Soft tissue procedure: ruptured patellar tendon in an operated ACL knee
42 yr old male patient, professional weight lifter presented
with sudden giving way of right knee while jerking to lift weight. There was
excruciating pain and sudden swelling of knee. This knee had been operated by
us for ACL reconstruction using semitendinosus and gracilis graft one and half
year back. On examination, the right knee was swollen, bruised, and lack of
active extension was there. X-rays showed patella alta and no bony avulsion/
fracture. The limb was splinted in slab and analgesics/ anti-inflammatory medicines
were given. On next follow-up at one
week, there was reduction in swelling, extensor lag was more evident. MRI was
done; findings were patellar tendon rupture from near its insertion and rupture
of medial lateral retinaculum. The patient was taken to operation theatre for
surgery. The knee joint was exposed anteriorly using midline vertical incision.
The patellar tendon was exposed. The frayed end of tendon was debrided and the
remaining stump at insertion on tibial tuberosity identified. Holding sutures
were passed through medial and lateral retinaculum ends, to felicitate
identification and closure at later stage. 2 anchor 4.5mm sutures were inserted
into tibial tuberosity area after baring the bone. The suture threads were
woven into the main remnant of proximal tendon and tightened with knee in full
extension. The distal part of patellar tendon was fanned over this repair. Gracilis
tendon was harvested from opposite knee and prepared. This tendon was passed
through a tunnel each in tibial tuberosity and patella horizontally forming a
figure of 8 construct. When sutured, this tendon acted as support to the
overall construct. The retinaculum was repaired at both ends. The wound was
closed in layers over drain and the limb was splinted in above knee slab. Important to notice in this case was use of
tendon graft from opposite limb, as the same tendon had already been used in
this leg. The use of tendon loop also provided good strength the
construct.