What are the options for patella tendon reconstruction?

Patellar Tendon Reconstruction Options

For patellar tendon reconstruction, autograft options using hamstring tendons are preferred due to their excellent outcomes, reduced donor site morbidity, and anatomical reconstruction capabilities. 1

Autograft Options

• Hamstring tendon autografts (semitendinosus and gracilis) provide excellent outcomes with good stability and functional restoration for patellar tendon reconstruction 1
• Quadriceps tendon-patellar bone composite autografts offer reduced morbidity while allowing secure bone-to-bone fixation 2
• Bone-patellar tendon-bone (BPTB) autografts have advantages in reducing graft failure risk but may increase anterior or kneeling pain compared to hamstring grafts 3

Allograft Options

• Achilles tendon allografts can be used for chronic patellar tendon ruptures, especially when combined with autograft augmentation 4
• Allograft options eliminate donor site morbidity but carry potential risks of disease transmission and higher costs compared to autografts 5

Synthetic Options

• Synthetic mesh (knitted monofilament polypropylene) can be used for reconstruction, particularly in cases of subacute or chronic patellar tendon disruption following total knee arthroplasty 5
• Synthetic options eliminate disease transmission risk and may be more cost-effective than allografts 5

Combined/Augmented Techniques

• A three-fold reconstruction using Achilles tendon allograft augmented with vascularized ipsilateral hamstring tendon autograft and additional suture augmentation can restore patellar height and prevent extensor lag 4
• Hamstring tendon grafts can be secured through transverse patellar tunnels and firmly fixed to restore function 6

Rehabilitation Considerations

• Early mobilization should be implemented with caution, monitoring for signs of donor site pain or weakness 3
• Open kinetic chain exercises should be started cautiously from 4 weeks postoperative in a restricted range of motion (90°-45°) 7
• Gradual progression of range of motion is recommended with full ROM by week 8 7
• Both concentric and eccentric training improve quadriceps strength during rehabilitation 7

Decision-Making Algorithm

1. Assess patient factors:

   • Age and activity level (younger, active patients may benefit from stronger autograft options) 3
   • Chronicity of injury (chronic cases may require more complex reconstruction) 1
   • Previous failed repairs (may necessitate allograft or synthetic options) 5

2. For acute primary reconstructions:

   • Consider hamstring autografts for reduced donor site morbidity 1
   • Consider BPTB autografts when maximum initial strength is required 3

3. For chronic or revision cases:

   • Consider combined techniques with allograft and autograft augmentation 4
   • Consider synthetic mesh for cases following total knee arthroplasty 5

Common Pitfalls and Caveats

• Inadequate restoration of patellar height can lead to extensor lag and poor functional outcomes 4
• Insufficient graft fixation may result in early failure within the first 6 months 5
• Overly aggressive early rehabilitation may compromise graft healing 7
• Regular assessment of anterior knee pain during rehabilitation is essential, as it may indicate excessive strain on the reconstructed tendon 7