Patellar Tendon Rupture
Patellar Tendon Rupture
Patellar Tendon Rupture
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)
• 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
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
Radiologic examination
Right Knee
Insall Salvati Ratio
2.6
Left Knee
Insall Salvati Ratio
1.2
Intra Operative
Graft Harvesting
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
and Marder and Timmerman demonstrated that repair alone is equally durable
without augmentation. 5
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.
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
2. Andarawis-Puri N, Sereysky JB, Sun HB, Jepsen KJ, Flatow EL. Molecular
response of the patellar tendon to fatigue loading explained in the context
of the initial induced damage and number of fatigue loading cycles. J
Orthop Res. 2012 Aug. 30 (8):1327-34.
4. Krackow KA, Thomas SC, Jones LC. A new stitch for ligament-tendon
fixation. Brief note. J Bone Joint Surg Am. 1986 Jun. 68(5):764-6.
11. FINLAYSON GR, SMITH G Jr, MOORE MJ. EFFECTS OF CHRONIC ACIDOSIS
ON CONNECTIVE TISSUE. JAMA. 1964 Feb 29. 187:659-62.
16. Krushinski EM, Parks BG, Hinton RY. Gap formation in transpatellar
patellar tendon repair: pretensioning Krackow sutures versus standard
repair in a cadaver model. Am J Sports Med. 2010 Jan. 38 (1):171-5.