MS, DNB, FAMS, FRCS, FACS, MNAMS, FIMSA
Government Medical College Hospital Chandigarh
Chandigarh, Chandigarh | India
Main Specialties: Orthopaedic Sports Medicine, Orthopaedic Trauma, Orthopaedics
Additional Specialties: Orthopaedics
Primary Affiliation: Government Medical College Hospital Chandigarh - Chandigarh, Chandigarh , India
4PubMed Central Citations
MOJ Sports Med. 2018;2(3):84‒86.
MOJ Sports Med
AbstractPatellar tendon ossification after anterior cruciate ligament reconstruction (ACLR) with Bone-patellar tendon-bone (BPTB) graft is an extremely rare complication. We are reporting a case of patellar tendon ossification and heterotrophic ossification after ACLR with BPTB graft in the same patient. This patient was managed non-operatively as it was not causing hindrance to his daily activity.Keywords: patellar tendon ossification, heterotrophic ossification, BPTB, ACLIntroductionACLR is a commonly done procedure in orthopaedics. Hamstring tendon graft and BPTB graft are two most commonly used autograft for ACLR. BPTB graft is observed to be associated with more donor site morbidity as compared to hamstring tendon graft1. Patellar tendon ossification is one such rare complication seen with BPTB graft.Case presentationACLR was done using BPTB graft in 30 years old badminton player (recreational). The time interval between index injury and surgery was 1 month. Patient also had a concomitant tear in the posterior horn of the medial meniscus for which meniscal repair was done. Next day after surgery knee bending (up to 90º), quadriceps strengthening exercises and non-weight bearing walking started. At 6 weeks, cycling, full knee bending and half squats were added to the rehabilitation program.At 9 months patients presented to the clinic with anterior knee pain, restricted range of motion and difficulty in doing squats. On examination bony swelling was present on the medial aspect of the knee, tenderness was present at the donor site and the range of motion was restricted (0-110º). All stability was normal. The arthrometer (KT-1000TM) measurement showed that anterior translation of tibia was 4 mm in the normal knee and 5 mm in the operated knee. X-ray of the knee showed that patellar tendon ossification and heterotrophic calcification at the medial femoral condyle (Figure 1). Patient was managed non-operatively as he did not have any limitation of daily activity.Figure 1 AP view of x-ray showing heterotrophic ossification on medial femoral condyle and lateral view of left knee x-ray showing patellar tendon ossification.DiscussionBPTB graft is considered as a gold standard graft for ACLR because of better knee stabilty1,2 and higher return to sports after ACL reconstruction with BPTB graft.1,3,4However, BPTB graft is criticized for donor site morbidity like anterior knee pain, patellar fracture, quadriceps tendon rupture etc.5−7 Among the variously described complication of BPTB graft, patellar tendon ossification is one such rare complication. Patellar tendon ossification has been reported mainly in patients with knee injury,8 total knee replacement,9 partial patellectomy,10,11 intramedullary nail12 and after spinal cord injury.13 Patellar tendon ossification after ACLR is extremely rare. This complication has been reported by only few studies in literature14−18 (Table 1). The cause of patellar tendon ossification is not cleared. Gianluca Camillieri et al.16 gave hypothesis that persistence of bone debris inside the patellar tendon may trigger calcification. However, they did not have an immediate postoperative x-ray to prove their hypothesis. In the present case report, we had postoperative CT scan (5th day) which showed the loose bone fragments in the joint (Figure 2) which support the hypothesis given by Gianluca Camillieri et al.16 & Erdogan et al.19 gave another hypothesis he believed aggressive rehabilitation causes microtrauma within patellar tendon.19 However same rehabilitation protocol was followed by others patients and none of them showed patellar tendon ossification. Another possible pathogenesis given by Bonamo et al.20 he stated that devascularization of the graft during harvested results in avascular necrosis. Heterotrophic ossification is commonly encountered problem in orthopaedics. The incidence of heterotrophic ossification after ACL reconstruction with BPTB graft vary from 1.54%-2.58%.21Mohamed A et al.22 observed that incidence of bone debris after ACL reconstruction surgery was 15% if thorough debridement was done and 65% if no specific debridement protocol was followed.22 Treatment of patellar tendon ossification is still not well established. However, some authors showed good results with surgical resection of ossification.14 We managed our patient non-operatively as he did not have any limitation of daily activity. In the present case report, we observed that patient had both patellar tendon ossification and heterotrophic ossification. There was no case reported in the literature which showed both patellar tendon ossification and heterotrophic calcification in the same patient after ACL reconstruction with BPTB graft.ArticleAge/sexType of graftTreatmentDuration of injuryGianluca Camillieri42/maleBPTBExcision of ossification-Homero Valencia29/maleBPTBExcision of ossification10 monthsMehmet Erdil36/maleBPTBExcision of ossification3 monthsFahri Erdogan45/maleBPTB-5 monthsTable 1 Review of literatureFigure 2 Post-operative (5th day) CT scan showing loose bone debris in the joint.AcknowledgementsWritten and informed consent was taken from the patient.Conflict of interestNo conflict of interest.ReferencesHeijne A, Werner S. A 2-year follow-up of rehabilitation after ACL reconstruction using patellar tendon or hamstring tendon grafts: a prospective randomised outcome study. Knee Surg Sports Traumatol Arthrosc. 2010;18(6):805−13.Li S, Chen Y, Lin Z, et al. A systematic review of randomized controlled clinical trials comparing hamstring autografts versus bone-patellar tendon-bone autografts for the reconstruction of the anterior cruciate ligament. Arch Orthop Trauma Surg. 2012;132(9):1287−97.Nwachukwu BU, Voleti PB, Berkanish P, et al. Return to Play and Patient Satisfaction After ACL Reconstruction: Study with Minimum 2-Year Follow-up. J Bone Joint Surg Am. 2017;99(9):720−5.Gudas R, Jurkonis R, Smailys A. Comparison of Return to Pre-Injury Sport After 10 mm Size Bone-Patellar Tendon-Bone (BPTB) versus 8 mm Hamstring Anterior Cruciate Ligament Reconstruction: A Retrospective Study with a Two-Year Follow-Up. Med Sci Monit. 2018;24:987−96.Monaghan PKL, Salem H, Ross KE, et al. Long-term outcomes in anterior cruciate ligament reconstruction: a systematic review of patellar tendon versus hamstring autografts. Orthop J Sports Med. 2017;5(6).Kartus J, Movin T, Karlsson J. Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy.2001;17(9):971−80.Webster KE, Feller JA, Hartnett N, et al. Comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction: a 15-year follow-up of a randomized controlled trial. Am J Sports Med. 2016;44(1):83−90.Matsumoto H, Kawakubo M, Otani T, et al. Extensive post-traumatic ossification of the patellar tendon: a report of two cases. J Bone Joint Surg Br. 1999;81(1):34−6.Majeed H, McBride D. Massive Patellar Tendon Ossification: Excision and Simultaneous Total Knee Replacement. Scientific Pages Orthop Surg.2017;1(1):17−9.Kelly MA, Insall JN. Postpatellectomy Extensive Ossification of Patellar Tendon: A Case Report. Clin Orthop Relat Res. 1987;(215):148−52.Gosselin RA, Belzer JP. Contreras DM. Heterotopic ossification of the patellar tendon following intramedullary nailing of the tibia: report on two cases. J Trauma.1993;34(1):161−3.Tan L, Wang T, Li Y-H, et al. Patellar tendon ossification after retrograde intramedullary nailing for distal femoral shaft fracture: A case report and review of the literature. Medicine. 2017;96(47):e8875.Yamamoto N, Miki T, Nishiyama A, et al. Extensive Bilateral Patellar Tendon Ossification in a Spinal Cord Injury Patient. Acta Med Okayama. 2018;72(1):89−93.Valencia H, Gavín C. Infrapatellar heterotopic ossification after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2007;15(1):39−42.Erdil M, Aşık M, Sen C, et al. Heterotopic bone formation following anterior cruciate ligament reconstruction with BPTB autograft. Acta Orthop Traumatol Turc.2012;46(1):72−6.Camillieri G, Sanzo V, Ferretti M, et al. Patellar tendon ossification after anterior cruciate ligament reconstruction using bone–patellar tendon–bone autograft. BMC Musculoskelet Disord. 2013;14:164.Erdogan F, Aydingoz O, Kesmezacar H, et al. Calcification of the patellar tendon after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004;12(4):277−9.Lerat JL, Besse JL, Vincent P, et al. Sequelae in the knee extensor system following graft removal for the "Mac in Jones" type procedure. Rev Chir Orthop Reparatrice Appar Mot. 1995;81(5):404−9.Erdogan F, Aydingoz O, Kesmezacar H, et al. Calcification of the patellar tendon after ACL reconstruction. A case report with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2004;12(4):277−9.Bonamo JJ, Krinick RM, Sporn AA. Rupture of the patellar ligament after use of its central third for anterior cruciate reconstruction. A report of two cases. J Bone Joint Surg Am. 1984;66(8):1294−7.Bhandary B, Shetty S, Bangera VV. To study the incidence of heterotopic ossification after anterior cruciate ligament reconstruction. J Clin Diagn Res. 2013;7(5):888−91.Imam MA, Abdelkafy A, Dinah F, et al. Does bone debris in anterior cruciate ligament reconstruction really matter? 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Arthroscopy Techniques, Vol -, No - (Month), 2016: pp e1-e6
We present a technique for anterior cruciate ligament (ACL) reconstruction using hamstring tendon autograft with preserved tibial insertions. The tendons, harvested with an open-ended tendon stripper while their tibial insertions are preserved, are looped around to prepare a quadrupled graft. The femoral tunnel is drilled independently through a transportal technique, whereas the tibial tunnel is drilled in a standard manner. The length of the quadrupled graft and loop of the RetroButton is adjusted so that it matches the calculated length of both tunnels and the intra-articular part of the proposed ACL graft. After the RetroButton is flipped, the graft is manually tensioned with maximal stretch on the free end, which is then sutured to the other end with preserved insertions. We propose that preserving the insertions is more biological and may provide better proprioception. The technique eliminates the need for a tibial-side fixation device, thus reducing the cost of surgery. Furthermore, tibial-side fixation of the free graft is the weakest link in the overall stiffness of the reconstructed ACL, and this technique circumvents this problem. Postoperative mechanical stability and functional outcome with this technique need to be explored and compared with those of ACL reconstruction using free hamstring autograft.
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Senior Resident, Department of Orthopedics, Government Medical College and Hospital, Chandigarh, India.
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Associate Professor, Department of Orthopedics, Government Medical College & Hospital, Chandigarh, India.
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Consultant Orthopaedics and Musculoskeletal Oncology, Centre for Bone and Joint, Mumbai 400053, India.
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Senior Resident, Department of Orthopaedics, Government Medical College and Hospital, Sector 32, Chandigarh, India.
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The role of an intact meniscus in providing mechanical stability to the knee of anterior cruciate ligament (ACL) deficient and ACL reconstructed patients has not been well studied.
This was a prospective cohort study. A total of 205 patients undergoing ACL reconstruction were enrolled, of which 61 had normal menisci, 49 had a tear in the posterior horn of the medial meniscus (PHMM) (tear <40% of width = 19; >40% of width = 30), 35 had a tear in the lateral meniscus (<40% of width = 15; >40% = 20), 13 had a tear in the body and/or anterior horn of the medial meniscus (<40% of width = 6; >40% = 7) and 47 patients had a tear in both menisci. Patients with a tear in both menisci were excluded. The anterior translation of the tibia (ATT) was calculated preoperatively and postoperatively at three months and six months using KT-1000. Partial meniscectomy was performed in all unstable meniscal tears.
The mean age at the time of surgery was 25.2 ± 5.1 years. Patients with a normal meniscus showed side to side difference in KT-1000 of 4.8 ± 2.5 mm whereas those with a <40% tear and >40% tear in PHMM had a difference of 5.36 ± 3.07 mm (P = 0.46) and 7.08 ± 2.78 mm (P = 0.0002), respectively. Patients with a lateral meniscus <40% and >40% tear had a mean difference of 5.68 ± 2.96 mm (P = 0.22) and 5.95 ± 2.39 mm (P = 0.09), respectively. Patients with body and/or anterior horn of medial meniscus <40% and >40% had a difference of 5.41 ± 1.11 mm (P = 0.59) and 5.78 ± 2.38 mm (P = 0.35), respectively. At three months and six months KT-1000 differences of 2.3 ± 1.2 mm and 2.1 ± 1.2 mm were seen in patients with normal meniscus; 2.26 ± 1.51 mm and 2.16 ± 0.9 mm with partial meniscectomy of the PHMM <40%; 2.65 ± 1.53 mm and 2.4 ± 1.35 mm with partial meniscectomy of the PHMM >40%; 2.27 ± 1.19 mm and 2.07 ± 1.52 mm with partial meniscectomy of the lateral meniscus <40%; and 2.27 ± 1.44 mm and 2.07 ± 1.14 mm with partial meniscectomy of the lateral meniscus >40%; 2.55 ± 1.56 mm and 1.91 ± 1.09 mm with partial meniscectomy in body and/or anterior horn of medial meniscus <40% and 2.07 ± 1.81 and 2.14 ± 1.10 mm with partial meniscectomy in body and/or anterior horn of medial meniscus >40% (P > 0.05).
PHMM acts as a secondary stabilizer of the knee joint in the absence of functional ACL. There is no effect of partial meniscectomy on mechanical stability of the knee in ACL reconstructed patients. Medial or lateral partial meniscectomy performed at the time of ACL reconstruction does not affect the stability of ACL reconstructed knee. However, the presence of a concomitant tear in PHMM is associated with increased instability in ACL deficient knee.
Copyright © 2018 Elsevier B.V. All rights reserved.
ACL tear; Knee stability; Meniscus tear
onliine Jounral of Clinical Orthop Trauma https://doi.org/10.1016/j.jcot.2018.08.012
Journal of Clinical Orthopaedics and Trauma
We treated proximal tibia fractures according to our own CT based classification in which we divided these fractures into different varus and valgus fractures. We also provide a guide for reduction of these fractures and the sequence in which different fractured fragments of proximal tibia should be fixed.
Patients were identified from the hospital records, treated according to classification based upon mechanism of injury, from August 2014 to December 2016. Patients were called for follow up in outpatient department for evaluation. Functional evaluation was done according to Rasmussen functional grading score.
Twenty one patients of proximal tibia fracture were treated between august 2014 to December 2016 according to our method. There were 17 male and 4 female. Age ranged from 20 year to 65 year (average 35.19 year). 17 patients were turned up for latest follow up who were analysed for Rasmusssen functional grading score. 14 patients had excellent and 3 patients had good function according to Rasmussen functional grading score.
Our classification system provides a guide for reduction of proximal tibia fractures and also tells us the sequence of different fracture fragments.