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Chronic Patellar Tendon Rupture Reconstructed with Hamstring Graft – A Case Report

Neglected patella tendon rupture which are presented 6 weeks after injury are rare but it can be disabling. Aim of study is to determine the outcomes of chronic patellar tendon rupture reconstructed using hamstring graft. This case report concerns a 26 year-old man who came with complaints of weakness of legs, difficulty in climbing stairs up and down, difficulty in getting up from squatting position. X-ray of Right knee showed high riding patella. MRI showed full thickness rupture of ACL. The patient was operated with a combination of Chen et al and ganga hospital SR Sundararajan 7 . Our outcome was also excellent with no extensor lag, Kujala score was 94.1, Lysholm score was 92.3. From our study it is found that even in chronic neglected cases of patellar tendon rupture, good functional results can be obtained by repair using hamstring graft.


INTRODUCTION
Neglected patella tendon rupture which are presented 6 weeks after injury are rare but it can be disabling [1]. It occurs usually beneath the inferior pole of patella in younger population during sport related activities [2][3][4][5]. Patients are usually would have undergone native splinting. They are usually tough to repair [3,6]. Although different techniques have been described we have reconstructed using hamstring graft [7-9].
Neglected cases of Patellar tendon rupture are rare. Immediate post traumatic presentations are most common. So, Objective of this case study is to determine the outcomes of chronic patellar tendon rupture which is repaired using hamstring graft.

CASE REPORT
26-year-old male came with complaints of weakness of legs, difficulty in climbing stairs up and down, difficulty in getting up from squatting position. Patient also complains of apprehension to fast walking or running due to buckling of knee. He had a past history of fall from motorcycle, over a flexed knee, 6 months ago, for which he underwent native splinting for 3 months, 6 splints each for 15 days. On examination patient could not do active extension. Passive ROM was full. Quadriceps power was 3/5.Quadriceps wasting of 1cm was present. A palpable defect was felt beneath the inferior pole patella. Knee X ray showed high riding patella. Pre operative MRI showed full thickness rupture of ACL.

OPERATIVE PROCEDURE
Under spinal anaesthesia, parts painted and draped, patella was marked, and tibial tuberosity was marked (Fig. 1), a midline anterior incision was made, we found complete rupture and degeneration of the tendon (Fig. 2), ACL ruptured end was visualised (Fig. 3). The upward migrated patella was tracked down without any difficulty. Two transverse tunnels were made within the patella (Fig. 4) by guide wire and another tunnel parallel to these was within the tibial tuberosity. both semi tendinosis and gracilis was sutured with 2-0 ethibond to complete the tendon reconstruction (Fig. 7,8). Fluoroscopy was used to confirm the position of the patella to maintain Insall-salvati ratio at 30° of flexion. The strength of the construct was tested by flexing the knee to 90° (Fig. 9). Cerclage wire was put to maintain the stability of the construct.

POST OPERATIVE CARE AND REHABILITATION
Patient was immobilised in long knee brace and was started on static quadriceps exercises for 4 weeks. Cerclage wire was removed at 4 th week, was started on ROM exercises with continuous passive motion, touch weight bearing was started on 6 weeks period, full weight bearing was started on 10 weeks period.

RESULTS
One year postoperatively patient was able to gain active flexion of 130° with no extensor lag, quadriceps power regained to 4/5, insall salvati ratio maintained to 1.07, outcome was evaluated by rao criteria [1] was excellent, kujula score was 94.1, lysholm score was 92.3.

DISCUSSION
Neglected patella tendon rupture which are presented 6 weeks after injury are rare but it can be disabling [1]. It occurs usually beneath the inferior pole of patella in younger population during sport related activities [2][3][4][5]. Neglected cases of patellar tendon rupture or patients who underwent native splinting are usually tough to repair [3]. Ecker et al. [10] in 1979 reported four cases of late patellar tendon reconstruction using both the gracilis and semitendinosus tendons. Each tendon was passed through separate tunnels in patella and was sutured together. A cerclage ss wire was used to give stability. Dejour et al. [11] [20]. Our outcome was good with active flexion of 130° with no extensor lag, quadriceps power regained to 4/5, insall salvati ratio maintained to 1.07,outcome was evaluated by rao criteria [1] was excellent, kujula score 94.1, lysholm score 92.3. However it is imperative to maintain normal length of patella tendon to prevent alta and baja, can hamper knee function, and reduce pressure of patella over trochlea which can accelerate patellofemoral arthritis.

CONCLUSION
Our operative procedure was a combination of Chen et al and ganga hospital SR Sundararajan, our outcome was also excellent with no extensor lag after 1 year of follow-up, good rao, kujala, lysholm scores. From our study it is found that even in chronic neglected cases of patellar tendon rupture, good functional results can be obtained by repair using hamstring graft.

CONSENT
All the necessary investgations and procedures were done after obtaining written and informed consent from the patient.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).