We report the case of a 23-year-old female, former Division III basketball athlete, with a PT rupture 2 years after a BPTB ACL reconstruction due to a fall from her bicycle. Physical exam showed a large effusion, palpable defect inferior to the patella, patella Alta on clinical exam and lateral X-ray, and no active extension of the leg (Fig. 1). Magnetic resonance imaging was obtained and revealed disruption of the PT (Fig. 2). The purpose of this study is to describe a novel repair technique for the proximal medial and distal-lateral pattern PT rupture.
The patient was positioned appropriately and draped. The tourniquet was inflated and an 18 cm midline incision was made which incorporated and excised the previous incision. The correct fascial plane overlying the tendon and paratenon was identified, and flaps were elevated both medially and laterally. The remnants of the tendon were cleared of all scar tissue to adequately achieve exposure. The tendon remnants were then thoroughly interrogated to identify the appropriate reduction, similar to fracture care.
On examination, the PT was found to have ruptured medially off of the patella and laterally off of the tibial tubercle in an angulated fashion, as previously described (Fig. 3). Using SutureTape (Arthrex, Naples, F1), Krackow whipstitch of the medial tibial based PT was performed. Of note, the angulated nature of the rupture presented with a larger medial segment as compared to the lateral-patella based segment and was able to accommodate two SutureTape limbs along its width while laterally only one Krackow suture was possible (Fig. 4). A bleeding bone bed was then created on the medial aspect of the patella to improve healing and reattachment of the tendon to the patella (Fig. 5). The same process was repeated on the bone at the lateral aspect of the tibial tubercle.
The first anchor, preloaded with TigerTape for internal brace fixation, was drilled and tapped deep to the lateral tendon remnant on the patella. Before anchor insertion, a lateral X-ray was performed at 30 degrees of knee flexion to confirm the appropriate length of the tendon.
One limb from each Suture Tape from the medial, tibial-based tendon remnant was passed through the suture anchor and secured with insertion for a knotless fixation lateral to the patella. Care was taken to ensure appropriate length was maintained during fixation. A small rent through the tendon just off the patella was then created, and the two strands of the Tiger Tape were pulled through.
The second anchor, again preloaded with Fiber Tape for internal brace fixation, was drilled and tapped at the medial patella. The remaining medial, tibial-based Suture Tapes were then passed through the anchor and secured through the lateral drill hole for knotless fixation of the PT to the medial patella. This effectively spread the fixation among two anchors proximally.
Two holes were then drilled and tapped at the most proximal insertion of the tibial tubercle on the medial and lateral edges. Care was taken to avoid over constraining the internal brace while maintaining the appropriate length of the PT. One limb from the Fiber Tape and Tiger Tape and both limbs of the Suture Tape from the lateral patella-based tendon were then passed through the third anchor and secured at the lateral insertion of the tendon on the tibial tubercle. The remaining limbs of the Fiber Tape and Tiger Tape from the medial patella were passed through the final anchor and secured at the medial aspect of the tibial tubercle (Fig. 6).
We then used the FiberWire from our proximal anchor to incorporate both the medial and lateral PT segments together. The integrity of the repair and possibility of over tensioning was evaluated and ruled out. There was no evidence of pull-off of the tendon, and excellent fixation was noted.
The paratenon was then repaired in a running fashion with absorbable suture (Fig. 7). The wound was closed in layers, and the patient was placed in a sterile compressive dressing, and a hinged knee immobilizer locked in extension.