Abstract
Technique Video
Introduction (0-7 seconds). Author disclosures (8-12 seconds). With the patient in the supine position on the operating room table, a midline incision is made over the patellar tendon (13-41 seconds). The patellar tendon tissue must be examined to determine how the surgeon can repair it. As shown, the surgeon identifies the midsubstance tear and the proximal and distal remnants of the tissue. Two No. 5 FiberWires are placed in a running locking fashion in the proximal tissue fibers (42 seconds to 1 minute 7 seconds). These FiberWire sutures will be anchored into the proximal tibia. The surgeon slides the allograft tendon through the tunnel just created in the tibial tubercle (1 minute 8 seconds to 1 minute 37 seconds). Both the allograft limbs are brought up along the medial and lateral side of the patellar tendon. By use of a tonsil clamp, the graft is passed below the retinacular layer to the superior pole of the patella (1 minute 38 seconds to 1 minute 46 seconds). The allograft is slid under the retinacular layer and will exit at the superior pole of the patella. With the knee flexed to 30°, the allograft is tensioned down and 3 No. 5 FiberWire sutures are placed in a figure-of-8 fashion to help approximate the 2 graft ends (1 minute 47 seconds to 2 minutes 2 seconds). This step is critical because the augmentation protects the tendon repair. The surgeon should ensure that the allograft is secured. In preparation for the distal tendon tissue to be anchored into the inferior pole of the patella, 2 guide pins are placed in the inferior pole of the patella, separated by 20 mm (2 minutes 3 seconds to 3 minutes 6 seconds). The surgeon then reams over those guide pins, and the distal tendon tissue will be anchored in. The proximal patellar tendon leaflet is anchored in distally on the proximal tibia (3 minutes 7 seconds to 3 minutes 28 seconds). The proximal tendon is overlapping the distal tendon leaflet that is anchored into the inferior pole of the patella. The allograft augmentation is on the medial and lateral aspects of the tendon and is under the retinacular layer and is tied at the superior pole of the patella. The graft is placed over the midportion of the patellar tendon and sutured in with interrupted No. 1 Vicryl (3 minutes 29 seconds to 3 minutes 39 seconds).
Surgical Technique
Indications
Patient Evaluation


Procedure
Exposure of Patellar Tendon

Patellar Tendon Remnant Suture Management

Allograft Augmentation



Patellar Tendon Repair and Anchor Placement


Bioinductive Implant Placement


Postoperative Protocol
Discussion
Pearls |
Tie the allograft augmentation at the superior pole of the patella with the knee in 30° of flexion. |
Anchor the distal tendon leaflet first into the inferior pole of the patella; then, overlap this with the proximal leaflet and anchor it into the proximal tibia. |
Using suture, tie down the bioinductive graft circumferentially and in multiple locations to avoid displacement. Do not simply rely on suturing down the corners to the tissue. |
Take a preoperative lateral radiograph of the contralateral knee to work toward an equal Insall-Salvati ratio postoperatively. |
Pitfalls |
Do not pass the allograft augmentation into the capsule. Note that the layer is above the capsule and below the retinaculum. |
Ensure the bone quality in the inferior pole of the patella is appropriate for anchor placement and size. |
Advantages |
Allograft augmentation allows the patient to start range of motion earlier by protecting the repair. |
The bioinductive implant promotes tendon healing at the tear site. |
The technique allows the surgeon to reconstruct the tendon using the patient’s tissue rather than performing an allograft reconstruction. |
Disadvantages |
There is a risk of fracture with anchors in the inferior pole of the patella. |
There is a risk of fracture due to drilling of a tunnel for the augmentation through the tibial tubercle. |
The surgeon should avoid anchor placement at the inferior pole of the patella through the cartilage and into the joint. |
Supplementary Data
- ICMJE author disclosure forms
- Video 1
Introduction (0-7 seconds). Author disclosures (8-12 seconds). With the patient in the supine position on the operating room table, a midline incision is made over the patellar tendon (13-41 seconds). The patellar tendon tissue must be examined to determine how the surgeon can repair it. As shown, the surgeon identifies the midsubstance tear and the proximal and distal remnants of the tissue. Two No. 5 FiberWires are placed in a running locking fashion in the proximal tissue fibers (42 seconds to 1 minute 7 seconds). These FiberWire sutures will be anchored into the proximal tibia. The surgeon slides the allograft tendon through the tunnel just created in the tibial tubercle (1 minute 8 seconds to 1 minute 37 seconds). Both the allograft limbs are brought up along the medial and lateral side of the patellar tendon. By use of a tonsil clamp, the graft is passed below the retinacular layer to the superior pole of the patella (1 minute 38 seconds to 1 minute 46 seconds). The allograft is slid under the retinacular layer and will exit at the superior pole of the patella. With the knee flexed to 30°, the allograft is tensioned down and 3 No. 5 FiberWire sutures are placed in a figure-of-8 fashion to help approximate the 2 graft ends (1 minute 47 seconds to 2 minutes 2 seconds). This step is critical because the augmentation protects the tendon repair. The surgeon should ensure that the allograft is secured. In preparation for the distal tendon tissue to be anchored into the inferior pole of the patella, 2 guide pins are placed in the inferior pole of the patella, separated by 20 mm (2 minutes 3 seconds to 3 minutes 6 seconds). The surgeon then reams over those guide pins, and the distal tendon tissue will be anchored in. The proximal patellar tendon leaflet is anchored in distally on the proximal tibia (3 minutes 7 seconds to 3 minutes 28 seconds). The proximal tendon is overlapping the distal tendon leaflet that is anchored into the inferior pole of the patella. The allograft augmentation is on the medial and lateral aspects of the tendon and is under the retinacular layer and is tied at the superior pole of the patella. The graft is placed over the midportion of the patellar tendon and sutured in with interrupted No. 1 Vicryl (3 minutes 29 seconds to 3 minutes 39 seconds).
References
- Semitendinosus augmentation of acute patellar tendon repair with immediate mobilization.Am J Sports Med. 1995; 23: 82-86
- Novel augmentation technique for patellar tendon repair improves strength and decreases gap formation: A cadaveric study.Clin Orthop Relat Res. 2016; 474: 2611-2618
- Augmentation of patellar tendon repair with autologous semitendinosus graft—Porto technique.Arthrosc Tech. 2017; 6: e2271-e2276
- Patellar tendon repair augmentation with a knotless suture anchor internal brace: A biomechanical cadaveric study.Am J Sports Med. 2018; 46: 1199-1204
- Patient-reported outcomes after use of a bioabsorbable collagen implant to treat partial and full-thickness rotator cuff tears.Arthroscopy. 2019; 35: 2262-2271
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The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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