Combined Tibial Tubercle Fracture With Patellar Tendon Avulsion in an Adult: A Rare Case and Novel Fixation Technique

Abstract

Tibial tubercle avulsion fracture with simultaneous patellar tendon avulsion is a rare injury that has only ever been reported in adolescents; the diagnosis and management of this combined lesion has not been described in the adult population. A healthy 62-year-old male presented with acute knee pain and an inability to walk after a fall on ice. Radiographs demonstrated a displaced fracture of the tibial tubercle; patellar tendon integrity could not be verified by ultrasonography. Intraoperatively, the patient was found to have a distal avulsion of the patellar tendon in addition to tubercle fracture. First, the tendon was secured to the tubercle fragment with transosseous sutures. A novel slotted-plate construct was used to fix the tubercle fragment prior to tightening the sutures. Postoperatively, the patient was permitted to bear weight as tolerated with the operative knee immobilized in extension. After six weeks, knee range of motion was gradually increased using a hinged brace. At one year, the patient had achieved excellent range of motion (full extension to 135 degrees of flexion) and strength (5/5 knee flexion and extension) without residual pain or complications. This case represents the first description of diagnosis, management, and rehabilitation of a combined tibial tubercle fracture with distal patellar tendon avulsion in an adult. The unique construct, a slotted-plate over transosseous sutures, provided excellent results and likely has further applications.

Neglected Rupture of the Patellar Tendon After Fixation of Tibial Tubercle Avulsion in an Adolescent Male Managed With Ipsilateral Semitendinosus Autograft Reconstruction

“…In contrast, Bauer et al [17] reported five cases (23%) in their review of 22 patients with tibial avulsion fractures. This injury mainly affects adolescents (aged 13 to 16 years), which is consistent with the time of secondary ossification of the tibial tubercle apophysis; there is only a single report in the literature describing tibial tuberosity and patellar tendon avulsion in an adult patient [18].…”

A novel technique of tibial tuberosity fracture fixation with two knotless suture anchors in an adult: A case report and literature review

“…Tibial tuberosity fractures in adults due to direct trauma have already been reported, and direct trauma may be one of the mechanisms that can cause fractures in adults. 5 , 6 , 9 The fracture of our patient was also caused by direct trauma, and the characteristics of the fracture were different from avulsion fractures. It is known that when tibial tuberosity avulsion occurs, rotation of the bone fragment is followed.…”

“… 2 Therefore, TTF in adults are rare, and only a few cases have been reported, including cases in which fractures were caused by direct trauma. 1 , 5 , 6 …”

A Unique Patellar Tendon Rupture and Small Tibial Avulsion fracture in a Post-Menopausal Patient

“…Avulsion fracture of the tibial tubercle is also a rare injury, more so with an associated patellar ligament rupture, which occurs most commonly in athletic adolescents due to an open physis [ 2 ] [ 3 ]. The first reported case was identified by Mayba in 1982 during which the mechanism of injury was theorized to occur through significant and continued contraction of the quadriceps muscle with a fixed foot or an external force causing contraction [ 3 ] [ 10 ]. The injury can present with a gap along the patella ligament and significant limitations in the extensor mechanism.…”

“…Tibial avulsion fractures are mostly seen in adolescents but are rare in adults [ 2 ]. Tibial avulsion fractures are associated with a patellar ligament rupture, and its treatment involves open reduction and internal fixation using screws, wires, or plates [ 2 ][ 3 ]. However, chronic injuries may require reconstruction of the patellar tendon due to marked deformity and limitations in motion [ 4 ][ 5 ].…”