Neglected Patellar Tendon Rupture With Massive Proximal Patellar Migration Treated With Patellar Transport and Staged Allograft Reconstruction

Abstract

Neglected or chronic ruptures of the patellar tendon are defined as ruptures presenting after 6 weeks. Late presentation is often due to neglect or missed diagnosis. 1,12 With chronic ruptures, the patient presents with weakness, instability, and pain. Management of patients with chronic ruptures is difficult due to adhesions, proximal patellar migration, contracture, and quadriceps muscle atrophy. 29 Before reconstruction of the patellar tendon (using autografts, allografts, or synthetic materials), the position of the patella must be normalized. Several methods had been reported to relocate the proximally migrated patella distally to its anatomic location, including preoperative traction, intraoperative traction, quadricepsplasty, and external fixation. 8,15,17,20,27,30,31,33 The aim of this case report was to present the use of ring and wire external fixation applying the lengthening principles of Ilizarov 13 to mobilize the proximally migrated patella distally as a successful treatment of chronic neglected patellar tendon rupture followed by second-stage patellar tendon reconstruction using an allograft. We report our experience in 2 cases, with an improved modification of the external fixator construct used for distal patellar transport in case 2. This report of 2 cases was approved by the Hospital for Special Surgery Institution Review Board. CASE 1A 44-year-old man presented to the office of the senior authors (S.H.C., S.R.R.) with bilateral posttraumatic chronic patellar tendon ruptures and proximal migration of the patellae. The patient was involved in a severe jet-ski accident in which he sustained this bilateral injury and ruptured his spleen and was on a ventilator due to a brain injury for almost 1 year. Because of the severity of his other injuries, the patellar tendon ruptures were not initially diagnosed. After being weaned from the ventilator, it was noted that he had bilateral extensor lag, with both patellae migrated proximally into the midthigh region. He was in a rehabilitation facility since he came off the ventilator. The patient presented in a wheelchair with a chief complaint of inability to walk accompanied by bilateral anterior knee pain. The patient presented to the sports medicine service 3 years after the injury.The patient, who was not able to stand, had full painless range of motion (ROM) of both hips. The knee ROM on both sides was from 15 to 110 of flexion, and there were severe extensor lags of both knees of 25 . Both patellae were migrated proximally at the junction of the proximal

Neglected patella nonunion successfully treated after 8 years by quadriceps distractive lengthening with a spanning unilateral external fixation system

“…Using skeletal traction to gradually mobilize the proximally migrated patella is not a new concept but its original description required lengthy hospitalization [6]. Isiklar et al [3] and Elattar et al [1] have reported the use of a circular frame to advance a proximally retracted patella in patients with neglected patella tendon tears. Elattar improved the technique allowing for free knee motion by inserting the Ilizarov frame pins only to the femur.…”

“…Elattar improved the technique allowing for free knee motion by inserting the Ilizarov frame pins only to the femur. However, both authors admitted that skin irritation was a concern and Elattar and colleagues elected to modify the position of the transosseous wires in their second patient [1].…”

“…Patella non‐unions are rare, usually reported from countries with vast remote areas and limited availability of medical care [2, 7]. Various methods have been proposed to restore the extensor mechanism including preoperative traction, V–Y lengthening of the quadriceps [2], augmentation with tendon grafts [1, 4] and tissue distraction using an external fixator circular frame [1, 3]. In a recent meta‐analysis of patella non‐unions, the time between injury and treatment was between 2 and 34 months [4].…”

Extensor mechanism reconstruction with peroneus longus tendon autograft for neglected patellar fracture, report of 2 cases

“…1,2 However, the surgical intervention is more challenging in delayed or neglected patellar fractures due to concomitant quadriceps tendon retraction and patellar migration superiorly. 3,4 Various methods have been described in the literature including V-Y lengthening of the quadriceps, tendon graft augmentation, external fixator distraction or preoperative traction. 5e7 Paxinos et al 5 reported a multi-trauma patient with a fracture in the inferior pole of the patella, followed-up with conservative treatment for 8 years.…”

Patellar Transskeletal Traction for the Treatment of Chronic Patellar Pseudoarthrosis

“…The gap between these fragments develops more frequently in transverse fractures. In this type of injury, the constant contraction of the quadriceps performed over time causes the proximal fragment of the fracture to rise up [1, 4, 5].…”