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Clinical Outcomes are Similar Between Graft Types Used in Chronic Patellar Tendon Reconstruction: A Systematic Review

Open AccessPublished:August 01, 2022DOI:https://doi.org/10.1016/j.asmr.2022.06.007

      Purpose

      To compare clinical outcomes between graft types and techniques used to repair chronic patellar tendon injuries to help surgeons make evidence-based decisions.

      Methods

      Medline, Embase, and Cochrane libraries were searched through January 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Inclusion criteria were surgical treatment of chronic patellar tendon injury (defined as >6 weeks old), article available in English, and human subjects, minimum 1-year follow-up, and level of evidence I-IV. Studies describing chronic patellar tendon ruptures in the setting of total knee arthroplasty were excluded. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal tools for case reports and case series.

      Results

      A total of 642 studies were identified through the initial search with 9 studies meeting all inclusion criteria. All studies included were case series encompassing 96 patients with follow-up ranging from 21 months to 7.2 years. Reconstruction techniques included the use of semitendinosus and/or gracilis tendon(s), Achilles tendon, bone-patellar tendon-bone (BTB), or direct repair. The most common graft choice was semitendinosus and/or gracilis tendon(s). Each reconstruction method yielded improvement in respect to range of motion (ROM), extensor lag, quadriceps strength, and patient-reported outcome measures (PROMs). Commonly reported complications were pain and numbness with only one reported instance of graft failure.

      Conclusions

      In this study, we found that all reconstructive methods described in the literature can produce satisfactory outcomes with improved function, strength, and minimal complications after chronic patellar tendon ruptures. Because of study heterogeneity and low levels of evidence, consensus cannot be reached on a single superior reconstruction method.

      Level of Evidence

      Level IV, systematic review of level IV studies.

      Introduction

      Patellar tendon ruptures are injuries usually seen following trauma and present with pain, a palpable tendon gap, and the inability to achieve or maintain knee extension against gravity.
      • Pengas I.P.
      • Assiotis A.
      • Khan W.
      • Spalding T.
      Adult native knee extensor mechanism ruptures.
      Surgical treatment is the gold standard for these injuries as nonoperative management leads to patellar tendon retraction and scarring, loss of normal knee biomechanics, and poor long-term function.
      • Pengas I.P.
      • Assiotis A.
      • Khan W.
      • Spalding T.
      Adult native knee extensor mechanism ruptures.
      ,
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      Primary patellar tendon repair is typically indicated for acute ruptures; however, the surgical technique used for treating chronic patellar tendon rupture depends on the length of time between injury and surgery, as well as the quality of the remaining tissue.
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      Chronic patellar tendon ruptures, usually defined as injuries greater than 6 weeks old, are complicated by proximal patellar migration and compromised tendon tissue, which usually makes primary repair difficult or impossible.
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      Patients typically present with extensor weakness and varying degrees of extensor lag that significantly compromises function. Therefore, chronic patellar tendon ruptures usually require the use of autografts, allografts, or synthetic material to reconstruct the tendon, restore patellar height, and achieve active knee extension.
      • Pengas I.P.
      • Assiotis A.
      • Khan W.
      • Spalding T.
      Adult native knee extensor mechanism ruptures.
      Techniques previously described include a variety of graft reconstructions (synthetic, allograft, and autograft), with or without augmentation, and primary repair with augmentation. Although many different graft types and techniques have been described, there is no consensus on which provides the best clinical outcomes. A previous systematic review from 2015 found that reconstruction of the patellar tendon with autogenous grafts was the best treatment option for chronic patellar tendon tears due to lower failure rate and lower complication rate when compared to primary repair alone.
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      However, this study did not primarily look at chronic patellar tendon injuries, and this study is now outdated with numerous studies on chronic patellar tendon injuries added to the literature since 2015.
      The purpose of this study was to compare clinical outcomes between graft types and techniques used to repair chronic patellar tendon injuries to help surgeons make evidence-based decisions. We hypothesized that autologous grafts would produce the best outcomes for chronic patellar tendon reconstruction.

      Methods

      Medline, Embase, and Cochrane libraries were searched according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following search term was developed for Medline and was adjusted as necessary for other databases: chronic patellar tendon rupture or chronic patellar tendon injury or “Patellar Ligament/injuries”[Mesh]) and (reconstruction or repair or treatment or “Transplants”[Mesh] or “Reconstructive Surgical Procedures”[Mesh] or “Rupture/surgery”[Mesh] OR “Patellar Ligament/surgery”[Mesh]) not (anterior cruciate ligament, or ACL) not tendinopathy.
      Covidence software was used in study screening and data extraction. Two authors independently screened studies for inclusion. Studies that met the following criteria were included: 1) surgical treatment of chronic (>6 weeks) patellar tendon injury, 2) available in English language, 3) human subjects, 4) clinical outcomes described, 5) minimum 1 year follow-up, and 6) level of evidence I-IV. Studies that met the following criteria were excluded: 1) acute patellar tendon rupture, 2) non-English language, 3) nonhuman studies, 4) clinical outcomes not described, and 5) chronic patellar tendon ruptures in the setting of a total knee arthroplasty. Disagreements were resolved through discussion with all authors. Full text screening and data extraction were then independently performed by two authors. A standardized form within the Covidence software was used to extract data, including publication title, authors, year published, journal, patient demographics, technique for restoring patellar height, graft type and fixation technique, augmentation technique, suture type and configuration, follow-up time, range of motion (ROM), patient-recorded outcome measures (PROM), extensor lag, complications, and any additional indicators of patient function.
      Two authors independently assessed risk of bias of included studies using the Joanna Briggs Institute Critical Appraisal tools for case reports and case series. Disagreements were settled by consensus.

      Results

      There were 642 studies identified from our initial search. Forty-eight studies were sent for data extraction after the screening process (Fig 1).
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      • Belhaj K.
      • El Hyaoui H.
      • Tahir A.
      • Meftah S.
      • Mahir L.
      • Rafaoui A.
      • Lmidmani F.
      • Arsi M.
      • Rahmi M.
      • Rafai M.
      • Garch A.
      • Fadili M.
      • Nechad M.
      • El Fatimi A.
      Long-term functional outcomes after primary surgical repair of acute and chronic patellar tendon rupture: Series of 25 patients.
      • Bouguennec N.
      • Colombet P.
      Iterative rupture of the patellar tendon: A case report of an original technique for revision reconstruction using an adjustable loop and an artificial ligament.
      • Caldas M.T.L.
      • Gonçalves T.J.
      • Bárbara G.H.S.
      • Rodrigues R.A.
      • Figueiredo V.R.
      • de Paulo J.P.
      Treatment of chronic patellar ligament lesion with autograft and v-y quadricepsplasty.
      • Campbell M.P.
      • Barnes B.J.
      • Vap A.R.
      Reconstruction of chronic patellar tendon injury with Achilles tendon allograft: A case report.
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      • Chen B.
      • Li R.
      • Zhang S.
      Reconstruction and restoration of neglected ruptured patellar tendon using semitendinosus and gracilis tendons with preserved distal insertions: Two case reports.
      • Cherrad T.
      • Louaste J.
      • Kasmaoui E.H.
      • Bousbaa H.
      • Rachid K.
      Neglected bilateral rupture of the patellar tendon: A case report.
      • Cusano A.
      • Curry E.J.
      • Marinko L.N.
      • Li X.
      Extensor mechanism reconstruction for chronic patellar fracture.
      • El Guindy A.
      • Lustig S.
      • Servien E.
      • et al.
      Treatment of chronic disruption of the patellar tendon in osteogenesis imperfecta with allograft reconstruction.
      • Falconiero R.P.
      • Pallis M.P.
      Chronic rupture of a patellar tendon: A technique for reconstruction with Achilles allograft.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      • Frois Temponi E.
      • de Carvalho L.H.J.
      • da Silva Bernardes C.O.
      • Presses Teixeira B.
      Reconstruction of chronic patellar tendon rupture using graft from contralateral patella graft together with reinforcement from flexor tendons. Case report.
      • Gomes J.L.E.
      • de Oliveira Alves J.A.
      • Zimmermann J.M.J.
      Reconstruction of neglected patellar tendon ruptures using the quadriceps graft.
      • Harris J.D.
      • Fazalare J.J.
      • Phieffer L.S.
      • Flanigan D.C.
      Patellar tendon reconstruction with semitendinosus-gracilis autograft.
      • Heutschi-Ozturk H.
      Chronic patellar tendon rupture on a native knee: Reconstruction with an Achilles tendon allograft with a calcaneal block. A case report.
      • Iacono V.
      • Cigala F.
      • Fazioli F.
      • Rosa D.
      • Maffulli N.
      Reconstruction of chronic patellar tendon tear with allograft in a patient with Ehlers-Danlos syndrome.
      • Isiklar Z.U.
      • Varner K.E.
      • Lindsey R.W.
      • Bocell J.R.
      • Lintner D.M.
      Late reconstruction of patellar ligament ruptures using Ilizarov external fixation.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      • Jablonski J.J.
      • Jarmuziewicz P.
      • Druzbicki M.
      Reconstruction of chronic patellar tendon rupture with semitendinosus tendon: Case report.
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      • Jain S.
      • Jain A.K.
      • Dhammi I.K.
      • Modi P.
      Neglected patellar tendon rupture treated by trans-osseous encirclage wire and turn-o-flap: Case report.
      • Kandeel A.A.-M.A.
      • El-Saeady A.I.
      • Eid T.A.-S.
      Intra-operative patellar fracture during chronic patellar tendon rupture reconstruction: Salvage and prophylactic modified techniques.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      • Karunakgaran K.
      • Adeeban K.
      • Ahmad Faizal A.
      • Sivapathasundaram N.
      Chronic patellar tendon rupture reconstruction with semitendinosus and gracilis tendons with preserved distal insertions. Case report.
      • Kumar A.
      • Rutherford-Davies J.
      • Thorpe P.
      • Newson A.
      Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction (using a tendoachilles allograft) in a case of chronic patellar tendon rupture: A case report.
      • Labib S.A.
      • Wilczynski M.C.
      • Sweitzer B.A.
      Two-layer repair of a chronic patellar tendon rupture: A novel technique and literature review.
      • Lamberti A.
      • Loconte F.
      • Spinarelli A.
      • Baldini A.
      Bilateral extensor mechanism allograft reconstruction for chronic spontaneous rupture: A case report and review of the literature.
      • Lewis P.B.
      • Rue J.P.
      • Bach Jr.,
      BR. Chronic patellar tendon rupture: Surgical reconstruction technique using 2 Achilles tendon allografts.
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      • Magnussen R.A.
      • Lustig S.
      • Demey G.
      • et al.
      Reconstruction of chronic patellar tendon ruptures with extensor mechanism allograft.
      • Matus-Jiménez J.
      • Martínez-Arredondo H.
      Treatment of old patellar tendon lesions. Case report and literature review.
      • McNally P.D.
      • Marcelli E.A.
      Achilles allograft reconstruction of a chronic patellar tendon rupture.
      • Milankov M.Z.
      • Miljkovic N.
      • Stankovic M.
      Reconstruction of chronic patellar tendon rupture with contralateral BTB autograft: A case report.
      • Mittal R.
      • Singh D.P.
      • Kapoor A.
      Neglected patellar tendon rupture: Preserve the fat pad.
      • Naim S.
      • Gougoulias N.
      • Griffiths D.
      Patellar tendon reconstruction using LARS ligament: Surgical technique and case report.
      • Nguene-Nyemb A.G.
      • Huten D.
      • Ropars M.
      Chronic patellar tendon rupture reconstruction with a semitendinosus autograft.
      • Palencia J.
      • Alfayez S.M.
      • Alshammri A.A.
      • Serhan H.S.
      • Serro F.
      • Alomar A.Z.
      Late reconstruction of the patellar tendon in rheumatoid arthritis using bone-patellar tendon-bone allograft.
      • Ramanath S.K.
      • Shah R.H.
      • Patil S.
      • Umesh S.
      Reconstruction of neglected patellar tendon rupture using tendoachilles’ allograft with transosseous tunnels: A case report.
      • Samagh S.P.
      • Huyke F.A.
      • Buchler L.
      • Terry M.A.
      • Tjong V.K.
      Treatment of a neglected patellar tendon rupture with a modified surgical technique: Ipsilateral semitendinosus autograft reconstruction with suture tape augmentation.
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      • Takazawa Y.
      • Ikeda H.
      • Ishijima M.
      • et al.
      Reconstruction of a ruptured patellar tendon using ipsilateral semitendinosus and gracilis tendons with preserved distal insertions: Two case reports.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      • Van der Bracht H.
      • Verdonk R.
      • Stuyts B.
      Augmentation of a patellar tendon repair with an autologous semitendinosus graft.
      • Wascher D.C.
      • Summa C.D.
      Reconstruction of chronic rupture of the extensor mechanism after patellectomy.
      • Wuller T.G.
      • Jansson K.A.
      • Bruner B.W.
      Augmentation of the patellar ligament with a bone-patellar tendon-bone inlay allograft.
      • Yang F.
      • Huang R.
      • Ma H.
      • Wang G.-D.
      • Zhao X.-W.
      Ligament augmentation reconstruction system artificial ligaments in patellar tendon reconstruction-a chronic patellar tendon rupture after multiple operations: A case report.
      • Yoon J.-R.
      • Kim T.-S.
      • Lee S.-R.
      • Yang J.-H.
      Patella tendon rupture neglected for 55 years.
      Two studies were excluded because of insufficient reporting of patient demographics and outcomes,
      • Heutschi-Ozturk H.
      Chronic patellar tendon rupture on a native knee: Reconstruction with an Achilles tendon allograft with a calcaneal block. A case report.
      ,
      • Magnussen R.A.
      • Lustig S.
      • Demey G.
      • et al.
      Reconstruction of chronic patellar tendon ruptures with extensor mechanism allograft.
      two studies were excluded due to inadequate follow-up,
      • Caldas M.T.L.
      • Gonçalves T.J.
      • Bárbara G.H.S.
      • Rodrigues R.A.
      • Figueiredo V.R.
      • de Paulo J.P.
      Treatment of chronic patellar ligament lesion with autograft and v-y quadricepsplasty.
      ,
      • Gomes J.L.E.
      • de Oliveira Alves J.A.
      • Zimmermann J.M.J.
      Reconstruction of neglected patellar tendon ruptures using the quadriceps graft.
      and 35 studies were excluded due to being level V evidence,
      • Belhaj K.
      • El Hyaoui H.
      • Tahir A.
      • Meftah S.
      • Mahir L.
      • Rafaoui A.
      • Lmidmani F.
      • Arsi M.
      • Rahmi M.
      • Rafai M.
      • Garch A.
      • Fadili M.
      • Nechad M.
      • El Fatimi A.
      Long-term functional outcomes after primary surgical repair of acute and chronic patellar tendon rupture: Series of 25 patients.
      ,
      • Bouguennec N.
      • Colombet P.
      Iterative rupture of the patellar tendon: A case report of an original technique for revision reconstruction using an adjustable loop and an artificial ligament.
      ,
      • Campbell M.P.
      • Barnes B.J.
      • Vap A.R.
      Reconstruction of chronic patellar tendon injury with Achilles tendon allograft: A case report.
      ,
      • Chen B.
      • Li R.
      • Zhang S.
      Reconstruction and restoration of neglected ruptured patellar tendon using semitendinosus and gracilis tendons with preserved distal insertions: Two case reports.
      • Cherrad T.
      • Louaste J.
      • Kasmaoui E.H.
      • Bousbaa H.
      • Rachid K.
      Neglected bilateral rupture of the patellar tendon: A case report.
      • Cusano A.
      • Curry E.J.
      • Marinko L.N.
      • Li X.
      Extensor mechanism reconstruction for chronic patellar fracture.
      • El Guindy A.
      • Lustig S.
      • Servien E.
      • et al.
      Treatment of chronic disruption of the patellar tendon in osteogenesis imperfecta with allograft reconstruction.
      • Falconiero R.P.
      • Pallis M.P.
      Chronic rupture of a patellar tendon: A technique for reconstruction with Achilles allograft.
      ,
      • Frois Temponi E.
      • de Carvalho L.H.J.
      • da Silva Bernardes C.O.
      • Presses Teixeira B.
      Reconstruction of chronic patellar tendon rupture using graft from contralateral patella graft together with reinforcement from flexor tendons. Case report.
      ,
      • Harris J.D.
      • Fazalare J.J.
      • Phieffer L.S.
      • Flanigan D.C.
      Patellar tendon reconstruction with semitendinosus-gracilis autograft.
      • Heutschi-Ozturk H.
      Chronic patellar tendon rupture on a native knee: Reconstruction with an Achilles tendon allograft with a calcaneal block. A case report.
      • Iacono V.
      • Cigala F.
      • Fazioli F.
      • Rosa D.
      • Maffulli N.
      Reconstruction of chronic patellar tendon tear with allograft in a patient with Ehlers-Danlos syndrome.
      • Isiklar Z.U.
      • Varner K.E.
      • Lindsey R.W.
      • Bocell J.R.
      • Lintner D.M.
      Late reconstruction of patellar ligament ruptures using Ilizarov external fixation.
      ,
      • Jablonski J.J.
      • Jarmuziewicz P.
      • Druzbicki M.
      Reconstruction of chronic patellar tendon rupture with semitendinosus tendon: Case report.
      ,
      • Jain S.
      • Jain A.K.
      • Dhammi I.K.
      • Modi P.
      Neglected patellar tendon rupture treated by trans-osseous encirclage wire and turn-o-flap: Case report.
      ,
      • Kandeel A.A.-M.A.
      • El-Saeady A.I.
      • Eid T.A.-S.
      Intra-operative patellar fracture during chronic patellar tendon rupture reconstruction: Salvage and prophylactic modified techniques.
      ,
      • Karunakgaran K.
      • Adeeban K.
      • Ahmad Faizal A.
      • Sivapathasundaram N.
      Chronic patellar tendon rupture reconstruction with semitendinosus and gracilis tendons with preserved distal insertions. Case report.
      • Kumar A.
      • Rutherford-Davies J.
      • Thorpe P.
      • Newson A.
      Combined quadriceps lengthening (using an external ring fixator) and patellar tendon reconstruction (using a tendoachilles allograft) in a case of chronic patellar tendon rupture: A case report.
      • Labib S.A.
      • Wilczynski M.C.
      • Sweitzer B.A.
      Two-layer repair of a chronic patellar tendon rupture: A novel technique and literature review.
      • Lamberti A.
      • Loconte F.
      • Spinarelli A.
      • Baldini A.
      Bilateral extensor mechanism allograft reconstruction for chronic spontaneous rupture: A case report and review of the literature.
      • Lewis P.B.
      • Rue J.P.
      • Bach Jr.,
      BR. Chronic patellar tendon rupture: Surgical reconstruction technique using 2 Achilles tendon allografts.
      ,
      • Magnussen R.A.
      • Lustig S.
      • Demey G.
      • et al.
      Reconstruction of chronic patellar tendon ruptures with extensor mechanism allograft.
      • Matus-Jiménez J.
      • Martínez-Arredondo H.
      Treatment of old patellar tendon lesions. Case report and literature review.
      • McNally P.D.
      • Marcelli E.A.
      Achilles allograft reconstruction of a chronic patellar tendon rupture.
      • Milankov M.Z.
      • Miljkovic N.
      • Stankovic M.
      Reconstruction of chronic patellar tendon rupture with contralateral BTB autograft: A case report.
      • Mittal R.
      • Singh D.P.
      • Kapoor A.
      Neglected patellar tendon rupture: Preserve the fat pad.
      • Naim S.
      • Gougoulias N.
      • Griffiths D.
      Patellar tendon reconstruction using LARS ligament: Surgical technique and case report.
      • Nguene-Nyemb A.G.
      • Huten D.
      • Ropars M.
      Chronic patellar tendon rupture reconstruction with a semitendinosus autograft.
      • Palencia J.
      • Alfayez S.M.
      • Alshammri A.A.
      • Serhan H.S.
      • Serro F.
      • Alomar A.Z.
      Late reconstruction of the patellar tendon in rheumatoid arthritis using bone-patellar tendon-bone allograft.
      • Ramanath S.K.
      • Shah R.H.
      • Patil S.
      • Umesh S.
      Reconstruction of neglected patellar tendon rupture using tendoachilles’ allograft with transosseous tunnels: A case report.
      • Samagh S.P.
      • Huyke F.A.
      • Buchler L.
      • Terry M.A.
      • Tjong V.K.
      Treatment of a neglected patellar tendon rupture with a modified surgical technique: Ipsilateral semitendinosus autograft reconstruction with suture tape augmentation.
      ,
      • Takazawa Y.
      • Ikeda H.
      • Ishijima M.
      • et al.
      Reconstruction of a ruptured patellar tendon using ipsilateral semitendinosus and gracilis tendons with preserved distal insertions: Two case reports.
      ,
      • Van der Bracht H.
      • Verdonk R.
      • Stuyts B.
      Augmentation of a patellar tendon repair with an autologous semitendinosus graft.
      • Wascher D.C.
      • Summa C.D.
      Reconstruction of chronic rupture of the extensor mechanism after patellectomy.
      • Wuller T.G.
      • Jansson K.A.
      • Bruner B.W.
      Augmentation of the patellar ligament with a bone-patellar tendon-bone inlay allograft.
      • Yang F.
      • Huang R.
      • Ma H.
      • Wang G.-D.
      • Zhao X.-W.
      Ligament augmentation reconstruction system artificial ligaments in patellar tendon reconstruction-a chronic patellar tendon rupture after multiple operations: A case report.
      • Yoon J.-R.
      • Kim T.-S.
      • Lee S.-R.
      • Yang J.-H.
      Patella tendon rupture neglected for 55 years.
      leaving 9 studies for inclusion in our review.
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      ,
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      ,
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      ,
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      ,
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      ,
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      ,
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      ,
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      All of the included studies were case series.
      Figure thumbnail gr1
      Fig 1PRISMA Flowchart of search results and study selection procedure.

      Hamstrings Tendon

      Six studies reported the use of semitendinosus and/or gracilis tendon(s) grafts on 69 patients (Appendix Table 1, Appendix Table 2, Appendix Table 3),
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      ,
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      ,
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      ,
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      ,
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      all of which were autografts. Forty-nine patients were male, 11 were female, and 9 patients did not have a sex stated. The age of patellar tendon injury ranged from 17 weeks to 16.4 months. Follow-up time ranged from 21 months to 7.2 years. Graft fixation to the tibia was achieved with transosseous tunnels.
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      ,
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      ,
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      ,
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      Graft fixation to the patella was achieved with transosseous tunnels in all studies. Augmentation methods included stainless-steel wire.
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      Range of motion was reported qualitatively as comparable to contralateral
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      and numerically with mean 1-128°.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      ,
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      ,
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      ,
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      Mean extensor lag was 1.5°.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      ,
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      Quadriceps strength was reported qualitatively as comparable to contralateral.
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      Thigh girth was reported numerically as mean 1.5-cm difference compared to contralateral.
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      Lysholm score improved by 25 points
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      in the study that reported preoperative score. The mean postoperative Lysholm score was 90.6.
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      ,
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      ,
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      International Knee Documentation Committee (IKDC) score improved by mean 50.5 points.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      ,
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      Visual analog scale improved by 1.6 points.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      Cincinnati Knee Rating System (CKRS) improved by mean 50.8 points.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      ,
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      Kujala score improved by 39 points.
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      Complications reported are listed in Appendix Table 4.

      Achilles Tendon

      One study reported the use of Achilles tendon allograft on 11 patients (Appendix Tables 5 and 6).
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      Eight patients were male, and three were female. Mean follow-up time was 56 months. Graft bone block fixation to the tibia was achieved with screws.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      Proximally, graft fixation was achieved with transosseous tunnels in the patella.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      Range of motion was mean 1-122°.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      Mean extensor lag was 2°.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      Thigh girth was mean 1.5-cm difference compared to contralateral.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.

      Bone-Patellar Tendon-Bone

      Two studies reported the use of bone-patellar tendon-bone (BTB) graft on 10 patients (Appendix Tables 7 and 9).
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      ,
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      One study used autografts from the contralateral knee,
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      while the other study used allografts.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      All of the patients were male. Mean age of patellar tendon injury was 16.3 months in the study that reported it.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Follow-up time ranged from 41.3 months to 67 months. Graft bone block fixation to the tibia was achieved using screws in all studies. Proximally, graft fixation was achieved by screws to fix the proximal bone block to the patella
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      and K-wires to fix the proximal bone block to the patella.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      Augmentation methods included cerclage wire.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      ,
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Mean ROM was 4-124°.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      ,
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Mean extensor lag was 2.5°.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      ,
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Quadriceps strength was reported numerically as 3.07/5.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Thigh girth was mean 2.4cm different compared to contralateral.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      ,
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Lysholm score improved by 33.6 points.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      International Knee Documentation Committee score improved by a mean 19 points.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Tegner activity score improved by a 3 points.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.

      Direct Repair

      Two studies reported the use of direct patellar tendon repair on six patients (Appendix Tables 10 and Appendix Tables 11)
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      All patients were male. Mean age of injury was 3.5 months. Mean follow-up time was 2.5 years. Both studies augmented the repair with wire.
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      Mean flexion was 116.3°.
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      Mean extensor lag was 0°.
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      ,
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      International Knee Documentation Committee score improved by 69 points, and Cincinnati Knee Rating System improved by 65.5 points.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      One study reported two patients experienced wire breakage that did not require removal.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.

      Discussion

      In this systematic review, the literature shows that all described methods of repairing chronic patellar tendon ruptures lead to improved clinical outcomes with low failure rate. However, there is significant heterogeneity in outcome reporting between studies making comparison between the different methods of repair difficult.
      The most commonly reported outcome after treatment for chronic patellar tendon rupture was ROM, which was reported in all of the included studies. ROM was comparable between the different reconstruction techniques studied in this review. Studies that used hamstring(s) tendon grafts recorded the greatest mean ROM of 1-128°, and studies that used direct repair recorded the lowest mean ROM of 116.3°. The greatest mean ROM from this review is greater than the highest mean ROM of −11-110° from two studies using hamstring(s) tendon grafts found by Gilmore et al.’s review.
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      Studies using direct repair reported the lowest mean extensor lag of 0°. Only two studies reported patients’ postoperative quadriceps strength with one study using hamstring tendon(s) grafts reporting quadriceps strength to comparable to contralateral,
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      while one study using BTB graft reported mean quadriceps strength as 3.07/5.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      This result is in accordance with Pengas et al.’s review on knee extensor mechanism injuries, which noted residual loss of quadriceps strength as an expected outcome after chronic tears.
      • Pengas I.P.
      • Assiotis A.
      • Khan W.
      • Spalding T.
      Adult native knee extensor mechanism ruptures.
      Patient-reported outcome measures improved from preoperative levels in all chronic patellar tendon rupture studies that reported them. Lysholm and IKDC scores were the most reported patient-recorded outcome measure (PROM) appearing in 4 out of 12 studies each. Temponi et al.’s patients treated with BTB graft achieved the greatest improvement in Lysholm score from their preoperative state with an improvement of 33.6 points.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      Jabalameli et al.’s patients treated with hamstring(s) tendon grafts achieved the greatest improvement in IKDC score from their preoperative state with an improvement of 61 points.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      Gilmore et al.’s review found the Hospital for Special Surgery Knee Score to be the most common PROM reported in studies on chronic patellar tendon repair and found a study using a synthetic ligament to have the highest score.
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      However, this previous review included patients with previous total knee arthroplasty, explaining their absence from our review.
      Complications after chronic patellar tendon reconstruction were common with an overall complication rate of 47%. Studies using autogenous hamstring(s) tendon grafts reported the most complications with persistent knee pain being the most common complication. Additionally, only superficial infections and failure of a graft were reported in patients treated with an autogenous hamstring(s) tendon graft.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      This is in conflict with the findings of Gilmore et al.’s review, which reported no instances of failure in studies using autogenous grafts for chronic patellar tendon reconstruction and a complication rate of only 6%.
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      Wire breakage was a commonly reported complication in studies that used wire for augmentation of the graft. However, there were only a few cases in which this was symptomatic and required removal.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      No complications were reported in studies that used Achilles tendon or BTB grafts.
      Interestingly, two studies treated chronic injury of the patellar tendon using direct repair with no major complications, which differed from previous reports on this repair method.
      • Gilmore J.H.
      • Clayton-Smith Z.J.
      • Aguilar M.
      • Pneumaticos S.G.
      • Giannoudis P.V.
      Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today.
      Direct repair of chronic patellar tendon injuries is typically rare because of contracture of the quadriceps and lack of viable tissue. This result shows that direct repair and augmentation with cerclage wire is a viable option for treating chronic patellar tendon ruptures in cases where contracture is not severe and viable tissue remains.

      Limitations

      This study has several limitations. With only case series included, our review constitutes level IV evidence. This is due to a lack of high-level evidence for chronic patellar tendon injuries. Second, outcomes included in this review were heterogeneous. This not only made comparison between studies difficult, but also prohibited any sort of meta-analysis of the data. Finally, the small sample size of this study challenges the reliability of results.

      Conclusion

      In this study, we found that all reconstructive methods described in the literature can produce satisfactory outcomes with improved function, strength, and minimal complications after chronic patellar tendon ruptures. Because of study heterogeneity and low levels of evidence, consensus cannot be reached on a single superior reconstruction method.

      Appendix

      Appendix Table 1Demographic and Surgery Information for Studies Using Both Autologous and Allogenic Hamstring Tendon(s) Grafts
      Author(s)Number of PatientsAgeSexAge of InjuryFollow-Up TimeGraft TypeAugmentationGraft Fixation
      Maffulli et al.
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      194616 Male, 3 Female3.8 months5.8 yearsAutograftTransosseous tunnels in tibia and patella with interference screw in tibial tunnel
      Jabalameli et al.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      6375 Male, 1 Female16.4 months7.2 monthsAutograftFiberwire and wireTransosseous tunnels in tibia and patella
      Abdou
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      173014 Male, 3 Female21 monthsAutograftStainless steel wireTransosseous tunnels in tibia and patella
      Jain et al.
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      931.517 weeks4.5 yearsAutograftTransosseous tunnels in tibia and patella
      Sundararajan et al
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      741.86 Males, 1 Female9 months40.7 monthsAutograftTransosseous tunnels in tibia and patella
      Friedman et al.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      1146.68 Male, 3 Female8 months54.9 monthsAutograftTransosseous tunnels in tibia and patella with suture anchor
      Appendix Table 2Functional Outcomes Reported for Studies Using Both Autologous and Allogenic Hamstring Tendon(s) Grafts
      Author(s)Range of Motion (°)Extensor Lag (°)Quadriceps StrengthThigh Girth (ΔCm)Insall-Salvati RatioCanton-Deschamps Index
      Maffulli et al.
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      132 flexion1.5
      Jabalameli et al.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      3-11831.06
      Abdou
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      Jain et al.
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      0-1491.17
      Sundararajan et al.
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      125 Flexion04.7/50.51.08
      Friedman et al.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      0-1170.98
      Appendix Table 3Patient-Reported Outcome Measures for Studies Using Both Autologous and Allogenic Hamstring Tendon(s) Grafts
      Author(s)Preoperative Lysolhm ScoreLysholm ScoreKOOSPreoperative IKDCIKDCPreoperative VASVASPreoperative CKRSCKRSPreoperative Kujala ScoreKujala ScorePROMIS
      Maffulli et al.
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      44.5844281
      Jabalameli et al.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      23.784.726.488.4
      Abdou
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      6085
      Jain et al.
      • Jain J.K.
      • Vidyasagar J.V.S.
      • Chabra R.
      Percutaneous reconstruction of patellar tendon using semitendinosus tendon in chronic patellar tendon injury—Case series and outcome.
      94.4
      Sundararajan et al.
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      92.446.886.894.5
      Friedman et al.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      64.1 Pain, 55.8 Symptoms, 61.5 ADL, 27.8 Sports, 34.1 QOL4.32.746.9 ± 8.7 Mental health score, 42.0 ± 9.8 Physical health score
      CKRS, Cincinnati Knee Rating System; IKDC, International Knee Documentation Committee score; KOOS, Knee injury and osteoarthritis outcome score; KSS, Knee society score; PROMIS, Patient-Reported Outcomes Measurement Information System; SF-36, 36-item Short Form Health Survey Questionnaire; VAS, visual analogue scale.
      Appendix Table 4Complications for Studies Using Both Autologous and Allogenic Hamstring Tendon(s) Grafts
      Author(s)Complications
      Maffulli et al.
      • Maffulli N.
      • Del Buono A.
      • Loppini M.
      • Denaro V.
      Ipsilateral hamstring tendon graft reconstruction for chronic patellar tendon ruptures.
      9 degenerative changes of patellofemoral joint, 1 lateral aspect of patella partially breached, 1 anterior aspect of tibial tuberosity was partially detached, 5 hypoesthesia and numbness over anterior aspect of knee, 3 persistent anterior knee pain
      Abdou
      • Abdou Y.E.
      Reconstruction of a chronic patellar tendon rupture with semitendinosus autograft.
      12 patients with pain, 3 patients with swelling
      Jabalameli et al.
      • El Guindy A.
      • Lustig S.
      • Servien E.
      • et al.
      Treatment of chronic disruption of the patellar tendon in osteogenesis imperfecta with allograft reconstruction.
      6 wire breakages with 2 requiring removal
      Sundararajan et al.
      • Sundararajan S.R.
      • Srikanth K.P.
      • Rajasekaran S.
      Neglected patellar tendon ruptures: A simple modified reconstruction using hamstrings tendon graft.
      knee tightness and numbness
      Friedman et al.
      • Friedman J.M.
      • You J.S.
      • Hodax J.D.
      • et al.
      Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.
      1 persistent contracture, 1 superficial infection, 1 failed reconstruction
      Appendix Table 5Demographic and Surgery Information for Studies Using Achilles Tendon Graft
      Author(s)Number of PatientsAge (years)SexAge of InjuryFollow-Up TimeGraft TypeAugmentationGraft Fixation
      Karas et al.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      11388 Male, 3 Female42 monthsAllograftBone block was fixed to tibia with AO screws. Achilles tendon passed through transosseous tunnel patella and sutured at superior pole.
      Appendix Table 6Functional Outcomes Reported for Studies Using Achilles Tendon Graft
      Author(s)Range of Motion (°)Extensor Lag (°)Thigh Girth (ΔCm)
      Karas et al.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      1-12221.5
      Appendix Table 7Demographic and Surgery Information for Studies Using BTB Graft
      Author(s)Number of PatientsAgeSexAge of InjuryFollow -up TimeGraft TypeAugmentationGraft Fixation
      Temponi et al.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      733Male16.3 months41.3 monthsAutograftCerclage wireBone blocks were fixed to tibia and patella with screws.
      Karas et al.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      350Male67 monthsAllograftCerclage wireBone block was fixed to patella with K-wires. Bone block was fixed into tibial tubercle with AO screws.
      Appendix Table 8Functional Outcomes Reported for Studies Using BTB Graft
      Author(s)Range of Motion (°)Extensor Lag (°)Quadriceps StrengthThigh Girth (ΔCm)Canton-Deschamps Index
      Temponi et al.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      1-12713.073.61.2
      Karas et al.
      • Karas V.
      • Sherman S.
      • Hussey K.
      • et al.
      Allograft reconstruction for extensor mechanism injuries.
      6-12161.2
      Appendix Table 9Patient-Reported Outcome Measures for Studies Using BTB Graft
      Author(s)Preoperative Lysholm ScoreLysholm ScorePreoperative Tegner Activity ScoreTegner Activity ScorePreoperative IKDCIKDC
      Temponi et al.
      • Temponi E.F.
      • Camelo N.
      • Tuteja S.
      • et al.
      Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft.
      45.4791445.564.5
      IKDC, International Knee Documentation Committee score.
      Appendix Table 10Demographic and Surgery Information for Studies Using Direct Repair
      Author(s)Number of PatientsAgeSexAge of InjuryFollow-Up TimeGraft TypeAugmentation
      Casey, Jr., and Tietjens
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      429Male2 yearsDirect repair1.5-mm wire
      Mahmoud Jabalameli et al.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      2242 Male3.5 months3 yearsDirect repairNo. 2 FiberWire
      Appendix Table 11Functional Outcomes and Patient-Reported Outcome Measures Reported for Studies Using Direct Repair
      Author(s)Range of Motion (°)Extensor Lag (°)Insall-Salvati RatioPreoperative IKDCIKDCPreoperative CKRSCKRS
      Casey, Jr., and Tietjens
      • Casey M.T.J.
      • Tietjens B.R.
      Neglected ruptures of the patellar tendon. A case series of four patients.
      112.50
      Mahmoud Jabalameli et al.
      • Jabalameli M.
      • Bagherifard A.
      • Hadi H.
      • Mohseni M.M.
      • Yoosefzadeh A.
      • Gha ari S.
      Surgical treatment of chronic patellar tendon rupture: A case series study.
      12000.9313.882.81883.5
      CKRS, Cincinnati Knee Rating; IKDC, International Knee Documentation Committee score. System.

      Supplementary Data

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