Ruptures of the patellar tendon usually occur in patients under age 40 years, with men having a higher incidence than women.1 History of local steroid injection,2,3 total knee arthroplasty,4-8 anterior cruciate ligament reconstruction with central third patellar tendon autograft,9-11 and a variety of systemic diseases are associated with an increased tendency to rupture.12-15 Primary acute ruptures of the patellar tendon can be difficult to repair because of the quality of remaining tissues. In cases of chronic tendon ruptures subject to delayed treatment, additional complications such as tissue contracture and scar-tissue formation are likely to exist.15-17
Complications after intramedullary (IM) nailing of the tibia include infection, compartment syndrome, deep vein thrombosis, thermal necrosis of the bone with alteration of its endosteal architecture, failure of the hardware, malunion, and nonunion.18 The most common complaint after IM nailing of the tibia is chronic anterior knee pain and symptoms similar to tendonitis; incidences as high as 86% have been reported.18-20 Extensive review of the literature found only 2 reports of patellar tendon rupture after IM nailing of the tibia; both cases used a patellar tendon–splitting approach. The first report described patellar tendon rupture 8 years after IM nailing of the tibia during a forced deep-flexion movement.21 Radiographic examination showed the IM nail positioned proud relative to the tibial plateau, impinging upon the patellar tendon. An intraoperative examination confirmed the radiographic findings and found rupture of the patellar tendon to be consistent with the exposed tip of the IM nail. The second report described patellar tendon rupture 2 months postoperatively in a patient with Ehlers-Danlos syndrome, a hereditary disorder characterized by alterations to muscle/tendon tissue and hyperextensible skin.22
Patellar tendon rupture after IM nailing of the tibia is a rare complication. Patellar tendon re-rupture after primary repair in a patient with history of IM tibial nailing has not been reported. This case outlines the progression of such a patient with a recurrent patellar tendon rupture that was successfully reconstructed using an Achilles tendon allograft. The patient’s surgical history of IM tibial nailing through a mid-patellar tendon–splitting approach 4 years prior to initial tendon rupture is noteworthy and potentially predisposed the patient to injury. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 44-year-old woman, 5 ft, 3 in tall, and weighing 129 lb (body mass index, 22.8), with a history of osteoporosis and transverse myelitis, presented with pain and persistent swelling about the left knee. Her baseline ambulatory status required crutches because of decreased sensation and strength in her lower extremity in conjunction with a foot drop; she had mild quadriceps and hamstring muscle weakness but otherwise normal knee function. The patient had been seen 4 years earlier at our facility for IM fixation of a distal tibia fracture through a patellar tendon–splitting approach. The fracture was well healed and showed no signs of complication or nail migration; the nail was not proud.
Initially, the patient was admitted to another hospital through the emergency department for swelling and pain about the left knee. She was believed to have an infection and was placed on antibiotics by the primary care team. An orthopedic evaluation showed induration, edema, and warmth in the patellar tendon region of the left knee. Magnetic resonance imaging (MRI) showed a full-thickness patellar tendon rupture. Aspiration of the knee was performed and cultures were negative; white blood cell, erythrocyte sedimentation rate, and C-reactive protein values were normal. The risks and benefits of various treatments were discussed, and surgical intervention was elected to repair the patellar tendon.
Intraoperative findings showed a massive midsubstance rupture of the patellar tendon, accompanied by medial and lateral retinacular tears and a quadriceps tendon partial rupture; the central aspect of the quadriceps tendon attaching to the patella remained intact. The patella was retracted proximally; no evidence of active infection was present. Good-quality tissue remained attached to both the tibial tuberosity and the inferior pole of the patella. A No. 2 FiberWire suture (Arthrex, Inc, Naples, Florida) was used to run whip stitches in the distal end of the patellar tendon and a second No. 2 FiberWire suture was used to run whip stitches in the proximal aspect of the patellar tendon rupture. The 4 ends of the sutures were tied together, thus re-approximating the distal and proximal ends of the ruptured patellar tendon. No bone drilling was used because the midsubstance tear was amenable to good repair with reasonable expectation of healing based on tissue quality. The quadriceps tendon, which was partially torn, was repaired with a No. 1 Vicryl suture (Ethicon, Somerville, New Jersey). The medial and lateral retinacula were also repaired with a No. 1 Vicryl suture. The suturing scheme effectively re-approximated the knee extensor mechanism, and the patient was placed in a knee immobilizer that permitted no flexion for 6 weeks postoperatively.