range 5–7), preopera-
tively was 1 (range 1–2) and 4 (range 2–5) postoperatively
(p = 0.0001). All patients had quadriceps wasting with
a difference in thigh girth between the injured side and
healthy side of 3.6 ± 0.7 cm (ns). No surgical complica-
tions were encountered.
Conclusions In this limited cohort, surgical reconstruc-
tion of chronic patellar tendon ruptures using contralateral
bone-tendon-bone graft was a safe and viable option that
improves clinical and functional outcomes compared to
presurgical function. However, despite the restoration of a
normal patellar height, function did not return to preinjury
level.
Keywords Patellar tendon rupture · Chronic injury ·
Autograft · Reconstruction · Bone-tendon-bone
Introduction
Chronic patellar tendon rupture is a rare injury, and the
prevalence of this lesion is unknown [8, 10, 11, 15, 23].
There is no consensus in defining the time frame in which a
patellar tendon injury should be considered chronic [4, 10],
yet extensor mechanism impairment leads to great disabil-
ity in daily life [4, 10, 11]. It is known that early diagnosis
and surgical treatment of patellar tendon rupture has good
Abstract
Purpose To evaluate the clinical and functional outcome
following the reconstruction of chronic patellar tendon
ruptures using the contralateral bone-tendon-bone (BTB)
autograft.
Methods The records of seven patients who underwent
reconstruction of chronic patellar tendon rupture with
contralateral patellar BTB were retrospectively reviewed.
Chronic tears were defined as a minimum of 3 months from
injury to initial clinical evaluation. Clinical assessments
included range of motion of the knee, Tegner, Lysholm
and International Knee Documentation Committee (IKDC)
score and a radiographic analysis of patellar height (Caton–
Deschamps index). Postoperative complications and
quadriceps strength at last follow-up were reported.
Results The mean age of the patients undergoing sur-
gery was 33 (±10.5) years with a mean follow-up of 41.3
(±29.7) months. Reconstruction surgery was performed at
None of the following authors or the departments with which
they are affiliated have received anything of value from or owns
stock in a commercial company or institution related directly or
indirectly to the subject of this article.
Electronic supplementary material The online version of this
article (doi:10.1007/s00167-015-3951-7) contains supplementary
material, which is available to authorized users.
* Eduardo Frois Temponi
dufrois@gmail.com
1 Hospital Madre Teresa, Av. Raja Gabáglia 1002, Gutierrez,
Belo Horizonte, Minas Gerais 30430-142, Brazil
2 Centre Orthopedic Santy, FIFA Medical Center of Excelence,
Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz,
Hôpital Privé Jean Mermoz, Lyon, France
3 Kansas City University, Kansas City, MO, USA
Knee Surg Sports Traumatol Arthrosc
1 3
clinical and functional outcome with a low failure rate
[2, 3, 6, 10, 11, 23, 27]. However, delayed diagnosis and
reconstruction of chronic patellar tendon ruptures is a tech-
nically challenging and demanding surgery with inconsist-
ent outcomes [6, 10, 12, 14, 17, 21, 25].
Proximal patellar migration due to quadriceps contrac-
tion, poor quality of the remaining tendon and knee stiff-
ness due to tissue scarring are some of the issues of delayed
reconstruction surgery [2, 4, 6, 8, 10, 12, 14, 17, 21, 25].
Postsurgical complications including loss of knee flexion,
quadriceps weakness, wound problems and surgical failure
are described in the literature [10, 15]. Many different sur-
gical methods have been reported for the reconstruction of
chronic patellar tendon ruptures: one- or two-stage recon-
struction, autograft, allograft and even synthetic graft have
been reported [10, 12, 14, 17, 21, 27]. Reconstruction using
contralateral bone-tendon-bone (BTB) autograft has been
already described in the literature [6]; however, radiologi-
cal indexes and functional outcomes of this technique have
not yet been described.
It is hypothesized that reconstruction using contralat-
eral BTB autograft provides ideal radiological indexes with
improvement in both clinical and functional parameters.
The purpose of this study is to describe a specific recon-
struction of chronic patellar tendon rupture using contralat-
eral BTB autograft and to evaluate its clinical and func-
tional outcomes in a case series.
Materials and methods
Between 2009 and 2014, seven patients were operated by
two senior surgeons (E.F.T and B.S.C). Standardized tech-
nique of reconstruction of chronic patellar tendon rupture
using contralateral BTB autograft as described below was
used in all patients. The definition of chronicity is given
as inadequate remnant tissue for repair and/or repair after
4 weeks of injury [10]. A minimum of 3 months was the
time interval from injury to surgery in this study. No acute
cases were included. Risk factors such as systemic inflam-
matory disease, chronic metabolic disease, anabolic ster-
oid abuse, local steroid injection or patellar tendinitis were
evaluated. All patients presented with symptoms of weak-
ness with difficulty in getting up from a sitting position,
climbing up and down the stairs and frequent falls while
walking due to loss of balance. Although walking distance
was not limited, the gait was cautious due to fear of knee
buckling.
All patients were reviewed by the senior surgeon, and
their clinical data were retrospectively analysed. For patel-
lar tendon rupture, diagnosis was confirmed by clinical
examination, radiographs and magnetic resonance image
(MRI) (Fig. 1). Presence of extension lag and high placed
patella (compared to the contralateral knee) was required
[7, 19]. Clinical examination included extension lag, range
of motion (ROM) of the knee joint and quadriceps vol-
ume measured as the difference in the thigh girth at 10 cm
above the superior pole of the patella between the injured
and contralateral knees. Preoperative and postoperative
radiological examinations included Caton–Deschamps
index (CD) [7], bone healing and degenerative radiographic
signs. Preoperative and postoperative functional assess-
ments included the International Knee Documentation
Committee (IKDC), Tegner activity scale [26] and Lysholm
score [1, 26].
Surgical technique
The surgery was performed with general and regional
anaesthesia, using tourniquet.
Fig. 1 a Lateral radiograph: right-sided chronic patellar tendon tear showing a high riding patella in comparison with the unaffected side. b
MRI showing disruption and signal intensity changes in the patellar tendon on T2-weighted sagittal image with a knee joint effusion
Knee Surg Sports Traumatol Arthrosc
1 3
• First, a midline longitudinal incision was performed
from the patella down to the tibial tuberosity with care-
ful subcutaneous dissection to harvest a 25-mm-long
and 10-mm-wide BTB autograft, similar to the one used
for ACL reconstruction from the contralateral knee.
• Second, a 15-cm-long skin longitudinal midline incision
was made on the injured knee. The paratendon was iden-
tified and retracted on both the medial and lateral sides.
The site of the patellar tendon rupture was exposed and
the infrapatellar branch of the saphenous nerve iden-
tified and retracted. Mobilization of the patella was
achieved by releasing adhesions between patella and
femoral trochlea. Quadriceps release was achieved with
subperiosteal elevation of the vastus intermedius from
the anterior femoral cortex, and further release could
be obtained with lateral retinacular release. Scar tis-
sue found in the remnants of the patellar tendon was
excised, and the patella was mobilized until its distal
pole lies just proximal to the joint line when the knee
is in slight flexion. After debridement of the scar tissue
in the patellar tendon area, a 30-mm-long and 10-mm-
wide bone trough was created in the tibial tubercle and a
20-mm-long and 10-mm-wide bone trough was created
in the central portion of the patella. The tibial bone plug
of the autograft was press-fitted into the tibial recipient
area and secured with two screws, and the patellar bone
plug was pulled in the patella and secured with a screw.
After this, a metallic wire cerclage was made to support
the construct (Fig. 2). The surgical technique can be
seen in the video available in supplementary documents.
Postoperatively, patients were immediately allowed to
perform full weight bearing as tolerated while in a knee
brace locked in extension. Passive range of motion from 0
to 90° was allowed during controlled physiotherapy. After
6 weeks, the brace was unlocked, allowing for full ROM
and active knee extension. The brace was discontinued at
2 months. Quadriceps-strengthening exercises were allowed
after 3 months with gradual increases in resistance. Running,
if desired, was started gradually after 6 months. Patients
were allowed to resume full sport activities at 9 months.
This study was approved by the Ethics Committee at the
Hôpital Privé Jean Mermoz and the Centre Orthopédique
Santy (13-2015), and written informed consent was obtained
from each participant prior to inclusion in the study.
Statistical analysis
Statistical analyses were carried out with the aid of Graph-
Pad Prism software® (San Diego, California, EUA) with
the level of statistical significance set at p < 0.05. Mean
values and standard deviations were made for demographic
data, ROM, quadriceps atrophy, CD index, IKDC, Tegner
activity scale and Lysholm score. To compare and analyse
Fig. 2 a Operative image showing the discontinuous patellar tendon
with retraction of the paratenon on either side. b Graft placed in the
troughs made over the tibial tuberosity and lower pole of patella. The
graft is fixed proximally and distally with screws. A stainless steel
cerclage wire is added to reinforce the construct
Knee Surg Sports Traumatol Arthrosc
1 3
all previous variables, the paired Student’s t test was uti-
lized for quantitative variables in times pre- and postopera-
tively, with exception of quadriceps atrophy that compare
the normal side with injury side. For Tegner activity scale,
a Friedman test compared preinjury, postinjury, presurgical
and then postsurgical values considered. Data were tested
for normality of distribution using the Shapiro–Wilk and
Kolmogorov–Smirnov tests.
Results
All patients were male, and in four, the right side was
affected. The mean of age at rupture was 33 (±10.5) years.
The mean follow-up was 41.3 (±29.7) months. Average
time from rupture to surgery was 16.3 months (±20.7,
3–60 months). Operative outcome is described in summary
in Table 1. In this case series, no risk factor for patellar ten-
don rupture was found.
Mean patellar height according to CD index was 1.5
(±0.2) in preoperatively and 1.2 (±0.07) in postoperatively
(p = 0.01). Only one of the patients had a high patella (CD
1.3) and his ROM had limited extension (ROM 5–125°).
All patients presented with quadriceps atrophy, and the dif-
ference in thigh girth between the injured side and healthy
side was 3.6 ± 0.7 cm (ns).
According with functional outcomes, the mean IKDC
score obtained was 45.5 (±10.8) in preoperative and 64.5
(±12.4) in postoperative (p = 0.0001). Lysholm mean
score was 45.4 (±11.3) and 79 (±11.8) pre- and post-op
(p = 0.0001). The median Tegner activity scale preinjury
was 6 (range 5–7), preoperatively was 1 (range 1–2) and
4 (range 2–5) postoperatively (p = 0.0001). None of the
patients returned to their preinjury level. No donor-site
problems on the healthy knee were reported. At 3 months
post-op, radiographs of the knee confirmed bony union in
anatomical position without secondary displacement in all
patients. No surgical complications were encountered, and
no additional surgeries were required.
Discussion
The most important finding of the present study was that
despite the recovery of normal patellar height in most
patients, they did not return to preinjury level remain-
ing at poor-to-moderate function following a chronic
patellar tendon rupture repair with contralateral bone-
tendon-bone graft. The failure of anatomical reconstruc-
tion in one patient may be due to the fact that this patient
had a metallic wire cerclage broken during the healing
stage. The major disadvantage of this technique is tak-
ing a graft from a healthy knee [22]. However, Shel-
bourne et al. [20] showed that taking a BTB graft from
a healthy knee does not impact its function. Donor-site
morbidities, such as quadriceps weakness and anterior
knee pain, are common complications, already reported
in other series [6, 14]. These complaints were not found
in this limited cohort.
Rupture of the patellar tendon is a rare condition.
Chronic patellar tendon injuries are reported as either a
result of neglect, failure of native treatment or missed
injury. High index of suspicion is needed for the correct
diagnosis. Radiographic and MRI findings can help con-
firm the diagnosis. Extensor mechanism reconstruction
in chronic patellar tendon ruptures is a complex surgery:
patellar relocation, restoration of the quadriceps function
and patellar tendon repair must be attended during the pro-
cedure [6, 8, 10, 11, 15]. Several reconstruction techniques
were described using different autografts, allografts and
Table 1 Operative outcomes of chronic reconstruction of patellar tendon rupture
n.s not significant
p < 0.05—significant
Follow-up
(months)
Time from
rupture to
surgery
(months)
Lysholm
(pre-op/
post-op)
(p = 0.0001)
IKDC (pre-
op/post-op)
(p = 0.0001)
Caton–Des-
champs
Index
(pre-op/
post-op)
(p = 0.01)
Quadriceps
strength
ROM
(post-op)
Tegner
preinjury
Tegner
presurgery
(p = 0.0001)
Tegner
postsurgery
1 102 8 53/78 42.5/58.6 1.3/1.2 −2.5 0–120 6 2 4
2 40 3 22/57 28.7/43.7 1.4/1.1 −4 0–130 6 1 2
3 47 25 47/75 34.5/56.3 1.5/1.2 −2 0–131 6 1 4
4 44 3 56/95 54/73.6 1.3/1.1 −3 0–130 7 2 5
5 23 9 47/81 58.6/80.5 1.4/1.3 −3 5–125 5 1 5
6 17 60 51/88 51.7/70.1 2.0/1.2 −3 0–130 7 2 5
7 16 6 42/79 48.3/69 1.5/1.1 −4 0–120 5 1 3
Knee Surg Sports Traumatol Arthrosc
1 3
synthetic grafts. Gillmore et al. [10] suggest that autog-
enous reconstructions are the methods of choice in the
chronic setting with a lower failure rate. Since several auto-
grafts (STG tendons, patellar retinaculum and fascia lata)
have been used with generally good results, none of them
have the mechanical properties of the patellar tendon [10,
11, 14, 17, 24, 25].
The most common and comparable scoring system
in the chronic repair group in other studies was the HSK
score, indicating a moderate functional outcome [5, 9, 13,
18, 28]. This series was the first to use more valid current
parameters to globally assess the functional and physical
outcomes. Both IKDC and Lysholm scores have improve-
ments for all variables; however, these findings demon-
strated that the final Tegner activity scale level improved
with surgery, but was worser than preinjury condition.
The mean ROM was comparable with others series with
a higher flexion, although without a statistically signifi-
cant difference [18, 28]. The results of this study con-
firm improvements in all outcome scores and an excellent
ROM although persistent quadriceps weakness exists and
no patient was able to return to their preinjury level of
activity.
Despite the recovery of normal patella height, patients
did not return to their preinjury level of activity, with only
poor-to-moderate functional outcomes. No other stud-
ies analysing chronic patellar treatment described specific
patella height before and after surgery [2, 3, 6, 10, 11, 14,
15, 17, 21, 24, 25, 27]. A possible reason may be linked to
the quadriceps weakness resulting from associated quadri-
ceps activation failure and quadriceps muscle atrophy. New
strategies in quadriceps strengthening and reactivation may
optimize the functional outcome in these patients and avoid
persistent quadriceps weakness [20, 22, 27]. In this series,
no difference was observed in thigh girth between injury
and normal sides; however, this was measured singularly,
which may have altered the exact value. It is possible that
a preoperative training and early accelerated rehabilitation
protocols could help improve quadriceps strength, with
consequent improvement in clinical and functional out-
comes. Early immobilization can be achieved with a fixed
hinged brace, allowing early protected movement and full
weight bearing [10]. This may reduce complications and
failure rates.
In this cohort was utilized a modified technique from
Dejour et al. [6] in which a composite of “quadriceps ten-
don, patella, patellar tendon and tibia” was used to relo-
cate the patellar tendon. As described, the use of contralat-
eral patellar tendon allows the anatomical patellar tendon
reconstruction [6]. Its anatomical length serves as a ref-
erence that may lead to diminishing the threat of obtain-
ing patella alta or baja during the procedure [19]. Fur-
thermore, this technique provides accelerated healing and
preservation of the repaired tendon’s blood supply and may
lead to stronger short-term and long-term stability by using
the contralateral patellar tendon to anatomically relocate
the injured side [6, 14, 16, 29].
The limitations of this study are limited cohort and rela-
tively short follow-up, which means that data must be inter-
preted with caution when extrapolated; however, the results
are significant due to rarity of injury and specific treatment.
Because of low incidence, most of the published studies are
case reports, so comparative studies addressing different
methods have not been reported. This article provides sur-
geons another surgical option for this rare and debilitating
condition (Fig. 2)
Conclusion
In this limited cohort, surgical reconstruction of chronic
patellar tendon ruptures using contralateral bone-tendon-
bone graft was a safe and viable option that improves clini-
cal and functional outcomes compared to presurgical func-
tion. However, despite the restoration of a normal patellar
height, function did not return to preinjury level.
Compliance with ethical standards
Conflict of interest None.
References
1. Bollen S, Seedhom BB (1991) A comparison of the Lysholm
and Cincinnati knee scoring questionnaires. Am J Sport Med
19(2):189–190
2. Casey MT Jr, Tietjens BR (2001) Neglected ruptures of the
patellar tendon A case series of four patients. Am J Sport Med
29(4):457–460
3. Chagar B, Boussouga M, Lazrak KH, Taobane H (2003) [Neglected
spontaneous bilateral rupture of the patellar tendon: a case report].
French. Rev Chir Orthop Reparatrice Appar Mot 89(8):733–737
4. Chen B, Li R, Zhang S (2012) Reconstruction and restoration of
neglected ruptured patellar tendon using semitendinosus and gra-
cilis tendons with preserved distal insertions: two case reports.
Knee 19(4):508–512
5. Crossett LS, Sinha RK, Sechriest VF, Rubash HE (2002) Recon-
struction of a ruptured patellar tendon with achilles tendon allo-
graft following total knee arthroplasty. J Bone Joint Surg Am
84-A(8):1354–1361
6. Dejour H, Denjean S, Neyret P (1992) [Treatment of old or recur-
rent ruptures of the patellar ligament by contralateral autograft].
French. Rev Chir Orthop Reparatrice Appar Mot 78(1):58–62
7. Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors
of patellar instability: an anatomic radiographic study. Knee Surg
Sports Traumatol Arthrosc 2(1):19–26
8. Ecker ML, Lotke PA, Glazer RM (1979) Late reconstruction of
the patellar tendon. J Bone Joint Surg Am 61(6):884–886
9. Fukuta S, Kuge A, Nakamura M (2003) Use of the Leeds-Keio
prosthetic ligament for repair of patellar tendon rupture after
total knee arthroplasty. Knee 10(2):127–130
Knee Surg Sports Traumatol Arthrosc
1 3
10. Gilmore JH, Clayton-Smith ZJ, Aguilar M, Pneumaticos SG,
Giannoudis PV (2015) Reconstruction techniques and clini-
cal results of patellar tendon ruptures: evidence today. Knee
22(3):148–155
11. Greis PE, Lahav A, Holmstrom MC (2005) Surgical treatment
options for patella tendon rupture, part II: chronic. Orthopedics
28(8):765–769
12. Isiklar ZU, Varner KE, Lindsey RW, Bocell JR, Lintner DM
(1996) Late reconstruction of patellar ligament ruptures using
Ilizarov external fixation. Clin Orthop Relat Res 322:174–178
13. Jaureguito JW, Dubois CM, Smith SR, Gottlieb LJ, Finn HA
(1997) Medial gastrocnemius transposition flap for the treatment
of disruption of the extensor mechanism after total knee arthro-
plasty. J Bone Joint Surg Am 79(6):866–873
14. Milankov MZ, Miljkovic N, Stankovic M (2007) Reconstruc-
tion of chronic patellar tendon rupture with contralateral BTB
autograft: a case report. Knee Surg Sports Traumatol Arthrosc
15(12):1445–1448
15. Mittal R, Singh DP, Kapoor A (2011) Neglected patellar tendon
rupture: preserve the fat pad. Orthopedics 34(2):134
16. Miyamoto W, Takao M, Matsushita T (2012) Reconstructive sur-
gery using autologous bone-patellar tendon graft for insertional
achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc
9:1863–1867
17. Naim S, Gougoulias N, Griffiths D (2011) Patellar tendon recon-
struction using LARS ligament: surgical technique and case
report. Strateg Trauma Limb Reconstr 6(1):39–41
18. Rand JA, Morrey BF, Bryan RS (1989) Patellar tendon rupture
after total knee arthroplasty. Clin Orthop Relat Res 244:233–238
19. Shabshin N, Schweitzer ME, Morrison WB, Parker L
(2004) MRI criteria for patella alta and baja. Skelet Radiol
33(8):445–450
20. Shelbourne KD, Beck MB, Gray T (2015) Anterior cruciate
ligament reconstruction with contralateral autogenous patellar
tendon graft: evaluation of donor site strength and subjective
results. J Bone Joint Surg Am 43(3):648–653
21. Shelbourne KD, Darmelio MP, Klootwyk TE (2001) Patellar
tendon rupture repair using Dall-Miles cable. Am J Knee Surg
14(1):17–20
22. Shelbourne KD, Urch SE (2000) Primary anterior cruciate liga-
ment reconstruction using the contralateral autogenous patellar
tendon. Am J Sport Med 28(5):651–658
23. Shepard GJ, Christodoulou L, Hegab AI (1999) Neglected
rupture of the patellar tendon. Arch Orthop Trauma Surg
119(3–4):241–242
24. Sundararajan SR, Srikanth KP, Rajasekaran S (2013) Neglected
patellar tendon ruptures: a simple modified reconstruction using
hamstrings tendon graft. Int Orthop 37(11):2159–2164
25. Takazawa Y, Ikeda H, Ishijima M, Kubota M, Saita Y, Kaneko
H, Kobayashi Y, Sadatsuki R, Hada S, Kaneko K (2013) Recon-
struction of a ruptured patellar tendon using ipsilateral semiten-
dinosus and gracilis tendons with preserved distal insertions: two
case reports. BMC Res Notes 6:361
26. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of
knee ligament injuries. Clin Orthop Relat Res 198:43–49
27. Tsitskaris K, Subramanian P, Crone D (2013) Neglected patel-
lar tendon rupture. Reconstruction using semitendinosus-gracilis
tendon grafts and FiberWire augmentation. JRSM Short Rep
4(8):2042533313490286
28. Williams S, Ireland J, El Zebdeh MY (1997) Late reconstruction
of the patellar tendon: two case reports. Knee 4(2):113–115
29. Yang L, Guo L, Dai C, Han XS, Chen GX, Duan XJ, Dai G, Xie
F (2007) Bone-patellar tendon-bone graft in anterior cruciate lig-
ament reconstruction: allograft versus autograft. Zhonghuawai-
kezazhi [Chinese Journal of Surgery] 45(2):82–85
