Jeff C Brand Jr

In This Chapter

Quadriceps tendon rupture

Surgery—quadriceps tendon repair Patellar tendon rupture

Surgery—patellar tendon repair

INTRODUCTION

Extensor mechanism disruptions include quadriceps and patellar tendon rupture.

Bilateral atraumatic simultaneous quadriceps tendon ruptures tend to occur in patients with systemic disease.

Diagnosis is made by clinical examination and radiographic findings in most instances.

Surgery is necessary to restore the extensor mechanism anatomy.

Rehabilitation is determined by the type and strength of the repair.

Weakness, atrophy, and functional losses are common postoperative problems.

QUADRICEPS TENDON RUPTURES

Relevant Anatomy

The quadriceps tendon is the tendinous confluence, approximately 3 cm proximal to the patella, of the vastus lateralis, medialis longus and obliquus, rectus femoris, vastus intermedius, and articularis genu. The tendon is broad based and has a trilaminar depth with fat between the tendon planes. The rectus femoris is the most superficial of the three layers. The rectus direct head arises from the anterior inferior spine and indirect head is from the anterior capsule of the hip. Innervation as for all the quadriceps is from the femoral nerve. It is a two-joint muscle unique among the quadriceps muscles. Distally, fibers form the superficial layer of the quadriceps tendon that traverse over the patella and insert in the infrapatellar tendon. The trilaminar expansion of the quadriceps tendon consists of the superficial layer described, the intermediate layer of the lateralis and medialis, and the deep layer of the intermedius. The lateralis sends fibers to the lateral patellofemoral ligament as well. The vastus lateralis arises from the lateral flare of the greater trochanter along the linea aspera. The vastus intermedius arises from the mid-anterior femur. The vastus medialis originates at the ante rior femur just below the level of the lesser trochanter and inserts in the middle layer on the superior medial border of the patella. Its distal fibers contribute to the medial retinaculum. The articularis genu, an anatomic variant, arises deep to the intermedius and inserts on the superior capsule of the knee serving to retract it from the patella.1

Biomechanics

The patella acts as a moment arm for knee extension through the quadriceps mechanism and patellar tendon attachment on the tibia. Forces in the quadriceps tendon and patellar tendon vary with flexion angle but are consistently reported to be greater at 60 degrees of knee flexion. At 30 and 120 degrees, forces in both structures are roughly one half of these peak values. At 60 degrees of knee flexion, the forces in each tendon are approximately equal. The force in the patellar tendon (FL) is approximately 30% greater than the force in the quadriceps tendon (Fq) at 30 degrees of knee flexion. At 90 degrees of knee flexion, Fq is 30% greater than FL. The patellar contact area moves proximally with increased knee flexion. With the knee in 30 degrees of flexion, the patellar contact area is on the distal portion positioning the patellar tendon at a mechanical disadvantage and increasing forces within the patellar tendon compared to the quadriceps tendon. This suggests that the patella functions as more than a simple pulley that would have equal forces in each the patellar tendon and quadriceps tendon at all knee flexion angles.2 Changing the length of the lever arm by changing the length of either the patellar tendon or the quadriceps tendon can occur with extensor mechanism tendon repair. This will change force loading in each tendon and the contact area of the patella.

Cause of Injury

An intact healthy extensor mechanism, particularly the quadriceps tendon, is unlikely to rupture. The tendon most commonly ruptures through a histologically proven degenerative area.3 Patients with bilateral simultaneous quadriceps tendon ruptures frequently have degeneration as a result of a systemic disease. Although the spontaneous atraumatic rupture of bilateral quadriceps tendons simultaneously is a frequent subject of case reports, it is uncommon in case series.

Clinical Features and Evaluation

The patient with a quadriceps tendon rupture is commonly a male in the sixth decade of life, may have systemic disease, and suffers an indirect eccentric load to the knee with a misstep. Historically, quadriceps tendon rupture was thought to be rare in the patient younger than 40 years of age.4 Forty-five years ago Scuderi stated, "There should be no difficulty in diagnosing a

Table 58-1 Clinical Evaluation of Patients with Extensor Tendon Disruption

Mechanism of injury

Consider systemic medical conditions

Hemarthrosis

Loss of active knee extension Palpable defect

Patella alta (patellar tendon rupture) or baja (quadriceps tendon rupture) on plain radiographs

Magnetic resonance imaging if diagnosis is not clinically evident

Rights were not granted to include this figure in electronic media. Please refer to the printed publication.

ruptured quadriceps tendon, but the diagnosis is all too frequently missed."5 An inability to voluntarily extend the leg, patella baja on exam and a hemarthrosis combined are quite accurate (Table 58-1). Plain radiographs may reveal avulsion fractures and patella baja, which can be assessed with the Insall-Salvati method of measurement. Less than 0.8 suggests patella baja (Fig. 58-1). The "tooth" sign seen on the axial patellar radiographs may be an indication of quadriceps tendon degeneration at its insertion on the patella6,7 (Fig. 58-2).

Magnetic resonance imaging, as reported in small series, shows a discontinuity in all three layers of the quadriceps tendon.8,9 The patellar tendon, with an intact quadriceps tendon and normal tension in the extensor mechanism, displays a linear or nearly linear appearance. If the quadriceps tendon is ruptured, the patellar tendon has a corrugated or wrinkled appearance due to lack of tension in the extensor mechanism10 (Fig. 58-3). Most authors agree that magnetic resonance imaging is not necessary in patients who have the usual findings of extensor mechanism disruption, but it may be useful when the diagnosis is in doubt.

Surgery Acute Repair

A longitudinal incision offers an extensile approach that can be used for secondary procedures such as a total knee arthroplasty.

Figure 58-2 A, Normal patella as seen on a tangential view. B, A superoinferior radiograph of the specimen demonstrates the toothlike structures intimately fused with the anterior cortex of the proximal pole of the patella. (From Greenspan A, Norman A, Kia-Ming Tchang F: "Tooth" sign in Patellar degenerative disease. J Bone Joint Surg Am 1977;59:483-485.)

Rights were not granted to include this figure in electronic media Please refer to the printed publication.

Figure 58-1 The Insall-Salvati ratio in a normal knee (A) and in one with patella alta (B). LI? length of the patella; LT, length of the patellar tendon. (From Rose PS, Frassica FJ: Atraumatic bilateral patellar tendon rupture. A case report and review of the literature. J Bone Joint Surg Am 2001;83:1382-1386.)

Figure 58-3 Magnetic resonance imaging of a patient 3 months after quadriceps tendon repair with suture anchors, demonstrating failure of the repair. The end of the quadriceps tendon is attenuated with signal change within the attenuated portion. The patellar tendon is wrinkled, consistent with relaxation of tension within the patellar tendon due to lengthening of the extensor mechanism.

Figure 58-3 Magnetic resonance imaging of a patient 3 months after quadriceps tendon repair with suture anchors, demonstrating failure of the repair. The end of the quadriceps tendon is attenuated with signal change within the attenuated portion. The patellar tendon is wrinkled, consistent with relaxation of tension within the patellar tendon due to lengthening of the extensor mechanism.

After the incision, the hematoma is evacuated. Intra-articular structures are inspected for further injury to the degree that is possible. The margins of the quadriceps tendon and retinaculum are débrided. As the majority of these lesions occur at the insertion of the tendon onto the superior pole of the patella, the bone of the superior pole of the patella is prepared. Classic descriptions include a trough; however, soft-tissue removal from cortical bone may be adequate as is performed in rotator cuff repair preparation of the greater tuberosity.

Three longitudinal drill holes are drilled in the patella. One is drilled in the center of the patella in the coronal plane. A parallel drill hole is positioned on either side of the middle drill hole for a total of three drill holes. An anterior cruciate ligament drill guide may be used to drill the holes in a more controlled fashion.11 Two no. 5 braided Ethibond sutures (Ethicon, Somerville, NJ) or similar suture is passed through the quadriceps tendon in a grasping configuration, such as a Krackow stitch (Fig. 58-4). The sutures are positioned to allow the central limbs of each suture to pass through the central drill hole of the patella. The opposite limb of each suture is passed with a Beath pin or suture passer (Fig. 58-5) through the drill holes along the medial and lateral sides of the patella, respectively. Opposite ends of each suture loop are knotted over the distal pole of the patella (Fig. 58-6). Alternatively, suture anchors drilled and deployed in the position where the bone tunnels would normally be drilled can provide fixation to the patella. The suture from the suture anchors is passed through the tissue in weave or grasping suture.12 Usually there is a defect in the medial and lateral retinaculum that is repaired with no. 2 braided nonabsorbable suture in an interrupted figure-eight fashion. The natural space that is anterior to the repair and deep to the skin should be obliterated in the closure. Meticulous hemostasis and possibly a surgical drain prevent a postoperative hematoma that can become infected.

Figure 58-4 Schematic diagram of ligament fixation with the Krackow grasping suture. (From Krackow KA, Thomas SC, Jones LC: A new stitch for ligament-tendon fixation. J Bone Joint Surg Am 1986;68:764-766.)

Chronic Repair

For patients who have near-normal length of the quadriceps tendon, standard repair techniques perform well. For the patients without normal length and tension in the quadriceps mechanism, the surgeon must decide between measures to add length to the tendon and those meant to substitute for the defect. Often the defect in the quadriceps tendon consists of variable amount of amorphous, nonfunctional scar tissue that should be resected.13 Length may be restored to the quadriceps tendon mechanism through the Codivilla technique described by Scuderi14 (Fig. 58-7). An inverted V is cut through the full thickness of the proximal segment of the quadriceps tendon with the inferior ends of the V ending 1.5 to 2 cm proximal to the rupture. The triangular flap thus fashioned is split into an anterior part of one third of its thickness and the posterior part of two thirds. The tendon ends of the rupture are then apposed with interrupted nonabsorbable sutures. The anterior one third thickness is turned distally and sutured (see Fig. 58-7). The open upper part of the V is closed with interrupted sutures. The stability of the repair is evaluated with passive range of motion (ROM).15

Postoperative Treatment

A hinged rehabilitative brace provides protection, controlled ROM and access to the incision. For the rare patient who may not be compliant with postoperative instruction, a cast may be more secure. Initially the brace is locked into full extension for 1 to 2 weeks to allow wound healing. This period varies depend-

Figure 58-5 A, Hewson suture passer (Smith & Nephew, Memphis, TN). B, The tip of the suture passer.

ing on coexistent medical issues, immunosuppressive medications, and repair strength. After wound healing is achieved, progressive ROM starts from 0 to 30 degrees for 1 to 2 weeks, 0 to 60 degrees for the next 1 to 2 weeks, 0 to 90 degrees for the following 1 to 2 weeks. Most braces allow a 15-degree progression of ROM if the surgeon desires a slower progression of ROM. Weight bearing is full from the time of surgery with the hinges of the brace locked in full extension. Until 4 to 6 weeks post-operatively, strengthening is by isometrics, quadriceps-setting exercises, and straight leg raises in the brace with the hinges on the brace locked in full extension. At 4 to 6 weeks, the patient may start closed-chain strengthening. Proprioceptive or neuro-muscular activities are an important part of the rehabilitative process as many of these injuries likely result from a misstep. At 10 to 12 weeks, plyometrics and functional activities may be added depending on the patient's demands and capabilities.

This progression of activities can be slowed for chronic repairs or reconstructions of the extensor mechanism. The quality of tissue, quality of the repair, and knee flexion obtained at the time of surgery all are important factors that influence the progression of activities.

Results

If proven surgical principles and techniques are practiced, patient results are generally good, independent of the quadriceps tendon repair method.4,13,16 Weakness is the most common adverse outcome that may occur as often as 30% or more with isokinetic testing.17 Extensor lag, although less common with more aggressive rehabilitation programs, still affects some patients after repair, and particularly after delayed reconstruction. Return to daily or occupational activities takes approxi-

Figure 58-6 Technique for quadriceps tendon repair via drill holes in the patella. Sutures (dashed lines) are passed through three parallel drill holes and tied distally. The central two suture strands are passed through the same central hole and tied to the corresponding medial or lateral strand. (From Ilan DI, Tejwani N, Keschner M, Leibman M: Quadriceps tendon rupture. J Am Acad Orthop Surg 2003;11:192-200.)

Figure 58-6 Technique for quadriceps tendon repair via drill holes in the patella. Sutures (dashed lines) are passed through three parallel drill holes and tied distally. The central two suture strands are passed through the same central hole and tied to the corresponding medial or lateral strand. (From Ilan DI, Tejwani N, Keschner M, Leibman M: Quadriceps tendon rupture. J Am Acad Orthop Surg 2003;11:192-200.)

Figure 58-7 Codivilla method of quadriceps tendon lengthening and repair. A, Chronic quadriceps tendon tear exposed. Proximal retraction prevents direct opposition of the tear. Dashed lines represent inverted V cut (full thickness) to be made. B, The inverted V cut allows the tear to be approximated and repaired. C, The proximal aspect of the inverted V repaired side to side. A full- or partial-thickness flap may be used to augment the repair, as in the Scuderi technique. (From Ilan DI, Tejwani N, Keschner M, Leibman M: Quadriceps tendon rupture. J Am Acad Orthop Surg 2003;11:192-200.)

mately 4 months, but full recovery is longer with some patients. Most patients are able to return to vigorous occupations, but as many as 50% are unable to return to previous recreational activities.18,19

Scuderi stated,5 "It is axiomatic that the earlier a ruptured quadriceps tendon is diagnosed and repaired, the better the end result will be." A delay in surgical repair results in a greater need for ambulatory aids, a decreased ability to climb stairs, and an increased incidence of an extensor lag. Return to work and recreational activities are similarly affected. Patient satisfaction scores are lower with a delayed surgical repair. Although the best results have been seen in patients who were repaired within 7 days, surgical repair for a chronic rupture is recommended.12,15

Patients with bilateral simultaneous quadriceps tendon rupture do not perform as well as patients with unilateral rupture. The majority of these patients are affected by chronic medical conditions (76%). In one study, results in 57% were considered favorable and 43% had a poor outcome. Older patients did not fare as well as younger patients.20

Complications

In a review of multiple series of quadriceps tendon repairs, the most common complication is postoperative stiffness, either extensor lag or loss of flexion. Wound-healing problems and infection are also potential complications. Rerupture of the repair can occur, although it is relatively rare. Other described complications include postoperative hemarthrosis, and deep venous thrombosis or pulmonary embolus.

PATELLAR TENDON RUPTURES

Relevant Anatomy

The patellar tendon is the distal insertion of the extensor mechanism into the proximal tibia through the tibial tubercle. It is obliquely orientated in the coronal plane with the patella lying slightly medial to the tibial tubercle. It is wider and thinner proximally at its attachment on the distal pole of the patella. The patellar tendon fibers merge to attach on the tibial tubercle. Consequently, the tibial insertion is narrower and thicker than the patellar origination. The patellar origination on the distal pole of the patella arcs a crescent in the coronal plane with the medial and lateral fibers attaching more proximally. The patellar tendon attaches to the anterior aspect of the distal pole of the patella. The nonarticular zone is largely devoid of patellar tendon attachment.21

Cause of Rupture

The patellar tendon ruptures through an area of degeneration or impairment3 (Table 58-2). Mechanical impairment may be due to harvest of the middle third of the tendon for ligament reconstruction surgery. Compared to a control group, a test group that experienced harvest of the middle third of the patella in young human cadavers (mean age 24.86 ± 7.13 years) measured a mean area of 48.67 mm2 (49.64% less) and load of 2226.58 N (51% less), and energy level at failure of 32.58 J (45.14% less).22

Cortisone injections into the patellar tendon for inflammatory conditions or anterior knee pain are discussed in several reports as a cause of patellar tendon rupture.6,23 A biochemical investigation demonstrated that dexamethasone significantly decreased cell viability, suppressed cell proliferation, and reduced collagen synthesis in cultured human tenocytes.24

Table 58-2 Patellar Tendon Ruptures

Causes

Mechanism

Harvest of the middle third of the patellar tendon for ligament reconstruction22

Mechanical

Cortisone injection6,24,33

Decreased cell viability, suppressed cell proliferation, and reduced collagen synthesis

Jumper's knee6

Degeneration

Rheumatoid arthritis1

Fibrosis, synovitis

Obesity1

Fatty degeneration

Fluoroquinolones1

Osgood-Schlatter disease6,30

Mechanical

Clinical Evaluation

The clinical findings of patellar tendon rupture mirror those of the quadriceps tendon rupture (see Table 58-1). Patients with a patellar tendon rupture are generally younger than those with a quadriceps tendon rupture.

Biomechanics of Repairs

In an investigation of elderly cadaveric knees (mean age, 66 years), three methods of patellar tendon repair were loaded in a cyclical fashion for 250 cycles at 0.25 Hz. In the first group, the patellar tendon was sutured with no. 5 Ethibond in a Krackow stitch passed through longitudinal drill holes in the patella (mean gap across the repair site 11.3 ± 0.5 mm). The second group added a no. 5 Ethibond suture augmentation as a cerclage passed through a transverse drill hole at the mid-patella and then passed through a transverse drill hole through the tibial tubercle and tied at 90 degrees of flexion (mean gap, 4.9 ± 0.5 mm). The third group used a 2.0 Dall-Miles cable (Howmedica Inc., Rutherford, NJ) augmentation (mean gap, 3.5 ± 0.8mm). Although this investigation was a biomechanical evaluation, the authors believed that the Dall-Miles augmentation allowed an accelerated rehabilitation consisting of full weight bearing in extension, knee ROM from 0 to 90 degrees, and isometric quadriceps/hamstring muscle strengthening.25

A similar method of augmentation with the semitendinosus tendon placed through drill holes allowed an accelerated rehabilitation program that obtained ROM through continual passive motion for 2 weeks combined with passive and active-assisted ROM. Low-resistance cycling started at 2 weeks postoperatively. Three of four patients were identical to the contralateral leg with Cybex dynamometer, Lysholm knee scoring scale, one-legged hop test, ROM, and radiographic evaluation.26

Acute Repair

A longitudinal midline approach to the patellar tendon from the vastus medialis oblique to just beyond the tibial tubercle allows other procedures at the same time or as a delayed procedure.27 Creating thick skin flaps prevents wound-healing complications.

A 60-degree lateral radiograph of the contralateral knee pre-operatively serves as a guide to patellar tendon length (Fig. 588) that restores normal patellar tracking in all planes. Skin incision and prepatellar bursa excision expose the ruptured patellar tendon. Mid-substance tears and the tendinous portion of the proximal and distal repairs can be sutured with a grasping suture such as the Krackow stitch. For either proximal or distal tears, an anatomic attachment to bone needs to be recreated. The bone should be debrided of soft tissue to allow restoration of the normal tendon to bone insertion. Insertion site anatomy can be restored through either bone anchors or tunnels placed through bone. Transosseous tunnels are favored by history; bone anchors are favored by ease and exposure. A braided no. 5 nonabsorbable suture has been traditionally chosen for these repairs (Fig. 58-9). Newer suture with improved biomechanical properties (Fiberwire; Arthrex, Naples, FL) is currently available.

Augmentation with wire,28 Dall-Miles cable,27 or biologic tissue (semitendinosus26) is advocated by some authors. Augmentation can allow a more rapid or accelerated rehabilitation program through improved biomechanical properties of the surgical repair site.25,27 It is most commonly used in circumstances in which tissue quality is considered compromised or when patient compliance with a postoperative program is a concern. Shelbourne et al27 apply the Dall-Miles device after the sutures

Rights were not granted to include this figure in electronic media. Please reter to the printed publication.

Figure 58-8 Preoperative lateral radiograph is taken of the normal knee to obtain the normal patellar tendon length. (From Shelbourne KD, Darmelio Ml? Klootwyk TE: Patellar tendon rupture repair using Dall-Miles cable. Am J Knee Surg 2001;14:17-21.)

Figure 58-9 Diagram of the repair technique with tendon reattachment through vertical drill holes in the patella using nonabsorbable suture (solid arrow) and reapproximation of the retinaculum using interrupted absorbable sutures (open arrow). (From Kuechle DK, Stuart MJ: Isolated rupture of the patellar tendon in athletes. Am J Sports Med 1994;22:692-695.)

Figure 58-9 Diagram of the repair technique with tendon reattachment through vertical drill holes in the patella using nonabsorbable suture (solid arrow) and reapproximation of the retinaculum using interrupted absorbable sutures (open arrow). (From Kuechle DK, Stuart MJ: Isolated rupture of the patellar tendon in athletes. Am J Sports Med 1994;22:692-695.)

Rights were not granted to include this figure In electronic media. Please refer to the printed publication.

Figure 58-10 The Dall-Miles cable is placed through the patella and tibia and is clamped at the joint line. The placement of the cable allows knee flexion to approximately 120 degrees without placing undue tension on the patellar tendon repair. (From Shelbourne KD, Darmelio Ml? Klootwyk TE: Patellar tendon rupture repair using Dall-Miles cable. Am J Knee Surg 2001;14:17-21.)

are positioned but before they are tied. A drill hole is placed transversely across the patella at the mid-portion. A similar transverse hole is drilled across the tibial tubercle. The Dall-Miles cable, neutralization wire, or semitendinosus can be ten-sioned and lateral radiograph obtained with the knee in 60 degrees of flexion that is compared to the preoperative contralateral knee radiograph. The length of Dall-Miles cable or neutralization can be adjusted until the repaired tendon length is equal to the opposite side (Fig. 58-10). Grasping sutures are tied and knee flexion is evaluated for the limits to postoperative rehabilitation. The space anterior to the repair and deep to the skin is closed with meticulous hemostasis and possibly a surgical drain to prevent a postoperative hematoma.

Chronic Repair or Reconstruction

If possible, the chronic repair should be performed using the techniques and principles detailed in the acute repair section previously discussed. This approach will not likely be possible beyond 6 weeks from the time of injury. By that time, due to the retraction of the patella alta from the quadriceps muscle, the patellar tendon has healed in an elongated position with biomechanically inferior fibrous tissue.

Allograft tissue as a reconstructive option offers ease of use, avoidance of graft site morbidity, availability, and often shorter operating times. Unfortunately, viral or bacterial disease may be transmitted by the allograft tissue. Allograft tissues add to the expense of the operation and are not available in all parts of the world. Anterior cruciate ligament reconstruction results with allograft tissue have been comparable, in some series, to those results obtained with autogenous tissue. The results of patellar tendon reconstruction are limited to either case reports or small case series.

Mills29 published a very complete description of the reconstruction of the patellar tendon with an allograft Achilles tendon, and the reader may wish to refer to this description for further details. Five- to 10-degree flexion contractures are treated with physical therapy, dynamic splinting, and possibly serial casting. Flexion contractures greater than 10 degrees are treated surgically as the first stage of a two-stage reconstruction. The second stage is reconstruction of the patellar tendon. Extensive quadriceps retraction and scarring are treated with a quadri-cepsplasty. This procedure may reduce flexion after surgery, and the patient should be warned of this possibility.

A longitudinal incision from 2 cm proximal to the patella to the distal extent of the tibial tubercle is created. Thick skin flaps are made to protect the vascular supply to the skin edges. The patellar tendon scar is incised in midline providing a sleeve for the allograft. This soft tissue is subperiosteally elevated off the patella and tibial tubercle. Retropatellar and suprapatellar adhesions are resected. The patellar fat pad should be protected and retained if not diseased. A large Weber reduction clamp applies traction to restore the patella to its anatomic position after it is mobilized. If the patella cannot be restored to its anatomic position, a series of quadriceps releases are performed. First, the quadriceps is elevated through the suprapatellar pouch, dissecting between the periosteum of the anterior femur and vastus intermedius with a Cobb elevator. If this fails to restore length to the extensor mechanism, a V-lengthening of the scarred distal vastus intermedius from the undersurface of the quadriceps mass is performed. The next step is to resect the vastus inter-medius, maintaining the fibers of the rectus femoris, if inadequate length of quadriceps tendon is not obtained with the measures mentioned previously.

The Achilles allograft bone plug is shaped into a rectangular block 30 mm in length, 10 mm in depth, and 10 mm wide. The tendon is divided into a two-tailed graft. The tendinous ends of the graft are tubularized to fit through 6-mm bone tunnels (Fig. 58-11A). A trough is created with a small oscillating saw on the tibial tubercle to match the bone plug on the tendon allograft. The bone plug is extracted from the tibial tubercle with a thin osteotome. A vertical proximal wall of the trough stops graft migration proximally. The bone plug is secured in the trough with two 3.5-mm small fragment cancellous screws (ASIF; Synthes, Paoli, PA).

The bone tunnels in the patella are drilled over a Beath pin. The Beath pin can be positioned with the anterior cruciate ligament tibial drill guide. The bone tunnels are parallel and about 8 mm from the midline in the coronal plane. The grafts are passed with the Beath pin. A plain lateral radiograph or fluoroscopy with the knee in 30 to 45 degrees of flexion confirms the correct length of the reconstructed patellar tendon. The allo-graft tendon tails are sutured with braided nonabsorbable suture material into the quadriceps expansion. The remaining tails are brought over the superficial surface of the patella and sutured to allograft tails (Fig. 58-11B). The soft-tissue envelope is sutured over the graft. Knee flexion is evaluated in order to guide postoperative knee flexion.29

Postoperative Treatment

The techniques and principles of rehabilitation discussed in the postoperative treatment section of the quadriceps tendon repair apply to the patellar tendon repair.

Was this article helpful?

0 0
Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

Get My Free Ebook


Post a comment