Patellar Tendon Excision and Repair for Residual Patella Alta after Prior Failed Patellar Tendon Repair: Surgical Decision Making and Outcome

Abstract

Presented in this report is a complex revision case of a patellar tendon repair preceded by excess tendon excision to correct for recurrent patella alta deformity, in a workers' compensation patient. The goal of this procedure was to alleviate this patient's pain, to preserve his ability to function in his activities of daily living, and to allow him to return to work at some capacity. On postoperative radiographs, the revision procedure appeared to have successfully corrected this patient's patella alta deformity. After an extended rehabilitation process, this patient had reached maximal medical improvement at 1-year follow-up. He displayed modest improvements in all PROs, including a clinically significant improvement in his short-form mental component score. Despite his functional capacity being still somewhat limited, this patient reported subjective satisfaction after this complicated salvage procedure.

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“…He was later scheduled for wire removal in the right knee but due to COVID affecting attendance, was advised to re-engage with orthopaedics to discuss left tendon revision at a later date. If the left repair does get revised, similar cases have shown good long term recovery with further rehabilitation (10).…”

“…His patella tendon length as a ratio of his patella height (insall-salvati ratio) was approximately 2.3, measured objectively using a tape measure. A previous study reported a PTR case required repair when their insall-salvati ratio reached 1.55 [10] whilst [12] defined a repair failure if a tendon displacement reached 11cm. This may indicate a failed repair and coincided with pain developed in the PFJ when contracting his quads in full knee extension -attributed to the patella alta (13,14).…”

“…Prompt surgical management of acute PTR's is recommended to avoid the need for reconstruction and tends to lead to better outcomes [9]. Repair failures are rare in the literature but are normally associated with underlying systemic illness such as diabetes [10].…”

“…Prompt surgical management of acute PTR's is normally recommended to avoid repair failure and tends to lead to better outcomes [9]. Repair failures are rare in the literature but are normally associated with underlying systemic illnesses such as diabetes [10]. This bilateral PTR case study is unique in that both knees were injured at different points along the tendon complex, 5 months apart and from different mechanisms.…”

Previous Extensor Mechanism Repair Is Associated With Increased Rates of Surgical Complications Following Total Knee Arthroplasty: A Propensity-matched Analysis

“…Despite preventing re-rupture, these fixation devices and the overall construct rarely achieve native motion, especially in flexion [ 8 ]. Improper technique or scarring of the quadriceps or patellar tendon can cause patellar alta or baja, respectively, which can complicate a knee replacement [ 9 , 10 ]. Furthermore, a devastating complication of primary TKA is extensor mechanism disruption, which commonly requires a revision surgery to address, although a previous history of extensor mechanism disruption prior to primary TKA has not been previously evaluated as a risk factor for complication following TKA.…”