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Autologous fat grafting as a mesenchymal stem cell source and living bioscaffold in a patellar tendon tear.

CASE REPORT (INSERTIONAL PATELLAR TENDINOSIS WITH LARGE COMPLEX INTERSTITIAL TEARS) A 17-year-old basketball player with a tibial tubercle avulsion fracture through the physis was diagnosed with a partial patellar tendon avulsion at the time of surgery. Two large fragment screws were placed for osseous fixation, and #2 FiberWire (Arthrex, Inc, Naples, Florida) was used to attach the tendon to the periosteum. Six months after the operation, he continued to have pain and was unable to jump or play basketball without considerable pain. Magnetic resonance imaging revealed a thickened patellar tendon insertion. A second surgery was recommended. However, he decided to explore nonsurgical alternatives. Upon initial visit with one of the authors (J.J.A.), diagnostic ultrasound revealed an extremely thickened patellar tendon at the insertion on the tibial tubercle with extensive linear hypoechoic areas, hyperemia, and some calcification (Figure 1). Distension of these hypoechoic areas with local anesthetic confirmed large complex interstitial tears. Two ultrasound-guided injections of 8 to 10 mL of PRP, activated with recombinant thrombin, were administered 5 weeks apart. In each procedure, 1 to 2 mL of 1% lidocaine (plain) was introduced using a 22-gauge needle, which was also used to provide multiple fenestrations in the abnormal areas. At 12 weeks after the initial injection, the patient reported improvement in symptoms such that he could actively scrimmage but had a significant pain afterward. Ultrasound revealed persistent interstitial tears. Retreatment was performed using a combination of bone marrow aspirate, PRP, and autologous fat graft for adipose-derived stem/stromal cells. Lipoaspirated fat graft provided cellular and scaffold (biomatrix) elements and was placed via ultrasound-guided injection to fill the tears at the thickened insertion. Autologous fat harvesting was accomplished according to standard aesthetic surgical technique using a 20-mL Monoject syringe (Covidien Co, Mansfield, Massachusetts) and the Tulip Medical (San Diego, California) closed syringe system (with a 2.1-mm caraway 3-port harvester microcannula) and Superluer loc hub. Forty-five milliliters of bone marrow was obtained as per the standard protocol described in the literature and filtered according to the manufacturer’s instructions, mixed with 15 mL of whole blood, and centrifuged down to 6 mL. Three milliliters of this mixture was mixed with 3 mL of lipoaspirate and injected into the tears. The remaining 3 mL of the concentrated bone marrow aspirate/PRP was then injected into the surrounding tissue. The Arteriocyte Magellan system was used for all the treatments, both PRP and bone marrow. He started basketball practice 2.5 weeks after the PRP/fat grafting treatment, and, by 3.5 weeks, started full scrimmage. At 6 weeks, he displayed diminished pain with jumping and was able to play a complete game at a fully competitive level. By 15 weeks, he could play 1.5 hours with minimal discomfort afterward. At 6 months, he played twice per week without pain during and after the activity.