PORTFOLIO

Identity
Name : Ny. Elma Sari
Sex : Female
Age : 54 y.o
Insurance : JKN
No. MR : 439-40-74
Attending : Dr. dr. Andri MT Lubis, SpOT(K)

Chief Complaint
Unable to active extent her right lower leg since 7 months ago
History of present illness
• Patient had history or bilateral Total Knee Replacement on RSUD Bekasi
(Right TKR à Nov 2018 , Left TKR à March 2019)

• She was able to walk before the surgeries

• After right TKR she did a physiotherapy for several weeks, once she told to
learn to stand on a walker, she couldn’t able to do that.

• She quit the physiotherapy due to the left knee that will be replaced too

• She continue physiotherapy right after the left TKR for couples week, but she
still unable to walk because of the right leg which cannot be actively extent

• Patient referred to RSCM for further treatment

General state
Head: eye, there is ptosis, positive endophthalmus, and pupil miosis on the left eye.
Extremity: warm, capillary refill time less than 2 seconds, dry skin on the left upper
extremity

Local state of right shoulder

Look
Deformity (-), swelling (-), scar (+), wound (-)
Feel
Tenderness (-), Normal distal sensory, CRT<2”
Move
ROM Knee flexion-extension
Active : 70o-115o
Passive : 0o-115o

Radiologic examination

Right Knee
Insall Salvati Ratio
2.6

Left Knee
Insall Salvati Ratio
1.2
Intra Operative

Drapping and Graft Incision

Graft Harvesting

Expose Pattelar Tendon

Patellar tendon splited (Krackow suture) Bone tunneling
INTRODUCTION

The patellar tendon serves as the distal extent of the quadriceps insertion.
Rupture of the patellar tendon usually occurs at the osseotendinous junction and
causes complete derangement of the knee extensor mechanism. This is a
disabling injury in an active person, resulting in an inability to actively obtain
and maintain full knee extension. The patellar tendon ruptures relatively
infrequently. However, the complications of an untreated rupture to the extensor
mechanism can be extremely disabling. If the tendon does not heal properly and
at the correct length and tension, knee range of motion (ROM) and strength can
be altered significantly, leading to early fatigue, patellofemoral pain, and,
possibly, instability, which can thereby prevent return to preinjury status. 1, 2

Immediate surgical repair is recommended for optimal return of knee

function and power. Surgical intervention allows excellent recovery of motion
and strength, provided that the injury is diagnosed in a timely fashion and
repaired immediately. In the past, the surgical technique for acute rupture of the
patellar tendon was primary suture repair. Augmentation of the repair was
believed to be necessary and was achieved by using a cerclage of wire, suture, or
autogenous graft (eg, semitendinosus) in order to reinforce the repair. 3
Routinely, the knee was kept locked in extension for up to 6 weeks to prevent
undue stress on the repair. Earlier and more aggressive rehabilitation techniques
are now available. Krackow introduced a novel interlocking stitch technique, 4

and Marder and Timmerman demonstrated that repair alone is equally durable
without augmentation. 5

Patellar tendon ruptures also can occur as a complication of total knee

arthroplasty, anterior cruciate ligament(ACL) reconstruction using the patellar
tendon as an autograft, or excision of chronic tendinosis. However, the etiology
and treatment in these circumstances are beyond the scope of this article.
ETIOLOGY

Patellar tendon rupture often occurs in the setting of long-standing patellar

tendon irritation. The rupture is the final result of chronic tendon degeneration
due to repetitive microtrauma. Histopathologically, ruptured tendons studied by
Kannus et al demonstrated changes consistent with chronic inflammation and
degeneration.6 Ruptures also may occur after local injection of corticosteroid
near the inferior pole of the patella as treatment for patellar tendinitis (ie,
jumper's knee).
Patellar tendon rupture is usually unilateral and is the result of a
traumatic athletic injury. The typical mechanism is a sudden eccentric
contraction of the quadriceps, usually with the foot planted and the knee flexed
as the person falls. However, in the setting of systemic inflammatory disease,
diabetes mellitus, or chronic renal failure, bilateral ruptures can occur with
lower-energy stress. Additionally, patellar tendon ruptures can result from a
posterior knee dislocation.7 Systemic disorders are related to an increased
incidence of tendon ruptures. Pritchard et al found that tendon ruptures in
systemic lupus erythematosus (SLE) appear to be associated with extended
disease duration, long-term corticosteroid therapy, evidence of steroid-induced
musculoskeletal complications, minimal disease activity at the time of rupture,
and deforming hand arthropathy. 8 Inflammatory changes have been noted at the
site of rupture in patients with SLE, 9 amyloid deposition has been noted at the
site in patients with chronic renal failure undergoing dialysis, 10
and elastosis has
been noted in patients with chronic acidosis. 11 Patellar tendon ruptures also can
occur after surgery for total knee arthroplasty, procedures using the central
third of the patellar tendon as an autograft, or excision of patellar tendinosis.

DIAGNOSIS
In most instances, the history, the physical examination, and standard
radiographs suffice for making a diagnosis of acute patellar tendon rupture.
Disruption of the patellar tendon is associated with immediate disabling pain.
Acute rupture frequently results in an immediate "pop" or tearing sensation. The
patient usually notes immediate swelling and difficulty with rising and
weightbearing after the injury.

On physical examination, diffuse swelling in the anterior knee with ecchymosis,

hemarthrosis, and patella alta is observed. Tenderness exists along the anterior
knee and retinacula, and a defect at the level of the rupture is usually palpable
(see the image below), though significant swelling can make this difficult to
appreciate initially. The patella may also feel proximally displaced as compared
with the contralateral side. The patient is usually unable to bear weight,
especially in a single-leg stance, and has a tense hemarthrosis. With a tendon
rupture extending through the medial and lateral retinacula, active extension is
completely lost, and the patient is unable to maintain the passively extended
knee against gravity. If the rupture involves only the tendon and the retinacular
fibers remain intact, some extension is possible, though an extensor lag is noted.
Occasionally, a deceleration injury can cause a disruption of the extensor
mechanism. In this setting, it is also important to assess both the integrity of the
meniscal cartilage with palpation of the joint line and the anterior cruciate
ligament (ACL) with a Lachman test. 12
If the diagnosis of tendon rupture is delayed, scar tissue may obliterate what
previously had been a palpable defect. In this scenario, some degree of active
extension may be possible, but with weakness and some degree of extensor lag.
Quadriceps atrophy may also be noted, with considerable weakness, especially
with weightbearing, stair climbing, and rising from a seated position. The
weakness can exist to such a degree that the patient performs a forward
thrusting motion of the limb in the swing phase of gait and complains of stance
instability.

WORK UP
Plain Radiography
Plain radiographs (anteroposterior [AP], lateral, and axial) should be obtained in
all patients presenting with a traumatic injury to the knee or with a
hemarthrosis. Contralateral films should also be obtained as a means for
comparison of patellar height. Even if a palpable gap in the extensor mechanism
allows easy recognition of a patellar tendon rupture, radiographs are still
necessary to assess for any other concomitant abnormalities. The lateral view is
particularly helpful to determine whether a patellar rupture has occurred. The
classic finding is patella alta, but one may also notice calcification indicative of
chronic patellar tendinosis (see the image below). In addition, the axial view
assists in determining whether any preexisting patellofemoral arthritis exists,
which may impact the rehabilitative efforts and prognosis.

Ultrasonography
High-resolution ultrasonography (US) can be useful in the diagnosis of acute and
chronic patellar tendon ruptures. Hypoechogenicity is associated with acute
tears, whereas thickening of the tendon at the rupture site and disruption of the
normal echo pattern are observed with chronic tears. Although US is widely
available and does not expose the patient to radiation, many do not have the
experience necessary to perform or interpret this type of study reliably. For this
reason, US is not routinely used in the United States for the diagnosis of patellar
tendon rupture, though it is used quite frequently for this purpose in Europe.
Ultrasound elastography (USE), in the form of either compression elastography
(CE) or shear-wave elastography (SWE), has been advocated on the grounds that
in comparison with conventional US, it may yield increased sensitivity and
diagnostic accuracy in tendinopathy and may be able to detect pathologic
changes before they are visible on conventional US. [13] However, the procedure
has several technical limitations, and standardization remains to be achieved. If
the diagnosis cannot be established on the basis of clinical and radiographic
examination, magnetic resonance imaging (MRI) is the imaging study of choice.
The typical finding is discontinuity of tendon fibers with adjacent hemorrhage or
edema.14

REPAIR AND RECONSTRUCTION OF RUPTURED PATELLAR TENDON

The patient is positioned supine on the operating table after a regional or general
anesthetic is administered. Because nonabsorbable material is used, a first-
generation cephalosporin typically is administered. The procedure begins with
an examination of both knees. ROM assessment and ligamentous examination
are performed to determine whether any motion deficits or concomitant
ligamentous injuries are present.
A tourniquet is placed on the involved leg, and typically, both legs are cleansed
and draped free. After the limb is exsanguinated and the tourniquet started, a
straight midline longitudinal incision is made that extends from the superior
pole of the patella to the medial aspect of the tibial tubercle. Thick medial and
lateral subcutaneous flaps are created to the extent of the retinacular tears.
The torn end of the patellar tendon is then mobilized and minimally debrided of
friable tissue. Depending on the location of the tear, the tibial tubercle, inferior
pole of the patella, or both are debrided of soft tissue and subsequently
decorticated with a curette or bur.

REPAIR AND RECONSTRUCTION OF RUPTURED PATELLAR TENDON

The patient is positioned supine on the operating table after a regional or general
anesthetic is administered. Because nonabsorbable material is used, a first-
generation cephalosporin typically is administered. The procedure begins with
an examination of both knees. ROM assessment and ligamentous examination
are performed to determine whether any motion deficits or concomitant
ligamentous injuries are present.
A tourniquet is placed on the involved leg, and typically, both legs are cleansed
and draped free. After the limb is exsanguinated and the tourniquet started, a
straight midline longitudinal incision is made that extends from the superior
pole of the patella to the medial aspect of the tibial tubercle. Thick medial and
lateral subcutaneous flaps are created to the extent of the retinacular tears.
The torn end of the patellar tendon is then mobilized and minimally debrided of
friable tissue. Depending on the location of the tear, the tibial tubercle, inferior
pole of the patella, or both are debrided of soft tissue and subsequently
decorticated with a curette or bur (see the image below).
Troughs are not created. Nonabsorbable sutures are then inserted with a
Krackow stitch into each half of the tendon. 16
Three parallel tunnels are placed
through the patella or tibial tubercle.
The authors advocate the technique described by Ong and Sherman, in which an
ACL tibial tunnel guide is used during this aspect of the procedure to maneuver
the drill more accurately to the desired endpoint (see the image below). Using
the tunnel guide decreases the risk of violating the articular surface, reduces the
number of passes required to obtain an optimal position, minimizes injury to the
quadriceps tendon, and eliminates the additional step of retrieving sutures
through drill holes.
The drill is then replaced with a Beath pin (see the first image below). The inner
limbs of each stitch are passed through the central tunnel, and then the outer
limbs are passed through the outer tunnels (see the second image below). In
certain situations, the authors have used suture anchors in both the patella and
the tibial tubercle with good results, but at this time, they still favor the use of
tunnels.
A drill hole is then created transversely through the tibial tubercle, and an
additional No. 5 nonabsorbable suture is passed through this hole. This suture is
then passed superiorly within the quadriceps tendon along the superior pole of
the patella (see the image below). This is accomplished by passing a 16-gauge
spinal needle along the superior pole and then threading the suture through.
Both knees are then positioned in 30° of flexion. The patellar height is measured
from the tibial tubercle to the inferior pole of the patella on the noninvolved leg
and recreated in the involved leg by increasing tension in the cerclage suture.
Once the correct position is obtained, the repair sutures are tied and the knee
reexamined to assess the degree of knee flexion that can be obtained without
causing excessive tension on the repair. Alternatively, an intraoperative
radiograph can be obtained on the involved knee, before the repair sutures are
tied, and compared with the radiograph of the contralateral knee obtained in the
preoperative period. The repair site is then oversewn with 0 absorbable suture
to bring the loose ends remaining on the avulsed side over the repair. The
retinacular tears are closed with the same suture material but with the knee held
in 30º of flexion to limit the possibility of capturing the knee and thus limiting
motion.
Situations exist in which acute repair with sutures alone is not adequate. This
may be the case when the patient has a midsubstance tear, has a chronic rupture,
or has undergone a previous resection of chronic patellar tendinitis or a recent
ACL reconstruction with the use of patellar tendon autograft. In these situations,
augmentation or reconstruction may be necessary. Described techniques involve
the use of both autograft (eg, hamstrings, 15 fascia lata, or central quadriceps
tendon) and allograft (eg, Achilles tendon) tissue, as well as synthetic material.
Regardless of the material used, these techniques generally involve weaving the
supplemental tissue through the native patellar tendon or through bone tunnels
within the patella, tibial tubercle, or both. In the individual with a chronic tear,
other factors are involved. Because the patella has been retracted for an
extended period, significant scarring may develop, which limits the surgeon's
ability to recreate normal patellar height and the ability to regain full knee
motion. Adequate mobility can usually be obtained after thorough debridement
of the medial and lateral gutters and subperiosteal elevation of the vastus
intermedius from the anterior femur. If this is inadequate, a two-stage
reconstruction with preoperative traction with the use of a transverse
Steinmann pin placed in the patella can be performed. When the remaining
tendon is scarred and attenuated, a Z-lengthening of the quadriceps and Z-
shortening of the patellar tendon can be performed. This allows sliding of the
patella back to the anatomic position. A reconstructive technique as mentioned
above then should follow. Allograft reconstructive techniques have also been
described for care of the chronic patellar tendon rupture. The procedure
involves placement of the bone-block end of the graft into a trough created in the
tibial tubercle. The tendinous end is then split and passed through one or more
tunnels within the patella and/or encircling the patella medially and laterally.
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