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Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 69-71

Management of patellar tendon avulsion following total knee arthroplasty using artificial ligament

Department of Orthopaedics, VPS Lakeshore Hospital, Kochi, Kerala, India

Date of Submission12-Jan-2021
Date of Decision20-Feb-2021
Date of Acceptance28-Feb-2021
Date of Web Publication08-Mar-2021

Correspondence Address:
A N Sukesh
Department of Orthopaedics, VPS Lakeshore Hospital, Kochi - - 682 040, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joasis.joasis_2_21

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Patella tendon avulsion injury following total knee arthroplasty (TKA) is one of the rarest complications to occur. A breach in the extensor mechanism severely affects the knee function. A spectrum of treatment options with unpredictable outcomes is enumerated in the literature. We present a case of patellar tendon avulsion injury following TKA in a 74-year-old diabetic woman managed by percutaneous extraarticular reconstruction using artificial ligament.

Keywords: Neoligament, patella tendon rupture, reconstruction, total knee arthroplasty

How to cite this article:
Sukesh A N, Rao A, Thomas AB, Varughese J. Management of patellar tendon avulsion following total knee arthroplasty using artificial ligament. J Orthop Assoc South Indian States 2020;17:69-71

How to cite this URL:
Sukesh A N, Rao A, Thomas AB, Varughese J. Management of patellar tendon avulsion following total knee arthroplasty using artificial ligament. J Orthop Assoc South Indian States [serial online] 2020 [cited 2021 Sep 25];17:69-71. Available from: https://www.joasis.org/text.asp?2020/17/2/69/310996

  Introduction Top

Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic surgeries worldwide. Although rare, patellar tendon rupture is a devastating complication after TKA with a reported incidence of 1%–1.5%.[1] The patellar tendon is an important part of the knee extensor mechanism and an injury to the extensor apparatus significantly affects the knee biomechanics. The cause of patellar tendon rupture is multifactorial and more common in patients with systemic risk factors. An intact retinaculum helps individuals to perform some extensor function but gradually causes implant loosening.[1] Different treatment modalities ranging from nonoperative bracing to surgical repair/reconstruction are described, but the results are often disappointing.[1],[2],[3] Reconstruction of the injured tendon has superior results compared to direct repairs.[1],[4] However, with the numerous surgical techniques for reconstruction, the results have not been impressive. We are presenting a surgical method of patellar tendon reconstruction following a trauma in an elderly diabetic patient with promising results.

  Case Report Top

A 74-year-old woman presented to us with a history of fall at the home following which she had pain and swelling over the left knee. She underwent a bilateral TKA 15 years ago and was very active until the recent trauma.

On clinical examination, her left knee was swollen, erythematous, and had an abrasion on the anteromedial aspect [Figure 1]a. She had tenderness at the tibial tuberosity and was unable to extend her knee and does an active straight leg raise test. She also had a healed midline surgical scar over the left knee. She is under treatment for her diabetes and on regular medications. Radiographic evaluation showed a rupture of the patellar tendon from tibial tuberosity with attached flakes of bone and a high riding patella [Figure 1]b. A patellar tendon reconstruction with artificial ligament was planned.
Figure 1: (a) Clinical presentation of the left knee showing an anteromedial abrasion and healed midline scar. (b) Radiograph showing avulsion of the patellar tendon with attached flakes of bone (red arrow)

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An extraarticular percutaneous reconstruction [Figure 2]a and [Figure 3] of the patellar tendon using polyethylene terephthalate tape (Neoligaments, Patellar Tape System, a division of Xiros Springfield House Whitehouse Lane LEEDS) was performed. The neoligament was traversed through a drilled bone tunnel made 1 cm distal to tibial tuberosity from the lateral to medial aspect. The proximal part of the previous midline TKA incision was used to expose the distal quadriceps tendon. The medial and lateral free ends were crossed in a “Figure of 8” manner and passed percutaneously to the medial and lateral aspect of the superior pole of the patella [Figure 2]b. The woven mesh was then passed transversely from the medial to lateral aspect through the distal portion of the quadriceps tendon and along the superior margin of the patella [Figure 2]c. The free ends of the artificial ligament were tightened and knotted on the lateral suprapatellar area with the knee in 20° flexion.
Figure 2: (a) Intraoperative photograph of percutaneous incisions. (b) Free ends pulled from the distal end of the quadriceps tendon (black arrows). (c) Free end passed from medial to lateral aspect through quadriceps tendon superior to the patella (dotted black arrow)

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Figure 3: Illustration of the surgical technique

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The limb was kept in a knee brace postoperatively. Active and passive and range of movements (knee flexion and straight less raise) were started within a week [Figure 4]. Suture removal was performed at the end of 2nd week and full weight-bearing was started after 4 weeks. She had no postoperative wound healing problems and could achieve a good range of motion by 3 months (0–110) [Figure 5]. She was followed up regularly for 1 year, and we are happy to report that she was able to maintain her attained knee range of motion with no extensor lag.
Figure 4: Postoperative radiograph of the knee

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Figure 5: Clinical photograph of the patient at 3-month follow-up with knee flexion (a) and extension (b) with no lag

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  Discussion Top

Patellar tendon rupture following TKA is a rare complication.[1] An injury to the extensor apparatus of the knee causes serious functional impairment. Rand et al.[1] have reported that a failure to address the injury promptly can be a major treat for implant loosening as the patient tries to hyperextend the knee on walking. The cause of patellar tendon disruption following TKA is multifactorial. Diabetes mellitus, old age, and other systemic illnesses are potential risk factors.[5]

A direct repair of the extensor mechanism works well in a virgin knee as suggested by Dobbs et al.[4] A repair with augmentation (autograft/allograft) seems to be promising, but multiple studies have reported variable mid-term and long-term results.[3] The problems of graft site morbidity, adhesions, quadriceps atrophy, graft stretching, immune reactions, and disease transmission are real concerns when using a tissue graft. Augmentation with any sort of metal implants requires additional surgery for the removal of the hardware. Artificial grafts[6] are in use for ligament reconstruction since 1976. The advantages of using an artificial graft over the others are

  1. Early mobilization and faster recovery
  2. Avoids donor site morbidity
  3. Maintains the tensile strength and no stretching of graft over time
  4. An open woven mesh of the artificial graft acts as a scaffold for the ingrowth of fibroblasts
  5. Monofilament mesh acts as a substitute for the fragile and degenerated host tissue.

A modification of Fujikawa et al.[7] technique and a “Figure of 8” repair pattern described by Takazawa et al.[8] were advocated in our patient for the reconstruction. The resurfaced patella was not disturbed and no metal implant was used in our patient.

Fukuta et al.[9] reported excellent results of patellar tendon reconstruction using Leeds-Keio ligament in two patients with 3-year follow-up. The use of artificial ligament in chronic patellar tendon ruptures. Leeds-Keio ligament was used by Ecker et al.[10] for chronic patellar tendon ruptures. Their study has reported achieving a good functional outcome with the use of artificial ligament.

We preferred the technique of percutaneous extraarticular woven mesh reconstruction of the patellar tendon in view of her poor host tissue quality and reduced proliferative capacity due to diabetes mellitus.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

  References Top

Rand JA, Morrey BF, Bryan RS. Patellar tendon rupture after total knee arthroplasty. Clin Orthop Relat Res 1989;244:233-8.  Back to cited text no. 1
Järvelä T, Halonen P, Järvelä K, Moilanen T. Reconstruction of ruptured patellar tendon after total knee arthroplasty: A case report and a description of an alternative fixation method. Knee 2005;12:139-43.  Back to cited text no. 2
Cadambi AJ, Engh GA. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. J Bone Joint Surg Am 1992;74:974-9.  Back to cited text no. 3
Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes. J Bone Joint Surg Am 2005;87:37-45.  Back to cited text no. 4
Altinel L, Kose KC, Degirmenci B, Petik B, Acarturk G, Colbay M. The midterm effects of diabetes mellitus on quadriceps and patellar tendons in patients with knee arthrosis: A comparative radiological study. J Diabetes Complications 2007;21:392-6.  Back to cited text no. 5
Levin PD. Reconstruction of the patellar tendon using a Dacron graft: A case report. Clin Orthop Relat Res 1976;118:70-2.  Back to cited text no. 6
Fujikawa K, Ohtani T, Matsumoto H, Seedhom BB. Reconstruction of the extensor apparatus of the knee with the Leeds-Keio ligament. J Bone Joint Surg Br 1994;76:200-3.  Back to cited text no. 7
Takazawa Y, Ikeda H, Ishijima M, Kubota M, Saita Y, Kaneko H, et al. Reconstruction of a ruptured patellar tendon using ipsilateral semitendinosus and gracilis tendons with preserved distal insertions: Two case reports. BMC Res Notes 2013;6:361.  Back to cited text no. 8
Fukuta S, Kuge A, Nakamura M. Use of the Leeds-Keio prosthetic ligament for repair of patellar tendon rupture after total knee arthroplasty. Knee 2003;10:127-30.  Back to cited text no. 9
Ecker ML, Lotke PA, Glazer RM. Late reconstruction of the patellar tendon. J Bone Joint Surg Am 1979;61:884-6  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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