Rev. bras. ortop. vol.52 número1

rev bras ortop.2017;52(1):111–114

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

report

Simultaneous

bilateral

patellar

tendon

rupture

夽

Diogo

Lino

Moura

_,

_José

_Pedro

_Marques,

_Francisco

_Manuel

_Lucas,

Fernando

Pereira

Fonseca

CentroHospitalareUniversitáriodeCoimbra,DepartamentodeOrtopedia,Coimbra,Portugal

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Articlehistory:

Received22March2016

Accepted28March2016

Availableonline22June2016

Keywords:

Patellarligament

Rupture,spontaneous

Tendoninjuries

Steroids Rehabilitation

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Bilateralpatellartendonruptureisarareentity,oftenassociatedwithsystemicdiseases

andpatellartendinopathy.Theauthorsreportararecaseofa34-year-oldmanwith

simul-taneousbilateralruptureofthepatellartendoncausedbyminortrauma.Thepatientis

aretiredbasketballplayerwithnopastcomplaintsofchronickneepainandahistoryof

steroiduse.Surgicalmanagementconsistedinprimaryend-to-endtendonrepairprotected

temporarilywithcerclagewiring,followedbyashortimmobilizationperiodandintensive

rehabilitationprogram.Fivemonthsaftersurgery,thepatientwasabletofullyparticipate

insportactivities.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Rupturas

bilaterais

simultâneas

dos

tendões

patelares

Palavras-chave:

Ligamentopatelar

Rupturaespontânea

Traumatismosdostendões

Esteroides Reabilitac¸ão

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e

s

u

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o

Asrupturasbilateraisdostendõespatelaressãoumaentidaderara,muitasvezesassociadas

comdoenc¸assistêmicasetendinopatiapatelar.Apresentamosumcasorarodeumhomem

de34anoscomroturabilateralsimultâneadostendõespatelarescausadaportraumaleve.

Opacienteéumjogadordebasquetebolaposentado,semqueixasdedorcrônicadojoelhoe

comhistóriadeconsumodeesteroides.Otratamentocirúrgicoconsistiunareparac¸ão

tendi-nosaprimáriadepontaaponta,protegidatemporariamentecombandadecerclage,seguida

decurtotempodeimobilizac¸ãoeprogramaintensivodereabilitac¸ão.Aoscincomesesapós

acirurgia,opacienteeracapazdeparticiparsemrestric¸õesematividadesdesportivas.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

夽

WorkperformedattheOrthopedicsDepartment,CoimbraHospitalandUniversityCenter,Coimbra,Portugal.

∗ _{Correspondingauthor.}

E-mails:[email protected],[email protected](D.L.Moura).

http://dx.doi.org/10.1016/j.rboe.2016.03.006

2255-4971/©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle

112

Introduction

Disruptionofknee’sextensormechanismisnotunusualand

affectsthepatellabonemorefrequently.1,2_Bilateral

simulta-neousruptures ofthepatellar tendonsare rarelyseenand

haveonlybeendocumentedincasereports.1,3,4

Case

presentation

Wepresenta34-year-oldblackmalethatafterasudden

run-ningstopwithbothkneesinslightflexionassociatedwitha

twistingmovement,heexperiencedfailuresensationand a

severesharppaininbothknees.Hefelltothegroundandwas

unabletostandandwalk.

At the emergency orthopedic department the patient

referredbilateralkneepainandtenderness.Bothknees

dis-played some superficial abrasions and a mild effusion. A

bilateral infrapatellar gap with cephalic migration of both

patellaecouldbefelt.Activestraightlegraisingtestwas

nega-tiveforbothextremitiesandthepatientwasunabletoperform

activeextensionofbothknees.Neurovascularexamination

wasunremarkable.

Thepresumptiveclinicaldiagnosisofbilateralruptureof

thepatellartendonwasmade.

Thepatienthadbeenaprofessionalbasketballplayerfrom

18to25yearsoldandpracticedcompetitiveweightliftinguntil

30yearsold.Headmittedhavingtakenafewcycles oforal

andinjectablesteroidsduringtheweightliftingcompetitive

practicetime.Currently,heisabouncerandarecreational

weightlifting practitioner. The patient assured not having

taken steroidsorany other supplements forthe last three

years.Hereportednopreviousinjuriestohiskneesanddenied

chronickneepain.Atthetimeofthetrauma,thepatientbody

typewasathletic,weighing120kgandwas192cmtall.

TheX-raysshowedcephalicpatellarmigrationandsmall

calcification avulsions of the inferior poles of both

patel-lae.Anisolatedundisplacedspiralfractureoftheleftfibular

Fig.1–Lateralprojectionkneeradiographsafterbilateral patellartendonrupture,showingcephalicpatellar migration(“patellaalta”),avulsionfracturesofinferior polesofbothpatellaeandanisolatedundisplacedspiral fractureoftheleftfibularneck(leftside).

Fig.2–Bilateralpatellatendonruptureatsurgery: monofilamentloopsuturethatallowed,byitspassagein themiddleoftheloop,apropertendonsuturetension.

neckwasalsoidentified(Fig.1).Ultrasoundconfirmedtotal

bilateralruptureofthepatellartendons.Intraoperativelywe

foundbothtendonstornintheirsubstanceneartheinferior

patellarpoles,withsomesegmentsavulsedfromthe

patel-lar insertion. Lateraland medial retinacula were disrupted

bilaterally.Anend-to-endprimaryKessler-typetendonrepair

reinforcedwithintraosseoussutureswasperformedinboth

knees.Wetemporarilyprotecteditwithcerclagewiring,

fol-lowedbyimmobilizationwithalegcylindercast.Wechose

a nonabsorbable monofilamentloop suturethat alloweda

propertendonsuturetension,byitssecondpassagethrough

themiddleoftheloop(Fig.2).Thetensionwithinstitcheswas

carefullyadjustedtoavoidshorteningofinfrapatellarlength,

according tothe patellaeposition. Theruptured retinacula

wererepairedwithVicrylsutures.Thestrengthoftherepair

wastestedbycarefulflexionofbothknees(Fig.3).Cerclage

wiringwasappliedinafigure-of-eighttensionbandrunning

aroundthesuperiorpoleofthepatellae,passinginfrontof

the tendon,fixedwithatransversescrewthroughthetibia

tubercleandtiedataverage60◦_{ofkneeflexion(Fig.4).}

rev bras ortop.2017;52(1):111–114

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Fig.4–Cerclagewiringapplicationineightformtension bandbetweenthedistalquadricipitaltendonanda transversalscrewintheanteriortibialtuberosity.

Thepostoperativecoursewasuneventfulandradiographic

controlwassatisfactory(Fig.5).Thecastimmobilizationwas

removedatthethirdpostoperativedayandthepatientbegan

ambulationwithcrutches usingextensionkneebracesand

fullweight-bearingallowedastolerated.Atthe2rd

postop-erativeweekhebeganperiodicremovalofkneebracesanda

dailyrehabilitationprogram,initiallyconsistinginisometric

musclestrengtheningandkneeflexionexercisesrestrictedto

60◦_{,complementedwithperipatellarsofttissuemassage.At}

the4thweekthepatientcouldwalkwithoutcrutches,hadno

painandattained40◦_{ofmaximumbilateralactiveknee}

flex-ion.Atthe6thweekhehad60◦_{offlexionandthekneebraces}

were discontinued.Atthe8th postoperativeweek, the

cer-clagewirewasremovedandthepatientcontinuedthedaily

physiotherapyprogramwithprogressiontofullkneeflexion

allowed and emphasis on muscle strengthening exercises.

Stationary bicycle was introduced atthe 9th week. Eleven

weeks after surgery, the patient presented 100◦ _maximum

bilateralkneeflexionandreturnedtowork.Onexamination

5monthsaftersurgery,thepatientpresentedasatisfactory

range of motionof bothknees (135◦ _{flexion, 0}◦ _extension)

goodquadricepsstrengthandnosignsofmuscularatrophies

orextensorlag(fig.6).Hedeniedanysenseofinstabilityor

swelling,andthereforehereturnedtorecreational sportive

activities.Hereportedfeelingthathiskneeswereasstrongas

theywerepriortothelesionsandhewasabletorun,squat,

andhopinplacewithoutdifficulty.

Discussion

Patellartendonrupturesaremostlyassociatedwithunhealthy

patellartendons.1_{Thispatienthadanabolicsteroid}

consump-tionhistory,whichcouldbeheldaccountablefordegenerative

changes that weaken the structural tendon integrity with

a higher risk for rupture, even in the context of minor

trauma.1,2,4–8 _{In addition, the patient’s heavy body weight}

andthepreviousparticipationinhigh-levelcompetitivesport

activitiesmighthaveinflictedchronicdegenerativechanges

to hispatellar tendons,as wecan supposebecause ofthe

inferiorpatellapolecalcifications,despitehisdenialforany

chronic knee pain or discomfort compatible with patellar

tendinopathy.9

Fig.5– Twoweeksaftersurgery:radiographiccontrol.

114

Primary tendon repair should be performed assoon as

possibletoavoidproximalpatellarretraction,scarring,

com-plicatedrepairand diminishedlong-termfunction.1,6 _Local

repairsecured by a tension band wire technique to

coun-teracttheforcesgeneratedacrosstheextensormechanism,

diminishing tension at the repair sites and permitting an

uneventfulhealing. Althoughthe use ofcerclage wiringin

bilateral patellar tendon ruptures is still controversial, we

believethisallowedallthebenefitsofaminimalcast

immobi-lizationandanearlycontrolledphysiotherapybeginningtwo

weekspostoperatively,whichwasimportanttoavoid

quadri-cepsatrophy.Therehabilitationprogramprescribedallowed

fastamplitudegainingandanearlierreturntoworkandsport

activitieswhencomparedwithreportsintheliterature.1,6,9,10

Inconclusion,wepresentabilateralpatellartendon

rup-turecaselikelyassociatedwithanabolicsteroidsintakeand

repetitivelocalstress.Thebilateralinjurynaturecanmake

rehabilitationdifficult.Webelievethemainreasons forthe

excellentandearlyfunctionalresultswere:earlytendonrepair

and propersuturetensionand strength;cerclage wireuse;

minimalcastimmobilizationtime;intensive,controlledand

specializedphysiotherapyprogramandastronglycommitted

patient.

Conflict

of

interests

Theauthorsdeclarenoconflictofinterests.

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